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Cultural sensitivity was one of the topics covered under module five’s “Nursing is cultural and contextual”. During that week, we delved into the many cultural differences, disparities and how it affect the overall delivery of care. One area that stood out to me was healthcare and Indigenous communities.

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https://youtu.be/IVPTVXq6AQg?si=HFO5DM-wjmmDiM_s&t=1790

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indigenous people and the problems in health care 

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Indigenous Peoples and the problems in health care | APTN InFocus

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A caller called Josh opens the video at 29:00 and tells a startling story about how a hospital offered him tobacco in exchange for his training on cultural sensitivity after refusing to pay him for his professional services. The prejudice and disregard that Indigenous people frequently experience in healthcare settings are brought to light by this episode.

When is it okay to use such misguided gestures to undermine professional contributions? Some could counter that Josh's tobacco offer from the hospital is an acknowledgment of his culture.

However, instead of appreciating the value of professional skills and fair compensation, this approach is insensitive and misguided, treating cultural appreciation merely as a token. This is why we, as healthcare professionals, must be culturally aware, sensitive, and competent when dealing with people from other cultures, ensuring that our actions are respectful and just.

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“They’re ignored, whispered about, the nurses assume you’re drunk or on drugs or that you’re drug-seeking.” (“Racism in Indigenous Health: It Still Exists,” n.d.)

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This is a quote from Dr. Margaret Moss, the interim Associate Vice President of Equity and Inclusion at UBC, as she talks about the stereotypes Indigenous patients face in healthcare. The statement made by Dr. Moss highlights the widespread prejudices and biases that Indigenous patients face, underscoring the critical need for cultural competence and equity in healthcare settings. Healthcare practitioners should endeavor to create a more inclusive and courteous atmosphere for all patients by recognizing and resolving these challenges.

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Figure 1. Student engagement in cultural humility. 

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(Sedgwick & Atthill, 2020)

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This artefact talks about how we as nursing student can take the first steps towards changing the negative stereotypes associated with not just the first nation people but with every other minority group that experiences racism and disparities in the health care setting.

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Fitzpatrick et al. (2023) research on understanding of virtual primary healthcare for Indigenous communities. This article examines the way Indigenous people receive primary healthcare (PHC), emphasizing the disparities that result from a lack of services that are local and Indigenous centered as well as mistrust of the healthcare system due harmful past experiences. The study highlights how crucial it is to include Indigenous communities in the planning, execution, and assessment of virtual care initiatives to guarantee culturally appropriate and successful medical treatment.

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A study by Webb et al. (2023) titled Indigenous Cultural Safety Trainings for Healthcare Professionals Working in Ontario, Canada: Context and Considerations for Healthcare Institutions sheds light on the systemic challenges that Indigenous people face in healthcare settings, such as inconsistent application of cultural safety training and a lack of community involvement. This article highlights the need for continuous improvement in healthcare operations by highlighting shortcomings in the existing training curricula, including inconsistent application and a lack of comprehensive assessment methods. It provides suggestions for improving ICST programs, such as including more Indigenous people, utilizing standardized assessment instruments, and modifying the curriculum to enhance treatment delivery equity and cultural sensitivity.

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Fitzpatrick, K. M., Ody, M., Goveas, D., Montesanti, S., Campbell, P., MacDonald, K., Crowshoe, L., Campbell, S., & Roach, P. (2023). Understanding virtual primary healthcare with Indigenous populations: a rapid evidence review. BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-09299-6

Racism in Indigenous health: It still exists. (n.d.). UBC Applied Science. https://apsc.ubc.ca/news/2022/racism-in-indigenous-health-it-still-exists

Sedgwick, A., & Atthill, S. (2020). Nursing Student Engagement in Cultural Humility Through Global Health Service Learning: An Interpretive Phenomenological approach. https://www.semanticscholar.org/paper/Nursing-Student-Engagement-in-Cultural-Humility-An-Sedgwick-Atthill/093bfa26ca0a62dfbd1093fb4859fd28d1e20722/figure/0

Webb, D., Stutz, S., Hiscock, C., Bowra, A., Butsang, T., Tan, S., Scott-Kay, B., & Mashford-Pringle, A. (2023). Indigenous cultural safety trainings for healthcare professionals working in Ontario, Canada: Context and considerations for healthcare institutions. Health Services Insights., 16, 117863292311699. https://doi.org/10.1177/11786329231169939

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The first thing that comes to my mind when the word “family” is mentioned is my ride or die companions.

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(Patient & Family Centred Care — North Shore Health Network, n.d.) 

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I chose this image because it deeply reminded me of my family. As humans, we strive to be healthy, and while we may sympathize with those who are terminally ill, we never hope or imagine ourselves in their situation. My family is no different. Coming from a background where most members work in healthcare, we never thought we would face a scenario where my uncle succumbed to cancer. This experience truly solidified my understanding of what family means. I witnessed how every member took turns contributing to his medical bills and collaborated with the nurses. One key moment I would like to highlight is my deep appreciation for the nurses who communicated with us and involved us in his care plan, allowing us to spend more time with him.

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Here is a picture of my family. Ten years ago, my grandma was diagnosed with tuberculosis, which was devastating for us. The healthcare team responsible for her care was truly amazing. They ensured we were involved in every integral decision regarding her treatment and thoroughly explained both the positive and negative effects of each choice we made.

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Homelessness has become a major issue in Canada, and it is now also affecting our mental health

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I completed my clinical placement in the mental health unit this past summer. It was filled with diverse people with unique situations. Two thoughts come to mind when reading a patient's chart and seeing that they have been hospitalized for an extended length of time. Are they in the unit because their treatment is not progressing as much as it could, or are there outside issues that are making them stay longer? Homelessness was among the most important external variables I saw. Patients and healthcare professionals face difficulties when mental health and homelessness coexist.

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I selected this artifact because it illustrates the yin and yang nature of the interaction between mental health and homelessness. It's challenging to escape this vicious circle. The question arises, after effectively treating their mental illness to minimize the symptoms, do we just send them home? But wait a minute, they do not have homes, so we're just throwing them back on the streets, where the unforgiving environment and lack of assistance can easily lead to a recurrence of their mental health problems.

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So, one could wonder if the housing crisis is to blame for a majority of those suffering from mental illness. When do nurses enter this scenario, then? In this case, nurses like us act as advocates. As nurses, it is our responsibility to speak up for people who are vulnerable, such as the homeless and those who are struggling with mental health difficulties. We may accomplish this by bringing attention to the issue and working with housing organizations and social workers.

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The article, titled "Homelessness, housing instability, and mental health: making the connections," written by Padgett (2020), examines the various elements that lead to the cycle of homelessness and mental illness. Padgett draws attention to the primary cause of homelessness, which is unaffordable housing, which exacerbates mental health issues, increases chronic stress, and increases healthcare use.

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Homelessness, housing instability and mental health: making the connections

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Research on the bi-directional relationship between mental health and homelessness is reviewed and extended to consider a broader global perspective, highlighting structural factors that contribute to housing instability and its mental ill health sequelae.…

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A CMHA article titled "Housing and Mental Health" examines the relationship between mental health and reasonably priced, suitable, and compatible housing. It highlights how those who have experienced mental health and addiction illnesses are disproportionately affected by homelessness, which exacerbates their symptoms. The report highlights the importance of supportive housing since it provides secure living arrangements and convenient access to critical mental health therapies.

(Housing and Mental Health, n.d.)

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Housing is a basic human right and requirement for good health. According to the United Nations' Universal Declaration Of Human Rights the right to housing is protected under international law, and Canada has endorsed such rights guaranteeing "an adequate standard of living... including adequate food, clothing and housing." Likewise, the Ottawa Charter for Health Promotion identifies shelter as a basic prerequisite for health.

Social Housing

According to the Ministry of Municipal Affairs and Housing (MMAH), Ontario has:

260,000 total social housing units

9,755 public housing units

2,000 urban Aboriginal housing units (nearest approximation)

158,245 co-op and non-profit units

[Source: MMAH communication, March 2014)]

Housing with Supports

Ontario's capacity for community-based mental health supports within housing is estimated at 12,137 units

Ontario provides support within housing programs to 15,371 unique individuals during 2012-2013.

These 15,371 unique individuals represent 3,402,487 resident-days of service volume.

Mental Health In-patient service volume in Ontario hospitals for same period was 1,577,904 patient-days.

Sources:
1. Connex Ontario, special data request, March 2014.
2. Health Indicators Table (HIT), Health Data Branch, Ministry of Health and Long-Term Care, FY2012/2013.

Adequate, suitable and affordable housing contributes to our physical and mental well-being. It leads to increased personal safety and helps decrease stress, leading to improved sleep and diet. All of these factors result in better mental health outcomes. When housing is inadequate or unavailable, personal as well as community well-being can suffer.

The high cost of rental accommodations has created a critical shortage of affordable housing and is a leading contributor to poverty in Ontario. According to the Ministry of Municipal Affairs and Housing approximately 15 per cent of the province's households are currently in dire need of affordable housing. Accommodation is considered affordable if it requires less than 30 percent of a household's total pre-tax income.

Many individuals with mental health conditions are on social assistance and majority do not have access to affordable housing. Adequate dwellings are defined as those not requiring major repairs, whereas suitable dwellings refer to those that have enough bedrooms for the size of the household.

Affordable housing is an investment in health promotion and illness prevention. When a person has adequate housing they experience fewer health problems and are able to devote more of their income to adequately feed and clothe themselves and their family.

Why Are People Homeless?

Two trends are largely responsible for the rise in homelessness over the past 20 years: a growing shortage of affordable rental housing and a simultaneous increase in poverty. Homelessness and poverty are linked. Poor people are frequently unable to pay for housing, food, child care, health care and education. Difficult choices must be made when limited resources cover only some of these necessities. Being poor means being an accident, an illness or a paycheck away from living on the streets.

Homelessness Is a Frequent Experience of Persons with Mental Health Conditions

It is difficult to state whether homelessness or mental illnesses occur first. Each case must be considered individually. Research tends to support both theories. The stress of being homeless may exacerbate a previous mental illness. However, the difficulties of being homeless may encourage anxiety or depressive disorders.

People with lived experience of mental health and addictions conditions (PWLE) are disproportionately affected by homelessness. While many factors can lead to homelessness, mental health plays a significant role-an estimated 25 to 50 per cent of homeless people live with a mental health condition. Solving this social crisis will require new ways of helping these critically vulnerable Canadians. The consequences of homelessness tend to be more severe when coupled with a mental health condition. PWLE remain homeless for longer periods of time and have less contact with family and friends. They encounter more barriers to employment and tend to be in poorer health than other homeless people.

What Constitutes Homelessness?

Persons who reside in places that are not intended as, or are unfit for, human habitation, including cars, abandoned buildings, bus or train stations, under bridges, in garbage or recycling dumpsters, parks, or other places lacking basic amenities.

Persons sharing housing at the whim of other persons on an interim or emergency basis.

Persons whose primary nighttime place of abode is a supervised publicly or privately operated shelter designed to provide temporary living accommodations, including shelters for victims of domestic violence, welfare hotels, congregate shelters and transitional housing.

Housing and Mental Health Conditions

For PWLE, safe and affordable housing can provide a place to live in dignity and move towards recovery. Individuals with serious mental health and addictions conditions frequently identify income and housing as the most important factors in achieving and maintaining their health. However, for many, maintaining safe and affordable housing can be difficult.

During periods of illness, individuals may be unable to work and/or experience a loss of income.
Without adequate income, they may have difficulty paying rent and may eventually lose their home and household contents. Consequently, many live in substandard housing that is physically inadequate, crowded, noisy and located in undesirable neighborhoods. Furthermore, persons who cannot afford to live in decent housing are more likely to experience exposure to violence, communicable diseases and increased chronic conditions.

Housing Makes a Difference

Many PWLE live independently; however for those with more serious mental health conditions, there are a variety of supports available to them. Research indicates that a stable, supported living environment is essential to maintaining the health and well-being of PWLE and is integral to their recovery. Housing with support can generate positive outcomes, including enhanced life skills, improved health status, an increased sense of empowerment and involvement in the community. Research shows that maintaining and improving the housing of individuals with serious mental health conditions can contribute to a reduction in psychiatric symptoms and therefore decrease the need for emergency and treatment services.

Housing with supports gives an individual access to a range of housing options: supportive housing, supported housing, and rent supplements. Supportive housing provides assistance by staffing housing units with 24-hour supports. Other individuals may live in the larger community and have supports, such as homecare and counseling when they need it. This is referred to as supported housing.

