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I have an assignment that is asking to propose a plan to improve teamwork between nurses and patient care techs. In order to create the plan I need to identify strengths, weaknesses, opportunities for improvement, and threats for my plan- SWOT analysis. I need 4 points for each category and it has to come from article Ill provide (other resources are ok too).Directions are in the word document!! teamwork_in_acute_care.pdf directions.docx Unformatted Attachment Preview Teamwork in Acute Care: Perceptions of Essential but Unheard Assistive Personnel and the Counterpoint of Perceptions of Registered Nurses Lanell Bellury, Helen Hodges, Amanda Camp, Kathie Aduddell Correspondence to: Lanell Bellury E-mail: bellury_lm@mercer.edu Lanell Bellury Associate Professor Georgia Baptist College of Nursing Mercer University 3001 Mercer University Dr. Atlanta, GA 30341 Helen Hodges Professor Georgia Baptist College of Nursing Mercer University Atlanta, GA Amanda Camp Nursing Supervisor Emory Saint Joseph’s Hospital Atlanta, GA Kathie Aduddell Director and Professor of Nursing Texas Lutheran University Seguin, TX Abstract: Teams of unlicensed personnel and registered nurses have provided hospital-based nursing care for decades. Although ineffective teamwork has been associated with poor patient outcomes, little is known of the perspectives of nursing assistive personnel (NAP). The purpose of this study was to gain insights into the perceptions of NAP and professional registered nurses (RNs) on teamwork in acute care. In a qualitative descriptive approach in a metropolitan hospital in the southeastern United States, 33 NAP participated in audio-recorded focus group sessions, and 18 RNs provided responses to open-ended electronic survey questions. Findings were examined in relation to previously identified coordinating mechanisms of teamwork: shared mental models, closed-loop communication, and mutual trust. None of the mechanisms was strongly represented in these data. In contrast to RNs’ mental models, NAP perceptions of teamwork included the centrality of holistic caring to the NAP role, functional teams as NAP-only teams, NAPs and RNs working in parallel spheres rather than together, and team coordination in silos. Closed-loop communication was less common than one-way requests. Mutual trust was desired, but RNs’ delegation of tasks conveyed to NAP a lack of value and respect for the NAP role, while RNs perceived a professional obligation to delegate care to ensure quality of care amid changing patient priorities. Further empirical research into NAP practice is needed to enhance understanding of teamwork issues and direct effective interventions to improve work environments and ultimately patient outcomes. ß 2016 Wiley Periodicals, Inc. Keywords: teamwork; unlicensed assistive personnel; nursing assistive personnel; delegation; work environment; work culture; communication; qualitative description Research in Nursing & Health Accepted 26 May 2016 DOI: 10.1002/nur.21737 Published online in Wiley Online Library (wileyonlinelibrary.com). For decades, nursing care in acute care settings has included unlicensed personnel and professional nurses. Effective teamwork is essential in an increasingly complex work environment (Kalisch, Curley, & Stefanov, 2007; Kovach, Simpson, Reitmaier, Johnson, & Kelber, 2010; Potter, Deshields, & Kuhrik, 2010). The importance of communication and teamwork in acute care work environments has been widely acknowledged (Kalisch & Begeny, 2005; Kalisch, 2006), and lapses in teamwork and delegation can compromise patient safety and outcomes (Kalisch, 2011; Standing & Anthony, 2008). The voice of the unlicensed team member is infrequently included in these investigations. The purpose of this study was to explore perceptions of teamwork among unlicensed nursing assistive personnel and professional nurses in acute care, to inform strategies for improving teamwork and patient outcomes. Nursing Assistive Personnel Consistent throughout recent decades have been concerns related to an “uneasy alliance” (Kleinman & Saccomano [2006], p. 162) between professional registered nurses C 2016 Wiley Periodicals, Inc. 2 RESEARCH IN NURSING & HEALTH (RNs) and nursing assistive personnel (NAP). Workforce redesign in the 1990s and nursing shortages worldwide have led to increased use of unlicensed caregivers (Duffield et al., 2014). Advantages and disadvantages of increasing use of unlicensed assistants were reported in the 1990s (Krapohl & Larson, 1996; Orne, Garland, O’Hara, Perfetto, & Stielau, 1998), and more recently concerns related to patient safety have been documented (e.g., Aiken et al., 2014; Blegen, Goode, Park, Vaughn, & Spetz, 2013; Ebright, 2010). Although RN concerns about use of unlicensed personnel have remained essentially unchanged, little systematic inquiry has been reported to address this problem. Standing and Anthony (2008) concluded that the “nurse-[assistive personnel] team is a basic unit of a health care microsystem” (p. 13). Kalisch and Begeny (2005) defined nursing unit teams as inclusive of unit secretaries, nurse managers, RNs, licensed practical nurses, and unlicensed nursing assistants. Reports have generally identified assistive personnel as nursing assistants or unlicensed assistive personnel. For the purposes of this study, the term nursing assistive personnel (NAP), as recommended by the American Nurses Association (2007), is used to identify assistive personnel who partner with RNs to deliver nursing care to patients in acute care settings. Teamwork Teamwork has been defined as “two or more individuals with specified roles interacting adaptively, interdependently, and dynamically toward a common and valued goal” (Salas, Sims, & Burke [2005], p. 559). Professional nurses have been defined as legitimate members of the interprofessional team (Henneman, Lee, & Cohen, 1995; Petri, 2010; Xyrichis & Ream, 2007), and a teamwork intervention of training, coaching, and group problem-solving produced improvement in rates of patient falls, patient satisfaction, perceptions of teamwork, and vacancy rates (Kalisch, Curley, & Stefanov, 2007), but research on teamwork and collaboration that includes assistive personnel is less robust, and defining teamwork involving NAP can be challenging. Few investigators have examined NAP perceptions of their workplace. Recent qualitative studies in acute care environments have included NAP perceptions of respect, career development, and communication (Akaragian, Crooks, & Pieters, 2013; Kalisch, 2011; Lancaster, Kolakowsky-Hayner, Kovacich, & Greer-Williams, 2015; Potter & Grant, 2004). Three teams investigated teamwork and found a perceived lack of respect, poor communication, and a lack of understanding of team roles (Kalisch, 2011; Lancaster et al., 2015; Potter et al., 2010). Kalisch and Lees cross sectional study (2014) demonstrated that nursing assistants’ job satisfaction was not related to overall staffing but to the number of other nursing assistants in the Research in Nursing & Health staffing mix. Previous investigators have predominantly privileged the RN perspective and have included NAP perceptions only as a component of study goals. Researchers who have addressed NAP roles and perceptions have framed their findings within RN standards of delegation. None were found focused mainly on the NAP perspective. To add to empirical support for interventions to improve teamwork and communication between NAP and RNs in acute care, research to explore the meaning of teamwork from the perspective of both groups is needed. In this study we addressed two research questions: 1. What is the nature of teamwork in the provision of patient care from the standpoint of nursing assistive personnel? 2. How do perceptions of teamwork differ between nursing assistive personnel and registered nurses? Method With the goal of qualitative description (Neergaard, Olesen, Andersen, & Sondergaard, 2009; Sandelowski, 2010), we explored perceptions of teamwork among NAP and RNs. The research team was composed of three RNs participating in a hospital-based research fellowship, a nurse researcher from the same hospital, and two nursing faculty from area universities, one of whom was involved in the fellowship program, and the other recruited as a methodological expert. To promote reflexivity (Jootun, McGhee, & Marland, 2009), team members openly examined assumptions brought to the study and monitored themselves to reduce bias during team discussions and analysis. Some of the identified assumptions (i.e., that NAP would be more comfortable discussing job issues with their peers) informed the data collection strategies, and others (e.g., the impact of recent organization changes and generational, ethnic, and educational differences) were frequently discussed to reduce potential bias in the analysis phase. Setting The study was conducted in a 410-bed hospital in a suburban area of a large metropolitan city in the southeastern United States. The hospital provides high-acuity care to adult patients. Consistent with the hospitals Magnet1 designation, the nursing culture is founded upon a mature shared governance structure. At the time of the study, the hospital employed approximately 200 NAP and approximately 700 RNs, with over 60\% of RNs prepared at the BSN level. Approximately 38\% of the RN workforce (approximately 266 RNs) and a majority of the NAP worked in nine 24-28-bed acute-care units that followed a patientfocused care delivery model (Seago, 1999) using NAP/RN teams to deliver nursing care. NAP-RN PERCEPTIONS OF TEAMWORK/ BELLURY ET AL. As a result of RN practice council recommendations and current best practice, staffing ratios were realigned several months prior to data collection, decreasing patientto-RN ratios on most acute-care units from 6:1 to 5:1 for day shifts and from 8:1 to 6:1 for night shifts. This shift in RN resource allocation led to an increase in the night shift patient-to-NAP ratio in the acute-care units from 12:1 to 20:1. 