Team nursing and ITU – a good combination?

Original article

© 2000 Harcourt P

Team nursing and ITU – a good combination?Paul Gill, Jane Ryan, Orla Morgan and Angela Williams

Paul Gill RGN, ITUDip, BSc (Hons),MSc (Oxon),PostgraduateStudent, WolfsonCollege, Universityof Oxford, Oxford;Jane Ryan RGN,WNB100, BSc(Hons), PGCE,Lecturer, School ofNursing, College ofMedicine, Cardiff;Orla MorganRGN, ENB100, CMS,Sister, HDU,University Hospitalof Wales, Cardiff;Angela WilliamsRGN, WNB100,Senior Staff Nurse,General ITU, UHW,Cardiff, UK.

At time of study,all Senior StaffNurses, GeneralITU, UniversityHospital of Wales,Heath, Cardiff

Requests foroffprints to: PaulGill, 80 BirchgroveStreet, Porth, Mid-Glamorgan CF399UT, UK. Tel.: +44(0)1443 684630; E-mail:[email protected]

Manuscriptaccepted 20/3/00

Deficits in ‘measurable care’, in an 11-bedded intensive care unit, prompted a pilot study ofteam nursing. Team nursing was introduced for three beds out of the total 11 for a period of sixmonths. In order to evaluate the effects, aspects of care and job satisfaction were measured andcompared between the team nursing beds and the rest of the unit. The study revealed that jobsatisfaction and the levels of ‘measurable care’ did not improve whilst team nursing waspractised. Based on this evidence, the authors question the relevance of team nursing in thisparticular intensive therapy unit (ITU) and maintain that the best method of delivering nursingcare in ITU remains unclear. © 2000 Harcourt Publishers Ltd

IntroductionAll professions now work in environments thatdemand a high-quality service, and nursing is noexception. Nurses are constantly being challengedto seek ways of improving standards of care, notonly for the benefit of patients but also theprofession itself.

One possible way of achieving a high-qualitynursing service is through the system of caredelivery. For example, research by Higgins andDixon (1992), O’Connor (1993) and Manley (1989)suggests that delivering care by means of team orprimary nursing can result in improvedstandards of care for patients and greater jobsatisfaction for nurses.

The purpose of this pilot study was to evaluatewhether team nursing can achieve theseoutcomes when introduced onto a busy 11-bedded general intensive therapy unit (ITU).

Literature reviewBackground

The current method of care delivery in theauthors’ unit is that of patient allocation. This is ascheme whereby a nurse (or group of nurses)delivers care to patient(s), usually on a shift byshift basis. This method is completely ad hoc andoften results in one nurse caring for a differentpatient each day.

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The daily allocation of staff, in such a scheme,is frequently influenced by factors such asproviding specific experience for nurses (Manley1994), fulfilling the individual needs of learnersand constraints of skill mix. Patient allocationundoubtedly provides nurses with considerablevariety, allowing them to care for many differentpatients according to their own needs. However,patient allocation provides little continuity of careand therefore frequently leads to fragmentationof care (Gardner & Tilbury 1991). The issue ofaccountability is also raised since this method issteeped in hierarchy, as junior staff often have toreport back to the nurse in charge.

In order to examine whether patient allocationcan result in below-standard, fragmented careone of the authors (OM) performed a series ofaudits of measurable care over several months,throughout 1996. The audit tool used was a 63point checklist that examined a total of 14different aspects of care (many of which wererelated to daily living activities) (Fig. 1). A pointis awarded for each action that has been correctlyperformed at the time of the audit. The points arethen totalled and a percentage given. So, forexample, if 63 points are awarded out of apossible 63, a score of 100% is conferred. The toolwas specifically adapted from the officialHospital Trust Ward Audit Tool (1998). Care ofpatients in three beds was audited, at random,over several months.

e and Critical Care Nursing (2000) 16, 243–255 243

244 Intensive and Critical Care Nursing (2000) 16, 243–255 © 2000 Harcourt Publ ishers Ltd

Intensive and Critical Care Nursing

ICU audit tool, showing main areas and sample questions in each.

A VENTILATION YES NO INCOMPLETE N/A

Have you observed the patientsrespiratory function & colour?

1

1

2 Has suction been given PRN

B C.V.S.

Are emergency drugs in easy access?