Supports within housing include:

Up to 24-hour support for PWLE and their significant others to ensure a stable housing environment

Individualized assessment and planning, hands-on assistance with activities of daily living, coordination and support, crisis management, facilitating peer and group support and resident input to their housing environment

Support services provided to individuals who are homeless, or at a risk of being homeless

Support services such as connecting with landlords, matching people to housing, housing advocacy, and teaching life skills

Service providers have also identified the following factors which support successful housing arrangements: rent geared to income, community support services, a strong personal support network, and availability of case management.

Residential care and permanent supported housing approaches appear to yield the greatest reductions in hospitalizations. People living in housing with support have also been found to be less likely to be institutionalized in jails and prisons. Individuals in supported housing also report higher quality of life due to their housing, more choice and control over their housing and better quality of housing. Other research has shown that improvements in personal coping, relationships and community involvement are greater for individuals with housing supports.

Rent supplements or rent-geared-to-income housing are two strategies that can provide individuals with the financial resources they need to access desirable housing in their community.

Affordable Housing and Housing with Supports Makes Economic Sense

Homelessness is a significant health care issue and continues to produce enormous costs to our economy. According to the Mental Health Commission of Canada, an estimated 150,000 to 300,000 people across Canada are homeless, which results in $1.4 billion each year in costs to the health care, justice and social services systems.

Housing designed for people with mental health conditions can contribute to significant cost savings for the health system. It costs $486 a day ($177,390 per year) to keep a person in a psychiatric hospital, compared to $72 per day ($26,280 per year) to house a person in the community with supports.

Challenges to Affordable Housing

As of July 2012, 41 percent of people receiving ODSP have a primary diagnosis of mental health/psychiatric disorders, according to a recent IPSOS survey. The maximum income for a single person receiving ODSP is $1075. However, in Ontario, the average market rent for a one-bedroom apartment is $866. For most people it is not feasible to allocate on average 80% of one's social assistance to housing; and this situation is putting people on ODSP at risk of losing their home.

The challenges of poverty, stigma and discrimination that PWLE face directly impact their ability to access and to find and keep housing. Due to stigma, the typical reaction encountered by someone with a mental health condition is fear and rejection. Many PWLE are often denied housing in the private market as a result of their mental health and addictions conditions.

Furthermore, many supportive housing projects also encounter a "not-in-my-backyard" response (NIMBYism) from neighbours, businesses, councillors, etc. This type of behaviour may include discriminating and slandering comments in person, by e-mail, or through flyers and posters which protest a new supportive housing development.

Despite improvements in Ontario's economy and a modest level of rental development in a number of markets, there continues to be a serious housing affordability issue in Ontario. There are fewer affordable housing units available now than a decade ago. Between 1996 and 2006, after adjusting for inflation, more than 78,000 units were lost in the moderately affordable rent ranges ($400 to $800) in Ontario. According to the Ministry of Municipal Affairs and Housing :

Between 2004 and 2012, the number of households on waiting lists for rent-geared-to-income social housing units has increased by 32,000, to nearly 158,500.

Between 1991 and 2006, the number of Ontario households in need of affordable housing increased by over 200,000.

627,535 (15 per cent of the province's households) are currently in urgent need of affordable housing.

Recent policy reports addressing housing have included Ontario's affordable housing strategy launched in 2010, Building Foundations: Building Futures, and the Social Assistance Review's Brighter Prospects: Transforming Social Assistance in Ontario. Both reports speak to making the current housing system less complicated by revising rent geared to income calculations, and introducing standard rates as well as housing benefits. However, housing affordability, and supports for PWLE are not addressed in any significant way.

Current Activities at CMHA Ontario

CMHA Ontario is active in monitoring and addressing housing concerns experienced by PWLE. We do this in partnership with other housing providers and community advocates. We are also involved in promoting mental health through highlighting public issues and recommending options to create inclusive and supportive environments.
In our efforts to keep the government's focus on the need for more affordable housing and income security for PWLE, on January 24, 2014 CMHA Ontario made a submission to Ontario's Minister of Finance as part of the 2014 pre-budget consultations. The pre-budget submission recognized the government's 2011 Comprehensive Mental Health and Addictions Strategy that committed to investing $257 million over three years for child and youth mental health services. However, in looking forward towards years four to ten of the Strategy, CMHA Ontario recommended that the government take concrete steps to:

Develop a Housing First model across Ontario to support marginalized populations, where housing is provided as the first step, in combination with supportive services, to people who are homeless and living with mental health and addictions issues; ,

Ensure that any current and new investments in housing provide access to a range of housing options, including supportive housing, supported housing, and rent supplements for vulnerable populations, including those with mental health and addictions needs;

Incrementally increase the minimum wage of $10.25 over 5 years to reach a wage of 10% above the poverty line by 2018.

References

¹United Nations' Universal Declaration of Human Rights, Article 25 (1948).
http://www.un.org/en/documents/udhr/index.shtml#ap

² United Nations, Office of the High Commissioner for Human Rights, "International Covenant on Economic, Social and Cultural Rights," (1976), http://www.unhchr.ch/html/menu3/b/a_cescr.htm

³World Health Organization: Ottawa Charter for Health Promotion. (1986).
http://www.who.int/healthpromotion/conferences/previous/ottawa/en/

⁴ Ministry of Municipal Affairs and Housing. (2014) Retrieved from http://www.mah.gov.on.ca/Page10444.aspx

⁵Canada Mortgage and Housing Corporation. (2006 Census Year). Core Housing Need Status Definitions
http://cmhc.beyond2020.com/HiCODefinitions_EN.html#_Core_Housing_Need_Status

⁶Mental Health Commission of Canada: Housing and Homelessness Issue Paper
Retrieved March 31, 2014 from http://www.mentalhealthcommission.ca/English/issues/housing?terminitial=23

⁷Canada Mortgage and Housing Corporations. (2006 Census Year). Core Housing Need Status Definitions
http://cmhc.beyond2020.com/HiCODefinitions_EN.html#_Core_Housing_Need_Status

⁸Canada Mortgage and Housing Corporation-Homeless Hub. (2007) Canadian Definition of Homelessness.
http://www.cmhc-schl.gc.ca/en/corp/li/rere/rere_008.cfm

⁹ C. Walker. (1998). Homeless People and Mental Health. American Journal of Nursing 98, no. 11: 26-32

¹⁰ T. Morrell-Bellai.(2000). Becoming and Remaining Homeless: A Qualitative Investigation," Mental Health Nursing 21, no. 6 581-604

¹¹ Mental Health Commission of Canada. Retrieved (March, 2014) http://www.mentalhealthcommission.ca/English/issues/housing?routetoken=90a4ae271b2c565880fe670200571cbf&terminitial=23

¹²R. Benger and B. Cameron.( 2000). Asylum: Falling through the Cracks. Witness, Canadian Broadcasting Corporation
Retrieved January 31, 2003, from http://www.tv.cbc.ca

¹³ J. Trainor, E. Pomeroy and B. Pape, eds. (1999). Building a Framework for Support: A Community Development Approach to Mental Health Policy Canadian Mental Health Association, Toronto.

¹⁴ M.J.L. Kirby and W.J. Keon. (2006).Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addiction Services in Canada, Chapter One: Voices of People Living with Mental Illness, Final Report of the Standing Senate Committee on Social Affairs, Science and Technology.

¹⁵ B. Moloughney.(June, 2004). Housing and Population Health: The State of Current Research Knowledge. Canadian Institute for Health Information. Ottawa.

¹⁶ T. Middelboe (1997) Prospective Study of Clinical and Social Outcome of Stay in Small Group Homes for People with Mental Illness. British Journal of Psychiatry 171 :251-55.

¹⁷ Connex Ontario. (2014). Retrieved from http://www.mentalhealthhelpline.ca/Search/ServiceTypes

¹⁸ Toronto District Health Council. (September, 2001). Toronto Mental Health Housing Study.

¹⁹ Leff, H.S., Chow, C.M., Pepin, R., Conley, J., Allen, I.E., & Seaman, C.A. (2009) Does one size fit all? What we can and can't learn from a meta-analysis of housing models for persons with mental illness. Psychiatric Services, Vol. 60, No. 4, 473-482.

²⁰ Nelson, G., Aubrey, T. & Lafrance, A. A. (2007) Review of the literature on the effectiveness of housing and support, Assertive Community Treatment, and Intensive Case Management interventions for persons with mental illness who have been homeless. American Journal of Orthopsychiatry, Vol. 77, No. 3, 350-361.

²²Nelson, G., Hall, G.B. & Walsh-Bowers, R. (1995). An evaluation of supportive apartments for psychiatric
consumer/survivors. Canada's Mental Health, Vol. 43, No. 2, 9-16.

²³Mental Health Commission of Canada. Housing and Homelessness. (2013).
http://www.mentalhealthcommission.ca/English/issues/housing?routetoken=bfb3d5f7c38a731af637531e4c6c18ca&terminitial=23

²⁴ Ontario, Ministry of Health and Long-Term Care. (2006). Provincial Summary - Average Costs for CMH&A Service Recipient Activity.

²⁵ Cathexis (2012). Evaluation of the Ontario Disability Support Program (ODSP) Employment Supports Program. Final Report. http://cathexisconsulting.ca/our-work/

²⁶ Income Security Advocacy Centre Social Assistance Rates Update. (November/December 2012).

²⁷Canada Mortgage and Housing Corporation. (Fall 2011) Rental Market Report - Ontario Highlights.
http://www.cmhc-schl.gc.ca/odpub/esub/64507/64507_2011_B02.pdf

²⁸ Ontario Non-Profit Housing Association (2011) Where's Home? http://www.onpha.on.ca/Content/ONPHA/About/ResearchReports/WheresHome/WheresHome_2011.pdf

²⁹Pomeroy, S. (August, 2009). Understanding the Affordable Housing Issue: Background Diagnostic in Support of
ONPHA Response to the Long Term Affordable Housing Strategy. Toronto, ON: The Ontario Non-Profit Housing
Association, p. 8.; After adjusting for inflation, 37,941 units were lost in the $400 to $599 range and 40,754 units were lost in the $600 to $799 range for a total of 78, 695 units.

³⁰ Ministry of Municipal Affairs and Housing. (2014). http://www.mah.gov.on.ca/Page10444.aspx

³¹ Ministry of Municipal Affairs and Housing. (2010). Building Foundations: Building Futures: Ontario's Long-Term Affordable Housing Strategy.

³² Commission for the Review of Social Assistance in Ontario. (2012). Brighter Prospects: Transforming Social Assistance in Ontario. http://www.socialassistancereview.ca/final-report

³³Mental Health Commission of Canada. (2013). At Home/Chez Soi
http://www.mentalhealthcommission.ca/English/initiatives-and-projects/home?terminitial=38&routetoken=e97edbb456da307448350e136e4c05ad

³⁴ Employment & Social Development Canada. (January, 2014) http://www.esdc.gc.ca/eng/communities/homelessness/housing_first/approach/index.shtml

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Housing is a basic human right and requirement for good health. According to the United Nations' Universal Declaration Of Human Rights the right to housing is protected under international law, and Canada has endorsed such rights guaranteeing "an adequate standard of living... including adequate food, clothing and housing."

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Bsn, Z. S., RN. (2020, December 16). How nurses can advance their profession and patient care through advocacy. Nursegrid. https://nursegrid.com/blog/how-nurses-can-advance-their-profession-and-patient-care-through-advocacy/

Housing and mental health. (n.d.). https://ontario.cmha.ca/documents/housing-and-mental-health/

Mind. (n.d.). Housing and mental health. Retrieved July 28, 2024, from https://www.mind.org.uk/information-support/guides-to-support-and-services/housing/housing-and-mental-health/

Padgett, D. K. (2020). Homelessness, housing instability and mental health: making the connections. BJPsych Bulletin, 44(5), 197–201. https://doi.org/10.1192/bjb.2020.49

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As a future nurse, I would like to incorporate a patient and family-centered care approach into my nursing practice. Throughout my education, I have learned about this approach and I am a testament to the positive impact it can have. My personal experience has showed me firsthand the importance of involving family in the care process. It was not just about treating the disease but about supporting the person and their loved ones holistically.

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To broaden my understanding of this topic I found a research from Clay and Parsh (2016) titled Patient- and Family-Centered Care: It’s Not Just for Pediatrics Anymore. The approach of patient- and family-centered care is discussed in this article as having improved patient outcomes, reduced costs, and increased staff satisfaction.

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Journal of Ethics | American Medical Association

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Patient- and Family-Centered Care: It's Not Just for Pediatrics Anymore

Aaron M. Clay, RN and Bridget Parsh, RN, MSN, EdD

Patient- and family-centered care (PFCC) is changing the way hospitals provide patient care, increasing staff satisfaction, decreasing costs, and improving patient outcomes [1, 2]. Although hospitals make unique, organization-specific PFCC principles, all of them tend to endorse similar core values by recognizing the importance of family members' roles in individual patients' health care experience, establishing relationships with and supporting patients and families, and helping patients discover how their own strengths and weaknesses influence their health and health care. When patients' needs are prioritized, they engage in treatment and the treatments are more effective [1-4]. Hospitals where PFCC is part of the organizational culture find not only that patient, family, and staff satisfaction ratings significantly increase, but also that patients' health outcomes improve [2, 5]. Implementation of PFCC is also correlated with a decrease in patients' emergency department visits, faster recovery, and decreased utilization of health care resources [2, 6-7].

