Nursing Control Over Practice and Teamwork
High control over practice exerted a positive, statistically significant relationship with all five teamwork skill and behavior perceptions with small effect sizes. Additionally, there was an interaction effect between high control over practice and TeamSTEPPS® training to improved situation monitoring perceptions, suggesting training effectiveness is contingent upon nursing control over practice. Between nurses who had attended TeamSTEPPS® and those who did not, the only difference was the perception of leadership. Given the expectation that nurses who attended the workshop shared what they learned with coworkers who did not attend (or expectation of a diffusion of intervention), this is not a surprising finding. It is unclear if nurses with a greater sense and awareness of leadership would have self-selected to attend the training or if the exposure to education outside of the patient care environment enhanced perceptions of leadership.
Control over practice is not only an inherent employee characteristic, but a formalized organizational structure (Kramer & Schmalenberg, 2003). In nursing, professional autonomy is often synonymous with control over practice. When designing, performing, or scheduling any aspect of work or self-management, autonomy is the amount of independence and judgment an employee is afforded to complete the work (Cummings & Worley, 2009). Self-managed employees, across professions and workplaces, are more likely to be invested in the organization and feel responsible for the outcomes of their work. Empowered decision-making over team structure and resources needed in clinical practice are key to nursing control over practice (Kramer & Schmalenberg, 2003). High performing hospitals demonstrate not only higher levels of nursing control over practice at the point of care, but also within governance of the organization (Aiken, Clarke, & Sloane, 2002). This study contributed to the understanding of control over practice as a variable that has a positive relationship with teamwork skill and behavior perceptions.
Years of experience in the current role had a relationship with the global composite of all five dimensions of teamwork, but not with any one specific dimension. Thus, years of experience exerts a gestalt impact on elevating teamwork, without a statically significant relationship with any one dimension of teamwork. Further research is needed to uncover specifically how years of experience contributes to teamwork skills and behaviors and determine how this impact can be leveraged to enhance teamwork skills and behaviors.
The effect size of control over practice on the dimensions of teamwork is small, accounting for 2 to 4% of the overall variability in subjects' responses on teamwork. Likewise, years of experience accounted for 4% of the variability. This study supports the idea that the foundations and situations that lead to teamwork in healthcare are complex and multi-dimensional. While nursing control over practice is an essential component to elevating teamwork, additional contributors to teamwork must continue to be studied and supported.
As a single, cross-sectional design, the relationships do not demonstrate causation, only correlation. Selection bias may have impacted results as the survey relied on self-report and convenience sampling. Control over practice was measured with a single item and not a subscale with confirmed validity and reliability. The generalizability of the results is limited by the sample recruitment from one hospital system in one metropolitan area of the United States. The statistical assumption of normality was violated, as data was positively skewed. However, we utilized statistics that were robust to violation of the normality assumption when all variables are skewed in the same direction.
Discussion
High control over practice exerted a positive, statistically significant relationship with all five teamwork skill and behavior perceptions with small effect sizes. Additionally, there was an interaction effect between high control over practice and TeamSTEPPS® training to improved situation monitoring perceptions, suggesting training effectiveness is contingent upon nursing control over practice. Between nurses who had attended TeamSTEPPS® and those who did not, the only difference was the perception of leadership. Given the expectation that nurses who attended the workshop shared what they learned with coworkers who did not attend (or expectation of a diffusion of intervention), this is not a surprising finding. It is unclear if nurses with a greater sense and awareness of leadership would have self-selected to attend the training or if the exposure to education outside of the patient care environment enhanced perceptions of leadership.
Control over practice is not only an inherent employee characteristic, but a formalized organizational structure (Kramer & Schmalenberg, 2003). In nursing, professional autonomy is often synonymous with control over practice. When designing, performing, or scheduling any aspect of work or self-management, autonomy is the amount of independence and judgment an employee is afforded to complete the work (Cummings & Worley, 2009). Self-managed employees, across professions and workplaces, are more likely to be invested in the organization and feel responsible for the outcomes of their work. Empowered decision-making over team structure and resources needed in clinical practice are key to nursing control over practice (Kramer & Schmalenberg, 2003). High performing hospitals demonstrate not only higher levels of nursing control over practice at the point of care, but also within governance of the organization (Aiken, Clarke, & Sloane, 2002). This study contributed to the understanding of control over practice as a variable that has a positive relationship with teamwork skill and behavior perceptions.
Years of experience in the current role had a relationship with the global composite of all five dimensions of teamwork, but not with any one specific dimension. Thus, years of experience exerts a gestalt impact on elevating teamwork, without a statically significant relationship with any one dimension of teamwork. Further research is needed to uncover specifically how years of experience contributes to teamwork skills and behaviors and determine how this impact can be leveraged to enhance teamwork skills and behaviors.
The effect size of control over practice on the dimensions of teamwork is small, accounting for 2 to 4% of the overall variability in subjects' responses on teamwork. Likewise, years of experience accounted for 4% of the variability. This study supports the idea that the foundations and situations that lead to teamwork in healthcare are complex and multi-dimensional. While nursing control over practice is an essential component to elevating teamwork, additional contributors to teamwork must continue to be studied and supported.
As a single, cross-sectional design, the relationships do not demonstrate causation, only correlation. Selection bias may have impacted results as the survey relied on self-report and convenience sampling. Control over practice was measured with a single item and not a subscale with confirmed validity and reliability. The generalizability of the results is limited by the sample recruitment from one hospital system in one metropolitan area of the United States. The statistical assumption of normality was violated, as data was positively skewed. However, we utilized statistics that were robust to violation of the normality assumption when all variables are skewed in the same direction.
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