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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