PFCC has become widespread throughout health care [6, 8-12]. The PFCC concepts of patient-physician collaboration and treating the patient as a whole person are not new. Fifteen years ago, the Institute of Medicine (IOM) semi-annual report, Crossing the Quality Chasm [8], included PFCC as an initiative to improve quality in the list of ten rules for redesigning health care [13]. The IOM report emphasized the need to involve patients in their own health care decisions, to better inform patients of treatment options, and to improve access to information [8]. PFCC provides a holistic approach to patient care, including psychological, spiritual, cultural, and emotional considerations that contextualize experiences of illness or injury and go beyond a focus on disease processes only [1].

The term "family-centered" does not remove control from competent patients to make decisions concerning their own health care [11]. Instead, this concept emphasizes that a patient's health care decisions should be contextualized in terms of a patient's broader life experiences. This term also recognizes the role a patient's family members play in extended and at-home care planning and care giving.

As medical care continues to become more collaborative, with a focus on holistic care for patients and their sources of support, principles of PFCC are now commonly taught to medical residents [14, 15]. For example, to be recognized by the Magnet Recognition Program, developed by the American Nurses Credentialing Center, hospitals must implement family-centered care [16]. No longer just for pediatrics, patient- and family-centered care applies to patients of all ages and can be practiced in any health care setting and at any point in care delivery; the Joint Commission suggestions include providing discharge instructions that meet the patient's needs, informing patients of their rights, and identifying patients' dietary restrictions that affect treatment [1]. Giving patients control, customizing care according to patients' needs and values, and providing information to patients and their loved ones are other IOM recommendations that promote PFCC [8].

Recognizing the importance of patients' loved ones in patients' health care experiences, clinicians try to work with patients and families to ensure their health and well-being in a mutually beneficial relationship [8, 11, 12]. Principles of PFCC include listening to families, facilitating choice, sharing information, and building confidence to participate in health care decision making [2, 11]. By implementing PFCC, clinicians benefit by gathering more information, improving follow-through, making efficient use of professional time, and decreased health care utilization [6, 9, 11].

Based on the latest research and guidelines [1, 4, 10, 14], these strategies for successful patient- and family-centered care are suggested:

1. Communicate and collaborate. According to the Institute for Patient and Family Centered Care, the word "family" refers to two or more persons who are related in any way-biologically, legally, or emotionally. The patient defines who represents his or her family and the level of involvement each family member will have. Involve designated family members, or support individuals, in care discussions, making sure they are available for multidisciplinary rounds to discuss concerns, the health care plan, and progress, and encourage them to participate. Patients and family members can provide information missing from medical charts and can recognize and speak up about errors in care delivery [7].

2. Promote health literacy. Patients who are-and whose family members are-unaware of potential adverse effects or benefits of medications prescribed have poor compliance [17]. Providing information in terms patients and family members can understand and encouraging families to participate in the care of their loved ones can result in improved patient outcomes [18, 19]. Take time to understand any influences of language, health literacy, or social, educational, or cultural factors on patients or families. Use "teach backs" and "show backs," in which patients or family members restate information provided by clinicians or display newly taught skills to increase understanding and decrease confusion [20]. This practice gives the care team the opportunity to discern and correct errors or misunderstandings [1, 19].

3. Include the patient and family. Work toward a professional, respectful relationship with your patients, incorporating their preferences and values in care goals and plans. Identify and address patient communication needs promptly, such as assistance for family members whose preferred language is not English or who have sensory or communication impairments. Disclose and acknowledge any medical errors promptly, per your facility's policy. When making clinical decisions, consider individual patient values along with possible language barriers, cultural issues, health literacy, and other factors [21, 22].

Prominent organizations including the Institute of Medicine (IOM), the Institute for Patient- and Family-Centered Care (IPFCC), the Institute for Healthcare Improvement (IHI), the American Academy of Pediatrics (AAP), and the American College of Emergency Physicians have endorsed PFCC practices, helped to define PFCC, and illustrated the importance of incorporating patients and their loved ones into health care discussions and decisions [8-12]. PFCC improves quality and safety of care, chronic disease management, and patient satisfaction; reduces hospitalizations and medical errors; and lowers costs [1, 2, 6, 11, 17, 21].

Citation

AMA J Ethics. 2016;18(1):40-44.

DOI
10.1001/journalofethics.2016.18.1.medu3-1601.
Acknowledgements

Many thanks to Sacramento State for supporting nursing scholarship.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.

Author Information

Aaron M. Clay, RN is a registered nurse in the neonatal intensive care unit at University of California Davis Children's Hospital.

Bridget Parsh, RN, MSN, EdD is an associate professor in the School of Nursing at California State University, Sacramento.

# data[].attributes.attachment_link.title
Patient- and Family-Centered Care: It's Not Just for Pediatrics Anymore

# data[].attributes.attachment_link.description
Aaron M. Clay, RN and Bridget Parsh, RN, MSN, EdD Patient- and family-centered care (PFCC) is changing the way hospitals provide patient care, increasing staff satisfaction, decreasing costs, and improving patient outcomes [1, 2].

# data[].attributes.body
An article by Hsu et al. (2019) titled Actions and Processes that Patients, Family Members, and Physicians Associate with Patient- and Family-Centered Care. Positive reports were also reported in the article. It was discovered that establishing good rapport with patients, respecting their time, and offering tailored treatment were important factors in improving their health.

# data[].attributes.attachment_link.readable_text
Clarissa Hsu, ¹ Marlaine Figueroa Gray, ¹ Lauren Murray, ² Marie Abraham, ³ Wendy Nickel, ⁴ Jennifer M. Sweeney, ⁵ Dominick L. Frosch, ⁶ Tracy M. Mroz, ⁷ Kelly Ehrlich, ¹ Bev Johnson, ³ and Robert J. Reid ⁸

Abstract

Background

Patient- and family-centered care (PFCC) is increasingly linked to improved communication, care quality, and patient decision making. However, in order to consistently implement and study PFCC, health care systems and researchers need a solid evidentiary base. Most current definitions and models of PFCC are broad and conceptual, and difficult to translate into measurable behaviors and actions. This paper provides a brief overview of all actions that focus group respondents associated with PFCC in ambulatory (outpatient) care settings and then explores actions associated with the concept of "dignity and respect" in greater detail.

Methods

We conducted nine focus groups with patients, family members, and physicians in three metropolitan regions across the United States. Group discussions were transcribed and analyzed using a thematic analysis approach.

Results

We identified 14 domains and 47 specific actions that patients, family members, and physicians associate with PFCC. In addition to providing a detailed matrix of these domains and actions, this paper details the actions associated with the "dignity and respect" concept. Key domains identified under "dignity and respect" include: 1) building relationships, 2) providing individualized care, and 3) respecting patients' time. Within these domains we identified specific actions that break down these abstract ideas into explicit and measurable units such as taking time, listening, including family, and minimizing wait times. We identified 9, 6, and 3 specific actions associated, respectively, with building relationships, providing individualized care, and respecting patients' time.

Conclusions

Our work fills a critical gap in our ability to understand and measure PFCC in ambulatory care settings by breaking down abstract concepts about PFCC into specific measurable actions. Our findings can be used to support research on how PFCC affects clinical outcomes and develop innovative tools and policies to support PFCC.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0918-7) contains supplementary material, which is available to authorized users.

Keywords: Qualitative research, Health care improvement, Patient-centered care, Ambulatory care, Health care performance measurement, Clinical training

Background

Making health care more patient- and family-centered is an increasingly important goal for a range of stakeholders including private and government health care organizations, payers, research funders, patients and families, patient-advocacy groups, and clinician stakeholders [ 1- 6]. A growing body of evidence links improvements in patient- and family-centered care (PFCC) to improved communication and quality, better patient decision making, decreases in unnecessary procedures, and improvements in care efficiency [ 7- 11]. A challenge to improving and providing an evidentiary base for PFCC practices is the lack of consensus on how to define and measure PFCC [ 12]. There are numerous PFCC definitions and models, but most are broad and conceptual, and difficult to translate into measurable behaviors and actions. Systematic reviews have recently mapped the themes and concepts across PFCC definitions [ 2, 13- 16]. Common concepts include dignity and respect [ 2, 16, 17], individualized care [ 16, 18, 19], patient and family engagement, information sharing [ 2, 17, 18], emotional support [ 6], and access to care [ 15, 20, 21]. However, we still lack consensus regarding how best to translate these concepts into practical measurement tools to support PFCC research, improvement, and evaluation [ 12, 22, 23].

This paper is the result of a collaboration between the American College of Physicians, the Institute for Patient- and Family-Centered Care (IPFCC), the National Partnership for Women & Families, and Kaiser Permanente Washington Health Research Institute. The goal of our collaboration was to develop a behavior-based survey instrument to measure PFCC in primary care and other ambulatory care settings (such as outpatient specialty care). The survey was collaboratively developed by a team of patients, clinicians, and researchers. We began with a series of focus groups to elicit behaviors and actions that patients, family members (defined broadly to include friends and caregivers), and physicians associate with PFCC. We provide a brief overview of all actions respondents associated with PFCC in ambulatory care settings. Because of its particular saliency to patients and families, the actions and behaviors associated with the PFCC concept of "dignity and respect" are described in detail in this paper. These findings fill a critical gap in PFCC research by making abstract concepts about PFCC more concrete, observable, and measurable.

Methods

We conducted nine focus groups with 92 participants to understand how U.S. patients, family members, and physicians describe ideal PFCC, emphasizing details about specific actions.

To increase diversity in respondents' experiences and attitudes, we conducted focus groups in three metropolitan regions-Greater Seattle, Greater Dallas, and Greater Philadelphia. In each region, we conducted separate focus groups with patients, family members, and physicians who spent at least half of their time working in outpatient settings (includes primary care, urgent care and specialty care).

To recruit patient and family caregivers, we contracted with local market-research firms that used a screening questionnaire we developed. We recruited physicians through the American College of Physicians membership. The Additional file 1 have recruitment details and surveys.

Two research team members with experience facilitating focus groups and conducting qualitative research (CH and MFG) attended all focus groups. Participants received a meal and a cash incentive of $100.00 for patients and caregivers and $150.00 for physicians. Facilitators structured group discussions around a series of semi-structured questions that were developed to elicit stories about actions that participants felt were patient and family centered and to facilitate brainstorming around the specific actions they would associate with key concepts found in PFCC definitions (Additional file 1). Input about the questions was received from the entire research team as well as an advisory committee that included patients, clinicians, and researcher stakeholders. The interview guides were customized to each type of respondent-patients, family caregivers and physicians. Discussions lasted approximately 2 h for patients and family caregivers and 1.5 h for physicians.

The analysis team (MFG and CH) reviewed transcripts and the primary coder (MFG) drafted an initial code list using an inductive analysis approach that involves reading through the data and identifying themes that emerge organically from the data [ 24]. Because the interview guides emphasized eliciting actions respondents associated with PFCC, the majority of the emergent codes were specific actions that we organized under a priori domains. Both analyzers then coded a patient transcript using the draft code list, compared the results, discussed discrepancies and added and/or refined the codes to ensure that the codes were comprehensive and that the definitions were clear. After comparison, the process was repeated with caregiver and physician transcripts. After three rounds of iterative code development, the primary coder coded all transcripts using final codes and definitions. Atlas.ti was used to assist with coding and data management.

Once coding was completed, the full research team discussed key themes of interest and the organization of the codes. To develop an overall synthesis of the data, we extracted all relevant codes. The lead author (CH) reviewed the data with assistance from another team member (LM). We documented the synthesis with supporting codes in a coding memo. We organized findings in three levels: 1) PFCC concepts (based on the definition IPFCC, Table 1 ) [ 17]; 2) domains; and 3) actions. The coding memo and table were shared with all authors for input and feedback regarding the organization and language of data-derived domains and themes.

Table 1

History/Background

The core concepts of patient- and family-centered care were initially developed in the 1980s by patients, families, clinicians, researchers, and health care leaders. They were grounded in the conceptual frameworks of the consumer and family support movements that gained momentum in health care, social services, and education in the 1960s.

Core Concept

Explanation

Dignity and Respect

Health care practitioners listen to and honor patient and family perspectives and choices. Patient and family knowledge, values, beliefs and cultural backgrounds are incorporated into the planning and delivery of care.

Information Sharing

Health care practitioners communicate and share complete and unbiased information with patients and families in ways that are affirming and useful. Patients and families receive timely, complete, and accurate information in order to effectively participate in care and decision-making.