2 Have the alarm limits been setaccording to the patients needs?

C BODY TEMPERATURE

1 Has the patient’s temperature been recordedand relevant intervention given?

E ELIMINATION

1 Has bowel action been recorded?

F COMMUNICATION

1 Has the neurological status of thepatient been assessed?

D EATING & DRINKING

1 Has the NG tube been checked forpatency & position?

2 Has the patient been offeredappropriate communication aids PRN?

G SAFE ENVIRONMENT

1 Is the bed area safe for patient & staff?

H INFECTION CONTROL

1 Are adequate precautions in place toprevent cross infection?

I PATIENT HYGIENE

1 Are hygiene needs being met accordingto unit standards/individualrequirements?

J MOBILISING

1 Is the patient receiving the correctpressure relieving tool?

K PSYCHO-SOCIAL

1 Has effective communication withpatient prior to procedures beenachieved

L DYING & SPIRITUAL

1 Are the patient’s cultural & religiousneeds being respected

M ASSESSMENT

1 Is initial assessment complete &comprehensive?

N PLANNING

1 Has the care plan been formulatedwithin 24 hours of admission?

TOTALSYESNO

INCN/A

Fig. 1 ICU audit tool, showing main areas and sample questions in each.

Team nursing and ITU

© 2000 Harcourt

The acceptable standard of care was pre-determined at organizational level, and set at 80%(50 points out of 63). The audits revealedrepeatedly that care, across the unit, was belowthe standard of 80%. The problem areas identifiedwere very similar to a pre-team nursing study byO’Connor (1993). For example, there wasconsistent evidence of poor documentation (withlittle or no evidence of any nursing assessment ofpatient or pressure areas) and poor levels ofcommunication (written and verbal). It waspostulated that many of the problems might berelated to the discontinuity associated withpatient allocation.

Why change?

The impetus for change was fuelled by a greatdesire to provide a high-quality nursing service.The poor results from the care audits were,therefore, extremely influential in bringing aboutthe study. Nursing staff were particularly keen toexamine other nursing concepts as well.Theoretically, primary and team nursing offermany potential benefits such as improvements incontinuity of care/patient allocation, and levelsof communication between staff and relatives(Higgins & Dixon 1992; Thomas et al. 1992;O’Connor 1993).

There is a plethora of research, both in the UKand USA, describing the implementation of teamnursing in numerous clinical settings, though fewstudies are related specifically to its use inintensive care. The only available, relevant Britishstudies are those by Manley (1989) and Bray(1996) (and both authors examined primary andnot team nursing). Therefore it was felt that thispilot study provided an ideal opportunity toevaluate the effects of team nursing in a criticalcare environment, and to enhance professionalintegrity of nurses in an environment dominatedby medically orientated research.

In order to prepare for the study, a nursingconcept group was formed to examine methodsof delivering care in ITU. The group consisted of10 volunteer registered nurses of varying grades.In order to provide a better understanding ofother concepts of nursing the group met on aregular basis throughout 1996, undertook anextensive literature review and visited severalother clinical areas practising team or primarynursing (for example the Chelsea andWestminster ITU).

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What is team nursing?

Team nursing can be distinguished from patientallocation in that nurses are grouped together insome manner and allocated to groups of patientsfor variable but usually considerable lengths oftime (Waters 1985; Thomas & Bond 1990). Thebasic principle involves a group of nursesplanning, delivering and evaluating care as ateam rather than as individuals.

Team nursing is based on the premise thatnurses working together as a close group, with anappointed leader, can provide better care than ifindividuals work alone (Thomas et al. 1992).Team members share their efforts, findings andexpertise working together as a kind of mutualsupport network (Drummond 1990). The teamleader acts as a facilitator and concentrates on theneed to devolve care and responsibilities amongstall team nurses (Thomas et al. 1992). Sherman(1990; p. 44) expands on this idea and states:

When the activities and efforts of diversifiednursing personnel are co-ordinated by aprofessional nurse, the group’s total effort willsurpass what can be done individually.

O’Connor (1993) claims that team nursing holdsmany benefits for staff, patients and relatives. Forexample, increased nursing accountability, greaterjob satisfaction and improved continuity andquality of care, which Sherman (1990) claims isrelated to effective communication.

The postulated benefits in job satisfactionappear to be related to the philosophy of teamnursing and the apparent change in roles of teammembers. For example, Thomas et al. (1992)states that team nursing gives its members equalstatus and promotes democratic attitudes. Thiswould therefore suggest that the philosophy ofteam nursing is that of a flattened hierarchicalapproach to patient care. Bloom and Alexander(1982) pinpoint that professionalism withinteamwork initiates lateral co-ordination in theteam, but a certain measure of hierarchicalcontrol still remains.

