The BP Macondo Well Case

Executive Summary

The BP deepwater Horizon is one of the worst industrial catastrophes ever due to the oil rig

explosion on April 20, 2010, in the Gulf of Mexico. Eleven people died in what has become the worst

oil spill in the United States lasting 87 days with 507 million liters of oil spilled in the sea (US

Environmental Protection Agency, 2017). Multiple failing went right up to the top management of the

companies involved and multiple points at which it could have been averted. In this report we

addressed three of their major issues:

 BP’s safety culture

 BP’s risk-seeking culture

 The lack of ethics values

Issues will be identified then practical solutions to these issues will be presented. Finally,

recommendations will be made based on the pros and cons of each solution and thanks to the solution

ranking matrix.

Background

The BP deepwater Horizon is one of the worst industrial catastrophes ever due to the oil rig

explosion on April 20, 2010, in the Gulf of Mexico. Eleven people died in what has become the worst

oil spill in the United States lasting 87 days with 507 million liters of oil spilled in the sea (US

Environmental Protection Agency, 2017).

A single cause is not at the origin of the tragedy of the Macondo well. It is rather a ‘collection’ of

errors that led to the explosion and the fire of the platform. The leak was indisputably caused by

technical failures, but those –in turn - could have been avoided or at least lessened in impact and

probability if they had not had deeper organizational and systemic failures within BP. The US Federal

investigation identified the technical failures that led to the blow out, it includes: the cement failing to

seal the bottom of the well, lack of centralizers in order to center the pipe when pouring the cement,

the blowout preventer malfunction, the high pressure in the drill and the cement formula that was not

certified to function properly, etc.

However, multiple failure causes, in this author’s opinion, are traceable to project management issues,

which in turn can be linked to the top management of the companies involved and multiple points at

which it could have been averted. The three top issues that we can identify are BP’s safety culture,

BP’s risk-seeking culture and the lack of ethics values.

I will discuss three major project issues that have been identified within the “BP and the Deepwater

Horizon Disaster of 2010” that led up to the explosion and oil spill. Solutions and their pros and cons

will then be introduced along with recommendations of how the disaster could have been avoided.

Issues Identification

Issue 1

The first issue and the most important concerns BP’s safety culture. In fact, despite the fact

that BP had publicly declared its commitment for safety, BP had multiple issues with safety breaches.

In a previous accident in BP’s Texas City refinery which killed 15 persons, the investigation report

that they purposely cut back the maintenance and safety measures in order to limit costs.

Even after trying to improve personal safety, BP misunderstood that by decreasing and having a lower

personal injury rates do not mean that safety process is well implemented. According to Ingersoll C.

and al. (2012) U.S. refinery workforce believe that process safety is not a core value at BP. Meaning

that in BP the workforce is not able to perceive a clear corporate message coming from BP’s executive.

In BP’s 18 values, only one concerns health and safety, it claims: “no accidents, no harm to people,

and no harm to the environment” But nothing clear is stated concerning safety process and it has never

been a real commitment for BP. They never tried to implement new safety policies and processes, it

has been seen more as a way to communicate and articulate a “safety” message to maintain a

respectable corporate image than a real way to establish long-term change into their safety process.

Issue 2

The second issue is BP’s corporate risk management appetite which is very risk-seeking. It

has been stated that BP's culture is one that values doing as much as they can for a minimum budget.

It was expected that the Macondo well project had a budget of $96.2 billion and was scheduled to take

place in 51 days. In addition, the well started to be functional in January of 2010 and the explosion

occurred in April, so less than 3 months after the effort began.

Indeed, the project was six weeks behind schedule and $58 million over budget (National Commission

on the BP Deepwater Horizon Oil Spill and Offshore Drilling, 2011), with such time and cost

constraints we can surely imagine that decisions had been made in alacrity.

Moreover, with the technical issues that happen previously the blowout of Deep-Water Horizon, we

can affirm that with a proper risk management it would have unquestionably reduced, if not eliminated,

the probability of the blowout. In the conclusion stated in the National Commission's report (2011),

the explosive loss of the Macondo well could have been prevented. In fact, decisions made before and

during the disaster were never subject to an official risk assessment.

