Complex social circumstances, increased incidence of chronic illnesses, and atypical presentations of acute illness increase likelihood of health care providers becoming involved in managing health care of older adults (Arbaje et al., 2010; Smith-Carrier & Neysmith, 2014). Researchers have reported some success in improving care for older individuals when multidisciplinary teams are involved (Arbaje et al., 2010; Barrow, McKimm, Gasquoine, & Rowe, 2015). However, it is not clear how teamwork affects health care providers' perceptions about working with older adults or satisfaction with their work. The aim of the current study was to examine the influence of teamwork on health care workers' perceptions about delivering care to older adults and their job satisfaction.
Research on health care teams spans four decades and has been undertaken by several disciplines, exploring how interdisciplinary, multidisciplinary, and interprofessional team members collaborate (Paradis & Reeves, 2013). In the current study, team is defined as:
a work group made up of individuals who see themselves and who are seen by others as a social entity, who are interdepe ndent because of the tasks they perform as members of a group, who are embedded in one or more larger social system (organization) and who perform tasks that affects others.
Effective teamwork among health care workers has been shown to reduce clinical errors, enhance the quality and completeness of care, and improve patient safety (Havig, Skogstad, Veenstra, & Romøren, 2013; Kalisch & Lee, 2010; Kurowski, Gore, Buchholz, & Punnett, 2012; Martin, Ummenhofer, Manser, & Spirig, 2010; Temkin-Greener, Zheng, Cai, Zhao, & Mukamel, 2010). Havig et al. (2013) characterized “real teams” as having interdependence, stable membership, and group cohesion. Temkin-Greener et al. (2010) found that self-managed teams were more effective than formally structured teams. Unfortunately, development of effective teams and processes used by effective teams were not well described.
Working in teams is not without challenges. Factors such as member roles, scopes of practice, leadership, and context influence effectiveness of teams (Goldman, Meuser, Rogers, Lawrie, & Reeves, 2010). Manser (2009) found that strong communication, coordination, and leadership support team effectiveness. In addition, team structure and processes have been shown as important for effective teams (Xyrichis & Lowton, 2008). Health care providers must be socially competent and willing to share information, negotiate, and solve problems (Mickan & Rodger, 2005). Thus, it is understood that organizational context, team processes, and team relationships are factors that influence teamwork. What is not well understood is how health care providers form relationships with other team members and how these relationships influence their work with older adults and job satisfaction.
Focused ethnography was used to examine the contextual factors that influence how health care workers perceived their teams. Focused ethnography explores a topic in context and is characterized by short field visits, data analysis, and an emphasis on communication activities, in addition to its focus on cultural elements such as routines, ideas, knowledge, and actions (Knoblauch, 2005; Stahlke Wall, 2015).
After receiving ethical approval from the University of Alberta, recruitment of participants occurred at two care facilities in Western Canada. One was in a large city and focused on the complex care of older adults; the other was in a smaller urban setting and provided supportive living to older adults with less complex needs. Recruitment posters were placed on workplace bulletin boards and information sessions on the study were held by the researchers. Participants self-selected for the study by contacting one of the researchers. Inclusion criteria were workers within either facility who spoke English and viewed themselves as team members in their institution. Participants included eight health care aides, two licensed practical nurses (LPNs), two RNs, one manager, three recreational/activity aides, one recreational therapist, one social worker, one housekeeper, one office manager, one dietary aide, and one maintenance worker. Participants were diverse in cultural background, and many spoke English as a second language. In this article, the identities of the individuals are hidden, including ethnic identities.
Interviews were conducted with 22 participants across the two care facilities. The interviews were audio-recorded and transcribed verbatim. Questions included:
- “How would you describe the teamwork on your unit?”
- “What works well?”
- “How do you navigate your work when things don't work well?”
- “How does your experience of teamwork affect how you feel about your job?”
Interviews ceased when saturation of data occurred (i.e., when no new concepts were identified). Ten hours of participant observation of staff interactions in units, staff meetings, and shift report were performed to enhance understanding of work cultures and relationships within them. Interview data were corroborated by observations.
Initially, data were analyzed using line-by-line coding. Coding involves identification of persistent words, phrases, and concepts within data (Mayan, 2009). From codes, categories were formed to group similar codes or excerpts of data (Mayan, 2009). In ethnography, moving from particular instances to general patterns is accomplished by identifying themes and patterns and developing explanations about the social context of the study (Morse & Richards, 2002). Rigor was assured by building variation into the sample, creating thick descriptions of experience, recording a transparent analytic decision trail, and discussing evolving ideas about the categories and themes.