Team nursing has also been found to allownurses the opportunity to liaise with other healthcare workers (Manthey 1992). Especially topromote the significance of nurse-led medicalward rounds – which has remained the solehierarchical responsibility of the nurse in charge(Watkins 1993). So can greater collaborationreally be achieved in team nursing?


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9876543210

Numbers

G F E D

Grades

Numbers and grades of nursing staff involved inthe trial.

Fig. 2 Numbers and grades of nursing staff involvedin the trial.

Weeks et al. (1985) on combining the basicelements of primary and team nursing, revealedfollowing a three month pilot study, an increasein physician-nurse communication. O’Connor(1993) examined the effects of team nursing in ageneral medical setting. Part of the study focusedon nurse-doctor relationships and it was reportedthat communication between nurses and doctorsimproved by 19% in the first 6 months of theteam nursing study. However, these findings areboth biased and subjective as only nurses and notdoctors were asked their opinions in this area andO’Connor (1993) provides no additional evidenceto support this claim.

Proving the remainder of the suggestedbenefits of team nursing is also somewhattroublesome because of the difficulties inmeasurement. Moreover, many other authors,such as Hunt (1988), Manthey (1992) andDrummond (1990), suggest that team nursingdoes not and cannot achieve all that has beententatively claimed by others.

Watkins (1993) suggests that team nursing ismerely a system whereby fewer nurses do morethings for fewer patients. Rafferty (1992) alsoargues that team nursing retains the notions ofhierarchical structure where team membersmaintain some dependency on the shift leader fordirecting care delivery. Also, in some respectsteam nursing is viewed as having sharedresponsibility which is equated with noresponsibility, and through the pyramidalcommunication structure discourages nursesfrom thinking for themselves (Hunt 1988;Manthey 1992; Drummond 1990).

Why team nursing?

There were several reasons why the groupeventually opted for team nursing. Firstly it wasfelt that, due to staffing levels in this large busyITU, primary nursing would be impractical.Secondly it was considered that team nursingwould help to reduce the hierarchical nursingstructure by fostering more equal relationshipsamongst all grades of nursing staff – thuspromoting autonomy. Research by Higgins andDixon (1992) indicates that team nursing cannot only achieve this, but can also help toprovide greater support for junior staff. Thisissue was felt to be very important for thesuccess of the study. It was hoped for the above

d Critical Care Nursing (2000) 16, 243–255

reasons, that job satisfaction would alsoimprove.

The group were also encouraged by thepotential benefits, as discussed earlier, to patientsand relatives from improvements in continuityand quality of care. Finally, the decision to have atrial of team nursing was influenced by thepositive past experience of one of the authors(PG) with team nursing in a general medicalsetting.

Implementing the change

When the group decided to implement a teamnursing trial volunteers of all grades wererequested. A total of 23 full and part-time nursesof varying grades (approximately one-quarter ofthe unit’s nursing workforce) joined the group 1G, 5 F, 9 E & 8 D grades (Fig. 2).

It was decided to implement the project usinga normative re-educative approach, as in Bray’s(1996) study of primary nursing in ITU. Thismethod of change is often referred to as a ‘bottomup approach’ since it involves all members of thegroup contributing to the change process (Wright1990). The reason for approaching change in thisway was because the group, particularly thesenior members, wanted to encourage a teamapproach to implementing the project. Alsoresearch suggests that this approach can help toreduce resistance to change (Sheehan 1990).Decision-making was usually carried by majorityopinion but whenever this was not possible theproject leader (PG) had the final say, based ongroup opinions.

© 2000 Harcourt Publ ishers Ltd


© 2000 Harcourt

The time-span of the planning period (4months) was influenced by similar researchstudies by Webb (1990) and O’Connor (1993).This period included three formal study days tosolve problems and examine planning issues,group cohesiveness, teamwork and team nursing.

The group finally decided to open 3 of the 11ITU beds as team nursing beds. There were 2main reasons for this. Firstly, it was only possibleto staff 3 beds with 23 volunteers. Secondly,Thomas and Bond (1991) and Gardner andTilbury (1991) comment that most studiesexamining nursing concept issues fail to includeother nursing units for comparative purposes.Therefore, the remaining ‘non-team nursing beds’allowed the group to compare issues such as careand job satisfaction.