Furthermore, BP was conscious that they needed to provide maintenance to their machinery in order

to be in compliance. Indeed, a week before the accident, the blowout preventer (BOP) was accidentally

deteriorating (Greene-Blose, 2015). As an example, one of the censors of the control pod was not

working due to an emptied battery and the other was not working due to a defective solenoid valve

(National Commission, 2011). In fact, no one in the Deepwater horizon workforce and executive took

the necessary actions to solve this problem. According to Hillson R. & Webster M. (2005) what

characterizes risk seekers’ is that they tend to downplay threats.

One week prior to the blowout, the project team had actually failed to identify risk triggers resulting

in an extreme threat. Consequently, both the probability and impact of this risk has become more

important, it is then too late for preventive action, the risk is accepted.

Issue 3

The third issue concerns the lack of ethics in BP’s core values.. Or at least the conveyance of

those values to project team members. According to Jennings M. (2010): “BP's management

principles, business plans, and codes of ethics focused on safety and compliance, [but] something was

lost in translation between words and actions. The message in the written materials was not the

message that the employees heard or followed.

There was a long-standing cultural disconnect between outward appearances and internal behaviors.”

In fact, corporate ethics were sacrificed when it came to catch up their delay.

Moreover, Mr. Reilly, the former president of the United States environmental protection agency,

denounced "a culture of complacency" among BP corporations, resulting in "bad decisions" as they

were preparing to complete the drilling of the "Macondo" well at 1,500 meters below the sea surface.

In fact, there has been precipitation in the realization of the well because on site asset managers were

rushing in order to meet performance targets. Furthermore, they extended this practice among all

employees working on the site, so employee compensation was tied to asset performance and the

overall performance of the site. We can easily imagine how this manner to behave can impact the

project quality and push employees to question the respect of ethics.

Leadership responsibility, which is receiving more attention, has been widely discussed in the

context of large corporations that are suffering the consequences of their actions (or inaction).

Managers are often accused of acting selfishly and sacrificing the company's bottom line for their own

benefit. Already in the 1970s, Jensen and Meckling (1976) were suggested ways to counter such

behavior or to encourage managers to act in the interest of the company and the society.

In a general way, the CEO needs to enhance shareholder value, in line with the expectations of the

shareholders and, respectively, the management committee. However, what we do not know is how it

is supposed to achieve that goal, that is to say, what risks he must take. The CEO must therefore

improve the security aspect so as to minimize operational risks and limit potential liabilities. In the

case of BP, during the trial, Tony Hayward emphasized the $14 billion invested in security since his

appointment as CEO, but he was not able to say how it was spent. That’s why it is important spending

the time needed in order to investigate even the most minor failure and then implementing the

appropriate changes.

Proposed Solutions Table

Issues # - Solution # Solution

1-1 Create a company-wide initiative safety program that states clear safety

practices and standards that must be respected, with sanctions in case of

safety violation.

1-2 Training in order to educate the employee properly concerning the safety

practices to be in compliance.

2-1 Value scope by shifting from a risk-seeking company to a risk-adverse

company, this strategic change will impact positively BP company in a long-

term vision.

2-2 Establish a thorough risk management by providing a Plan Risk Management

in order to decrease the risk tolerance level, according to Greene-Blose, J.

M. (2015): “A simple cause and effect diagram (also known as a fishbone or

Ishikawa diagram), useful for identifying, assessing, and understanding the

root cause of risks (Project Management Institute, 2013, p. 236), may have

provided the necessary insight into the appropriate risk quantification and

response at BP.”

2-3 Establish thorough ERM throughout organization in order to reduce the risk

of regulatory non-compliance and allow BP to provide maintenance for their

equipment when it is needed.

3-1 Modify the policy concerning the asset federation model for meeting

performance targets in order to not sacrifice quality and ethics over budget

and time constraints.

3-2 Create a monitoring program and ethical training for all BP employees

resulting in leadership empowerment.

3-3 Implement a company-wide communication plan and encourage whistle-

blower in order to push employees to report unethical behavior.

