NICU Nursing Teamwork: Novel Framework and Implications for Practice

  

    
Tier
    
Factor
    
Definition
  
  

    
1
    
Team Orientation
    
An individual's propensity to prefer    to work as part of a team
  
  

    
Mutual Trust
    
A shared trust among team members    that they will perform their roles and strive towards team goals
  
  

    
Leadership
    
Behaviors the leader engages in to    establish, monitor, and achieve team    goals
  
  

    
Competence
    
An individual's knowledge, skills,    and abilities to perform their job roles and responsibilities
  
  

    
Accountability
    
How individuals are held responsible    for accomplishing their tasks and fulfilling their role on the team
  
  

    
2
    
Psychological Safety 
    
The degree to which team members feel    comfortable speaking up in group settings
  
  

    
Voice
    
Individual behavior to speak up and    express their opinions and concerns
  
  

    
3
    
Information Exchange
    
Communicating information within and    between teams
  
  

    
Coordination
    
The degree to which knowledge and    actions are aligned within and between teams to achieve overarching goals
  
  

    
Shared Mental Models
    
Shared understanding of the task and    the roles and responsibilities of team members 
  
  

    
4
    
Effective Patient & Family Care
    
The state of care provided to    patients and families
  
  

    
Organizational & Team Conditions
    
The culture or environment in which    the team operates
  

Table 1: TeamNICU factors and their respective definitions.

Healthcare literature enforces the need to build team relationships and cohesion [13], as well as establishing mutual trust and respect [2,14-16]. Indeed, team cooperation, which is attitudes and feelings such as team orientation and trust, constitute one of the eight C’s of team science [17]. These eight C’s of team science act as a scientifically based practical guide to understanding and improving teamwork and provide support for several elements of the proposed framework in this manuscript. Recent work has found that mutual trust is a prerequisite for nurses’ sense of safety and satisfaction with work [18]. Existing frameworks on healthcare teamwork include team orientation [19,20] and mutual trust [20-22]. Having sufficient team orientation and mutual trust within nurses and the other healthcare personnel that they interact with is essential for improving teamwork and ultimately to reduce patient safety events.

Implications for practice: Healthcare organizations should ensure that their team members are team-oriented and have a strong mutual trust between team members. There are several existing measures of team orientation [23,24] and mutual trust [25-27] that practitioners can use to diagnose their teams. If results indicate that there are deficits in either factor, leadership should utilize targeted interventions for improvement, and then follow up with additional measurement to ensure that positive changes in that factor occur. Existing evidence suggests that team orientation may be malleable, such that through training and positive team experiences an individual’s orientation towards teamwork can be enhanced [28,29]. Similarly, there exist team building exercises that can increase trust within teams [30]. Due to multiple team membership and member fluidity developing familiarity that predicts trust is often challenging, thus, interventions such as team building that require further interactions among team members are useful in promoting building bonds needed to foster mutual trust.

Leadership: Leadership is conceptualized as the enactment of leadership behaviors to establish and achieve team goals [31], and has been identified as an important aspect of teamwork for patient care [2]. Indeed, leadership is included in several existing frameworks of healthcare teamwork [20,22,32-34]. Four major leadership functions include information search and structure, information use and problem solving, managing personnel resources, and managing material resources [35]. There is evidence to suggest that effective coaching from leaders enhances goal attainment, resilience, and workplace well-being [36]. Within the function of managing personnel resources, expert coaching is an essential component, in which leaders should coach, develop, and motivate team members [35].

Specifically considering nurses, previous research suggests that to improve nursing performance, coaches (e.g., managers, team leaders) must engage in role preparation, understand the nature of motivation, foster internal motivation in nursing staff, and invest in positive relationships with subordinates [37]. Team leaders have a significant influence over team processes and performance, and leaders can often act as the most effective change agents, since they are routinely viewed as the holders of an organization’s values [38], when team culture or processes need adjustment. Therefore, if there are organizational values negatively affecting nurse teamwork, the team or unit leader can act as a change agent to shift team values in a positive direction (e.g., shifting focus to prioritizing patient safety over productivity).

Implications for practice: To evaluate the state of leadership within healthcare teams, organizations can either deploy safety culture assessments [39-41], which typically include leadership as a facet, or utilize leadership-specific measures [42,43]. Based on results, organizations can employ interventions to improve leadership as needed [44-46]. Additionally, there are interventions that target advancing women in leadership in healthcare, which may be particularly relevant for leadership roles within the nursing profession, such as charge nurses [47].