3 Table 1. Questions Used for NAP Focus Groups and RN Survey What is the role of the NAP in the patient care delivery team? Can you give examples of the tasks assigned to NAP? How are the tasks and patient information communicated to NAPs? What are your concerns, if any when working as a team doing patient care? Is there anything else you would like to share about communication and teamwork? Sampling and Sample Description Participants were recruited from the nine acute-care units. Inclusion criteria specified NAP and RNs who worked on those units. Procedural areas, the emergency department, and intensive care units did not use NAP consistently to deliver care and were not included. There were no restrictions based on age, race, gender, length of employment, or level of education. Thirty-three NAP, which represented approximately 16.5\% of the NAP workforce, participated in three focus groups of similar size. A large majority (88\%) reported training as patient care technicians, and 73\% worked day shifts (7a-7p). Their mean age was 49.3 years, and the mean number of years of employment at this hospital was 13. Eighteen RNs (approximately 6.8\% of RNs eligible) participated. They had a mean age of 46.8 years and a mean number of years of employment at this hospital of 12.4 years. Of the RNs, 78\% worked day shifts, and the same percentage had BSN degrees. Protection of Human Subjects The study was approved by the hospitals nursing research committee and institutional review board (IRB) and the IRBs of the universities with which researchers were affiliated. To ensure confidentiality, neither transcriptionist nor focus group facilitator was associated with the hospital or familiar with focus group participants. RN responses to the online survey were anonymous. Data Collection Data collection methods reflected forms of workplace communication familiar to the two groups. Because NAP had monthly meetings facilitated by an RN, data were collected via focus groups. Because RNs were accustomed to electronic charting and email communication, RN data were collected via electronic survey. Similar semi-structured questions were developed for the NAP focus groups and the RN online survey, based on the research questions, concepts found in the literature, and the expertise of the practicing nurses from the study hospital (See Table 1). Following IRB approvals, eligible NAP were invited to attend one of three 45-minute focus group sessions. Upon arrival, focus group participants provided written informed consent and completed an anonymous demographic Research in Nursing & Health questionnaire. Focus groups were facilitated by one research team member with expertise in the conduct of focus groups. The sessions included an introduction to the study, instructions related to confidentiality of information shared during the focus groups, and guided discussion based on the questions in the focus group protocol (Hays & Singh, 2012). Probes were used as needed to clarify comments and explore perceptions more deeply. The sessions were audio-recorded and transcribed verbatim. Concurrently, an electronic invitation was sent to all RNs working in the nine acute-care units, inviting them to submit responses to open-ended questions via an electronic survey. Online informed consent and anonymous demographic information were collected from RNs who agreed to participate. Data Analysis The research team followed the steps of general inductive analysis outlined by Thomas (2006). Analysis proceeded in an iterative fashion over the course of several months as NAP focus group audio-recordings were transcribed. Individual research team members carefully read each transcript and used margin notation as first-level coding. Team meetings followed, for further analysis. Meetings began with the focus group facilitator reviewing the transcripts and field notes to identify non-verbal communication, laughter, tone, and emphasis. Collaboratively, the team grouped codes into categories, and with further analysis refined categories into themes. Supporting statements were identified that provided examples of each theme. RN data were exported into a text document for similar analysis. Comparing and contrasting findings between NAP and RN groups for congruence was the final analytic step, along with an additional review of the literature. Iterative analysis with increasing abstraction also continued throughout manuscript preparation. During analysis, the authors discovered a teamwork model in the organizational science literature that has been widely used (King et al., 2008) and provided a useful structure for organizing and interpreting the data. Salas, Sims, and Burkes teamwork model (2005) had five key components—leadership, performance monitoring, back-up behaviors, adaptability, and team orientation—and three coordinating mechanisms—shared mental models, closed- 4 RESEARCH IN NURSING & HEALTH loop communication, and mutual trust—that served as cross-cutting facilitators of the components. While the five components were characterized as improving team success, only the three coordinating mechanisms were acknowledged as assuring it. For example, when