Participation

Patients and families are encouraged and supported in participating in care and decision-making at the level they choose.

Collaboration

Patients, families, health care practitioners, and hospital leaders collaborate in policy and program development, implementation, and evaluation; in health care facility design; and in professional education, as well as in the delivery of care.

Results

The number of participants per group and key descriptive information are summarized in Table 2 . Focus group participants represented a diversity of ages, races, and ethnicities.

Table 2

Patient Groups

Age (years):

Insurance type

Tricare a

2 (17%)

1 (8%)

3 (9%)

Race and Ethnicity

Hispanic b

2 (20%)

2 (6%)

Level of education

Family Groups

Age (years):

Race and Ethnicity

Level of education

Physician Groups

Characteristic

Region 1

Region 2 c

Region 3

All Regions Combined

Age (years):

Race and Ethnicity

Years in practice:

Number of providers in participant's practice (including participant)

Percent of time per week spent in direct patient care in an outpatient setting

Percent of time per week spent in direct patient care in a hospital setting

Percent of time per week spent doing administrative work

A key aim of our focus groups was to identify specific and concrete actions that respondents associated with PFCC that could be observed and measured (Table 3 ). Not all actions fit into the four PFCC concepts in the IPFCC definition (Dignity and Respect, Information Sharing, Participation, Collaboration) so we created an "Other PFCC actions" concept. Actions within the Dignity and Respect concept were the most numerous and most often mentioned in focus groups and will be the primary focus of these results. For the Information Sharing concept, participants identified several information types that physicians and patients share with each other such as test results, explanations of disease processes and treatment procedures, advice regarding health-related issues (e.g. physical activity), treatment options and decision-making advice, and patient education materials as well as the desire for physicians to maximize technology to facilitate communication through the use of texts, secure messaging, and online platforms. The Participation concept included actions that required physicians and patients to interact and share responsibility for outcomes, including shared decision making and health coaching. For Collaboration, participants had limited direct, personal experience with activities that fit in this concept such as patient and family advisory councils and patient advisor participation in quality improvement efforts; the exceptions were filling out patient experience surveys and participating in focus groups. However, participants were interested in the Collaboration concept and had many recommendations for improving collaboration. Two domains, "Advocates for patient needs" and "Coordinates patient care," and their associated actions were put in the "Other PFCC Actions" concept.

Table 3

Domain

Specific Actions/themes

PFCC Concept #1: Dignity and Respect

Builds relationship

Spends sufficient time

Listens/gives undivided attention

Expresses caring and empathy

Makes personal connection-verbal

Makes personal connection-nonverbal

Communicates with honesty and transparency

Responds without judgement

Protects privacy

Relays sense of hope

Personalizes care

Knows the patient

Includes family

Understands and accommodates personal circumstances

Elicits and respects patients' values

Practices cultural competence and sensitivity

Provides empathetic advice

Respects patient and family members' time

Minimizes wait times

Notifies patients about delays

Balances needed time to build relationships with delays in seeing patients

PFCC Concept #2: Information Sharing

Provides patients and family members with information

Provides information-test results and medical records

Provides information-disease processes and procedures

Provides information-advice/information regarding a health issue

Provides information-for decision making/options

Provides information-patient educational materials and programs

Helps interpret information

Follows up

Maximizes technology to communicate

PFCC Concept #3: Participation

Engages in shared decision making

Elicits patient's values

Explores options

Supports patient and family knowledge, priorities and/or decisions regarding health-related issues

Refers to alternative healing modalities

Partners with patient

Provides coaching support and advise

Acknowledges patient's role and responsibility

Sets priorities

PFCC Concept #4: Collaboration

Actively seeks out and supports opportunities to collaborate with patient and family members

Solicits input

Demonstrates commitment to change

Involves patients and family members in quality improvement

Provides training and incentives

Addresses concerns about providing input

Other PFCC Actions

Advocates for patient's needs

Advocates with insurance

Advocates with other clinicians

Helps find resources

Helps overcome obstacles to getting medication and/or care

Engages in persistent problem solving

Provides uncompensated services

Coordinates patient's care

Coordinates with other medical staff

Facilitates communication

Functions as quarterback for health care team

Provides quality referrals

Ensures access to care

Starts with conservative treatment

Has up-to-date technical knowledge

Supports wellness and quality of life

We asked participants to discuss PFCC in relationship to their "doctor's office or health care center," but they mainly talked about the actions of their physician or primary care provider. Therefore, we refer to physicians as carrying out PFCC actions although other care team members are also key to implementing PFCC. Related to the importance of all personnel implementing PFCC, we asked participants about openness to team-based care. Most were supportive if all team members exhibited professionalism comparable to their physician.

Deep dive: Dignity and Respect domains and action themes

We chose to focus on domains and actions in the Dignity and Respect for two reasons: 1) these actions were most frequently raised by participants, and 2) this concept is difficult to translate into observable actions and measures.

Builds relationships

The first domain of identified actions was associated almost exclusively with building ongoing patient-physician relationships.

You know, doctors are supposed to care. I mean, that's what we grew up with...I mean, some of them just act like they don't care. So I think the best bedside manner is when you make that person who's obviously in distress or in a crisis in their life, you let them know, "I really care"...I don't know if that can be trained into somebody, but that's something that a person needs to have as a human being to another human being, some kind of compassion...(Family, Region 3).

And we see her like every third day or something. Just sit down, kind of hand holding. And she will just come give me a hug. And she was like, "I just feel so much better just seeing you and just feel like somebody's there who cares for me." (Physician, Region 2).

Well, my primary, when I go to him...he'll stop and pull out a stool, sit down. Ask me how I'm doing, what's going on. And then what I thought was great was he went into his personal life: Well, you know, I'm going to see my parents, me and my wife, and we're going to spend some time there. And I was like, Okay, cool. That's great. So it's not all on me and what's going on with me. He takes the time to tell me what he's doing, you know, with his personal life. (Patient, Region 3)

One of the things we make sure we do is touch everybody.

FACILITATOR: Literally put your hands on?

PARTICIPANT 3: Human touch. You'd be surprised, the people that see doctors and never get a physical. (Physician, Region 3).

Personalizes care

The second domain of actions revolve around ways that physicians provide care that is personalized to individual history, needs and preferences.

They should take the time and reread your file so when you come in they don't say, remind me, what medications are you on again? Or what was the problem the last time? They know what the problem is, especially if it's chronic and say, okay, yes, I remember you came in and this was a problem, these were the drugs you were on, tell me about your experience. If it's not working, let's find a new way to do it. (Family, Region 1).

We had a family physician who saw my dad, my mom, all my siblings until he retired...he had an extensive knowledge of our family history on both sides of my mother and father and all the risks involved. And now every time I go to a new doctor...or a new hospital, I have to fill all this stuff out and think back to myself, okay, what do we have...So it would be nice to have...your history on MyChart, the family history. (Family, Region 2).

Also a patient was placed in a nursing home and everything was done and there were papers to sign. I went there and it doesn't look like the patient has dementia at all but you can't challenge the whole family and the doctor who has seen him for several months. But I walked to the patient's bedside and held his hand and said tell me what you like to do. His eyes brighten and he says "I like to cook"...He started to talk and it was normal. People said he didn't know what day it was but there was no calendar in his house. If you talk to him, he's completely normal. The only problem is he was not practicing good hygiene...He did not go to the nursing home, he stayed home just because of a little bit of communication. (Physician, Region 1).

I think something that when you have the time and take the time to understand what's going on with people, why they're not getting better when you expect they should be, with everything you're doing, you really often find out there's more social kind of things than real medical things. (Physician, Region 3).

I asked a couple of questions and he said a couple of times, well, for my mom, I would do this and in this situation, in my family, we would have done this or we would do this and that made me a lot more comfortable feeling like do we really need all these invasive things? If he was willing to do that for his mom, obviously, that would be the right choice for us, too. It made me more comfortable and confident in what he was saying. (Family, Region 1).

Respects patients' and family members' time

Respecting patients' and family members' time emerged as an important issue for many patient and family member participants.

I know everyone has had that experience where you go in to the doctor, you wait. Even though your appointment was at 2:00, you wait till 2:30. Or the nurse sees you, then you wait till like 3:00 or so like, eventually, it's like an hour. So they don't really take into consideration that your time is valuable sometimes. (Patient, Region 2).

Discussion

We identified specific actions that patients, family members, and physicians associate with PFCC that may be used for measurement and quality improvement purposes, with a particular focus on the concept of dignity and respect. Our data surfaced a detailed list of actions that we organized under IPFCC key PFCC concepts. Not all domains and actions fit neatly under the four concepts. Therefore, several domains were designated "Other PFCC actions." For this article, we chose to provide a detailed description of domains and actions under the Dignity and Respect concept, a critical aspect of PFCC that is often hard to translate into concrete measures, behaviors, and/or instructions for changes to clinical care. Within the concept of Dignity and Respect, we found three domains of actions: 1) building relationships, 2) providing individualized care, and 3) respecting patients' time. We identified actions in these domains that break down these abstract ideas into specific and measurable units such as taking time, listening, including family, and minimizing wait times.

While PFCC has been the subject of a great deal of attention in the health services and clinical quality improvement literature, definitions and frameworks continue to be relatively abstract [ 2, 6, 15, 16, 19, 25- 27] and measuring PFCC and associating outcomes [ 8, 11] continues to be a challenge. Existing measures used to assess PFCC focus primarily on patient satisfaction and/or patient-provider communication, which are overlapping but distinct constructs. We are not aware of any concrete measures of PFCC for primary care settings. Our paper fills this gap by elucidating specific, concrete actions that patients, caregivers, and physicians associated with PFCC. Our broad domains align with and expand upon previous work that focused on concepts such as respect [ 2, 16, 25], individualized care [ 16, 19, 26], participation [ 15, 25] and information sharing [ 2, 25, 26], while our action themes break these concepts down into discrete actions that can be operationalized and measured.

In addition to the work our team has done to translate these findings into a tool to help outpatient care teams improve and measure the patient and family centeredness of the care they provide, our findings have several other possible contributions to measuring and improving health care. Our action list may be helpful to practices and policymakers in planning and implementing redesign and "transformation" initiatives, specifically in prioritizing actions that patients and family members value and creating workflows and incentives that support care teams in providing PFCC. Finally, our findings could inform training for physicians and other health care workers who have direct responsibility for patient diagnosis, treatment, and ongoing preventive care.

Our study has several limitations. Although we gathered diverse opinions by conducting focus groups in three geographic regions and recruiting participants from a variety of ethnicities, ages, and insurance-coverage groups, our sample was self-selected. We might have missed perspectives not represented among our volunteers who lived primarily in urban and suburban areas. Also, many of the domains and actions were rooted in processes specific to the U.S. health care system and may have limited applicability outside the United States. Finally, for this paper, we chose to focus on the actions of physicians and care teams that contributed to PFCC in ambulatory care settings. However, we acknowledge that PFCC is a partnership between patients and care teams and a similar set of patient actions is likely to facilitate the provision of PFCC in other settings.

Conclusion

Promoting and facilitating PFCC is a key component of improving health care overall. As U.S. health care systems strive to achieve the triple aims [ 28], it is essential that we find effective and reliable ways to operationalize and measure PFCC and explore connections between PFCC and patient and clinical outcomes. This is especially true for the concept of dignity and respect in PFCC. Although these terms are frequently mentioned in the literature, no study has operationalized these terms in a way that promotes systematic research and evaluation. Our work is a critical step toward identifying and measuring dignity and respect when providing PFCC in ambulatory care settings. The domains and specific actions presented here are intended to support heath care research and innovations that thoughtfully and deliberately put patients and families at the center of care.

Acknowledgements

We want to express our appreciation to all the focus group participants for sharing their insights and experiences with us. We are grateful to Barb Forss for her insights as a patient advisor to this project. We also acknowledge our colleagues at the American College of Physicians for their project leadership-Steven Weinberger, MD-and assistance recruiting physicians to participate in focus groups-Arlene Weissman, PhD. Finally, we thank Chris Tachibana for providing technical editing for this manuscript.

Funding

This project was funded by the Gordon and Betty Moore Foundation.

Availability of data and materials

The authors declare that the data supporting the findings of this study are available within the article. However, additional data are available upon request from the corresponding author [CH]. The data are not publicly available since they contain information that could compromise respondents' confidentially as promised in the consent process.