Pros and Cons Matrix

Solution Pros Cons

1-1 Create a company-wide

initiative safety program  Impact future profit by

reducing repair costs for

major disaster

 Take time to be integrated

in every employees’

behavior

1-2 Implement safety training

and practices  Fewer workplace incidents/

employees have better

responses and behavior

 Take time to create those

kings of a training

 Very costly to establish

2-1 Shifting from a risk-seeking

company to a risk-adverse

company

 Value and quality over cost

and time constraints

 A better long-term vision

 Take time to realign

corporate strategy

 Change is difficult to adopt

2-2Build a strong risk

management  Risk quantification

 Better responses in case of

occurring

 Take time before the project

execution

2-3 Establish thorough ERM

through BP company  Limit the risk to be in non-

compliance

 Investments are made on

purpose when needed

 Can be expensive to

implement though the

company

3-1 Modify asset federation

model policy

 Limit the pressure for asset

managers to meet the

performance target

 Quality over Cost

constraints

 Less decision making for

the asset managers, limit

their actions

3-2 Create a monitoring

program and ethical training

 Improve leadership

empowerment

 Encourage good behavior

and positive management

 It is costly to create training

all over the company

 Employees can be reluctant

to change

3-3 Implement a company-wide

communication plan

 Encourages open exchange

of information and

viewpoints

 Limit unethical behavior

 Whistle-blower may be

misunderstood and seen as

oppressive

 Take time to implement

Solution Ranking Table [NOTE: NOT REQUIRED]

Solution Likelihood of

Success

Difficulty

Implementing

Solution

Score

Solution

Rank

1-1 Create a company-wide

initiative safety program

5 5 25 1

1-2 Implement safety

training and practices

4 4 16 3

2-1 Shifting from a risk-

seeking company to a risk-

adverse company

4 5 20 2

2-2 Build a strong risk

management

4 3 12 5

2-3 Establish thorough

ERM through BP company

3 5 15 4

3-1 Modify asset federation

model policy

2 2 4 6

3-2 Create a monitoring

program and ethical training

3 4 12 5

3-3 Implement a company-

wide communication plan

3 3 9 7

Recommendations

As a recommendation we can focus on the proposed solutions table and pros/cons matrix cross results.

In the solution ranking table above, we can see that the solution with the highest likelihood of success

(Create a company-wide initiative safety program) is also the most difficult challenging to achieve.

However, it will allow BP to implement an efficient and durable vision in order to provide the

necessary measures to prevent from future disaster. Moreover, if other major accidents happen in the

upcoming years, BP will not be able to recover the important monetary debt and its reputation will be

severely damaged. Furthermore, based on the solution ranking table, BP should focus, first of all, in

some solutions that have priority for the reinstate their credibility. First of all, they have to create a

company-wide initiative safety program, secondly, they need to shift from a risk-seeking company to

a risk adverse one and finally they need to implement safety practices and training for their employee.

These three solutions, if prioritized immediately can really decrease and mitigate upcoming potential

disasters.

References

Beever, J., & Hess, J. L. (2016). Deepwater Horizon oil spill: An ethics case study in environmental

engineering. American Society for Engineering Education.

Graham, B., Reilly, W. K., Beinecke, F., Boesch, D. F., Garcia, T. D., Murray, C. A., & Ulmer, F.

(2011). The National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling. Deep

Water. The Gulf Oil Disaster and the Future of Offshore Drilling. Report to the President.

Greene-Blose, J. M. (2015). Deepwater horizon: lessons in probabilities. Paper presented at PMI®

Global Congress 2015—EMEA, London, England. Newtown Square, PA: Project Management

Institute.

Hillson, D. A., & Murray-Webster, R. (2006). Understanding risk attitude. Association for Project

Management (APM) Yearbook 2006/2007, 25-27.

Ingersoll, C., Locke, R. M., & Reavis, C. (2012). BP and the Deepwater Horizon Disaster of 2010.

MIT Sloan School of Management, Case Study.

Jennings, Marianne M. WHAT BP TEACHES US ABOUT ETHICS, RISK, AND BUSINESS

MANAGEMENT. Corporate Finance Review 15.2 (2010): 38-42. ProQuest. Web. 21 Apr. 2019.

Jensen, M. C., & Meckling, W. H. (1976). Theory of the firm: Managerial behavior, agency costs and

ownership structure. Journal of financial economics, 3(4), 305-360.

