NICU Nursing Teamwork: Novel Framework and Implications for Practice

Research Article

Ann Nurs Res Pract. 2022; 7(1): 1049.

NICU Nursing Teamwork: Novel Framework and Implications for Practice

Kilcullen MP1, Woods AL2, Carroll S3,4,5, Balon-Lyon A6, Miller B7 and Salas E1*

1Rice University, TX, USA

2The University of Texas MD Anderson Cancer Center, USA

3Coastal Carolina Neonatology, PLLC, USA

4Children’s Hospital, Wilmington, NC, USA

5UNC Chapel Hill, USA

6Alberta Medical Association, USA

7Ronald McDonald House of Ann Arbor, USA

*Corresponding author: Salas E, Department of Psychological Sciences, Rice University, 429 Sewall Hall, Houston, TX 77005, USA

Received: February 01, 2022; Accepted: March 09, 2022; Published: March 09, 2022


Objective: To develop a comprehensive framework for nursing teamwork in neonatal intensive care units (NICUs). Background: Modern healthcare practices have moved towards focusing on multidisciplinary team-based models for providing patient care. There is an abundance of literature focusing on hospital safety culture, but a lack of comprehensive frameworks informing safety initiatives at the team-level, with a focus on nurses. This gap is addressed by presenting an evidence-based framework for effective teamwork in this environment.

Materials and Methods: The development of the TeamNICU framework was informed by a review of the literature, expert opinion, and behavioral observations and interviews. An interdisciplinary collaboration of healthcare professionals and team science experts was utilized to identify the need for a teamwork framework for nurses and to identify competencies needed. The framework was refined after behavioral observations and semi-structured interviews were conducted to observe teamwork firsthand. Finally, a review of the literature was conducted to address any remaining gaps in the framework.

Results: The TeamNICU framework consists of four tiers: 1) team orientation/ mutual trust, coaching, competence, and accountability, 2) psychological safety and voice, 3) information exchange, coordination, and shared mental models, and 4) effective patient and family care. This triangle is surrounded by team and organizational conditions that impact teamwork in this environment.

Conclusions: The TeamNICU framework provides guidance for future researchers as well as a resource for practitioners.

Keywords: Teamwork; Team coordination; Psychological safety; Voice; Patient safety; Nursing


Modern healthcare has moved towards a multidisciplinary teambased model for providing patient care. These multidisciplinary healthcare teams must coordinate in order to provide optimal care, and thus rely on effective teamwork and communication to safely care for patients [1]. Indeed, teamwork is essential for ensuring patient safety in the dynamic healthcare domain [2]. A voluntary and anonymous reporting of medical errors identified various incidents, including failure to follow policies or protocols, inattention, communication problems, and poor teamwork as some of the most frequently cited factors contributing to medical error [3]. Additionally, a Joint Commission investigation identified poor communication as a root cause in over 72% of perinatal injuries and deaths [4]. Previous research indicates that the odds of infants contracting healthcare-associated infection decrease by 18% with each 10% rise in respondents reporting good teamwork [5]. Therefore, effective teamwork can provide an avenue for enhancing patient care in healthcare. However, not all teams engage in effective teamwork at the outset, in fact, many individuals struggle to engage in teamwork and perform effectively as a unit. Fortunately, recent metaanalyses indicate that team training significantly improves teamwork and performance outcomes [6,7], and to pertinent to the present study, successful team training interventions rely on evidence-based frameworks.

Understanding communication and teamwork in healthcare is inherently complex and difficult to map due to the nested, interdependent nature of teams comprising the organizational structure. Depending on the unit, clinicians can have separate meetings to exchange information and engage in care planning (e.g., nurse huddle, physician huddle). Additionally, teams of healthcare personnel can often specialize in different types of cases, ranging from stable (i.e., primary care physicians) to critical care (i.e., emergency department), which can have their own separate meetings. Team interactions vary greatly, not only by which teams are interacting (e.g., transport interacting with surgical teams), but also by which individuals are on that team during the shift. Additionally, personnel within healthcare teams often rotate after a certain period of time, sometimes to give personnel a wide range of experience or to provide continuity of care to patients, and sometimes there is high turnover from residency and other time-limited programs. The nursing discipline is particularly complicated, as in any given healthcare team there can be nurses from varying specialties and educations. Understanding how these nurses communicate and work together collaboratively involves considering not only the challenges they face within their profession, but how they interact with other members of their healthcare team, including physicians, therapists, technicians, administration, and patients.