Abbreviations

IPFCC

Institute for Patient- and Family-Centered Care

PFCC

Patient- and family-centered care

Author's contributions

CH: Designed and collected qualitative data. Participated in the coding of the data, developed the analytic coding memo and drafted and revised the manuscript. MFG: Designed and collected qualitative data. Led the data coding process. Reviewed initial data analysis document (coding memo), reviewed multiple drafts of the manuscript. LM: Reviewed coded data and wrote first drafts of one section of the manuscript. Reviewed multiple drafts of the manuscript. MA: Provided leadership and input on the design for the project. Provided key background information and literature for the introduction and discussion. Reviewed and gave feedback on drafts of the manuscript. WN: Provided leadership and input on the design for the project. Reviewed and gave feedback on drafts of the manuscript. JMS: Provided leadership and input on the design for the project. Reviewed and gave feedback on drafts of the manuscript. DLF: Provided leadership and input on the design for the project. Reviewed and gave feedback on drafts of the manuscript. TMM: Provided input on the design for the project. Reviewed and gave feedback on drafts of the manuscript. KE: Provided overall project management and input on the design for the project. Reviewed and gave feedback on drafts of the manuscript. BJ: Provided leadership and input on the design for the project. Reviewed and gave feedback on drafts of the manuscript. RJR: As the principal investigator, was responsible for the overall design, collection and interpretation of the data. Reviewed and gave input into multiple drafts of the manuscript. All authors have read and approved the final manuscript.

Notes

Ethics approval and consent to participate

Study procedures were reviewed and determined to be exempt by the Kaiser Permanente Washington Health Research Institute's Human Subjects Institutional Review Board. The exempt status meant that the consent processes were not mandated or overseen by the IRB. Verbal consent was attained and participants were informed that participation was voluntary and that their discussion was being audio recorded and transcribed. All participants were informed that verbatim quotes might be used and that we would remove identifiers to protect their confidentiality. All were given the opportunity to withdrawal participation at any time without penalty to them.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

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Articles from BMC Family Practice are provided here courtesy of BMC

# data[].attributes.attachment_link.title
Actions and processes that patients, family members, and physicians associate with patient- and family-centered care

# data[].attributes.attachment_link.description
Patient- and family-centered care (PFCC) is increasingly linked to improved communication, care quality, and patient decision making. However, in order to consistently implement and study PFCC, health care systems and researchers need a solid evidentiary ...

# data[].attributes.body
Clay, A. M., & Parsh, B. (2016). Patient- and Family-Centered Care: It’s not just for pediatrics anymore. The AMA Journal of Ethic, 18(1), 40–44. https://doi.org/10.1001/journalofethics.2016.18.1.medu3-1601

Hsu, C., Gray, M. F., Murray, L., Abraham, M., Nickel, W., Sweeney, J. M., Frosch, D. L., Mroz, T. M., Ehrlich, K., Johnson, B., & Reid, R. J. (2019). Actions and processes that patients, family members, and physicians associate with patient- and family-centered care. BMC Family Practice, 20(1). https://doi.org/10.1186/s12875-019-0918-7

Patient & Family centred care — North Shore Health Network. (n.d.). North Shore Health Network. https://www.nshn.care/patient-family-centred-care

Patient-Centered care. (n.d.). CAMH. https://www.camh.ca/en/professionals/treating-conditions-and-disorders/approaches-to-care/patient-centred-care

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(Isis Nursing Horus | Third Intermediate Period–Late Period | the Metropolitan Museum of Art, n.d.)  

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The opening of Trent University's first Breastfeeding Friendly Space marks a significant step towards normalizing and supporting breastfeeding in public and educational settings. This initiative offers nursing moms a private, secure, and comfortable space to do so, demonstrating a dedication to promoting inclusive and family-friendly campuses. By doing this, Trent University is fostering a community that supports nursing moms and raises awareness of the health advantages of breastfeeding by establishing these places. This helps to lessen stigma and improve public acceptance of this normal activity.

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Women's Perceptions and Experiences of Breastfeeding: a scoping review of the literature by Beggs et al. (2021). Many people view breastfeeding as a positive experience since it strengthens the emotional bond between mother and child, strengthens the baby's immune system, and offers the mother a sense of accomplishment. However, they face challenges, such as feeling uncomfortable while providing care outside of their homes or inspected.

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Views and experience of breastfeeding in public: A qualitative systematic review written by Grant et al. (2022). explains how Many moms still face significant challenges, despite laws allowing breastfeeding in public places. The analysis highlights the need for cultural attitudes regarding breastfeeding to shift to improve the proportion of women who breastfeed their children. Whether or not mothers decide to breastfeed in public is greatly influenced by societal standards. Stigmatizing concepts such as the sexualization of breasts and stories of disgust discriminate against nursing mothers.

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Beggs, B., Koshy, L., & Neiterman, E. (2021). Women’s Perceptions and Experiences of Breastfeeding: a scoping review of the literature. BMC Public Health, 21(1). https://doi.org/10.1186/s12889-021-12216-3

Grant, A., Pell, B., Copeland, L., Brown, A., Ellis, R., Morris, D., Williams, D., & Phillips, R. (2022). Views and experience of breastfeeding in public: A qualitative systematic review. Maternal and Child Nutrition, 18(4). https://doi.org/10.1111/mcn.13407

Isis nursing Horus | Third Intermediate Period–Late Period | The Metropolitan Museum of Art. (n.d.). The Metropolitan Museum of Art. https://www.metmuseum.org/art/collection/search/553034

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Collaboration isn't just a skill, but a lifeline.

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This was the picture I chose for my aesthetic art project called “Unity in Crisis”. I chose this project because it provided me with three ways of knowing such as empirical inquiry: providing hands-on experience and evidence, ethical inquiry: testing ethical boundaries and decision-making abilities, and aesthetic inquiry: portrayal of oneness and unity.

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Here is a picture of me and my colleague on the last day of our clinical placement at Peterborough Regional Health Centre (PRHC). It was a bittersweet moment because we were happy that we finally concluded the semester, but we were sad because we would miss each other. I chose this picture because it represents strength and resilience. The faces in the picture are smiling, but the situations each of them is facing are critical. Some are mourning the loss of a parent, some just lost their job, some are facing issues with meeting the passing grade of the course, and some are facing troubles with their student visa. Despite this, we found each other as beacons of strength and support.

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(Top Nursing Team Building Strategies | Spring Arbor University, n.d.) 

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I chose this artifact because it depicts everyone coming together to achieve the same common goal, which is providing the best compassionate and competent care for our patients.

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The Relationship of Nursing Teamwork and Job Satisfaction in Hospitals article by Bragadóttir et al. (2023) speaks on the importance of teamwork and how it leads to a healthy work environment in nursing as it supports optimal nurse and patient outcomes.

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Helga Bragadóttir, RN, PhD, FAAN, 1, ² Beatrice J. Kalisch, RN, PhD, FAAN, ³ Birna G. Flygenring, RN, MSc, ¹ and Gudný Bergthóra Tryggvadóttir, MSc ⁴

Abstract

Introduction

Teamwork is identified as a key contributor to patient safety and good teamwork is recognized as one of the presumptions of healthy work environment in nursing. The importance of job satisfaction in nursing has repeatedly been confirmed, but only recently has the association of job satisfaction and nursing teamwork been identified.

Objective

To identify the level of nursing teamwork in hospitals in Iceland and its relationship with job satisfaction.

Methods

This was a quantitative descriptive cross-sectional study. Data were collected with the Nursing Teamwork Survey administered to nursing staff in medical, surgical, and intensive care units in hospitals in Iceland. This study is based on data from 567 participants.

Results

A logistic regression analysis indicated that work experience on current unit and perceived staffing adequacy contributes to job satisfaction and when controlling for unit type, role, experience on current unit and staffing adequacy, those reporting better teamwork are significantly more likely to be satisfied with their current position. With an additional unit for overall nursing teamwork, participants are almost five times likelier to be satisfied with their current position.

Conclusion

Study findings show that there is a significant relationship between nursing teamwork and job satisfaction. The findings of this study confirm the importance of adequate staffing and good teamwork for nurses' job satisfaction. Staffing however, will remain the most challenging part of the equation as lack of nursing staff is foreseen globally in the coming decades turning the spotlight to teamwork. All stakeholders, including clinical nurse leaders, administrators, and instructors, need to emphasize on strengthening nursing teamwork. Good teamwork with increased job satisfaction may prevent turnover and shortage of nurses, an issue expected to grow during and following the COVID-19 pandemic. Facilitating good teamwork should be one of the priorities of every nurse leader.

Keywords: hospitals, job satisfaction, nurses, nursing, nursing staff, teamwork

Introduction

The modern health care delivery system is complex and rapidly changing and it is therefore important for nursing staff to work together to secure patient safety ( Jomaa et al., 2021) and quality of care ( Kalisch et al., 2007; Zeleníková et al., 2020). Teamwork and team-based care are identified as key contributors to patient safety and quality patient care ( Mitchell et al., 2012; WHO, 2016). Good teamwork is also recognized as one of the presumptions for a healthy work environment in nursing as it supports optimal nurse and patient outcomes ( Aiken et al., 2013; Elbejjani et al., 2020; Kirwan et al., 2013; Lu et al., 2019). In a healthy work environment, staffing is appropriate, nurses can practice to their full potential and job satisfaction is high ( Kirwan et al., 2013; Kutney-Lee et al., 2013; Zeleníková et al., 2020). Teamwork and job satisfaction are significant contributors to patient and staff safety. Effective teamwork has been linked with higher job satisfaction and job satisfaction has been reported to have a strong positive association with nurses' intent to leave work and turnover ( Kalisch et al., 2010). The importance of job satisfaction in nursing has repeatedly been confirmed and its effect on turnover, but only a few studies have identified the association of job satisfaction and nursing teamwork ( Goh et al., 2020; Kalisch et al., 2010; Rafferty et al., 2001).

Few studies are published on the influence of teamwork on job satisfaction, indicating a need for the matter. The purpose of this study was to identify the level of nursing teamwork in hospitals in Iceland and its relationship with job satisfaction.

Review of Literature

The importance of teamwork in health care has received substantial attention in recent years as has the importance of job satisfaction in nursing. Teamwork is recognized as being a complex social activity where a group of people work together to achieve a task or goal ( Sargeant et al., 2008). Teamwork has always been important in nursing because it is vital for nursing staff to work together to be able to fulfill the goals of patient care needs, although often unrecognized ( Leonard et al., 2004). Study findings show the importance of nursing teamwork in the achievement of collaboration and communication ( Al Sayah et al., 2014; Kalisch et al., 2007) as well as its association with workload and work-related stress ( Kalisch & Lee, 2011), staffing adequacy ( Bragadóttir et al., 2019; Goh et al., 2020; Jomaa et al., 2021), nurses health outcomes ( Elbejjani et al., 2020), job satisfaction and intent to leave ( Abualrub et al., 2012; Gebregziabher et al., 2020; Goh et al., 2020; Kalisch et al., 2010; Rafferty et al., 2001). Internationally, study results indicate that good teamwork may prevent turnover and shortage of nurses and staff ( Abualrub et al., 2012; Al Sabei et al., 2022; Estryn-Behar et al., 2007).

Job satisfaction seems to differ significantly between countries ( Burmeister et al., 2019; Sanner-Stiehr et al., 2021). In Iceland, nurses' job satisfaction is known to be high ( Burmeister et al., 2019; Gunnarsdóttir et al., 2009), and indications are that number of variables contribute to nurses' job satisfaction, not least job stress and support from nurse unit managers (NUMs) ( Flygenring & Sveinsdóttir, 2014), but the extent to which teamwork contributes to job satisfaction of nursing staff in Iceland has not been studied previously. A previous descriptive study using the same data set, revealed a statistically significant correlation between teamwork and job satisfaction indicating more satisfaction of nursing staff with both their role and current position with better teamwork. Other studies on teamwork and job satisfaction among nursing staff in Iceland were not identified.

Job satisfaction indicates the extent to which people like or dislike their job ( Spector, 1997). However, job satisfaction does not depend entirely on the nature of the job, but no less on the expectations people have about their job ( Lu et al., 2012). Job satisfaction is the variable that has been studied widely in nurses' work environment, especially because of its strong positive link to nurses' turnover. Job satisfaction of nurses has also been found to link positively to a variety of work-related factors. Among others these factors are type of unit, the work environment of nurses, whether working overtime or not, absenteeism and length of tenure. Type of unit may contribute to job satisfaction as a cross-sectional study from the United States (US) with a sample of 53,851 nurses from 162 hospitals showed that nurses working in medical-surgical units reported significantly higher job satisfaction than those working in other type of units ( Klaus et al., 2012). A recent study conducted in hospitals in the Czech Republic, with a sample of 513 nurses providing direct patient care, indicated significantly more satisfaction with role as well as profession with better practice environment and better teamwork ( Zeleníková et al., 2020). Study findings indicate that nurses job satisfaction is significantly less when they work overtime ( Han et al., 2015; Klaus et al., 2012) and nurses with fewer absences from work are more satisfied with their work ( Burmeister et al., 2019; Roelen et al., 2013). Nurses with longer tenure are more satisfied than those with shorter tenure ( Bjørk et al., 2007) and nurses' job satisfaction correlates positively with their intention to stay in work ( Gebregziabher et al., 2020; Lu et al., 2019) which is a strong predictor of nursing staff turnover ( Murrells et al., 2008).