Julie, C., (2016). A Case Study in Engineering Ethics: The Deepwater Horizon Disaster.

A SunCam online continuing education course, Case Study. Retrieverd 4/16/2019 from:

https://s3.amazonaws.com/suncam/docs/257.pdf?1527836384

O'Connor, E. O. H. (2011). Organizational apologies: BP as a case study. Vand. L. Rev., 64, 1957.

US Environmental Protection Agency. (2017). Deepwater Horizon – BP Gulf of Mexico Oil Spill.

Retrieved 4/15/2019 from: https://www.epa.gov/enforcement/deepwater-horizon-bp-gulf-mexico-oil-

spill

ENHANCING TEAMWORK

Tiffini Collier

Kal Haile

Omolola Adebisi

j

 Improving Hand-off Report

Student Names

Team Name and First/Last Names of Participants

J Nurs Manag. 2018;1–8. wileyonlinelibrary.com/journal/jonm  |  1© 2018 John Wiley & Sons Ltd

Accepted: 1 October 2017

DOI: 10.1111/jonm.12582

O R I G I N A L A R T I C L E

Nursing teamwork in a health system: A multisite study

Jennifer A. Kaiser PhD, MSN, RN, CNE, Senior Nurse Researcher1  | Judith B. Westers MSN, BSN, RN, Director of Pediatric Services2

1Spectrum Health, Grand Rapids, MI, USA 2Helen DeVos Children’s Hospital, Grand Rapids, MI, USA

Correspondence Jennifer Kaiser, Spectrum Health, Grand Rapids, MI, USA. Email: [email protected]

Funding information This research did not receive any specific grant from funding agencies in the public, commercial, or not- for- profit sectors.

Aim: The aim of this study was to examine how the facets of teamwork exist among nurse- only teams in acute and continuing care settings. Background: The health care ‘team’ conventionally describes the interdisciplinary team in both literature and practice. Nursing- specific teams are rarely considered in the literature. An examination of this specific professional cohort is important to under- stand how teamwork exists among those who provide the majority of patient care. Method: This was a descriptive, comparative, cross- sectional study using the Nursing Teamwork Survey to measure teamwork of nursing- based teams among 1414 partici- pants in multiple acute care environments across a large Midwestern health system. Results: The characteristics of nursing teams were analysed. The results from the sub- scales within the teamwork model showed that nursing teams had a good understand- ing of the various roles and responsibilities. However, nurse team members held a more individualistic rather than collective team- oriented mindset. Conclusions and Implications for Nursing Management: Increased teamwork has a positive effect on job satisfaction, staffing efficiencies, retention and care delivery. Nurse leaders can use the information provided in this study to target the aspects of highly functioning teams by improving team orientation, trust and backup behaviours.

K E Y W O R D S

nursing, team, teamwork

1  | AIM

The aim of this study was to examine how the facets of teamwork exist among nurse- only teams in acute and continuing care settings. The facets of nursing teams were explored using a similar conceptual framework to those widely examined in the literature. The principal objective was to determine how acute care nursing teams align with the standards of highly effective teams in other professional domains. Additional questions to be answered included:

(1) What is the average level of nursing teamwork based on the characteristics used to describe highly effective teams?

(2) Are there differences in average total teamwork among various care settings (service lines)?

(3) Does one or more of the aspects of effective teamwork have a stronger prevalence in acute and continuing care settings?

(4) Are there differences in the average total teamwork based on edu- cation, gender, experience or work characteristics?

(5) Does teamwork correlate to job satisfaction, satisfaction with staff- ing and intent to leave the position?

2  | BACKGROUND

In the landmark reports To Err is Human, Crossing the Quality Chasm and The Future of Nursing, the Institute of Medicine clearly identi- fied the importance of team processes to high- quality health care.

