Nursing Management June 2010 53www.nursingmanagement.com

C a r e e r s c o p e : P a c i f i c M o u n t a i n

O ne thing you don’t learn in nursing school is project management. Or do you? Although nurses may not receive formal training on business topics, there are many skills you do learn that can help you conceive and manage projects in the workplace. In fact, the nursing

process provides an ideal background for using project management techniques. The nursing process incorpo- rates a systematic method of assessment, diagnosis, planning, implementation, and evaluation. Project man- agement encompasses similar procedures for successful results.

Project management includes the following steps: project initiation, planning, execution, monitoring, and closing. Originally conceived as a tool to ensure that projects using many disciplines would be correctly bud- geted and completed within a scheduled time frame, project management has become useful in a variety of settings from writing a book to building a skyscraper. The use of the systematic steps in project management can eliminate costly mistakes, increase quality, and save time. The nursing process may help the nurse manager understand how using a systematic process to complete a project is beneficial.

Initiation The first step in project management is initiation, which corresponds to the first two phases in the nursing process—assessment and diagnosis. It’s crucial that the goals and objectives of any unit project align with the overall goals and objectives of the organization. For ex- ample, if a hospital has an unacceptable number of mis- labeled lab specimens, the project of decreasing the number of mislabeled specimens may be assigned to a unit as part of the institution’s quality assurance goals.

At this point the overall goal is clear—to decrease the number of mislabeled specimens on the unit—but you must further define the objective by clarifying the out- come expected, as well as the constraints of the project in terms of budget, manpower, and time commitment. In many cases, these constraints may have already been defined as part of the larger organizational goals, such as

how the outcome will be measured in terms of time and success. For our unit project of decreasing mislabeled specimens, adding the needed information will give us a well-defined objective. The unit will decrease mislabeled specimens by 20% per quarter until it reaches zero misla- beled specimens. Progress toward the goal will be re- ported by the unit manager on a monthly basis and also reported at monthly quality assurance meetings. Well- defined outcomes in terms of time and measurement criteria are essential to make the evaluation process clear.

Planning When the outcome criteria are established, you’re ready to move to the next step—the planning phase. In our example, the number of mislabeled specimens on the unit must be established and the expectations identi- fied. These may include identifying what constitutes a properly labeled specimen, what items are needed to properly label a specimen, and what the current process for labeling currently involves.

You should recognize that this is a process problem and look for process solutions by identifying patterns and trends. If the data are examined they may show, for in- stance, that many mislabeled specimens occur more frequently when the labs are done within 2 hours of admission or when they involve nurses who are floating and not regularly on the unit. Identified trends allow the team to look for possible reasons for the problem and begin to formulate a plan.

Planning is a crucial phase in both the nursing process and project management. Initiation and planning are at times almost seamless. Project plans should be both de- tailed and transparent. Plans should identify process changes, materials needed to complete the change, and any educational needs. Everyone involved in a project should know what’s expected of them. This means that sharing a plan for change with the larger unit staff is a key to buy in, as is sharing the progress toward meeting the goal. Identification of unit champions is also a com- ponent of success in bringing the project to fruition. Finally, the timeline for each step and monitoring proce- dures should be detailed.

Execution The next step in project management is the execution phase, which corresponds to the implementation phase of the nursing process. Project execution requires that every member of the unit staff understands the goal, expectations, and timeline. A well-run project allows all participants to be able to instantly access the data. Suc- cess depends on every team member being a part of the

Get the keys to successful project management

By Penny Morgan Overgaard, BSN, RN, FAHCEP

Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

implementation process in ways that are vital and change oriented. In our project, involvement of the whole team also allows every mislabeled specimen to be an opportunity to evaluate where the process broke down and what was missing to allow for success. No one person is responsible for making a mistake, but every team member is responsible for investigating why the mistake was made and contributing to the process change.

Monitoring The monitoring, or evaluation, step in both project management and the nursing process is dynamic. The best results are produced when there’s constant evalua- tion and feedback. Whereas the manager in this project reports progress to administration monthly, results on the progress and why errors occurred should be given even more frequently to the unit team in order to allow for new information to be assimilated and the plan to be modified as needed. New information should be strategically added to the plan and then revaluated.

Closing The final step in project management is closing the project. This is a valuable step in the process because it ensures that the results of a project are complete and sustainable, and it allows for reflection about how to improve future endeavors. In our mislabeled specimen example, after the target outcome has been reached, the team should spend time making sure the new process is sustainable and that measures are in place to trigger a team review if the mislabeled specimens count rises again. The team should also review the project management process itself.