Competence and accountability: In order to build high performing provider teams, individual team members must be competent with their job-related knowledge and skills, as well as competent in safety skills and practices. These individuals must be held accountable to their job role and safety standards in order to ensure the effectiveness of the overall team and unit. Employee safety-related knowledge and competence is a key component of safety culture [48], and is critical for ensuring effective team care. Professional competence is listed as an essential element of teamwork in healthcare [14], but is present in few existing frameworks of healthcare teamwork [22]. When considering interprofessional teamwork in healthcare, there should be no assumption of competence in clinicians [49]. However, an employee’s belief that they are competent has been found to influence patient safety [50]. When there is team member turnover, new personnel need to be evaluated to make sure that they possess the clinical competence required for their work.

Not only must healthcare team members, such as nurses, be competent, but they must be held accountable for their actions and responsibilities, in order to ensure effective teamwork [14,16]. Healthcare teams can be held accountable to trust boards, general management, team managers, other team members, and clinical supervisors [51]. For team members to hold each other accountable, they must have a shared understanding of the roles and responsibilities of each team member. Time spent in behavioral observations indicated that having a shared understanding of team and individual responsibilities directly impacts employee and patient outcomes. Without this shared understanding which team members should be held accountable for which responsibilities, duties can be unnecessarily repeated or go unaddressed, resulting in wasted resources, provider burnout, or patient harm. In addition to developing a shared understanding of duties, it is crucial for nurses and care teams to set clear expectations for how those duties should be carried out (i.e., protocols, practices). When roles and responsibilities are effectively established within teams, all team members have a shared understanding of who is responsible for specific tasks and there are clear expectations for what that individual should do and how they should carry out that task.

Implications for practice: Healthcare organizations should ensure that all nurses and other providers in their teams have the necessary knowledge and skills to carry out the task assigned to them. Organizations can assess competency and accountability in their teams in a variety of different ways. One option is to send out a survey to providers, asking them to rate their perception of competency and accountability within their work environment [52]. Low results from such a survey would indicate the need for refresher training to improve safety competence, though any training deployed should target a specific deficit, which may require interviewing staff to uncover. To address issues with accountability, an overhaul of the system of personnel evaluation or incident reporting may be needed, such that providers that fail to complete their responsibilities are given feedback and the chance to learn from the error. Additionally, cross-training can be utilized to increase nurse and other provider awareness of team member roles, enhancing their ability to hold their team members accountable [53]. When assessing competency, and determining appropriate interventions, the mindset of team members should also be considered. Work on growth versus fixed mindsets holds implications for openness to learning new things, which is essential to fully engaging in interventions designed to enhance competence [54]. Therefore, deploying measures to assess team members’ mindsets could aid in determining readiness for competency training, or if supplemental training is needed to first target the mindset of the trainee.

Tier two

The second tier of the TeamNICU framework consists of psychological safety and voice. When individuals view their team as psychologically safe to take risks, they will be more likely to voice concerns and opinions. Nurses and other healthcare providers are more likely to feel that their team is psychologically safe and feel that they can voice their opinions when the factors in the first tier are present (e.g., effective leadership). This will in turn feed into the third tier, enabling effective information exchange, coordination, and shared mental models, ultimately improving patient care.

Psychological Safety: When a team is viewed as psychologically safe, individuals within the team feel comfortable speaking up during group discussions [55]. Psychological safety is of particular importance to the nurse population, because it fosters an environment in which personnel feel safe reporting mistakes and discussing errors, despite the presence of work hierarchy. Although a relatively new concept that’s getting traction in research, psychological safety is present as an essential factor of teamwork in recent healthcare teamwork frameworks [22]. Indeed, past research has found that nurses are more willing to report mistakes when they feel like their team is psychologically safe [55]. Psychological safety has been found to be an influential factor for patient safety competency in nurses [56]. Previous research has found that psychological safety predicts engagement in quality improvement work [57]. In healthcare environments in which there can be rotating physicians and presence of residents, there may be an exacerbated negative impact of hierarchy on psychological safety, such that it may be more difficult for team members to speak out and question one another [58]. Therefore, it is of particular importance to establish psychological safety in healthcare teams and ensure that it is maintained over time, despite turnover.

Implications for practice: Teams operating in healthcare contexts should routinely evaluate psychological safety, paying particular attention to the level of psychological safety reported by individuals that are not traditionally viewed as formal leaders. Psychological safety can be evaluated using several previously established measures [55,59-61]. Should psychological safety prove to be deficient in any given team, interventions and training programs can and should be utilized [62]. To further tailor interventions, organizations should consider assessing psychological safety across all team-unit structures. For example, nurses’ psychological safety could be high during rounds but low during patient handoffs.