Although studies on the influence of teamwork on job satisfaction are limited in number, they show that nurses with high interprofessional teamwork scores are more satisfied with their work and intend to stay in work ( Al Sabei et al., 2022; Ma et al., 2015; Rafferty et al., 2001). Also, a higher level of nursing teamwork leads to greater general job satisfaction ( Goh et al., 2020) as well as greater satisfaction with role and current position (Kalisch et al., 2010; Zeleníková et al., 2020) and nurses feel more satisfied with their work when they experience high-quality communication with other team members ( Trybou et al., 2015). Low scores of teamwork have been associated with increased intent to leave work among nurses ( Estryn-Behar et al., 2007). In summary, indications are that nursing teamwork may contribute significantly to job satisfaction, which in turn impacts a nurse's decision whether to stay or leave current work.

Methods

Design

The study was a quantitative descriptive cross-sectional study using a paper-and-pencil questionnaire.

Research Questions

The following research questions are addressed in this study:

1. How do nursing staff in hospitals in Iceland evaluate the level of nursing teamwork on their unit?

2. What are the relationships of hospital, unit and staff characteristics, and nursing teamwork and job satisfaction?

3. To what extent do unit and staff characteristics and nursing teamwork predict job satisfaction?

Setting and Sample

All nursing staff reporting to each NUM were included in the sample including the NUMs as well as registered nurses (RNs), practical nurses (PNs), and unit secretaries. Due to the small population of Iceland, and therefore the relatively low total number of nursing staff working in hospital units meeting the inclusion criteria, all eligible nursing staff were included in the study. The inclusion criteria for participating in the study were as follows: be at least 18 years old, belong to the nursing staff on the unit, be permanently employed, provide direct patient care, spend the majority of ones working time on the unit, understand Icelandic. Temporary staff were excluded from the study. The sample consisted of the entire nursing staff ( N   =  925) in all Icelandic inpatient medical, surgical, and intensive care units (ICUs) in the eight hospitals in the country. Total return rate was 69%. Data from 567 participants (61%) are used in this study.

Measures

A multiple-choice questionnaire was used for data collection including questions on background variables, questions on job satisfaction, and a question on nursing teamwork. The questionnaire used in this study is an Icelandic version of the Nursing Teamwork Survey ( NTS), NTS-Icelandic, developed in the US (Kalisch et al., 2010). The NTS, both the US and Icelandic versions, have undergone rigorous testing processes of its acceptability, reliability, and validity ( Bragadóttir et al., 2016; Kalisch, Lee & Salas, 2010). An overall test-retest intraclass correlation coefficient for the NTS-Icelandic was 0.693 (lower bound  =  0.498, upper bound  =  0.821) ( p < .001) with Cronbach's alpha reliability for the total scale and subscales ranging from 0.737 to 0.911. A confirmatory factor analysis indicated a good fit of the data with the five-factor model for nursing teamwork ( Bragadóttir et al., 2016).

Hospitals were categorized into teaching hospitals with one university hospital and one teaching hospital, and other hospitals with six small regional hospitals in rural areas. Patient units were categorized into medical units (11), surgical units (8), mixed medical and surgical units (5), and ICUs (3). All mixed medical and surgical units were in the small hospitals whereas all the ICUs were in the teaching hospitals. Participants were asked about the staffing adequacy on their unit, as to how often they felt the unit staffing was adequate, where they answered 100%, 75%, 50%, 25%, or 0% of the time. The staff characteristic variables used in this study were gender, age, role (job title), number of hours worked per week, what type of shift usually worked, experience in role, experience on current unit, overtime, sick days, and intent to leave.

The NTS has five subscales with a total of 33 items put forward as statements on: trust (7 items), team orientation (9 items), backup (6 items), shared mental model (SMM) (7 items), and team leadership (4 items). Participants are asked to answer by marking on a 5-point Likert-type scale to what extent each statement applies to their team: (1) rarely, (2) 25% of the time, (3) 50% of the time, (4) 75% of the time, and (5) always. A higher score indicates better teamwork.

Job satisfaction was measured with two questions with a 5-point Likert-type scale ranging from (1) "very dissatisfied" to (5) "very satisfied." One question asked about the satisfaction of the participant with current position and another question asked about how satisfied the participant was in their role, that is, RN, PN, NUM, or a unit clerk/secretary, independent of their current job.

Ethical Considerations

The study was approved by the Institutional Review Board in each hospital, or analogue body in the smaller hospitals and notified to the Data Protection Authority of Iceland (S5388/2011). Participation was anonymous and participating equaled a written informed consent. The names of participants were never revealed to the researchers and the liaison persons distributed the questionnaires with an invitation letter and a response envelope, to staff members. All data were preserved in a protected space.

Data Collection Procedures

Data were collected with the help of NUMs and a liaison person in each unit. The liaison oversaw the distribution of a questionnaire with a cover letter and a return envelope to each staff member. Participants returned their completed questionnaire in a sealed envelope, by dropping it in the in-house hospital mailbox or special study drop-box located on their unit.

Data Analysis

IBM SPSS version 24.0 (IBM Corp., Armonk, NY) was used for data analysis. The unit of analysis was the individual staff member. Data from participants who had answered at least 70% of the Nursing Teamwork Survey questions were included. Missing data were not compensated. Demographic and background variables were defined as categorical variables and recorded as dummy variables. The variable of nursing teamwork was defined as a continuous variable. For teamwork, an overall mean score was calculated as well as a mean score for each subscale and each item. For data analysis when using the chi-square test and for regression analysis, both variables of job satisfaction were treated as binary variables categorizing answers into "dissatisfied" (combining "neutral", "dissatisfied," and "very dissatisfied") and "satisfied" (combining "very satisfied" and "satisfied").

A previous study revealed that the overall teamwork score and the subscales of NTS were highly correlated opposing using the overall scale and as well as the subscales as separate measures for regression analysis ( Kalisch & Lee, 2010). As the variables hospital and unit covariate, only the variable unit was used for the model testing. For the model testing, satisfaction with current position was used as the variable for job satisfaction.

Frequency distribution, correlation test, and logistic regression analysis were used to answer the research questions. A chi-square test was used to calculate the differences between groups within each characteristic of hospitals, units, and participants. Where the expected frequency was low, the Yates' chi-square test was used. An independent t-test was used to identify the relationship between job satisfaction and overall teamwork and each of the subscales of teamwork. Binary logistic regression was used to test two models to answer the research question about the relationship of the unit and staff characteristics and nursing teamwork to job satisfaction. Model 1 tested to what extent unit and staff characteristics predicted the variance in job satisfaction and Model 2 tested the extent to which nursing teamwork predicted the variance in job satisfaction when controlling for unit and staff characteristics.

Results

Sample Characteristics

Table 1 shows the characteristics of hospitals, units, and participants. Most participants worked in the teaching hospitals (78.94%), in medical units (34.87%) and surgical units (31.15%). The majority were women (98.58%), 54 years or younger (81%), RNs (57.52%) and PNs (35.58%), working rotating shifts (81.59%), 30 h or more per week (76.02%). Most of them had greater than 10 years' experience in their current role (54.30%) and more than 5 years' experience on their current unit (55.90%). The minority (25.77%) had not worked any overtime in the past three months. Less than half of the participants (46.44%) had been absent more than one day in the past three months. The majority (70.86%) of the participants identified the staffing on their unit adequate half or less (0%, 25%, or 50%) of the time. The vast majority had no intent to leave their current position within the next year (87.84%).

Table 1.

Variable

n

%

Job satisfaction
- current position

Job satisfaction
- in role

% satisfied

% satisfied

Nursing Teamwork

Table 2 shows the mean (M) and standard deviation (SD) for the nursing teamwork scores. The mean overall teamwork score was 3.89 (SD  =  0.47). The subtheme scoring highest was SMM with a mean score of 4.20 (SD  =  0.48) and team leadership getting the lowest mean score of the subthemes, 3.65 (SD  =  0.75).

Table 2.

Factors and statements

M 1-5 (SD)

Team members trust each other (Q.33)

4.22 (0.67)

Team members readily share ideas and information with each other (Q.24)

4.08 (0.74)

Team members communicate clearly what their expectations are of others (Q.4)

3.64 (0.91)

When someone does not report to work or someone is pulled to another unit, we reallocate responsibilities fairly among the remaining team members (Q.32)

4.01 (0.81)

Team members value, seek and give each other constructive feedback (Q.31)

3.50 (0.95)

My team readily engages in changes in order to make improvements and new methods of practice (Q.23)

4.01 (0.81)

Team members clarify with one another what was said to be sure that what was heard is the same as the intended message (Q.25)

3.85 (0.87)

When a team member points out to another team member an area for improvement, the response is often defensive (Q.13)

4.08 (1.02)

If the staff on one shift is unable to complete their work, the staff on the on-coming shift complains about it (Q.15)

4.27 (0.95)

Team members are more focused on their own work than working together to achieve the total work of the team (Q.26)

3.64 (1.21)

Some team members spend extra time on breaks (Q.11)

3.84 (1.25)

Feedback from team members is often judgmental rather than helpful (Q.22)

4.23 (1.05)

Practical nurses and nurses do not work well together as a team (Q.18)

4.33 (1.09)

Team members ignore many mistakes and annoying behavior of teammates rather than discussing these with them (Q.5)

3.42 (1.24)

Staff members with strong personalities dominate the decisions of the team (Q.16)

3.13 (1.20)

Most team members tend to avoid conflict rather than dealing with it (Q.17)

3.33 (1.20)

My team believes that to do a quality job, all of the members need to work together (Q.9)

4.40 (0.69)

Team members willingly respond to patients other than their own when other team members are busy or overloaded (Q.30)

4.01 (0.90)

Within our team, members are able to keep an eye out for each other without falling behind in our own individual work (Q.28)

3.87 (0.84)

The nurses who serve as charge nurses or teamleaders are available and willing to assist team members throughout the shift (Q.19)

3.80 (1.03)

Team members frequently know when another team member needs assistance before that person asks for it (Q.3)

3.42 (0.91)

Team members notice when a member is falling behind in their work (Q.20)

3.35 (1.10)

Team members understand the role and responsibilities of each other (Q.29)

4.24 (0.70)

When the workload becomes extremely heavy, team members pitch in and work together to get the work done (Q.21)

4.21 (0.81)

Team members respect one another (Q.12)

4.24 (0.67)

Team members know that other members of their team follow through on their commitment (Q.7)

4.06 (0.71)

All team members understand what their responsibilities are throughout the shift (Q.1)

4.37 (0.66)

The shift change reports contain the information needed to care for the patients (Q.10)

4.28 (0.73)

Team members are aware of the strengths and weaknesses of other team members they work with most often (Q.14)

3.77 (0.77)

The nurses who serve as charge nurses or teamleaders give clear and relevant directions as to what needs to be done and how to do it (Q.27)

3.71 (0.95)

The nurses who serve as charge nurses or teamleaders balance workload within the team (Q.8)

3.90 (0.78)

The nurses who serve as charge nurses or teamleaders monitor the progress of the staff members throughout the shift (Q.2)

3.70 (0.97)

When changes in the workload occur during the shift (admissions, discharges, patients problems etc.), a plan is made to deal with these changes (Q.6)

3.29 (1.23)

Relationship of Characteristics of Hospitals, Units, and Participants and Nursing Teamwork With Job Satisfaction

Table 1 shows the unit and staff characteristics that had a statistically significant correlation with job satisfaction. A statistically significant relationship was identified between perceived adequacy of staffing and intent to leave current position and both satisfaction with current position and satisfaction in role. Participants who perceived staffing on their unit adequate half or more of the time and those who had no intention of leaving their position within the next year were more satisfied with their current position as well as in their role. Also, there was a significant relationship between years of experience on current unit and satisfaction with current position. Correlational tests showed no significant relationship between hospital, unit type, gender, age, role, work hours, hours worked per week, overtime, absenteeism, or years of experience in role.

Table 3 shows the relationship of nursing teamwork with satisfaction with current position and Table 4 shows the relationship of nursing teamwork with satisfaction in role. A statistically significant relationship was identified between overall nursing teamwork as well as all the subscales of teamwork and both satisfaction with current position and satisfaction in role. An independent t-test indicated that with higher overall teamwork as well as higher trust, team orientation, backup, SMM, and team leadership scores, there was more satisfaction with current position ( Table 3 ). Satisfaction in role tested significantly more with higher overall teamwork as well as higher team orientation, backup, and SMM ( Table 4 ).

Table 3.

n

Mean

SD

Independent t-test

Sig.