The 3 beds were initially located just off the mainunit as it was felt that this may help to reduce‘interference’ from the rest of the unit. It was alsoagreed to run the trial for a period of 6 months. Thisdecision was based on the need to have a periodlong enough for staff to overcome any problemsassociated with change but short enough to end theproject, if it were deemed to be unsuccessful.

The nurse to patient ratio was 1.3/1 per shift(normally 1.2/1). In order to address properlyany potential problems and to encourage a highstandard of communication the group arrangedto have monthly meetings, a communicationbook, regular teaching sessions for staff and teamconferences which Sherman (1990) claimsfacilitate team building and cohesiveness.

Several sessions were then arranged to informother members of nursing staff, not participatingin the study, about the plan and purpose of thestudy. These sessions were also an opportunityfor staff to discuss any concerns or worries. Allother health care professionals (e.g. medical staffand physiotherapists) on the unit were alsoupdated in a series of informal talks by thereport’s authors.

MethodologyAims of the study

The aims of this study were to:

• investigate the feasibility of team nursing inour ITU;

• establish whether team nursing could improvestandards of nursing care;


• establish if job satisfaction of nursing staffimproved.

Evaluating the effects of the study

There are many potential ways of analysing datain studies that examine such nursing concepts.For example, absenteeism, sickness levels, staffturnover (Thomas & Bond 1991), comparing costsand patient/relative satisfaction have beenexamined. However, researching patientsatisfaction with care in ITU may beinappropriate because most patients areunconscious or sedated (Manley 1994). Relatives’satisfaction is probably also inappropriate in anITU environment because of natural anxiety.Therefore the group opted for the more simplisticand possibly reliable areas.

The effects of the study were evaluated byseveral methods:

JOB SATISFACTION

This was measured through anonymous,confidential questionnaires (Fig. 3) distributedand then returned to a box in the sister’s office.These were completed at 3 and 6 month intervals,by all team nurses and a 50% random sample (bygrade) of qualified nurses not involved in thetrial.

The questionnaires examined several areasthat were believed to reflect some aspects of jobsatisfaction (for example, satisfaction with style ofnursing). The questionnaires were designed bytwo of the authors (PG, JR) and contained bothopen and closed questions, yielding quantitativeand qualitative data. The questionnaires werebased on several areas examined in O’Connor’s(1993) study – for example, positive and negativeaspects of team nursing. Also included wereissues the two authors felt were important orrelevant to the study.

Subjective feedback on job satisfaction andteam nursing amongst team nurses was alsoobtained in open monthly meetings.

NURSING CARE

This was evaluated through comparative auditsof ‘measurable care’. A pre-team nursing studyaudit was performed on care of patients inthree beds to provide a benchmark for the


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Please read the questions carefully and where appropriatecircle your answers.

Questions 1–4 on both papers are specifically related tograde, professional qualifications and length of timequalified and spent in'itu.

5) Have you ever practised team or primary nursingelsewhere prior to this study-YES/NO

If you answered YES please give brief details, includingwhen, where and if it was successful (in your opinion).

TEAM NURSES ONLY SECTION

6) In your opinion do you think that the planning for thisproject (e.g. the meetings) was satisfactory-YES/NO/DON'TKNOW

If you answered NO please state your reason(s) andsuggestions for how this could have been improved

7) What if any, do you think are the positive factors of teamnursing?

8) What if any, do you think are the negative factors ofteam nursing?

9) In your opinion do you think this trial has beensuccessful?-YES/NO/DON'T KNOWIf you answered NO please state your reason(s).

10) Do you think that feelings of 'them and us' exist as aresult of this trial? YES/NO/DON'T KNOW

11) Are you satisfied with the delivery of nursing care whenpractising team nursing-YES/NO/DON'T KNOW

Please give reasons for your answer.

12) When this trial is complete do you want to continuepractising team nursing?-YES/NO/DON'T KNOW

13) Any additional comments relevant to team nursing?

Fig. 3 Main content of the questionnaires, omitting the introductory sheet and space for extended responses andcomments.

study. Then, every month, care was audited,using the tool described earlier, for 2–3 teamnursing beds (depending on bed occupancy),by one of the authors (OM) and an assistant.For the purpose of comparison care was also


audited on the same number of non-teamnursing beds on the unit. These other bedswere occupied by patients of similardependency who were being cared for bynurses of similar abilities.



© 2000 Harcourt P

ONCE AGAIN THANK YOU FOR YOUR HARD WORK AND FOR TAKINGTHE TIME TO COMPLETE THIS SURVEY

NON-TEAM NURSES ONLY

6) Have you ever worked within the team nursing trial on ashift basis (e.g. to cover for sickness)-YES/NO

If you answered YES how did you feel about the shift (e.g. whatwas the level of support like?).