Voice: Voice is a relatively new construct and there is not much empirical literature available, particularly focusing on nurse voice. In an article translating teamwork behaviors from aviation to healthcare [63], assertion, or an individual voicing their opinion through questions or statements of opinion during critical times, was listed as an essential component for teamwork in healthcare contexts. Additionally, the literature has highlighted the significance of empowerment in healthcare [16]. When nurses engage in safety voice behaviors, they feel empowered and are more satisfied with their work [64]. Past research has shown that increased mechanisms for employee voice are associated with high retention rates in healthcare settings [65]. When employees have multiple means to voice concerns, they have higher expectancy for problem resolution and higher perceived effectiveness of organizational procedures for resolving problems, leading to lower turnover rates. Indeed, limited employee voice has been shown to have negative effects on engagement levels [66], which understandably may result in increased turnover as engagement decreases.

Employees do or do not engage in voice based on their initial motivation to speak up, their belief that speaking up will bring about a desired result, and the risk level of speaking out [67], illustrating the importance of establishing psychological safety in teams with nurses to promote employee voice behaviors. Indeed, previous research has found that when healthcare providers perceive greater psychological safety, they are more likely to speak up and discuss colleagues’ mistakes [68]. A model of employee voice hypothesizes that several factors contribute to employee decisions to voice opinions or express concerns. These factors may include motive to help organization or team, the perceived cost or safety of voice (i.e., psychological safety), perceived efficacy of voice (i.e., impact of voice), contextual factors (e.g., organizational culture, team size, supervisor openness, leadership style, collective level beliefs), and individual factors (e.g., job attitudes, personality, demographics, experience and tenure, performance, position) [69]. This model in turn proposes that employee voice impacts both outcomes for the organization or team (e.g., decision making, learning, group harmony, error correction) and outcomes for the individual (e.g., job attitudes, stress, performance evaluation, rewards) [69]. Given the potential impact that employee voice can have on individual, team, and organizational outcomes, it is pertinent to include voice when conceptualizing any team-based framework for success.

Implications for practice: Empowering voice, particularly for nurses, is critical for healthcare team performance and safety-related outcomes. Nurses in particular can suffer from hierarchy-related issues when trying to voice opinions or safety-related concerns. Organizations and teams can evaluate the level of voice that their nurses and other providers feel that they have using established measures [70,71]. If perceptions of voice are low, there are existing interventions to promote voice [62,72] in healthcare personnel. The linkage between psychological safety and voice has been wellestablished in the literature [73,74] and both hold significant practical implications for nurse leaders. Research has supported that inclusive leadership in nurse managers (e.g., openness and accessibility) [75] can promote voice through positively influencing psychological safety [76]. In an applied setting, this translates to deploying interventions in nursing leadership that train inclusive leader behaviors, as these behaviors are linked to psychological safety which then encourages voice.

Tier three

The third tier of the TeamNICU framework is composed of information exchange, coordination, and shared mental models. This framework proposes that when the factors from the first two are present and strong, nurses are better able to exchange information, coordinate effectively, and develop shared mental models with their healthcare teams. In turn, when these elements are present and effective, the result will be improved patient and family care.

Information exchange: Information exchange, or communication, involves sharing unique information between teams and individuals [31]. Effective information exchange is particularly important in healthcare contexts, arguably more so than for fields outside of healthcare. Inaccurate information exchange and miscommunication can result in not only a detriment to team and organizational performance, but most importantly can negatively impact patient safety incidents. Behavioral observations and interviews unsurprisingly revealed that effective information exchange is a critical component of teamwork to ensure safe care of patients and help reduce burnout in employees. Patient information must be exchanged between personnel accurately and timely, to ensure safe care of the patient and avoid errors such as inaccurate medication dosage. Practical systems for disseminating information to all personnel, such that all changes in policies and procedures in the unit are communicated to all teams in a timely manner. This will likely help to reduce burnout in employees by preventing personnel from being unfairly disciplined for being unaware of changes in policies and standard procedures. In particular, the nurse liaison role was found to be particularly relevant for effective information exchange. Nurse liaisons should function such that they attend physician huddles and communicate relevant information between teams.