A project end review sums up the process and allows team members to refine their project management skills. Lessons learned allow team members to utilize the proj- ect management technique in other areas. The astute nurse manager may mentor team members by assigning them to lead another unit project using the same five-step project management process.

Mastering the steps Although nurses aren’t usually specifically educated in business and management concepts, there are ways to adapt the unique skills involved in nursing to many of the nurse manager’s administrative and leadership responsibilities. Successful nurse managers can fulfill their business responsibilities using skills they’ve al- ready mastered. NM

Penny Morgan Overgaard is the Adult CF Program coordinator at Phoenix Children’s Hospital in Phoenix, Ariz.

www.nursingmanagement.com54 June 2010 Nursing Management

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Nancarrow et al. Human Resources for Health 2013, 11:19 http://www.human-resources-health.com/content/11/1/19

RESEARCH Open Access

Ten principles of good interdisciplinary team work Susan A Nancarrow1*, Andrew Booth2, Steven Ariss2, Tony Smith3, Pam Enderby2 and Alison Roots4

Abstract

Background: Interdisciplinary team work is increasingly prevalent, supported by policies and practices that bring care closer to the patient and challenge traditional professional boundaries. To date, there has been a great deal of emphasis on the processes of team work, and in some cases, outcomes.

Method: This study draws on two sources of knowledge to identify the attributes of a good interdisciplinary team; a published systematic review of the literature on interdisciplinary team work, and the perceptions of over 253 staff from 11 community rehabilitation and intermediate care teams in the UK. These data sources were merged using qualitative content analysis to arrive at a framework that identifies characteristics and proposes ten competencies that support effective interdisciplinary team work.

Results: Ten characteristics underpinning effective interdisciplinary team work were identified: positive leadership and management attributes; communication strategies and structures; personal rewards, training and development; appropriate resources and procedures; appropriate skill mix; supportive team climate; individual characteristics that support interdisciplinary team work; clarity of vision; quality and outcomes of care; and respecting and understanding roles.

Conclusions: We propose competency statements that an effective interdisciplinary team functioning at a high level should demonstrate.

Keywords: Interdisciplinary team work, Competencies, Intermediate care, Transitional care, Allied health, Systematic review, Evidence synthesis, Qualitative research

Background Interdisciplinary team work is a complex process in which different types of staff work together to share ex- pertise, knowledge, and skills to impact on patient care. Despite increasing emphasis on interdisciplinary team work over the past decade, in particular the growth of interdisciplinary education [1], there is little evidence as to the most effective way of delivering interdisciplinary team work [2]. This difficulty is compounded by the multifactorial nature of team work, which comprises the skill mix, setting of care, service organisation, individual relationships and management structures. Most existing research explores the impact of one or a

few of these aspects, rather than examining the relation- ships among several of these components on a range of staff and patient outcomes. Similarly, interventions

* Correspondence: [email protected] 1Southern Cross University, Military Road, East Lismore 2480, Australia Full list of author information is available at the end of the article

© 2013 Nancarrow et al.; licensee BioMed Cen Creative Commons Attribution License (http:/ distribution, and reproduction in any medium

designed to improve interdisciplinary team work tend to focus on specifics of team work activities such as: shar- ing of patient files [3], case-conferencing approaches [4,5], or meeting style or frequency [6-10]. To date, there is not a systematic framework around which these activities, or characteristics, of interdisciplinary working can be structured.

Terminology A wide range of terms are used to describe collaborative working arrangements between professionals [11]. Terms such as interdisciplinary, interprofessional, multiprofessional, and multidisciplinary are often used interchangeably in the literature to refer to both different types of teams and differ- ent processes within them [12]. They are also often used in conjunction with the term team work. However, there are some consistent distinctions that are useful to understand. The terms inter/multi-professional are generally narrower than the terms inter/multi-disciplinary [13-16] and refer to

tral Ltd. This is an Open Access article distributed under the terms of the /creativecommons.org/licenses/by/2.0), which permits unrestricted use, , provided the original work is properly cited.

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teams consisting exclusively of professionals from different professions or disciplines, or at least to the relationships between professionals in teams that may also include other non-professional staff. The terms inter/multi-disciplinary are broader and include all members of healthcare teams, professional and non-professional. Other authors have suggested use of the prefixes multi-, inter- and trans- to reflect differing intensities of integration [17]. The focus of this paper is on inter/multi-disciplinary

teams: the research, interventions, and data-gathering ac- tivities underpinning the study included all members of the respective healthcare teams. The term “interdisciplinary team” is used as a generic term of reference for these healthcare teams which included a range of health service workers, both professionals and non-professionals, with the majority being from professional groups. However, where authors have used the terms inter/multi/trans- professional or inter/multi-disciplinary the authors’ original terms will be used.

