The Role Of Nurses In High Functioning Teams In Acute Care .
The Role ofNurses in HighFunctioningTeams in AcuteCare Settings
The Role ofNurses in HighFunctioningTeams in AcuteCare SettingsAndrea Baumann PhD, FAAN, C.M.Director, WHO Collaborating Centre in PrimaryCare Nursing & Health Human ResourcesMcMaster University, Hamilton, ON CanadaMary Crea-Arsenio, MSc.Senior Research AnalystMcMaster University, Hamilton, ON CanadaPatricia Norman, RNResearch ConsultantMcMaster University, Hamilton, ON CanadaErin Eggleton, RN MSc.Clinical ManagerHamilton Health Sciences, Hamilton, ON CanadaContactDr. Andrea BaumannMcMaster UniversityPhone: (905) 525-9140, ext. 22581E-mail: baumanna@mcmaster.ca
Table of ContentsExecutive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3The Changing Roles of Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Healthcare in Ontario. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Sample and Setting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Ontario’s Nursing Workforce. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Interview Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12What are the characteristics of high functioning nurse teams?. . . . . . . . . . . . . . . . . . . . . . . . . 13How do high functioning teams work together?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14How has the role of the RPN evolved over time?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15What works? Mutual decision-making about complex patients. . . . . . . . . . . . . . . . . . . . . . . . . 16How do organizations support/recognize high functioning teams?. . . . . . . . . . . . . . . . . . . . . . 19Discussion and Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Appendix A - RN and RPN Entry to Practice Competencies. . . . . . . . . . . . . . . . 22Appendix B - Description of Hospital Sites and Units withHigh-Functioning RN/RPN Teams. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64The Role of Nurses in High Functioning Teams in Acute Care Settingsv
Executive SummaryTeamwork is a critical component of patient care. In Ontario, registerednurses (RNs) and registered practical nurses (RPNs) work togetheracross sectors and services. In 2018, there were 155,808 nurses*registered with the College of Nurses of Ontario (CNO): 105,098 RNsand 50,710 RPNs. Registered practical nurse positions are evenlydistributed in hospitals, long-term care homes and community settings.This study focused on high functioning nurse teams in the acutecare sector. The following key factors emerged from the findings: The RPN role has expanded overtime in response to educational andentry-to-practice requirements.RPNs worked to full scope inhigh functioning teams and therole was consistently valued. There is a clear understanding ofresponsibility and roles in complex situations. Role clarity was enhanced by communicationhubs and patient assignment tools. Nurses were able to identify subtle changesin patients and navigate the system. Nurses collaborated on plansand actions for patient care. Nurses supported each other throughoutthe day and ensured patient care was theprincipal focus of the care delivery model. Nurses shared common goals anddemonstrated commitment to each other. Teams worked together using abuddy system and consistentlyshared patient data. There was open communication andongoing dialogue in patient care. There was a high level of respectand trust between RPNs and RNs.The nurses’ roles were distinct but overlappeddepending on the patient assignment. High functioning teams used afluid approach to patient care.Teams had the ability to adjustassignments when patient needs changed. Supportive management is vital. Nurses work “independently buttogether” in providing patient care. Organizations recognized high functioningteams and engrained teamworkin their organizational culture.*throughout this report, the word nurse refers to RNs and RPNs unless otherwise specified.The Role of Nurses in High Functioning Teams in Acute Care Settings1
Background The Changing Roles of NursesBackgroundPatient care in Canada is provided by two categories of nurses:registered nurses (RNs) and registered practical nurses (RPNs).The most common employment setting for nurses is acute carehospitals, followed by community care organizations and longterm care (LTC) facilities (College of Nurses of Ontario [CNO], 2017).Studies have examined the contribution of interdisciplinary careand collaborative practice to safe quality patient care (Butler etal., 2011). However, less is known about how effective nurseteams work together to care for complex patients in acute care.To address this gap, we conducted a mixed methodsstudy using appreciative inquiry to identify the factorsthat contribute to success in high functioning nurseteams. Baumann, Blythe, Norman, & Crea-Arsenio(2014) define