Communication is frequently cited as a crucial element of healthcare teamwork [20,32,34]. However, effective communication is also listed as one of the main challenges to collaborative teamwork in clinical settings [49]. Additionally, fostering effective communication is a key component of effective healthcare culture [13,16]. The three most commonly reported information sources in neonatal intensive care unit (NICU) environments are 1) bedside flowsheet; (2) conversations with nurses; and (3) conversations with resident physicians [77]. In addition to communicating effectively with team members, it is also essential for providers to communicate with parents [78].

Implications for practice: Practical systems for disseminating information to all personnel should be established, such that all changes in policies and procedures are communicated to all teams in a timely manner. This will reduce burnout in employees by preventing personnel from being unfairly disciplined for being unaware of changes in policies and standard procedures. Specifically, a nurse liaison role can be particularly effective in aiding interprofessional patient information exchange, particularly when team “huddles” are profession-based (i.e., nurse huddle separate from physician huddle). Nurse liaisons should function such that they attend physician huddles and communicate relevant information between teams. Additionally, communication between nurses and with other providers can be improved by implementing structured communication policies, such as the SBAR strategy [79]. The SBAR strategy for improving communication between clinicians advises providers to consider the Situation and state what is happening at the present time, discuss the Background or circumstances leading up to the situation, give an Assessment of what they think the problem is, and Recommend what should be done to correct the problem [79].

Coordination: Not only must nurses accurately exchange patient information, but they must also effectively coordinate patient care plans, such that every member of the team understands and accomplishes their roles and responsibilities. Coordination involves using strategies to align knowledge and actions within and between teams. Improving team coordination is essential for promoting patient safety and deploying team coordination training can help avoid adverse events [5,80]. The importance of coordination in teams in general is illustrated through its inclusion as one of the seven C’s of team science [81]. Coordination is particularly important for healthcare providers, who have to adapt their coordination strategies to situational requirements [2]. This could involve teams engaging in more implicit coordination during routine situations that they have extensive experience with, while utilizing more explicit coordination strategies during critical or novel situations. Indeed, the literature on coordination states that effective collaboration and coordination are essential elements of teamwork [14].

Implications for practice: It is essential for nurses to engage in effective coordination with their healthcare team. Healthcare team leaders can evaluate the effectiveness of their teams’ coordination using a variety of different measurement techniques [82]. If coordination is found to be poor, this can have significant implications for team performance and patient safety. Thankfully, there exist several strategies and interventions for improving coordination in healthcare teams that organizations can utilize [83]. Specifically, they present several quality improvement strategies to enhance care coordination, including instituting clinician and patient reminder systems and providing feedback about coordination.

Shared mental models: A team has a shared mental model when there is a shared understanding of the task that is to be performed and of the involved teamwork [84]. The literature on team science suggests that cognitions, or shared understanding among team members, are an essential element of teamwork [81]. Despite being critical for effective teamwork, one of the main challenges for collaborative teamwork in clinical practice is understanding others’ roles [49]. Healthcare team culture research emphasizes that team members need to understand job role clarity and foster shared goals among the team [13]. Indeed, dominant mental models shared by staff have been shown to influence actions and behaviors and contribute to infection rates (Luan, 2006). Established frameworks of healthcare teamwork include shared mental models and clear definition of roles and responsibilities [20,22,32,33]. There are several established methods for measuring shared mental models in healthcare [85], which can be used to evaluate shared mental models in teams and determine if there is a need for training and development.

Indeed, observations and interviews revealed a trend around establishing a shared understanding of team roles and responsibilities. In particular, perception of duties and establishing expectations emerged as two essential themes for healthcare team effectiveness. Having a shared understanding of team and individual responsibilities directly impacts employee and patient outcomes. When the team does not have a shared understanding of roles, duties can be unnecessarily repeated or go unaddressed, resulting in wasted resources, provider burnout, or patient harm. In addition to developing a shared understanding of duties, it is crucial for teams to set clear expectations for how those duties should be carried out (i.e., protocols, practices). When roles and responsibilities are effectively established within teams, all team members have a shared understanding of who is responsible for specific tasks and there are clear expectations for what that individual should do and how they should carry out that task.

Implications for practice: To ensure effective patient care, healthcare teams need to ensure that there exists a shared mental model between nurses and other members of the care team. When this shared mental model is not present, there can be issues with communication and coordination, resulting in preventable errors and potentially patient safety incidents. Shared mental models can be evaluated in a several different ways, and the existing literature is littered with various measures that have been utilized in healthcare [85-88]. After evaluation, if team results indicate deficits in shared mental models, team training can be deployed for improvement [87,89]. Additionally, guided team self-correction can be utilized to increase team mental models [7].