Participants provided rich descriptions of their perception of teamwork and understanding of what facilitates teamwork. Themes developed from their descriptions were Perceptions of Teamwork, Characteristics of a Good Team, Managing the Challenges, and Impact of Teamwork (Table).
Perceptions of Teamwork
Participants defined their teams in various ways. In some instances, the team was viewed as one person with whom the participant shared the daily work, whereas in others, the entire organization was viewed as the team. For many, teamwork was a positive experience, but some described it as negative.
Views on teamwork varied depending on the health care worker's position within the health care facility. Individuals who occupied a leadership role expressed the view that everyone who worked in the care facility was part of one big team. For example, a participant in a leadership position reported, “I see one common team in my head and when I speak about it…it's one big team.” Further conversation with this participant revealed that there was a leadership team and nursing teams in each of the units. Thus, there were teams within the larger team. Participants frequently viewed their team as their immediate coworkers. For example, one participant referred to her team as “the other health care aide I work with.” Other participants expanded their perception of team to include those who worked on their smaller unit. For example, one participant stated, “My partners, care aides I work with, LPNs, and RNs are definitely a huge part of my team because I go to them with concerns or issues that are going on here, to have them listen to me and bring those concerns forward.”
Participants perceived that team-work could be challenging due to poor communication, gossip about team members, hierarchical relationships, workload issues, and not feeling valued or respected. Participants identified that poor communication occurred when health care workers had a narrow view of their team. For example, if evening shift and day shift workers did not view themselves as one team, communication suffered and confusion ensued. One participant noted, “You have evenings doing something different than what days are doing with the same resident.” According to the participant, this lack of communication across shifts resulted in “care aides getting inconsistent messages from the RN and the LPN.” Because care aides were primarily responsible for physical care of residents, inconsistent messages left them to interpret care strategies without the benefit of guidance from RNs and LPNs. One participant stated that communication challenges were amplified at times because “there is cultural diversity and language may be an issue.” Health care workers who did not have a strong command of English could misunderstand the plan of care and/or struggle to “get their point across because they can't understand the language,” as noted by a participant.
In addition, participants reported that gossip impacted teamwork because it was viewed as “putting one another down” and seen as circumventing direct conversations about issues that could lead to resolution. For example, one participant said, in regard to gossip, “You know the stuff isn't directly said to me. I wish it were, because I would handle it.” Another participant viewed the gossiping behavior as “people trying to gather all the praise and throw you under the bus to make themselves look better.” Whatever the cause of the gossip, participants agreed that talking about other team members without them knowing eroded team relationships and morale.
Participants discussed the impact of the hierarchical structure and chain of command. One participant explained: “You have to talk to the LPN first and then they'll come and look at [the resident issue], and then the LPN will get the RN to take a peek.” Team hierarchy became a challenge when the LPN or RN did not record or follow up with the resident's concern. For example, another participant said, “Sometimes when you tell them [the LPN or RN] something, they forget what you said.” When care aides had no documentation that the concern had been reported, conflict arose within the nursing team. One participant gave an example of this, saying: “We said something about this issue 3 days ago, but it's like taking our word against another staff's word.” Unresolved issues such as these led to some gossiping about the “hierarchy with regards to RNs, [who were perceived to have a] holier-than-thou outlook.” In short, functioning of the hierarchical structure, and communication and power dynamics within it, produced negative influences on effective teamwork.
Participants shared concerns about the connection of some team members to the team. Several staff had jobs in numerous facilities. In addition, relief staff were on the unit sporadically and did not know the residents. As a care aide explained: “I know one girl works three facilities…some work 80 hours in 1 week.” Another participant reported that “some RNs have three jobs.” Participants perceived health care workers who were working many hours in other agencies as tired at work and lacking commitment to the team and understanding about the nuances of residents' care. One participant exemplified this with the statement: “My biggest frustration here with teamwork [is] somebody coming here to fill in casual and knows nothing about the residents.” At times, team members performed extra duties to make up for care that was missed. As one participant said, “Once you get one person in the team that doesn't do the teamwork, then the others have to pick up the slack.” Health care workers who consistently worked on a unit knew the residents, what was expected of them, and team processes on that unit. Relief or new staff did not have as much knowledge regarding the facility, residents, and processes, and therefore relied on the permanent health care workers to fill in details.