effective teamwork as “. . . dependent ona clear perception of individual roles and responsibilities,established procedures, mutual trust and coordination”(p. 6). The study was guided by three main objectives: Profile the demographic and employmentcharacteristics of the existing RPN workforce; Identify the role of the RPN in high functioningintra-professional nurse teams; and Assess how the RPN role contributes to the deliveryof patient care in acute care settings across Ontario.We examined a representative sample of highfunctioning nurse teams in hospitals across theprovince of Ontario. Our findings provide importantinformation about how the role of the RPN complementsthe role of the RN in acute care settings. The term“nurse” will be used throughout this report to refer toboth RNs and RPNs, unless otherwise specified.The ChangingRoles of NursesThe role and scope of practice of both RNs and RPNs areregulated by the competencies for entry-level registerednurse practice as defined by the CNO (see AppendixA. RN and RPN Entry to Practice Competencies). Asmandated by provincial legislation, the College is“accountable for public protection by ensuring nursespractice safely competently and ethically” (Collegeof Nurses of Ontario, 2018c, p. 3). RNs and RPNshave shared areas of practice in the provision ofpatient care as well as independent responsibilities.In order to become a registered nurse in Ontario, anindividual needs to have passed the National CouncilLicensure Examination (NCLEX-RN) and either hold abaccalaureate degree in nursing from an accreditedThe Role of Nurses in High Functioning Teams in Acute Care Settings3
Background The Changing Roles of Nursesuniversity or have equivalent education approved by theCollege of Nurses of Ontario (CNO) (College of Nursesof Ontario, 2018a). The CNO became the regulatorybody for RNs under the Regulated Health ProfessionsAct in 1991 (College of Nurses of Ontario, 2018a). In1998, the CNO standardized RN entry-to-practice (ETP)competencies, including the provision that RNs wererequired to have a baccalaureate nursing degree, madeeffective since 2005 (Council of Ontario Universities,2010, p. 1). Previous to this change, completing a diplomain a college nursing program was sufficient for RNregistration (Council of Ontario Universities, 2010, p. 1).The current RN ETP competencies are described by 7overarching principles and can be organized into 9 roles:Clinician, Professional, Communicator, Collaborator,Coordinator, Leader, Advocate, Educator, and Scholar(College of Nurses of Ontario, 2018). At a national level,RN ETP competencies are revised every 5 years bythe Canadian Council of Registered Nurse Regulators4(CCRNR) to maintain relevance with the current contextof RN responsibilities; provincial regulatory bodies aretasked with matching these updates with their educationand regulation standards (College of Nurses of Ontario,2018a). The CNO has recently released a revised RNETP competency framework in 2018 that takes effect inSeptember 2020 (College of Nurses of Ontario, 2018a).Currently in Ontario, accreditation as a RPN requiressuccessful completion of the Canadian PracticalNurse Registration Examination (CPNRE) and eithersuccessful graduation from an approved practicalnursing college program in Ontario or completion ofan equivalent education program as assessed by theCNO (College of Nurses of Ontario, 2014). Historically,while practical nursing and training for such positionsemerged in Ontario in 1938, the title and role ofRegistered Practical Nurse was first defined by the1991 Regulated Health Professions Act and the ETPcompetencies for RPNs were instated in Ontario by theThe Role of Nurses in High Functioning Teams in Acute Care Settings
Background Healthcare in OntarioCNO in 1999 (Registered Practical Nurses Association ofOntario, 2013). In 2001, the Ontario Ministry of Training,Colleges and Universities (MTCU) ratified the PracticalNursing Program Standards where RPNs are required tocomplete a practical nurse community college programdesigned from these ETP competencies, made effectivein 2005 (Council of Ontario Universities, 2010, p. 1).The RPN ETP competencies used today are based on therevisions made in 2008 by the Practical Nurse ProgramCommittee and other stakeholders motivated by theneed to articulate the difference between entry-leveland ongoing nursing knowledge and competencies(College of Nurses of Ontario, 2014). The conceptualframework of RPN ETP competencies is organized into4 categories: assessment, planning, implementationand evaluation (College of Nurses of Ontario, 2014).Updates and revisions have been made every 2-4years to match evolving standards of practice andregulation for Controlled Acts (College of Nurses ofOntario, 2014). Most recently, the Canadian Councilfor Practical Nurse Regulators (CCPNR)in 2018 issueda Request for Proposals for provincial jurisdictions inorder to standardize RPN ETP competencies acrossthe provinces in Canada (College of Nurses of Ontario,2018b). The CNO has finalized updated interpretationsand is currently working with PN educators to implementthe new RPN ETP competencies by 2020 (PN ExamTransition Work Group, 2018). A public revision of theCNO RPN ETP competencies will be released in 2019(PN Exam Transition Work Group, 2018). This is in linewith the CCPNR’s goal for an updated CPNRE to be ineffect by 2022 (College of Nurses of Ontario, 2018b).Healthcare in OntarioOntario is home to more than 14.3 million people,of which five million are clustered in one majormetropolitan area (Ministry of Finance, 2018). As theThe Role of Nurses in High Functioning Teams in Acute Care Settings5
Background Healthcare in Ontariopopulation increases so does the demand for healthservices. Healthcare in Ontario includes acute carehospitals, LTC facilities, community and home careorganizations and academic health science centers.There has been growing interest in the acute caresetting regarding the composition, capacity and functionof teams and their impact on the provision of care.The Importance of TeamworkEarly investigations of team-managed care began inthe business sector and highlighted key facilitators ofteamwork such as training, mutual trust and respect(Tarricone & Luca, 2002). Within the context ofhealthcare, Oldenburger, Baumann, & Banfield (2017)examined team functioning in medical disasters anddetermined setting, leadership in command structuresand experience in training were significant for success,as were stress and the resulting coping mechanisms.Research has also been conducted in nursing teamdynamics. In their pilot study of high functioning nurseteams, Baumann, Blythe, Norman, & Crea-Arsenio (2014)looked at the contributions of RNs and RPNs working inteams, team characteristics and the types of decisionsmade. They identified various components of effectiveteamwork, including professional skills, being a teamplayer, tolerance for ambiguity and understandingboth scope of practice and the work environment.Participants cited the importance of communication,sharing and maintaining a strong patient focus. Otherstudies have noted the impact of age differenceson teamwork (Moore, Prentice, & Salfi, 2017).MacKinnon, Butcher, & Bruce (2018) discuss how theworking relationships between RNs and LicensedPractical Nurses are changing as a result of newmodels of nursing care delivery being introduced inresponse to nursing shortages. In their study, theauthors identify that RNs and LPNs primarily useskills to differentiate the tasks that they were eachallowed to do in their community hospital settings6The Role of Nurses in High Functioning Teams in Acute Care Settings
Background Healthcare in Ontario(MacKinnon, Butcher, & Bruce, 2018). In addition,both groups felt that the expanded LPN scope ofpractice resulted in fewer differences in skills andmore attention to the LPN comfort level with respectto the stability or predictability of their patients, thelatter being an important component of developinga collaborative team (MacKinnon et al., 2018).Moore, Prentice, & Salfi (2017) examined the factorsthat influenced collaboration among RNs and RPNsat one acute care hospital in Canada using a mixedmethods study design. A critical facilitator to RNand RPN collaboration in this study was havingboth groups of nurses working to their full scope.This resulted in reduced role ambiguity, whichcontributes towards successful team functioning asrole ambiguity can lead to workplace tension, lackof mutual trust, diminished professional identity andpoor teamwork (Moore, Prentice, & Salfi, 2017).Rochon, Heale, Hunt, & Parent (2015) specificallymeasured the level of nursing teamwork on eachpatient care unit of one acute care hospital in Ontario,Canada using the Nursing Teamwork Survey (Kalisch,Lee, & Rochman, 2010). This study explores theattributes of lower scoring units and teams and foundthat lower scores on the NTS tended to relate toyounger nurses, less experience and a higher intentionto leave (Rochon, Heale, Hunt, & Parent, 2015).Heale, Hunt, & Parent, 2015). Despite the literature todate, teamwork is an understudied area and findingsacross countries and settings are mixed (Kaiser, 2017;Rochon, Heale, Hunt, & Parent, 2015). Furthermore,the study sites vary, the number of participants isoften small and generalizability of results is limited.This study used a mixed methods design includinga secondary analysis of the College of Nurses(CNO) registration database and semi-structuredinterviews with high-functioning nurse teams. Thefollowing research questions were addressed:1. What are the characteristics of highfunctioning nurse teams?2. How do high functioning teams