6a) If you answered NO is there any reason why you haven't?

7) Have you received enough information about this teamnusing trial?-YES/NO/DON'T KNOW

8) What do you think of the team nursing trial?

9) What do you base your feelings about team nursing on (e.g.,experience, feedback from others)?

10) Are you satisfied with the delivery of nursing care whenpractising patient allocation?-YES/NO/DON'T KNOW

11) Do you think feelings of 'tham and us' exists as a resultof the team nursing trial?-YES/NO/DON'T KNOW

12) Do you think that team nursing could work ifimplemented into the whole unit-YES/NO/DON'T KNOW

Please give reason(s) for your answer.

13) Would you like to be involved in any future developmentof the concept of nursing in ITU?-YES/NO/DON'T KNOW

Please give reason(s) for your answer.

THANK YOU FOR COMPLETING THIS SURVEY

Fig. 3 continued.

Reliability

McColl (1993) states that if research results areto be significant data must be collected in areliable and valid manner. The notion ofreliability is essential when considering thedesign of the measurement tool. LoBiondo-Wood and Haber (1994) state that a reliablemethod of measurement should produce similarresults in a similar situation. The authorsattempted to ensure reliability in two significantways.

The job satisfaction questionnaire was initiallypiloted with a small number of nurses withsimilar characteristics (e.g., grade) to the actual

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sample group and the results were consistentwith the main findings.

Care was measured using a standardized careaudit tool, which had been in use throughout thehospital for some time. Oppenheim (1992) statesthat traditional methods of measurement oftenhave in-built reliability. However, it isacknowledged by the authors that repeated useof a research tool does not necessarily equatewith reliability.

Validity

Validity refers to whether or not a methodmeasures what it sets out to measure (Burnard &


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Table 1 Positive and negative factors of team nursing(as identified by team nurses) Please note more thanone response was given

Positive factors (n=18)

Improved knowledge ofPatients and relatives 13Better support for staff 12Improved team work 13Improved continuity of 7careImproved levels of 5communication

Negative factors (n=18)

Clash of personalities 12Monotonous with long term 12patientsLack of patient choices/ 14worried about deskillingClaustrophobic 4Restrictive off duty 4Feelings of isolation 10Oversupportive 6

Morrison 1994). There are several methods ofestablishing validity in research. However,validity in this study was based largely on ‘facevalidity’. Face validity is an intuitive type ofvalidity, where colleagues evaluate whether themeasurement tool appears to measure theconcept under study (LoBiondo-Wood & Haber1994). Following an extensive literature review, ajob satisfaction questionnaire was compiled andsubmitted to several senior nurses for commentsin order to help establish the concept of facevalidity. Also, to further help establish validityand reliability, the job satisfaction questionnairewas carefully worded to avoid the risk of ‘leadingor loaded’ questions that may have influencedthe answers of respondents.

Data analysis

The results yielded a combination of qualitativeand quantitative, descriptive data and wereanalysed by hand and displayed in the form offrequency tables and bar graphs.

ResultsTwenty-three questionnaires were distributed toboth team and non-team nurses at 3 and 6 monthintervals. At the 3 month interval 19 (83%)questionnaires were returned by the team nursesand 13 (57%) by the non-team nurses. At 6 months18 (78%) questionnaires were returned by teamnurses and, again, 13 (57%) by the non-team nurses.

As the results demonstrate team nursingoffered both advantages and disadvantages(Table 1). The most common positive factorsincluded improved knowledge of patients andrelatives (n = 13), better support for staff (n = 12)and improved teamwork (n = 13). Commonnegative factors included personality clashes (n =12), monotony (n = 12) and concerns overdeskilling (n = 14), due to lack of choices.

A high proportion of both team nurses (83%)and non-team nurses (77%) perceived there to befeelings of ‘them and us’ generated by the teamnursing trial (Table 2).

The overall satisfaction with the style ofnursing used remained unchanged amongst non-team nurses at 3 and 6 month intervals with 9nurses (69%) expressing satisfaction (Table 3).However, the same is not true amongst teamnurses. In this group, at 3 months, 53% expressed


satisfaction and 47% expressed dissatisfaction.However, at 6 months only 6% expressedsatisfaction, while the number of nursesdissatisfied had risen to 72%.