Participants reported that when they did not feel valued or respected by their team members or the facility management, they found it challenging to stay engaged within the team. In regard to a particular situation, one participant said, “I was just a number. I am just an employee.” According to the participant, this feeling contributed to a sense of dissatisfaction with the workplace. Another participant asked, “Why would I go out of my way to work twice as hard for your sake if there is no appreciation?” Thus, ensuring team members felt valued and respected and that all were doing their part contributed to health care workers' satisfaction.
Participants defined teams in various ways. Their definitions impacted understanding of the function of the team in terms of communication and view of the connection and engagement of others on the team. In addition, participants felt more connected and committed to the team if their efforts were recognized.
Characteristics of a Good Team
Participants described good teams as teams whose members have positive relationships, share common goals, and have open communication. The relationships participants had with other team members influenced whether they viewed their teams as successful. One manager explained the benefits of strong relationships among team members saying, “You can see the energy on the unit; you can see it in the communication, the joking, even sometimes in relationships outside of work.” The manager also had a supportive leadership team that was “so understanding, encouraging, and supportive [of her] to shoot for the stars.” Other participants identified the importance of having good relationships with supervisors as a requirement of a good team. One participant said, “A good team experience is just feeling valued—the encouragement, support, and valuing by my manager.”
Participants identified that individuals in good teams “all have a common goal.” Likewise, it was important that health care workers were “here for the right reasons.” The right reasons included “giving the best care [we] can to the people we are taking care of…listening to them, [providing] physical care, respecting their needs, [and remembering] this is [their] home.” According to team members, one important component in providing residents with care was trusting other team members so members did not have to explain their actions. For example, if a member reported a change in a resident's condition, it was important that the member could trust his/her teammates would act on this change. One participant stated, “We have the same outlook on things, so if we need to take an extra 5 minutes with someone, we know we are doing our jobs. We have trust in each other we know things are being dealt with; we are being heard.”
When teams shared the common goal of patient-centered care, health care workers experienced a “willingness to pitch in” and a “give-and-take relationship” within the teams. Supporting other team members, whether through encouragement or physical assistance, fostered positive team experiences. One participant explained it was important to look at the bigger picture: “A good team member is somebody who looks beyond what they are doing.” When team members looked beyond their own actions, the team was successful in terms of reaching its common goal of serving residents. If a team member helped another team member, it fostered a sense of reciprocity—the team member who had been helped felt a duty to return the favor in the future. In regard to this sense of reciprocity, one participant said, “I can walk in and I'm so glad [my team member is] working because if she has extra time, she'll do something for me. And then if I have extra time, then I'll do something for her.”
Part of working toward the common goal of providing the best care to residents included listening to residents and team members to develop plans for meeting individual needs of residents. One participant said that the team functioned better “if you listen to the older adults and hear their needs and then you are addressing things as a team and you are also hearing what your team members' issues are.” Another participant explained how the nursing team she worked with identified its common care plan and then worked as a team to meet residents' needs: “We [LPNs and RNs] divide whatever responsibilities that we have. If [my team member] asks for help, she calls me, and if I do, it's vice versa. Same way with the care aides; they can ask any time for help.”
Communication was an essential element in teamwork. If communication was effective, it was easier to work as a team. Regarding the team structure, one participant said, “We work well together and communicate well together.” Participants believed that health care workers had a responsibility to contribute to team dynamics by “taking the time to listen to one another and being open-minded.” It was suggested that smaller teams made communication easier, as there were fewer individuals to communicate with about the plan of care. According to one participant, “It's like a little family because we are smaller. There is more communication in smaller groups; there is more consistency.”
It is important to note that although language was a barrier to effective teamwork in some ways, it was also a facilitator of communication among staff with the same nationalities. As one team member noted, “I kind of talk to [my teammate] in my language when it's just both of us, right? So it's easier to communicate.” In addition, having a partner who spoke the same language was beneficial to the partners' understanding of English. For example, one participant said that if he was unable to understand an English direction, then he talked to his partner and “she [his partner] will say [it] in English words so they can explain to each other.”
Managing the Challenges
The health care workers in the current study had three main ways of managing the challenges associated with teamwork, including avoiding the issue, speaking to the individual with whom they had a challenge, or talking to the supervisor about the issue. Participants had various strategies they used to avoid teamwork challenges. Some would limit their focus to relationships with their closest work-mates; others would ignore the issues, hoping they would go away. One participant stated, “I fly under the radar as much as possible. I try to just be friends with everyone.” Other participants would take different shifts to avoid challenging team dynamics. For example, one participant discussed a situation in which she was “working with someone…not answering call bells.” She found that “it's very hard. It was draining by the end of the day.” Ultimately, she said that to solve the problem, “[I] switched my part-time rotation. I just said it will work better for my family.”