work together?3. How has the role of the RPN evolved over time?4. What works? Mutual decision-makingabout complex patients.5. How do organizations support/recognize high functioning teams?Effective teamwork is a critical component of providingsafe patient care (Rochon, Heale, Hunt, & Parent,2015). Salas, Sims, & Burke (2005) describes fivecore components of teamwork, which include teamleadership, mutual performance monitoring, backupbehavior, adaptability and team orientation. Theauthors also describe three supporting coordinatingmechanisms, which are shared mental models, closedloop communication and mutual trust (Salas, Sims, &Burke, 2005). For teamwork to be effective, all the corecomponents and coordinating mechanisms must beevident in a team and occurring concurrently (Rochon,The Role of Nurses in High Functioning Teams in Acute Care Settings7
Methodology Healthcare in OntarioMethodologyAn appreciative inquiry approach was used to identify how highfunctioning nurse teams function effectively to provide care to complexpatients. Appreciative inquiry focuses on the positive facilitators inan organization’s teamwork and management in order to suggestways to amplify its effects (Cooperrider, Srivastva, Woodman, &Pasmore, 1987). A demographic questionnaire and a semi-structuredinterview were used as the main approaches to data collection.8The Role of Nurses in High Functioning Teams in Acute Care Settings
Methodology Sample and SettingSample and SettingTwenty nurse teams working in acute care sites thatconsist of both RN and RPN members were sampled inone province. At each site, individual interviews wereconducted with two nurses and one manager. In totalthere were 60 interviews. The range of acute caresites included large academic health science centers(Group A), medium-sized community hospitals (GroupB) and small rural hospitals (Group C). Specifically,hospital size was based on the Ontario MOHTLCdefinition. Group A hospitals represent “generalhospitals providing facilities for giving instructionto medical students of any university, as evidencedby a written agreement between the hospitaland the university with which it is affiliated, andhospitals approved in writing by the Royal College ofPhysicians and Surgeons for providing post-graduateeducation leading to certification or a fellowshipin one or more of the specialties recognized by theRoyal College of Physicians and Surgeons”. GroupB hospitals represent “general hospitals havingno fewer than 100 beds”, and Group C hospitalsrepresent “general hospitals having fewer than 100beds” (Ministry of Health and Long-Term Care, 2015).In order to ensure that the sample of acute care siteswas representative of hospital size and urban andrural locations, a list of all 175 hospital sites in Ontarioorganized by region was created and each hospitalsite was categorized according to size (A, B, or C).Proposed hospital sites for this study were stratifiedby health region, size and location. Where two ofthe same group size hospital sites appeared withinthe same region, one of those sites was excluded.At least one hospital site was represented for eachlocal health integration network (LHIN). Presently,the LHIN structure is undergoing reorganizationby the Ontario MOHTLC, which may lead to thereconstruction and/or dissolution of the 14 healthregion stratification system used in this study.The Role of Nurses in High Functioning Teams in Acute Care Settings9
Methodology Data AnalysisClinical managers were contacted at each site and askedto identify a RPN/RN team that is high functioning basedon the following criteria: worked together with someregularity; recognized by peers as a high functioningteam; included experienced staff; routinely sharedcare for more than one patient; and managed somepatients that were considered “complex.” Once theteam was selected, the clinical manager, RPN and RNwere asked to complete a demographic questionnaireand participate in separate individual interviews.Data AnalysisSecondary analysis was conducted to calculatedescriptive statistics of the CNO database in orderto provide a snapshot of the RN and RPN workforcein 2018
The role and scope of practice of both RNs and RPNs are regulated by the competencies for entry-level registered nurse practice as defined by the CNO (see Appendix A. RN and RPN Entry to Practice Competencies). As mandated by provincial legislation, the College is “accountable for public protection by ensuring nurses
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Le genou de Lucy. Odile Jacob. 1999. Coppens Y. Pré-textes. L’homme préhistorique en morceaux. Eds Odile Jacob. 2011. Costentin J., Delaveau P. Café, thé, chocolat, les bons effets sur le cerveau et pour le corps. Editions Odile Jacob. 2010. 3 Crawford M., Marsh D. The driving force : food in human evolution and the future.