Care audits on 3 beds, chosen at random, inthe ITU just prior to the implementation of thestudy revealed scores of between 68% and 75%,with a mean score of 72% (Table 4).

The monthly care audit results (Table 5) showthat, due to bed occupancy, usually two bedswere audited. Only once (September 1997) wascare audited on three beds. The mean scores ofthe care audits for each month are also displayedgraphic form (Fig. 4)

At month 1 team nursing faired slightly betterin the care audit than did the non-team nursingbeds. At month 2, the mean score was notablybetter amongst the team nursing beds. However,at months 3, 4 the mean score amongst the teamnursing beds fell behind the non-team nursingbeds but was equal at month 5.

WeaknessesThere were several key weaknesses in this studythat probably influenced the outcome of theproject and the reliability of the findings. Forexample, there were simple weaknesses with thecare audit tool. This tool was only capable of



© 2000 Harcourt

Table 2 Do you think that feelings of ‘them and us’exist as a result of the team nursing trial? (At 6 monthsonly)

Team nurses Non-team nursesn=18 n = 13

Yes 15 (83%) 10 (77%)No 2 (11%) 1 (8%)Don’t know 1 (6%) 2 (15%)

Table 3 Are you satisfied with the style of nursingyou currently use?

At 3 months At 6 monthsTeam Non-team Team Non-teamnurses nurses nurses nursesn = 19 n = 13 n = 18 n = 13

Yes 10 (53%) 9 (69%) 1 (6%) 9 (69%)No 9 (47%) 3 (23%) 13 (72%) 3 (23%)Don’t know 0 (0%) 1 (8%) 4 (22%) 1 (8%)

Table 4 Care audits – pre-trial implementation

Bed 1 Bed 2 Bed 3 Mean

72% 75% 68% 72%

The percentage denotes the number scored as apercentage of the possible total 63.

examining certain aspects of care. It did not allowfor measurements of quality of care which can behighly subjective and, from a researchperspective, difficult to measure. Suchmeasurement requires defined quality criteriaand measurable indicators if it is to be useful.

Also the audit tool used relies heavily ondocumentation. Therefore, as in studies byO’Connor (1993) and Webb (1990), if care wasgiven but not recorded no score was given, thuslowering the final score. However, whilst relianceon documentation of care weakened the use ofthe audit tool, within this study it did highlight aproblem with nursing documentation in the unit.

There was a similar problem with measuringand evaluating job satisfaction. Unfortunately,this variable is also fraught with problems of


Table 5 Comparative care audits

TeamMonth nursing M

July ‘97 81%, 74% 7August ‘97 87%, 90% 8September ‘97 75%, 78%, 81% 7October ‘97 83%, 75% 7November ‘97 79%, 79% 7

The percentage denotes the number scortotal 63.

measurement, data analysis and interpretation offindings (Macdonald 1988). For example, whilstsatisfaction with style of nursing was measuredand recorded it has to be considered whether thisfinding truly reflects job satisfaction.

Also, as with all data collected throughquestionnaires, there was the dilemma thatrespondents may not be completely honest.Obviously in this study staff were aware thatdata would be analysed by two senior membersof staff involved in the study, and this could haveaffected responses.

Other changes, such as nurse-led ward rounds,new fluid charts and self rostering were alsoimplemented during the trial period. All of whichproved problematic and may well haveaccounted for increased stress during the changeperiod. This, of course, may have also affected theoutcome of the study. The introduction ofadditional changes perhaps detracted staff awayfrom the focus of the project, which was todetermine if a different approach to nursing carewas required in this ICU. These issues probablydemonstrate that significant changes in theworking environment are best implemented oneat a time rather than all together.

Obviously as this small pilot study was onlyconducted in one ITU the results cannot begeneralized and it should not be assumed that asimilar study in another ITU would revealcomparable findings.


Non-teamean nursing Mean

8% 75%, 73% 74%9% 79%, 82% 81%8% 82%, 78%, 85% 82%9% 92%, 85% 89%9% 79%, 78% 79%

ed as a percentage of the possible

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90%

80%

70%

60%

50%

40%

30%

20%

10%

0%MONTH 1 MONTH2 MONTH 3 MONTH 4 MONTH 5

TEAM NURSING NON-TEAM NURSING

Fig. 4 Comparisons of mean care and it scores forteam & non-team nursing beds.