team members actively monitored each others performance to facilitate team functioning (a key teamwork component), a shared mental model of team purpose, mutual trust, and open communication was essential, without which performance monitoring could easily devolve into a punitive, fault-finding exercise. The three coordinating mechanisms were interrelated and co-varied. For example, a team without effective closed-loop communication would be unable to maintain mutual trust; communication problems would undermine existing trust, and vice versa. We organized our findings by the three coordinating mechanisms of shared mental models, closed-loop communication, and mutual trust (Salas et al., 2005) in order to reveal aspects of teamwork in need of attention. Trustworthiness We aimed for authenticity, credibility, criticality, and integrity (Milne & Oberle, 2005; Whittemore, Chase, & Mandle, 2001). Throughout this study, efforts were made to ensure that perspectives of the NAP were given voice. This authenticity was achieved by allowing the participants to speak openly and freely, deciding to use focus groups with a facilitator unfamiliar with the settings work environment and cultural milieu, and carefully reviewing recordings and transcripts to ensure the transcriptions were accurate. Credibility was strengthened by probing during the focus groups for greater detail, depth, clarity, and examples of negative cases. Criticality and integrity were supported by team reflection and discussion. The team member/facilitator contributed ongoing reflective appraisal of methods, and the team critically appraised research decisions and monitored each other for assumptions as data were analyzed to assure results were from the participants themselves and not of researcher bias. Results Shared Mental Models Shared mental models have been conceptually defined as “individually held knowledge structures that help team members function collaboratively in their environments” (McComb & Simpson [2014], p. 1479). Salas et al. (2005) proposed that teams need shared mental models related to team goals, team member tasks, and coordination of the team. As described below and in Table 2, mental models of team goals, team member tasks, and team coordination were rarely shared by RN and NAP participants. NAP and RNs did not seem to have common or coordinated understandings or expectations of teamwork. Research in Nursing & Health Team goals. Shared understandings of who comprises the team, how the team should function, and barriers experienced in teamwork are important indicators of a shared mental model of team goals. Both NAP and RNs readily acknowledged the importance of working as a team and the need for teamwork to achieve quality care and positive patient outcomes, indicating some degree of shared team goals. NAP described two complementary models of teamwork. Teamwork was most often described as meaning NAP/NAP teamwork, which did not include RNs or other unit team members. For example, one NAP noted, “We help each other out, but with one [NAP], theres nobody else to help; there is no team.” NAP also understood teamwork as working in parallel to, rather than integrated with, RN work, explaining teamwork to be “while you’re doing that, I will do this; you don’t have to wait for me if I’m busy, you can just go do it.” RNs, on the other hand, described the NAP as “a critical team member who works with the nurse to provide patient care.” RNs’ understanding of teamwork implied a collaborative approach to work. For example, an RN wrote, “I remind NAPs that we are a team and to let me know if they need help with any of the assigned tasks.” RN and NAP differences in the understanding of who is a part of the team indicated significant dissonance around team goals. Individual variations in work styles, roles, and relationships were also described as affecting teamwork and team goals. NAP agreed, “it depends who came onboard on that shift whether you’re going to have a good day or a bad day.” Individual variation was mentioned within welldefined groups of RNs, such as new graduates or preceptors, novice or seasoned nurses, and in the extent to which RNs were flexible, helpful, and adaptable in daily work. These differences were essentially attributed to individuals rather than RNs as a group. RNs also recognized individual variation and found that it affected the team goals, such as when “RNs & NAPs are so focused on their own ‘to-do list’ and are not willing to help others.” RNs saw the NAP as a team member necessary to high-quality care, primarily by assisting the nurse in providing care. Team member tasks. NAP reported a list of job responsibilities, including taking vital signs and blood glucose measurements; feeding, bathing, and ambulating patients; and answering patient calls, retrieving supplies, and keeping the unit clean. NAP also described a set daily routine. In addition to the tasks mentioned above, a strong, shared understanding existed among NAP related to patient caring. Holistic patient cari ... Purchase answer to see full attachment