Overall nursing teamwork

Satisfied

493

3.94

0.43

5.46

***

Table 4.

n

Mean

SD

Independent t-test

Sig.

Overall nursing teamwork

Satisfied

526

3.91

0.46

3.50

***

The Extent to Which Unit and Staff Characteristics and Nursing Teamwork Predict Job Satisfaction

As seen in Table 5 , the two models tested with logistic regression analysis show a significant contribution of experience on current unit, perceived staffing adequacy, and overall nursing teamwork to job satisfaction. The testing of Model 1 indicated a non-significant contribution of unit type and role to the variance of satisfaction with current position. However, those participants who have up to 2 years' work experience on current unit are more than two times likelier to be satisfied than those with more than 2 years' experience, those who perceived the staffing on their unit adequate more than half of the time are almost three times as satisfied with their current position compared to those who perceived the staffing adequate half or less of the time. Model 1 explains 8% of the variance in job satisfaction. When adding overall nursing teamwork to the model (Model 2), the logistic regression shows that when controlling for unit type, role, experience on current unit, and staffing adequacy, those reporting better teamwork are significantly more likely to be satisfied with their current position. With teamwork added to the model it explains 18% of the variance in job satisfaction. With an additional unit for overall nursing teamwork, participants are almost five times likelier to be satisfied with their current position.

Table 5.

Model 1

Model 2

B

SE

OR

Sig.

B

SE

OR

Sig.

Unit

N

551

551

Nagelkerke R ²

0.08

0.18

−2 Log

390.315

361.283

df

8

9

Discussion

The findings of this study show that there is a significant relationship between nursing teamwork and job satisfaction. The study reveals both strengths and potentials for improvement of nursing teamwork on inpatient units in Icelandic hospitals, where experience on the unit and staffing need to be taken into consideration. These findings clearly indicate the importance of teamwork on job satisfaction.

When compared with findings from other countries using the same questionnaire, the mean overall score of nursing teamwork in our study seems higher than is seen in other studies ( Chapman et al., 2016; Goh et al., 2020; Kaiser & Westers, 2018; Kalisch & Lee, 2010). Similarities and differences are seen in the ranking of highest and lowest mean scores of subthemes, indicating some difference in work environment, systems, and culture. In our study, the ranking of subthemes of teamwork was: SMM, trust, team orientation, backup, and team leadership. In a recent study from the US, the ranking of subthemes was in the following order: SMM, team leadership, trust, backup, and team orientation ( Kaiser & Westers, 2018), and in another recent study from Singapore, the ranking of subthemes was in the following order: SMM, team leadership, backup, trust, and team orientation ( Goh et al., 2020). These findings may indicate cultural as well as organization and systems differences between countries. The important leadership role of NUMs for efficient nursing teamwork may be better recognized in both the US and Japan ( Furkawa & Kashiwagi, 2021; Manges et al., 2016), than in Iceland. In comparison to the US, one explanation of this difference may be that in the US the TeamSTEPPS® program, providing evidence-based tools for improving teamwork among health care professionals ( https://www.ahrq.gov/teamstepps/index.html), has been in place for almost two decades ( King et al., 2008). This may have made a difference in the improvement of clinical team performance and helped clarify the role of nursing team leaders ( Manges et al., 2016). No comparable teamwork training program is offered nationwide in Iceland.

Regarding job satisfaction, the majority of our participants were satisfied with their current position and with their role. Job satisfaction among nurses in Iceland has been measured high ( Gunnarsdóttir et al., 2009), and in a recent study including data from seven countries around the world, Icelandic nurses were the most satisfied with their current position as well as with their role ( Burmeister et al., 2019). A recent study including nurses from the US, Italy, and Finland, with the aim of identifying the difference in job satisfaction and multigenerational nursing characteristics between countries and generations, indicated a significant difference between nurse job satisfaction between countries and multigenerational characteristics, but not between generations ( Sanner-Stiehr et al., 2021). These findings are a manifesto about how complex the phenomenon of job satisfaction is as it does not only depend on the nature of the job, but also on the expectations people have about their job ( Lu et al., 2012) which again may depend on a number of different factors.

Staffing, not least nurse staffing, is one of the biggest challenges facing health care systems in the world at present and in the future ( WHO, 2020). In our study staffing adequacy and teamwork contribute significantly to job satisfaction. These findings point to the importance of preventing a vicious cycle of inadequate staffing, inefficient teamwork, job dissatisfaction, and turnover ( Sasso et al., 2019). Looking at the two influential variables, staffing and teamwork, it may be equally important for nursing and health care leaders to strengthen their teams through effective interventions ( Buljac-Samardzic et al., 2020), as it is to secure adequate staffing ( WHO, 2020).

Interestingly our findings on participants with up to 2 years' work experience on the unit being significantly more satisfied with current position is in concordance with findings from a comparable study in Singapore ( Goh et al., 2020), indicating some sort of honeymoon period in the first 2 years in nurses working life, which needs attention. These findings point to the importance of developing interventions to support the continuum of job satisfaction and retain nurses in their transition to practice ( Boamah & Laschinger, 2016; Brunetto et al., 2013; Edwards et al., 2015; Laschinger et al., 2016).

The key findings of this study are that experience on current unit, perceived staffing adequacy, and nursing teamwork contribute significantly to job satisfaction of nursing staff in hospitals in Iceland. These findings are somewhat comparable to those from a study in the US ( Kalisch, Lee, & Rochman, 2010) as well as a study from Singapore ( Goh et al., 2020) where experience on current unit, perceived staffing adequacy, and nursing teamwork were among variables that contributed significantly to job satisfaction, showing a significant positive relationship of teamwork and job satisfaction.

Implications for Practice

The findings of this study confirm the importance of adequate staffing and good teamwork for nurses' job satisfaction, and therefore quality of care, having implications for all stakeholders of health care services. Staffing however, will remain the most challenging part of the equation as lack of nursing staff is foreseen globally in the coming decades turning the spotlight to teamwork. Therefore, clinical nurse leaders, administrators, and instructors are encouraged to emphasize on strengthening nursing teamwork for the benefit of quality patient care.

Study Strengths and Limitations

This study has both strengths and limitations. The main strengths of this study are the use of a reliable and valid tool, the NTS-Icelandic, and a satisfactory response rate of 69% from a national sample of nursing staff. The first-time use of the questionnaire in Icelandic may be a limitation, also the varying response rates of each unit, and that no extraneous variables were controlled. However, the study is considered to have served its purpose.

Conclusion

Teams and team-based health care are identified as core components for patient safety ( Mitchell et al., 2012; WHO, 2016) where nurse clinicians as well as nurse leaders play a key role ( Institute of Medicine, 2004). Nurse leaders not only have the role and responsibility of leading teams but also it is their duty to see to it that nursing staff get any education and training needed for practicing effective teamwork ( Logan & Malone, 2018). Studies show that education and team training in nursing and health care is successful, not the least when it includes role plays and simulation ( Brodsky et al., 2013; Campbell et al., 2020; Kalisch et al., 2013). The findings from our study as well as the study from Kalisch et al. (2010) from the US and the study from Goh et al. (2020) from Singapore not only identify the significant association of nursing teamwork and job satisfaction, but also the importance of identifying characteristics at the organizational, unit and individual staff level which may influence teamwork. Therefore, culturally sensitive interventions ( Rice et al., 2021), directed at individual staff members, as well as the team or unit level, or even the organizational level, should be tailored to the different groups of staff according to work experience ( Delisle et al., 2020). During the COVID-19 pandemic this has become an even bigger concern than before and recent studies, conducted during the COVID-19 pandemic, confirm the importance of keeping our focus on teamwork and job satisfaction for nurse retention and quality of nursing care ( Anjara et al., 2021; Lavoie-Tremblay et al., 2022; Said & El-Shafei, 2021; Zhang et al., 2022). Facilitating and supporting good teamwork should therefore be one of the priorities in every nurse leader's work.

Supplemental Material

sj-docx-1-son-10.1177_23779608231175027 - Supplemental material for The Relationship of Nursing Teamwork and Job Satisfaction in Hospitals:
Supplemental material, sj-docx-1-son-10.1177_23779608231175027 for The Relationship of Nursing Teamwork and Job Satisfaction in Hospitals by Helga Bragadóttir and Beatrice J. Kalisch, Birna G. Flygenring, Gudný Bergthóra Tryggvadóttir in SAGE Open Nursing

Footnotes

Authorship Contribution Statement: It is confirmed that all listed authors meet the authorship criteria and all authors are in agreement with the content of the manuscript.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by research grants from the University of Iceland, Landspitali-University Hospital and The Association of Registered Nurses in Iceland.

Ethical statement: The study was approved by the Institutional Review Board in each hospital, or analogue body in the smaller hospitals and notified to the Data Protection Authority of Iceland (S5388/2011). Participation was anonymous and participating equaled a written informed consent. The names of participants were never revealed to the researchers and the liaison persons distributed the questionnaires with an invitation letter and a response envelope, to staff members. All data were preserved in a protected space.

ORCID iD: Helga Bragadóttir https://orcid.org/0000-0002-5616-8289

Supplemental Material: Supplemental material for this article is available online.

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Articles from SAGE Open Nursing are provided here courtesy of SAGE Publications

# data[].attributes.attachment_link.title
The Relationship of Nursing Teamwork and Job Satisfaction in Hospitals

# data[].attributes.attachment_link.description
Teamwork is identified as a key contributor to patient safety and good teamwork is recognized as one of the presumptions of healthy work environment in nursing. The importance of job satisfaction in nursing has repeatedly been confirmed, but only recently ...

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The beneficial effects of teamwork on patient-centered care are further highlighted by a different study by Baek, Han, Cho, and Ju (2023) titled "Nursing teamwork is essential in promoting patient-centered care: a cross-sectional study". The study revealed a substantial correlation between improved patient-centered care and nurses' teamwork levels, indicating that proficient teamwork can considerably improve patient outcomes.

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Abstract

Background

There has been little research regarding nursing teamwork, despite its important role in multidisciplinary teamwork in healthcare settings and its significance in ensuring high-quality nursing care. This study aimed to determine the teamwork levels of Korean nurses and examine the relationship between nursing teamwork and patient-centered care while controlling for other individual and work-related factors.

Methods

We conducted a cross-sectional analysis of online survey data. The study population consisted of 992 Korean registered nurses employed in hospitals who had a minimum of six months of clinical experience. We performed latent profile analysis to identify latent teamwork subgroups based on response patterns. We performed analysis of variance and Chi-square tests to examine differences in individual and work-related characteristics according to teamwork group. We used multiple linear regression to investigate how nursing teamwork could affect patient-centered care after controlling for covariates.

Results

We identified three nursing teamwork subgroups: low, mid, and high. Nurses with a higher level of teamwork in their units tended to work fewer hours with more adequate staffing ( F = 5.88, p = 0.003 for working hours; F = 7.68, p  < 0.001 for staffing adequacy). There was a significant positive association between nursing teamwork and patient-centered care after controlling for personal and work-related characteristics. Compared with low teamwork, mid and high teamwork increased patient-centered care scores by 0.32 (95% confidence interval [CI] = 0.23-0.40) and 0.57 (95% CI = 0.48-0.66), respectively.

Conclusion

Our findings indicate that enhancing nursing teamwork can serve as an effective strategy for promoting patient-centered care. Providing nurse education and training to equip nurses with the necessary knowledge and skills for effective teamwork is a crucial step. Additionally, fostering management commitment to create a supportive working environment, including adequate staffing, can facilitate improved nursing teamwork and, subsequently, patient-centered care.

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Background

Patient-centered care (PCC), often used interchangeably with person-focused or patient-focused care [ 1], is the standard for nursing care [ 2]. PCC is an approach that puts the individual patient at the center of the care process and consists of three components: holistic, collaborative, and responsive care [ 3]. This process can be implemented independently or collaboratively between healthcare professionals and patients to reflect patient needs and preferences [ 4]. It is highly valued as a critical component of healthcare reform in the United States [ 5] and is beneficial to patients, healthcare providers, and organizations [ 6]. Previous studies have indicated that PCC is associated with less hospitalization and fewer laboratory and diagnostic tests, leading to medical cost reduction [ 7, 8], improved staff productivity, and better resource allocation [ 6]. Furthermore, patient participation in the care process allows them to maintain control over their own lives and improves their quality of life [ 9]. For nurses, PCC has been found to correlate with their well-being and job satisfaction [ 10]. To motivate nurses to actively engage in providing PCC, potential factors that can influence the delivery of PCC need to be investigated.

