Different strokes for different folks? Staff perceptions of team functioning in Ontario Community Health Centres

Jennifer RaynerLaura MuldoonOntario Community Health Research RoundsJanuary 21, 2015

DetailsCOI - Investigators are employees of

CHCsFunding from University of Ottawa

Department of Family Medicine Research Funding Program

Ethics from Ottawa Health Sciences Research Network and Bruyère Continuing Care

What are PC teams?Inter-professional teamwork in

PHC is a priority in Canada2

Know more about who team members are than what they do or how they work together.3

Membership of PC teams vary widely depending on the setting2

Care is by “the integrated activities of clinical and non-clinical members of (PC) teams”4

What is team function?Multi-faceted concept and

includes the following5:Processes and psycho-social traits of the team

Links a team’s task design (types & features of the tasks)

Membership of the team

Team effectiveness

Is team function important? Quality of team function linked to

innovation and effectiveness in PC6 , technical quality of care.7

Quality of team function may have more influence over clinical behaviors in PC than individual provider or practice characteristics.8

Aspects of team function can be improved by certain interventions.9

Why look at CHC teams?Quality of primary care delivered in CHCs is

equivalent or superior to that in other PC models in Ontario.2, 11,12,13

ICES – CHC study“If you’ve seen one CHC, you’ve seen one CHC”Provincial tour – different “feel” to the teamsLittle is known about CHC PC team functionQuebec community-governed practices (some

similar to Ontario CHCs) had lower scores for team climate than professionally-governed practices14

Previous Research ResultsStaff Groups & Teams

Ontario: admin staff reported “suboptimal” team climate more than GPs.14

US CHC physicians dissatisfied with high workloads and administrative management.15,16

No literature on how other team members view team functioning

Organizational Features & Teams Leadership, professional governance, solo

practice, certain team cultures are associated with better team function

No association previously found with size of the team or number of sites (in PC)

Our Questions...How do CHC staff rate

the functioning of their teams?

Are there differences between different groups of staff in how team function is perceived?

Are there differences between different CHC organizations?

Are there organizational features which can explain the differences?

MethodsCross-sectional, part of proposed

larger study Ethics – OHSRN/Bruyère REBAll 75 CHCs invitedPHC director completed

organizational surveyED distributed on-line survey to PC

staff``any person who provided or

supported the provision of clinical care on a regular basis” (including administration & reception)

Organizational SurveyAdapted from CIHINumber of sites,

staffing, size, priorities, means of communication, rurality, years of operation, patient demographics

Staff SurveyDescriptive

(professional role, full-time status, number of years employed at the CHC , working off-site from the main clinic)

3 different scales

Team Climate InventoryTeam Climate:

shared perceptions of policies, practices & procedures within team

Short, validated 14 item versionVision Innovation Participative safetyTask Orientation

Organizational JusticeAssesses perceptions of fairness, equity &

respectProcedural Justice (PJ) – 7 items (perceived

fairness)“Procedures are in place to generate standards so that decisions can be made with consistency”

Interactional Justice (IJ) – 6 items (politeness, dignity & respect) “Primary health care team members consider your viewpoint.”

Organizational Citizenship Behaviour

Perceptions of the presence of work related behaviors that are:discretionarynot related to the formal reward systemin the aggregate promote the effective functioning of the organization.20

13 items “Help each other out if someone falls behind in his/her work”

Analysis Staff characteristicsResponses stratified by staff group (manager,

physician, NP, registered nurse, medical secretary, allied health, counselor, outreach, admin assistants)

One-way Anova to determine overall difference in team climate, organizational justice and citizenship behaviour between the different provider groups.

Bonferroni posthoc analysis based on apriori hypothesis

Organizational characteristicsLinear regressions relating organizational features

with the various measures of team function

Overall Results58 CHCs (77.8%)674 staff physicians, NPs,

nurses –57% of the respondents

Excluded “system navigators” due to low numbers

NP MD Nurse SW Allied Out MOA AA Mgr0

10

20

30

40

50

60

70

80

90

100

CHC Staff (Ontario)

Yrs x10FT (%)%

Results One way ANOVA –

significant difference between staff groups on mean scores for: Procedural Justice (p= 0.01)

Total TCI (p=0.03) Innovation subscale of TCI (p=0.011)

Team Climate Inventory

NP

Physi

cian

Nurse SW All

ied

Outrea

ch Sec AA

Manag

erTO

TAL

4.64.74.84.9

55.15.25.35.45.55.6

Organizational Justice

Physi

cian NP

Nurse SW All

ied

Outrea

ch

Secre

tary AA

Manag

erTO

TAL

4.2

4.4

4.6

4.8

5

5.2

5.4

5.6

Organizational Citizenship Behaviour

Physi

cian NP

Nurse SW All

ied

Outrea

ch

Secre

tary AA

Manag

erTO

TAL

4.7

4.8

4.9

5

5.1

5.2

5.3

5.4

Differences between groups

PJ - Organizational level results

Organizational features & team function

Association ONLY between higher number of sites and lower team function. (TCI and OJ p<0.05)

The different measures of team function were highly correlated at the organizational level

PJ

IJ

OJTCI

OCB

0

0.5

1

PJIJOJTCIOCB

DiscussionTCI ratings similar to other Canadian PC

studies.7,21

Citizenship behaviour and organizational justice within the range of results reported in other settings.8,22, 23

Similar views of vision and mandate of CHC, work well together, help each other

Differences between staff types for TCI, “innovation” and PJ Different expectations?

TCI link to patient-reported access, continuity, quality of diabetes care, patient satisfaction BUT not in every study.

Recent Quebec study “modest” association between TCI and technical quality of care

Procedural Justice NPs & physicians significantly lower than

admin staff & nursesPJ linked to improved quality of diabetes

care8, better glycemic control 22 more job satisfaction among physicians and nurses 26,27

Perceived injustice linked with poorer quality, lower productivity of health care work 28,29 stress-related disorders among staff30

Why the different PJ ratings?CHC model – managers manage Providers don’tMany managers MAY be from nursing background? NP and physician have different expectations?MD unhappy about management in US CHCsNP unhappy about division of labour on team?NP unhappiness about wages?Part-time employees rate team higher, more

resistant to change24,25

Longer duration of employment – effect?Medical secretaries left many questions

unanswered – questions too clinical? Or didn’t feel they were part of the team?

Organizational featuresCHCs have many organizational features in

common, such as community governance, inter-professional teams, model for remunerating staff and leadership model.

Staff of a team spread across many sites may not feel cohesive, may rate TCI and OJ lower for the entire team. (Future: assess as separate entities the “teamlets” that make up multi-site teams.)

Strengths/Weaknesses77% CHCs participatedLots of staff – BUT no denominatorValidated instruments

ConclusionAll staff had positive ratings of team climate,

organizational justice and organizational citizenship behaviours

Physicians and NPs had lower ratings for procedural justice.

Procedural Justice has been shown to be very important in other settings, and may be amenable to improvement through interventions.

The only Org feature relating to function was number of sites

Next stepsQualitative studyWorking on defining

the questionDifferences in PJ due

to expectations of NP& MD... systematic silencing...or both?

Will choose high and low performing sites for interviews

Staff of different types

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