Other participants described trying to resolve issues by either talking to a team member to work out challenges or debriefing a challenging team situation. In regard to open communication with the team, one participant said, “I will be open with them and say, ‘You know, I don't agree.’ I am very straight forward with them; we have to do something.” Other participants described a practice of “talking and sitting and having a little kind of powwow over what happened today” to keep on top of potential conflicts. Other participants described a strategy of talking to the person with whom there was conflict, and then talking to the manager if the issue was not resolvable between team members. For example, one participant said, “I confront them and talk to them, if it doesn't go right then I talk to the manager.”
Other participants described going directly to the supervisor before trying other strategies to resolve the team challenge. One participant said, “You can talk to your supervisors, say, ‘You know, we really need to get [team member] to step up to the plate a bit.’” There were times when talking with supervisors about issues with coworkers produced dramatic results such as suspension. For example, one participant reported, “I just let my boss know that, you know, these things are going on, and then they say pay attention to it. Then you hear [that person] has a suspension.”
Impact of Teamwork
Participants reported the impact of positive team relationships on health care workers' job satisfaction and care of older patients.
Participants identified that positive team relationships were an important part of work satisfaction and desire to stay in current positions. One participant said, “Happiness is defined as teamwork…I would say 80%.” Another participant noted that no matter how busy the day, she felt satisfaction in a job well done if she had a great team to work with: “We are the dream team. We are running all the time, [but] I go home every day and say, I've done a good day.” Another participant explained that a good team relationship could make the difficult tasks seem more manageable and sometimes even fun. According to the participant, “If you have a good partner, you cannot feel the pain; you are just laughing, and time flies so fast.”
Other participants explained that they felt cared for as individuals when their teammates helped them. One participant said, “If [my partner] does [work] for me, then it's just a nice feeling and I'm not stressed…and I feel like somebody cares about me.” Work relationships were an important element of health care workers' overall perceptions of their jobs. For example, one participant said, “It's not about the job itself; it's about how you care for your coworkers.” Participants noted that individuals in their teams had an impact on their desire to continue to come to work. As one worker said, “I like the people I am working with. That is why I am here.”
Supportive team relationships contributed to health care workers feeling fulfilled at work, and motivated to improve care provided to residents. One participant said, “I feel like coming to work; I get stuff done; I go home feeling fulfilled. I feel like I am going to come back the next day and find something else to work on.” Participants also identified that team relationships influenced how they acted toward their families after work. According to one participant, “[Teamwork is] so important. Without teamwork, you go home, you're stressed, you're angry; then, your family is stressed and angry, and it just ricochets. But if it's a happy work day, then you go home happy.”
Participants also expressed the sentiment that when health care workers worked collaboratively, it benefited the older adults in their care. A happy health care team could help create a positive environment for residents. One participant noted, regarding residents' perceptions of teams, “I think the better we work together and we are here for the right reasons, they can see it, they can feel it…it's in the energy they get given off by the entire team.” Conversely, if health care workers were not happy in their teams, their unhappiness could translate into negative relationships with the individuals in their care. As one participant said, “If you are not happy, I guess it trickles down to how the employees treat the residents.” Another participant summed up what others explained about how positive team relationships contribute to a secure environment for residents:
[The seniors] want to feel secure. And if we fight and we're the ones taking care of them, then they feel like they are not secure, I think. I have seen concern in their faces. It is not a nice thing to see and hear in their voices. [But when] people are having fun, the seniors of course love it, because they are watching us, and so that makes them feel more comfortable that we are getting along.
Participants in the current study emphasized that within health care teams, a sense of belonging, good communication, and having common goals were key elements that supported positive outcomes for older adults and contributed to health care workers' job satisfaction. Participants indicated that workers who had narrower perspectives of the team and teamwork were less likely to communicate patient issues effectively to health care workers on other shifts or of other disciplines within the health care field. Trust and reciprocity, communication patterns, and whether team members shared a common goal influenced participants' views of whether their team was a good team. Participants needed to trust that teammates would help them care for patients when help was needed. Previous research has identified that caring for older adults requires team members work together to provide physical care and solve problems or health challenges that arise (Dahlke & Baumbusch, 2015; Dahlke, Phinney, Hall, Rodney, & Baumbusch, 2015). In the current study, participants identified that the “give and take” of team relationships was part of developing social capital, known as “good will that is engendered by the fabric of social relations and that can be mobilized to facilitate action” (Adler & Kwon, 2002, p. 17). In addition, the notion of reciprocity, when help is given with the understanding that help should be repaid, has been identified as an important element in teamwork (Dahlke & Baumbusch, 2015). New team members in the current study may have found it hard to integrate into the team because they had not yet developed the social capital of established team members. Nurses could facilitate team relationships by explaining the importance of reciprocity within teams to new team members. Identifying ways that new team members could develop their social capital could strengthen team relationships.