Interdisciplinary team work Previous research has investigated the fundamental con- cepts and features associated with team work. A concept analysis [18] to explore the basic understanding of team work in the healthcare context drew on both healthcare and literature from other disciplines such as human re- source management, organisational behaviour, and edu- cation, and proposed the following definition for team work in the health care context:

“A dynamic process involving two or more health professionals with complementary backgrounds and skills, sharing common health goals and exercising concerted physical and mental effort in assessing, planning, or evaluating patient care. This is accomplished through interdependent collaboration, open communication and shared decision-making. This in turn generates value-added patient, organisational and staff outcomes.” (p.238).

This definition may be more optimistic and aspirational than realistic as it makes several assumptions about the characteristics that a team will possess. Enderby [19] iden- tified these characteristics to include a definable member- ship, group consciousness, shared vision, corporate sense of purpose, clear interdependence and interaction, and co-ordinated action. Xyrichis and Ream’s [18] literature analysis concludes

that the outcomes from team work could be experienced at three levels (healthcare professionals, patients, and healthcare organizations) and that these outcomes have an impact on staff satisfaction, quality of care, control of costs, well-being and retention. Molyneux [20] identified three indicators for positive team work: personal qualities

and commitment of staff, communication within the team, and the opportunity to develop creative working methods within the team. Further literature reviews [11] have identified the importance of two themes on interprofessional team work, team structure and team processes within which specific categories emerged: team premises, team size and composition, organizational support, team meetings, clear goals and objectives, and audit processes. Collaboration is acknowledged as an important compo-

nent of team processes. A concept analysis undertaken by Henneman et al. [21] identified that collaboration “re- quires competence, confidence and commitment on the part of all parties. Respect and trust, both for oneself and others, is key to collaboration. As such, patience, nurtur- ance and time are required to build a relationship so that collaboration can occur” (p.108). Identified factors that contribute to successful collaboration were: joint venture, cooperative endeavor, willing participation, shared plan- ning and decision-making, team approach, contribution of expertise, shared responsibility, non-hierarchical rela- tionships and shared power based on knowledge and expertise [21]. However, further reviews [22] have found that the reality of shared planning and decision-making, and shared power is very different from the ideal. Given the context of interprofessional teams, members will automatically come from different professions, therefore in practice “shared decision-making” is likely to conflate individual team members making decisions within their own scope of practice with the ideal of all team members sharing in all decision-making processes, or in other words, “appropriate” decision making. Shared power and leadership may also be a challenge when complex trad- itional hierarchical relationships, particularly those involv- ing medical practitioners, play a larger role and impact either implicitly or explicitly on team processes [23,24]. McCallin [23] suggests that shared leadership occurs only in smaller teams privileged with being free to choose all team members. When considering the characteristics important for

interprofessional team work within the context of organ- isational development, McCray [25] points out that little attention appears to have been paid to the actual pro- cesses of interprofessional practice within organisational strategy, local workforce development planning, and in- dividual continuing professional development.

Necessity of interdisciplinary team work The need for interdisciplinary team work is increasing as a result of a number of factors including:

(1)an aging population with frail older people and larger numbers of patients with more complex needs associated with chronic diseases;

Nancarrow et al. Human Resources for Health 2013, 11:19 Page 3 of 11 http://www.human-resources-health.com/content/11/1/19

(2)the increasing complexity of skills and knowledge required to provide comprehensive care to patients;

(3)increasing specialization within health professions and a corresponding fragmentation of disciplinary knowledge resulting in no-one health care professional being able to meet all the complex needs of their patients;

(4)the current emphasis in many countries’ policy documents on multi-professional team work and development of shared learning; and,

(5)the pursuit of continuity of care within the move towards continuous quality improvement [26].

Workforce re-structuring to meet these needs requires that interdisciplinary teams must integrate changing or- ganisational values with new modes of service delivery [13]. While these changes impact across healthcare as a whole, there are certain sectors where these organisa- tional challenges have encountered more widespread de- bate, in particular primary care, rehabilitation, and care of the elderly. Of these, primary care is perceived to have the least likely level of success with interdisciplinary team work. Indeed, some commentators suggest that an interdisciplinary culture may only be possible as new generations of healthcare professionals enter the work- force [27]. Despite the increasing focus on interdisciplinary team

work over the past two decades, there is still no clear synthesis of the “essence” of what makes a good interdis- ciplinary team and a lack of empirical research to define what such a team might look like. Similarly, there is a lack of data identifying the processes of interdisciplinary team work and linking these with outcomes. Studies tend to focus on processes or outcomes, but rarely both; or explore components of what defines an interdisciplin- ary team, without providing a clear guide on the attri- butes of good interdisciplinary team practice. This paper draws on a published systematic review of