DiscussionCare

Based on the audit tool used, this study appearsto demonstrate that team nursing did notsignificantly improve standards of measurablecare in this instance. Much of the previousresearch into care in team and primary nursinghas been equivocal. For example, O’Connor(1993) and Webb (1990) found that care in generalward setting improved significantly when teamnursing was introduced. However, an extensivereview of UK and US research by Thomas andBond (1991) reveals that whilst many studiessupport this finding, just as many do not!

The other major problem with comparing theeffects of team nursing on the delivery of care isthat very few studies have examined the effects ofthis approach in an ITU environment. Manley(1989) and Bray (1996) both claim that primarynursing resulted in improved levels of care inITU studies. However, both pieces of research areprobably as open to interpretation as this study.

The fact that so many studies revealambiguous findings makes comparisons verydifficult. It therefore is questionable whetherteam or primary nursing can improve care. Thereis, in fact, little consensus as to whether, andunder what circumstances, team/primarynursing results in improved levels of care forpatients (Thomas & Bond 1991).

Manley (1994) states that:

It cannot be stated categorically whether primarynursing is better, or worse than other approaches


to organising care, although many claims andsome evidence exists to support that it is better.

Team nurses were also asked informally, inmonthly team meetings, whether they feltnursing care was of a higher standard in the trialand most reported that it was no different to therest of the unit. Nevertheless the study identifiedpositive factors which staff felt contributed toenhancing quality of care. The study facilitated‘nursing’ which allowed staff to improve theirknowledge of patients’ conditions, and the eventsleading to alterations in medical treatment andnursing care (n = 13, 72%). The ethos behind thisproject supported establishing ‘normality’ forpatients in conjunction with their relatives, andthis mirrored the view of Sherman (1990) whodeclared a solid goal of team nursing is to meetindividual healthcare needs of the patient andfamily.

In the final team meeting, staff againexpressed their opinions that team nursing madelittle difference to levels and quality of care forpatients. Obviously this method of measurementis subjective and therefore, perhaps unreliable, asnurses often have different views on whatconstitutes ‘good’ nursing care.

Many authors identify the problems associatedwith measuring care and question whether it isthe effects of ward organization or the concept ofnursing in use which actually improvesstandards of care (Higgins & Dixon 1992; Furlong1994; Thomas et al. 1996).

Job satisfaction

The results appear to demonstrate that teamnurses were less satisfied with team nursingwhen compared to the other nurses’ satisfactionwith patient allocation. Also, it is worth notingthat satisfaction in non-team nursing wasunchanged at 6 months, whilst satisfaction inteam nursing had decreased considerably (Table3).

Again, as with care issues, research findingson job satisfaction are mixed (Thomas & Bond1991). Betz (1981) discovered that over a one yearperiod comparisons of job satisfaction in 3primary and 3 team nursing units revealed thatsatisfaction was higher in the team nursing units.O’Connor (1993) found that job satisfaction,morale and motivation of nursing staff improved



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6 months after the introduction of team nursingby approximately 6–15%.

However, again, just as many studies revealthat job satisfaction remained unchanged or evendeteriorated (Thomas & Bond 1991). Also studiesin the ITU environment are inconclusive eitherway. Manley’s (1989) study into primary nursingin ITU provides little evidence to suggest that jobsatisfaction improved following the trial. Bray(1996) suggests that job satisfaction improved inher ITU but provides little empirical evidence toback up this claim.

The first few weeks of the study wereobviously difficult because of the problemsassociated with change. The whole project wasobviously a major change and many staffnaturally found the initial transition quitedifficult. The project undoubtedly requiredchanges in the organization, culture and in theroles of all staff and these were, of course,stressful (Macdonald 1988).

What is also notable is the feelings about thetrial amongst all nursing staff. A large majority ofteam (n=15, 83%) and non-team nurses (n=10,77%) felt that the trial had caused feelings of‘them and us’ to develop (Table 2). Thisphenomenon could have lead to staff conflict andperhaps discouraged nurses from wanting tocontinue with the trial. However, such feelingsmay not be directly related to team nursing butrather due to the fact that some staff were directlyinvolved in the study whilst the majority werenot. Regardless of what was practised perhapssuch feelings would have arisen anyway becauseof the split in the unit staff.

Many junior nurses stated that team nursingdid provide increased levels of support (n=12),which may have led to improving confidencetowards administering nursing care (Table 1).However, the most notable issues are those whichstaff felt were the disadvantages of team nursing.For example, personality clashes (n=12) andfeelings of claustrophobia (n=4) (associated witha smaller working environment) (Table 1).