In recent years, multidisciplinary teamwork, referring to teamwork among physicians, nurses, and other relevant healthcare professionals in providing patient care [ 11], has attracted attention in healthcare research. Previous studies have shown that multidisciplinary teamwork leads to better PCC [ 12]. Teamwork failures cause more than 70% of sentinel events in the healthcare system [ 13, 14]. As nurses constitute a significant portion of the global healthcare workforce, fostering stronger teamwork among nursing staff is essential to promote effective multidisciplinary teamwork [ 15]. Therefore, it is imperative to further investigate the dynamics and implications of nursing teamwork [ 16]. Nurses are frontline care providers who spend the most time with patients, constantly monitoring and supporting them. Effective nursing teamwork, defined as effective work between two or more nurses who work together in the same unit to provide care and perform other tasks for patients [ 14], is vital for the provision of high-quality healthcare [ 17]. Nurses serve as the foundation for multidisciplinary teamwork in healthcare settings as intermediaries between various healthcare providers [ 18]. Therefore, determining whether and how nursing teamwork could contribute to PCC may provide guidelines for its facilitation.

While the need for the further investigation of nursing teamwork and PCC persists, a deeper understanding of this relationship requires the consideration of other organizational factors, as PCC approaches involve all levels of an organization [ 19, 20]. For example, while a staffing shortage is a barrier to effective care [ 21, 22, 23], previous research implies that effective teamwork can improve nursing care quality when staffing levels are adequate [ 24, 25]. Without adequate levels of teamwork and staffing, the core factors of PCC, such as patient education and communication with or comfort for patients and families, can be missed [ 25]. The importance of nursing teamwork in PCC remains an understudied area. To address this research gap, our study aimed to investigate the relationship between nursing teamwork and PCC.

Methods

Aims

Study design and sampling procedure

This study employed a cross-sectional design using online survey data. It was part of a research project on nursing teamwork related to nursing and patient outcomes. Data were collected from Korean nurses in May 2021. The data collection process was described in a previous study [ 27]. In brief, study participants were recruited from 'My Duty,' a work scheduler mobile application designed for shift-work nurses used by approximately 85% of Korean nurses. Current users were invited to participate in the survey via the mobile application and could complete it after they provided consent. We included RNs working in hospital settings with 100 beds or more who had over six months of clinical experience. For this study, we excluded nurses who were as the only nursing personnel in their units because nursing teamwork requires at least two nurses in the unit.

Measures

Nurses were asked about nursing teamwork within their units (as an independent variable) and PCC (as a dependent variable). Additionally, we measured work-related and individual characteristics as confounding variables.

Nursing teamwork

Nursing teamwork was measured using the Korean version of the Nursing Teamwork Survey (NTS-K) [ 14, 27]. We defined a nursing team as nurses and NAs working together in the same unit. It consists of 33 items in five sub-domains: trust (7 items), team orientation (9 items), backup (6 items), shared mental model (7 items), and team leadership (4 items), and is one of the most widely used instruments for measuring nursing teamwork levels. Previous studies have reported its strong validity - content, concurrent, construct [ 14, 27] - and good reliability (Cronbach's alpha = 0.825). The items were rated on a 5-point Likert scale (1 = rarely to 5 = always). The mean score of each sub-domain was calculated. We performed latent profile analysis (LPA) using the five sub-domain scores. LPA is a statistical modeling approach used to identify latent subgroups within a population based on continuous variables, presenting group membership as a categorical variable [ 28]. This could capture the heterogeneity of individual perceptions of nursing teamwork instead of creating a variable using the overall mean values. In this study, the three groups obtained by LPA indicated the three different levels of perceived nursing teamwork (low, medium, or high). We coded the three levels as a variable and used it as an independent variable representing the degree of nursing teamwork.

Patient-centered care (PCC)

For this study, we used the Korean version of the PCC scale [ 4, 29]. It consists of 23 items, including 8 items for holistic care, 9 items for collaborative care, and 6 items for responsive care. Each item was rated on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). We used the mean score of the 23 items as the overall score, with a higher score indicating a higher level of PCC provision as perceived by nurses. The measure had acceptable content and construct validity [ 4, 29], and its internal consistency was good (Cronbach's alpha = 0.935 in Lee et al. [ 29]; 0.949 in this study).

Work-related and individual characteristics

Nurses were asked about their work-related characteristics, including working hours per week, years of work experience in the current unit, unit type, and hospital size. Nurses rated the perceived staffing adequacy during the last month using a 5-point Likert scale (1 = rarely, 2 = 25% of the time, 3 = 50% of the time, 4 = 75% of the time, 5 = always). We included age as a covariate based on previous research findings [ 24].

Statistical analysis

Results

Sample description

Table 1 Characteristics of Korean hospital nurses according to the nursing teamwork level, n = 992

Of the 1,160 participants who completed responses, 45 were disqualified for various reasons during data cleaning (e.g., not a nurse or clinical experience of less than six months). We excluded another 123 participants in some nursing units (OR/PACU, outpatient, and NICU) because the 'PCC' and 'teamwork' measures were not validated or applicable. Finally, a total of 992 nurses were included in this analysis.

On average, the sampled nurses were 29 years of age (SD = 4.6) and had 3.5 years of working experience (SD = 3.2) in their current units (Table 1). They reported a mean of 44.8 working hours per week, including overtime, during the last month. Over 90% of the nurses worked in general hospitals and did shift work (two or three shifts). Most nurses (72%) worked in general wards (e.g., medical/surgical units), with 25% in intensive care units (ICU) or emergency departments (ER).

Nursing teamwork profile

Table 2 LPA indices for determining the group number

Perceived nursing teamwork levels of three teamwork groups

Note: The three groups were determined by LPA based on their responses to the five nursing teamwork sub-domains. The items were rated on a 5-point Likert scale (1 = rarely to 5 = always)

Individual and work-related characteristics according to the nursing teamwork level

There were significant differences in weekly work hours and staffing adequacy according to the perceived nursing teamwork level (Table 1). Nurses who perceived a higher level of teamwork in their units tended to work fewer hours with more adequate staffing ( F = 5.88, p = 0.003 for working hours; F = 7.68, p < 0.001 for staffing adequacy). No significant differences were noted in age, work experience in the current unit, unit type, or hospital size between the teamwork subgroups. Participants with a higher nursing teamwork level had a higher level of PCC ( M = 3.3 for low teamwork, 3.6 for mid teamwork, 3.9 for high teamwork; F = 74.64, p  < 0.001).

Nursing teamwork profile and PCC

Table 3 Coefficients of predictors for patient-centered care among Korean hospital nurses, n = 992

Table 3 shows the association between nursing teamwork and PCC while controlling for individual and work-related characteristics. The model containing all predictors (nursing teamwork, working hours, work experience, staffing adequacy, unit type, hospital size, and age) was significant ( F = 15.738, df = 10, 981, p < 0.001), explaining 13.8% of the variance in PCC (adjusted R ²  = 0.129). The PCC scores increased by 0.32 (95% CI = 0.23-0.40) and 0.57 (95% CI = 0.48-0.66) with mid and high levels of teamwork, respectively, compared to low teamwork.

Discussion

PCC provision is challenging due to its complexity. Therefore, compared with task-oriented care, it often requires more time for nurses to understand the patient's preferences and values and to reflect and coordinate them in the care process [ 33]. PCC can be affected by various factors, including individual nurse characteristics, such as age, compassion satisfaction, and burnout status [ 34]. These factors may not be amenable or could burden nurses if changes are forced. Institutional and organizational efforts could be more effective in creating a work environment to support PCC. Research on PCC indicates that a lack of time could lead to a discrepancy between what nurses know and what they actually do for PCC [ 33]. Currently, nursing techniques may not be profitable for hospitals, as their costs are usually included in procedures. Hospitals may be reluctant to prioritize investment in a favorable environment for quality nursing. Nevertheless, PCC is associated with positive patient and nursing outcomes [ 11, 35, 36], which will ultimately reduce operational costs and human resource requirements for hospitals. Our results showed that improving nursing teamwork could be a strategy for increasing PCC. Further training programs for nurses to empower them with the necessary knowledge and skills are recommended [ 34].

We identified three subgroups within the study sample based on the response pattern of NTS sub-domains. Each subgroup was defined according to the levels of NTS sub-domains (high teamwork group, mid teamwork group, and low teamwork group). In this study, the five NTS sub-domains were classified based on levels rather than distinct characteristics, which indicated that the components of nursing teamwork are not clearly distinguishable. Rather, they are interrelated concepts that change collectively. Indeed, the Salas theory, which is a framework for the NTS, assumes that interrelationships among the components of teamwork are facilitated by coordinating mechanisms [ 14, 37]. A previous study examining the facets of nursing teamwork in multiple acute care environments observed a constant trend in NTS sub-domains regardless of the nursing unit type [ 23], which is consistent with our findings. In addition, various studies have reported that NTS sub-domains have a moderate-to-strong correlation with each other [ 14, 38].

Nursing teamwork was significantly associated with work-related factors. Nurses with a lower level of nursing teamwork worked in a more austere environment. Longer working hours and inappropriate staffing levels could lead to heavier workloads [ 40, 41, 42]. This may deprive nurses of the energy or time to monitor and support each other and exchange information, all of which are required for effective teamwork [ 23, 36, 37]. Similar to previous studies, the results demonstrated that staffing adequacy may be closely related to overall nursing teamwork [ 24, 41, 43]. Adequate staffing allows team members to flexibly react to team tasks, thus improving team functioning [ 44]. Nursing teamwork is an effective strategy for preventing missed care [ 45] and increasing job satisfaction [ 46]. However, a lack of resources or support could hinder the creation of a supportive environment that promotes nursing teamwork.

While our research provides valuable insights, several limitations warrant consideration for a comprehensive understanding of the study results. The adjusted R-squared of our model is small, despite the significance. Our main objective was to investigate the influence of nursing teamwork on patient-centered care, rather than to predict the behavior of patient-centered care delivery. Notably, we observed a statistically significant B value for nursing teamwork concerning patient-centered care, rendering the acceptable R-squared value [ 47]. Our research findings were based on a cross-sectional dataset; thus, we cannot guarantee causal relationships among variables. Future research with a longitudinal design is warranted to examine the causal relationship between nursing teamwork and PCC.

Conclusion

PCC requires active collaboration and respectful conversation between healthcare professionals and patients, which contributes to an interactive healthcare environment [ 19]. In this context, this study highlights the importance of nursing teamwork for PCC. To improve nursing teamwork in clinical practice, management commitment and relevant policies should be prioritized. In addition, managerial efforts to ensure a supportive working environment, such as optimal staffing and maintaining proper working hours or schedules, support strong nursing teamwork, which in turn could enhance nurses' PCC practice. Education through awareness and knowledge starting from the undergraduate level (e.g., TeamSTEPPS) will provide basic skills for better teamwork [ 50], as well as organizational training such as virtual simulation and train-the-trainer interventions aimed at improving teamwork skills [ 51, 52], would be helpful for PCC. Further research is recommended on effective teamwork and its effect on PCC.

Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

References

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Funding

This research was funded by a National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (No. 2022R1A2C1009936).

Author information

Authors and Affiliations

1. School of Nursing, University of Maryland, Baltimore, MD, 21201, USA

Hyang Baek

2. College of Nursing, Chung-Ang University, Seoul, 06974, South Korea

Kihye Han

3. Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul, 03722, South Korea

Hyeonmi Cho

4. Graduate School, Chung-Ang University, Seoul, 06974, South Korea

Jieun Ju

Contributions

HB analyzed and interpreted the data, and wrote the manuscript. KH served as research advisor, analyzed and interpreted the data, and wrote the manuscript. HC collected, analyzed and interpreted the data. JJ collected and cleaned data. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Kihye Han.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Chung-Ang University Institutional Review Board (IRB no. 1041078-202103-HRSB-082-01). The study was conducted according to the appropriate guidelines and regulations. Study participation was voluntary, and informed consent was obtained from all survey participants.

Consent for publication

N/A.

Competing interests

The authors have no conflicts of interest to declare.

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Baek, H., Han, K., Cho, H. et al. Nursing teamwork is essential in promoting patient-centered care: a cross-sectional study. BMC Nurs 22, 433 (2023). https://doi.org/10.1186/s12912-023-01592-3
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# data[].attributes.attachment_link.title
Nursing teamwork is essential in promoting patient-centered care: a cross-sectional study - BMC Nursing

# data[].attributes.attachment_link.description
Background There has been little research regarding nursing teamwork, despite its important role in multidisciplinary teamwork in healthcare settings and its significance in ensuring high-quality nursing care. This study aimed to determine the teamwork levels of Korean nurses and examine the relationship between nursing teamwork and patient-centered care while controlling for other individual and work-related factors.

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Bragadóttir, H., Kalisch, B. J., Flygenring, B. G., & Tryggvadóttir, G. B. (2023). The relationship of nursing teamwork and job satisfaction in hospitals. SAGE Open Nursing, 9, 237796082311750. https://doi.org/10.1177/23779608231175027

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