Organizational and team conditions

The environment in which teams operate greatly influences team processes and performance. External factors such as organizational climate and resources, can impact whether or not team members engage in effective teamwork behaviors. Several healthcare frameworks of teamwork include organizational and team conditions as critical for affecting teamwork [22]. Indeed, the last of the seven C’s of team science is conditions, or external factors that influence teamwork [81], reaffirming that establishing the right conditions is necessary to promote effective team performance. Organizational and team conditions for facilitating effective teamwork can include reinforcing teamwork, establishing a supportive culture for teamwork, and ensuring that executive and division leadership are on board for promoting teamwork [22]. Indeed, previous work has asserted that there are ten principles for team cultures that enforce the importance of establishing an appropriate environment or atmosphere for effective teamwork [13]. For example, if a nurse is offered an opportunity to attend a training that provides essential knowledge their team needs, they may not take up that opportunity if their organization does not provide support, encouragement, and time off to do so.

Implications for practice: Leadership must ensure that critical organizational and team conditions are present to promote effective teamwork. Using a healthcare framework presented, conditions should be evaluated to ensure that there exists a culture of support for teamwork, that leadership is committed to teamwork, and that teamwork is reinforced through an evaluation and reward system. Results can inform quality improvement efforts to enhance a culture of teamwork, and results must be reliable and accurate which is only achieved through creating systematic processes to collect, analyze, and report data evaluating both culture and the effectiveness of interventions.

Tier four

Effective patient and family care: The first three tiers of the framework, along with the surrounding organizational and team conditions, enable effective teamwork in neonatal intensive care units. This teamwork has a direct impact on patient and family care, such that when nurses and healthcare teams are effective, families will be more satisfied with the care that is provided and there will be improved patient outcomes. Each layer of the framework builds upon the other to facilitate effective team performance, with the ultimate goal being value-based care. Value-based care is the development and maintenance of a healthy system that prioritizes patient health outcomes relative to the cost of said outcome.(90,91) Nurses work on the frontlines and have arguably some of the highest degrees of faceto- face patient interactions. Value-based nursing care, as supported by the three preceding tiers, creates an environment that is proactive, and patient-centered.

Discussion

The current effort combines evidence from existing knowledge, subject matter experts, observations, and interviews to provide a novel, comprehensive framework for understanding the factors that contribute towards effective teamwork between nurses and other healthcare providers. These factors and the surrounding team and organizational conditions enable clinicians to collaborate effectively, enhancing patient-centered care and reducing error and safety incidents. There are limited frameworks that focus on nursing specifically, and existing healthcare teamwork frameworks fail to address several critical factors presented in this framework, such as voice, psychological safety, competence, and accountability.

Implications for Future Research

Future work could develop a survey to address all elements in this framework to be administered to healthcare units for refinement and validation, with particular emphasis of developing the measure with a nurse population. This survey could be used by consultants, organizations, and unit/team leaders to assess teamwork effectiveness and diagnose problem areas. These problem areas could in turn be targeted with training programs or other interventions for improvement. As discussed earlier, there are already several existing strategies [79] and trainings [92] that target elements of this framework.

After development and validation of a TeamNICU survey, future studies could investigate which components from this framework are the most predictive of team and organizational outcomes such as burnout, employee and family satisfaction, patient health outcomes. This may inform another round of refinement of the framework. Indeed, a systematic review found that high workload and ineffective interpersonal relationship contribute to high levels of burnout, and that these high levels of burnout were related to worsening patient safety [93]. Testing this framework could expand the current understanding of the factors that impact burnout in employees and patient safety outcomes.

Conclusion

There is a significant need to better understand teamwork in healthcare contexts, as ineffective teamwork can lead to patient safety incidents and loss of life. To shed light on this issue and address the need for improved teamwork in practice, the TeamNICU framework was constructed, illustrating the elements that influence effective teamwork in healthcare. This framework contributes to the literature by beginning with expert opinion and interdisciplinary collaboration of healthcare and nonhealthcare professionals, further refining the framework with evidence from observations, interviews, and a review of the literature. The TeamNICU framework can be utilized by practitioners and researchers alike to advance our understanding of teamwork in healthcare contexts and engage in quality safety initiatives to improve patient safety.

Acknowledgements

This work was partially supported by the Center for Clinical and Translational Sciences (UT Health Science Center, Houston, TX), which is funded by National Institutes of Health Clinical and Translational Award UL1 TR003167 from the National Center for Advancing Translational Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Advancing Translational Sciences or the National Institutes of Health. Rice University is a partner in the award.

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