Although some personal feelings of staff werevery negative, the study further highlighted thatcohesive teamwork (n=13) emerged, which mayhave contributed to improved levels ofcommunication (n=5) amongst staff and betweenother disciplines.

Nurses also found it frustrating caring for thesame patients all the time. Whilst team nursing

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undoubtedly improved continuity of care itfrequently proved to be very monotonous.Nursing a single patient for a prolonged period,without a change, can be very stressful (Manley1994; Bray 1996). Nurses had gone from having11 patients to choose to care for to having 3 andmany, including the authors, found this difficult.

The other problem was again associated withcontinuity of care. Nursing staff often built upcloser relationships with patients and relativesthan would probably occur in patient allocation.Whilst this has advantages it also hasdisadvantages. For example, many staff found itvery stressful when well known patients died orwere suffering. Bowers (1989) comments that it isquite common, in such systems, for nursing staffto become over-involved with some patients. It is,therefore, worthwhile questioning whether nursesprefer a system of patient allocation because of itsemotional benefits. It has frequently beensuggested that patient allocation protects nurses’psychological well being by minimizing thepotential intensity of nurse/patient relationships(Bowers 1989; Manley 1994; Bray 1996).

There was also frequent conflict with medicalstaff, particularly with dying patients (e.g.reluctance to withdraw treatment). This oftencaused tension which, despite open discussion,could not always be resolved. The ‘autonomous’nurse is often locked in conflict with medicalstaff, as their commands limit what nurses maydo with patients (Salvage 1985).

Team nursing and ITU – how suitable?

Despite the claims of certain authors, for exampleO’Connor (1993), that team nursing improvedpatient care and job satisfaction this studyappears to demonstrate that team nursing did notsupport these assertions. Therefore, based onthese findings, the suitability of team nursing tothis particular ITU is questionable.

However, are the problems that emerged as aresult of this study related to team nursing orwere they there anyway? For example, inabilityto cope with dying patients and medicalconfrontations are problems that often exist butdo not always arise during patient allocationpartly because of increased choice of patients.Team nursing may have provided the vehicle tohighlight some of these problems that caring for afar smaller group of patients generated.


254 Intensive a


So should these problems be addressedproperly or should team nursing not be practisedin ITU? In an ideal world perhaps the problemsshould be addressed properly, and solutionsdeveloped to help staff cope and healthprofessionals collaborate efficiently. But if teamnursing, or primary nursing for that matter, is sogreat why are so few units practising it properly?

What should also be investigated further iswhy staff come to work in a large ITU. Perhaps itis to gain more experience that can only beoffered in larger units, in which case conceptssuch as team nursing could have a detrimentaleffect on recruitment and retention of staff.

ConclusionThis small-scale study appears to demonstratethat team nursing did not work in this instance,although certain positive factors emerged thatwould appear to benefit patient care. Whilst thenegative issues are similar to other studiesdiscussed in the text, there are just as many otherstudies with opposing results. However, the lackof available research in the ITU environment,unfortunately, limits comparison.

So exactly why is there such considerableambiguity in the research findings available? It isprobably because of the complexities of nursingsystems. Because there are so many intricatevariables researching outcomes associated withimplementation of different concepts of nursingis virtually impossible, as there is no way ofknowing “what really produced what”(Macdonald 1988; Thomas & Bond 1991).

Manley (1994) comments that establishingwhether primary nursing actually does improvethe quality of care in ITU is a question that stillneeds answering. Therefore, perhaps more large-scale research into systems of delivering nursingcare is needed to establish whether team orprimary nursing is suitable for ITUs.

However, years of research have failed toprove conclusively that team or primary nursingis better than other methods. So would furtherstudies not do the same? Whilst it is importantthat nurses strive to improve standards perhaps itis time to recognise that units should practisewhat they believe to be the most appropriatemethod of delivering care. Based on the availablefindings the authors of this article feel that teamnursing is unsuitable for use in their own ITU.

nd Critical Care Nursing (2000) 16, 243–255

However, it is important to recognize thatdissatisfaction with patient allocation originallyprompted this pilot study. Therefore, if teamnursing is deemed to be unsuitable, in thisinstance, then what is the best method ofdelivering nursing care in ITU?

Acknowledgement

The authors would like to thank Brian Millar,Lecturer, School of Nursing, University of WalesCollege of Medicine, for his help in preparing thisreport. Thanks also to the staff involved in thetrial, especially Linda Tew and Mark Smities

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Team nursing and ITU – a good combination?