While there is an abundance of literature focusing on hospital safety culture and healthcare teamwork, there is a dearth of knowledge on the components of teamwork that focus on nurses. There exists a need for a comprehensive framework focused on nurses for informing safety initiatives at the team-level, as nurses face unique challenges and fulfill a distinct role within teams that warrants a tailored guided perspective. We address this gap by presenting an evidence-based framework for effective nursing teamwork. Development of the framework involved a three-fold effort entailing subject matter expert (SME) input, behavioral observations and interviews, and a literature review. We begin by explicating each step of the development process, then expand on each tier and component(s) of the framework. Practical implications are interlaced throughout - corresponding with each framework component. We conclude with a broader discussion and agenda for future research.

Materials and Methods

The initial framework was generated based on expert opinion from an interprofessional and interdisciplinary council of subject matter experts (SMEs) in team science, neonatal healthcare, and clinical research. Behavioral observations within a neonatal intensive care unit (NICU) by team science experts served as an opportunity to gain an unbiased, outsiders’ perspective into the functionality of teamwork between nurses and other clinicians. Additionally, semistructured interviews were conducted to clarify team roles and shed light on factors that facilitate and inhibit effective team performance in this environment. Finally, a literature review provided insight into any missing team-based elements and informed the final refinement of the TeamNICU framework. Elaboration on each of these phases of framework refinement is provided below, followed by an overview of the framework and detailed discussion of each framework factor.

SME council

The need for a comprehensive framework for effective nursing teamwork was first discussed during a Vermont Oxford Network (VON) conference in the northwestern region of the United States. The TeamNICU framework was first conceptualized through collaboration with interdisciplinary and interprofessional subject matter experts (SMEs) and experts in team science. It was conceived during a homeroom session that typically meets three times a year to discuss and problem-solve current needs. These homeroom sessions are composed of interdisciplinary and interprofessional personnel. The amalgamation of this effort resulted in the initial stages of the teamwork framework, specifically constructed to focus on nurses.

Behavioral observations and interviews

While expert opinion is crucial, we endeavored to dig deeper and place team science experts within a hospital to uncover additional elements of teamwork that may be essential in this environment. To further understand the complexities of teamwork with nurses, the researchers embedded themselves within a mid-to-large sized neonatal intensive care unit (NICU) in the south-central region of the United States, engaging in behavioral observations and conducting interviews.

Observational shifts were conducted to further understand teamwork behaviors within and between NICU teams. Each shift, two team science experts participated in observations to ensure that essential elements of teamwork were not missed. To capture a holistic understanding of teamwork, and not of any singular team, observations happened during a variety of time points. This procedure helped to ensure that lessons learned apply to the entire network, and not solely a specific type of team within that network. Observations involved shadowing a variety of clinicians, witnessing interdisciplinary and interprofessional huddles, and observing patient/family consults. Collectively, these sessions provided ample opportunity to observe how personnel and nurses in particular communicate and handle patient information, perform patient transitions between teams, and interact as a larger network, or multiteam system (i.e., team of teams), to effectively deliver patient care.

During each observation, the researchers continually took notes on team interaction and semi-structured interviews were conducted with personnel when time permitted. The researchers strived to be as unobtrusive during observations as possible as to not influence team functionality. Breaks between team interaction and individual tasks were utilized to ask questions regarding team communication and collaboration, roles and responsibilities, and barriers and facilitators to effective team functioning. Interviews also provided the researchers with opportunities to ask questions and seek clarity on the various aspects of teamwork that they witnessed.

Review of the literature

After developing the initial framework through collaboration between team science and healthcare experts and refining the framework after behavioral observations and interviews, relevant literature was integrated into the framework to add additional breadth and address remaining gaps. Specifically, we drew from contemporary and seminal research on healthcare, team effectiveness, and teamwork to extract and synthesize information relevant to nurse teamwork. This effort enhanced our understanding of teamwork and subsequently enriched our framework.


Results from behavioral observations, interviews, and the literature review were qualitatively analyzed and prominent themes around teamwork were extracted. The integration of SME input, behavioral observations, interviews, and review of the literature resulted in the development of the hereby named TeamNICU framework. This framework (Figure 1) consists of four tiers, culminating in effective care, and the surrounding conditions that enable team effectiveness. Each element of the framework is discussed below, as well as the supporting evidence from the observations, interviews, and the literature.

Citation: Kilcullen MP, Woods AL, Carroll S, Balon-Lyon A, Miller B and Salas E. NICU Nursing Teamwork: Novel Framework and Implications for Practice. Ann Nurs Res Pract. 2022; 7(1): 1049.