the literature [28], combined with empirical data derived from interdisciplinary teams involved in the delivery of community rehabilitation and intermediate care services (CRAICs), to develop a set of competencies around effective interdisciplinary team practice. The research was contextualised in CRAICs. CRAICs in England are community-based services fre-

quently offering care for the elderly aimed at preventing admissions and facilitating earlier discharge from acute care. They exemplify the practice of interdisciplinary team work. Typically, CRAICs employ at least four dif- ferent staff types, including nurses, physiotherapists and occupational therapists [29]. They often exhibit high levels of joint working and role sharing, and employ a large proportion of support workers who, when used

appropriately, have been shown to facilitate interdisciplinary practice in this setting [29]. However, previous research by our team found a great deal of variety in the way that teams work together, and their levels of effectiveness as teams [30]. In response, we developed an Interdisciplinary Man- agement Tool (IMT) which was implemented iteratively, using an action research approach with 11 teams to explore the impact of the tool on those teams and their patient out- comes [31].

Methods This research formed part of a much larger project designed to develop, implement and evaluate an inter- vention to enhance interdisciplinary team work [28] through the development of an IMT [32]. The IMT is a structured change management approach which marries published research evidence relating to interdisciplinary team work with the tacit knowledge of the particular team to develop a tailored approach to optimize their interdisciplinary team work [33]. Development of the tool involved three systematic reviews, interactions with team members using an action research methodology, and capturing extensive, detailed qualitative and quanti- tative feedback from teams and service users. The findings presented in this paper draw on a sys-

tematic review of the literature relating to the compo- nents of interdisciplinary team work and the qualitative data derived from the implementation of the IMT. This latter component of the study included the exploration of team members’ perceptions of the important compo- nents underpinning interdisciplinary team work. Themes from these two perspectives were then examined for areas of agreement and dissonance to arrive at a set of competencies for good interdisciplinary team work.

Systematic review The systematic review, reported and published in full in the main study report [31], first considered quantitative studies; in particular randomised controlled trials (RCTs) published and unpublished between 1994 and 2009, that evaluated the process and outcomes of different interprofessional staffing models. Reference lists associ- ated with the identified reports and articles were also searched for additional studies. Results were limited to English language articles in recognition of the import- ance of cultural factors in team work, and issues relating to differences in terminology (for example, multi-, inter-, trans- and cross- disciplinary working). A total of 153 studies, including 11 systematic reviews or meta-analysis, were reviewed and analysed; however, only 101 were usable based on the supporting level of contextual detail. Data on team effectiveness was extracted along with de- tails on team processes, coordination, and leadership; all

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elements identified as important in the earlier concept analysis of the interdisciplinary team [18]. This initial review confirmed that a lack of contextual

detail, both in trials in general [33], and interdisciplin- ary studies in particular [34], makes it difficult to isolate the “ingredients” of effective interdisciplinary team work. Specifically, the research team identified a lack of “thick- ness” in the detail on context, team roles, and processes from the review of the RCTs. In the absence of mixed- method studies, suggested as a priority for future re- search by a recent review [34], the team designed a supplementary review strategy. This strategy examined findings from qualitative research on interprofessional team processes, independent from the RCTs. Inclusion criteria for the supplementary review were studies be- tween 2000 and 2010 involving an interprofessional team in CRAICs which included data focused on team processes. This complementary review identified 20 studies to supplement previous findings. The findings of the separate evidence bases from qualitative and quantitative studies were brought together and isolated to a data extraction table. Themes were identified using a constant comparative method [35] and then each study was coded appropriately. The constant compara- tive method involves the incorporation, collation and comparison of newly collected data with existing or previous data collected from earlier studies. Thematic synthesis was used to look for common patterns across studies [36].

Team perspectives Eleven CRAICs, including 253 staff were recruited to participate in an action research study, which examined the impact of implementing the IMT on service provision and outcomes for patients and staff. NHS eth- ics approval was obtained on 11 September 2008 (08/ H1004/124). All participating team members provided written consent for their involvement in this research. The IMT intervention was implemented through a

series of semi-structured workshops with the support of a trained facilitator. These workshops included an initial, full day “Service Evaluation Conference” to ascertain each team’s values, needs, and priorities, and then a series of half day “Team Learning Sets” designed to allow for reflective evaluation of their team practice. The activities undertaken included the identification of issues and priority actions that each team wanted to pursue and exploration of what they considered to be “charac- teristics of a good team”. The workshop outcomes were detailed in reports and action plans that guided the im- plementation of their proposed changes. These reports and plans provided the basis of the data for the team perspectives. The

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