Communication was viewed as a key element of teamwork in the current study. The significance of communication among health care workers has been identified in other research (Alexander, 2015; Polito, 2013), corroborating the findings of the current study. Scholars who have examined 25 years of literature related to teamwork and organizational effectiveness assert that “communication is the glue which links together all of the other teamwork processes” (Salas, Stagl, & Burke, 2004, p. 55). Wright and Leahey (2013) have illuminated that communication occurs through behaviors, feelings, and thoughts about contexts and circumstances. The current study has highlighted some of these complex issues, such as “casual” employment, with no guaranteed hours, and communication challenges that were sometimes due to culture and language issues. Researchers have identified that health care workers whose first language is not the dominant workplace language face challenges developing therapeutic relationships with care recipients and communicating vital therapeutic information (Lu & Maithus, 2012), but that language barriers do not interfere with their responses in care situations (Massey & Roter, 2016). Nurse leaders could explicate cultural cues of workplaces to facilitate communication around care practices and team-work, thereby leveraging the knowledge and skills of the entire team.
In addition, participants suggested that managers had an important role in fostering team relationships. Management influences organizational trust, which in turn influences health care workers' ability to trust one another (Cox, 2012). Management also influences health care worker's perceptions of being valued, which enhances desire to continue working (Probst, Baek, & Laditka, 2010). Nurse leaders could encourage open communication and negotiation of problems to nurture team relationships. Blustein (2011) used a sociological relational theory to explain that working is a relational act through which the worker derives some meaning. Workers' relationships influence workers' functioning and resilience in work and non-work settings (Blustein, 2011). Nurse leaders who foster team relationships will promote greater staff satisfaction (Kalisch & Begeny, 2005) and desire to continue employment (Lartey, Cummings, & Profetto-McGrath, 2014; Robson & Robson, 2015). More research is needed to understand the complexity that has been revealed in the current study of supporting teamwork in residential care settings.
Scholars who have studied team-work identify a lack of understanding about the processes through which health care workers communicate and collaborate with each other, with older adult patients, or with their families (Jones & Jones, 2011; Lemieux-Charles & McGuire, 2006; Paradis et al., 2014; Reeves, Lewin, Espin, & Zwarenstein, 2010). The current study provides insights into team processes important to health care workers, such as reciprocity and respectful communication patterns. These findings add to the findings of other scholars that effective teamwork requires patterns of communication, coordination, leadership, and willingness to negotiate and solve problems (Manser, 2009; Mickan & Rodger, 2005).
Limitations and Research Implications
The current study is limited by scope in that only health care workers' perspectives about how teamwork impacted care of older adults were included. Future studies could include older adults' perspectives about how health care teamwork contributes to their sense of safety and well-being. In addition, further research related to team processes could demonstrate how teams are able to work through communication challenges. Critical research that explores inequalities, diversity, hierarchies of power, and organizational contexts is needed to understand teamwork at a deeper level before problem-solving strategies can be implemented. Although the current study identified the importance of management in supporting team-work, research is needed to better understand the complexity of promoting team collaboration when health care workers have multiple jobs and much of the work force is part time or casual workers.
The current study provided insight into teamwork within the context of residential care, revealing details about how teamwork is perceived and how it impacts staff and residents. Participants offered perspectives about what it means to be a team member and the impact of teamwork on job satisfaction and resident well-being. Participants identified trust and reciprocity, communication, and sharing a common goal as critical factors in effective teamwork. Participants also pointed to the importance of management in setting the tone for teamwork. Future research is needed to understand the complexity of supporting teamwork in residential settings given the challenges of culture, diversity, and individuals working multiple jobs.
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|Perceptions of teamwork||Teams within teams|
| Challenges||Poor communication|
|Gossip about team members|
|Feeling not valued or respected|
|Characteristics of a good team||Good relationships with one another|
|Sharing common goals|
|Having open communication|
|Managing the challenges||Avoiding the issue|
|Speaking to the individual with whom they had a challenge|
|Talking to the supervisor about the issue|
|Impact of good teamwork||Health care workers' job satisfaction|
|Improved care of older adults|