2  |     KAISER And WESTERS

Like safety culture and systems thinking, the benefits of teamwork have been demonstrated in multiple industries including aviation, nuclear medicine and the military (Baker, Day, & Salas, 2006; Salas, Cook, & Rosen, 2008). These industries are considered ‘high reli- ability organisations’, defined as organisations that operate with low levels of safety events despite a complex hazardous environ- ment (Agency for Healthcare Research and Quality, 2006). A con- ceptual framework for highly effective teams has been established in high- reliability organisations (HROs) and adopted into the health care domain (Baker et al., 2006; Brady, Battles, & Ricciardi, 2015; Gaston, Short, Ralyea, & Casterline, 2016; Jain, Thompson, Chaudry, McKenzie, & Schwartz, 2008).

The common framework and interventions for teamwork thereby originate from non- health care organisations. The Agency for Healthcare Research and Quality (AHRQ) studied the processes of teamwork in high reliability organisations and created TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), a curriculum designed to improve teamwork skills and com- munication among health care professionals (Agency for Healthcare Research and Quality, 2006). TeamSTEPPS has been implemented in areas most comparable to its prototype, namely emergency depart- ments, surgical services, intensive care units and in situations such as cardiac arrest (Jones, Podila, & Powers, 2013; McCulloch et al., 2017). ‘Teams’ among the predominant health care literature are primarily in- terdisciplinary and largely situational or episodic as in surgery or emer- gency situations (Gaston et al., 2016; Jones et al., 2013; McCulloch et al., 2017).

To date there is little known research that provides a comprehen- sive analysis of teamwork specific to the health care industry with its own variants in practice, nor does the research on teamwork within health care extend much beyond its original settings of surgical, criti- cal and emergency care (Alexanian, Kitto, Rak, & Reeves, 2015; Baker et al., 2006; Kalisch, Lee, & Salas, 2010). The vast majority of studies of teamwork in health care are interprofessional (Alexanian et al., 2015; Baker et al., 2006; Korner, Wirtz, Bengel, & Goritz, 2015). ‘Although a large proportion of health care is delivered by nursing work teams in acute care hospitals, there has been very little research about team- work in this setting’ (Kalisch et al., 2010, p.42).

There are some key differences in the structure of nursing teams versus the multidisciplinary health care team. Kalisch defines nursing teams as the staff members – registered nurses, licensed practical nurses, nursing support staff – who work together on a given patient care unit. This nursing team provides the care and related administra- tive tasks for a group of patients (Kalisch et al., 2010). A primary differ- ence is that most professionals other than nurses spend time both on and off the unit in their normal workflow. A specific time set aside for collaboration, such as interdisciplinary rounds, is one of the few times in which all the team members are physically located in the same space and interacting face- to- face. Nursing teams continually work together for extended periods of time and workflow among team members directly overlaps.

Additionally, the ‘leader’ position of the interdisciplinary teams described in the literature has been held primarily by medical providers

(Alexanian et al., 2015; Baker et al., 2006; Korner et al., 2015). This history fails to consider nursing leadership in the team structure. Numerous researchers have identified that leader–member relation- ships directly affect the quality of team cohesion and effectiveness (Brunetto, Shriberg, Farr- Wharton, Shacklock, & Newman, 2013). An examination of teamwork with a nurse as the team leader may show significant differences from previous studies and present a critical fac- tor in teamwork.

The Nursing Teamwork Survey (NTS) was developed by Dr B. Kalisch in response to a lack of a teamwork measurement tool specific to health care with sound psychometric properties that could be used in a variety of patient care settings (Kalisch et al., 2010). The NTS has a reliability coefficient ranging from 0.77 to 0.87, and an internal consis- tency alpha coefficient of 0.94. Additional factor analysis showed item loading consistent with Salas’ Big Five framework (Kalisch et al., 2010). A unique aspect of the Nursing Teamwork Survey is that it is designed to focus specifically on nursing teams as opposed to interdisciplinary healthcare teams.

The conceptual model for this tool is Eduardo Salas’ ‘Big Five’ framework of teamwork. Salas’ framework was selected as the basis for the Nursing Teamwork Survey ‘because it is based on team- work behaviours and offers a practical explanation of the dynamics of teamwork’ (Kalisch et al., 2010; p. 43). The model upon which the NTS is based has similar subscales and origins of the widely used TeamSTEPPS® model developed by the Agency for Healthcare Research and Quality (AHRQ), with five subscales congruent to those in the NTS (Agency for Healthcare Research and Quality, 2006).

The ‘Big Five’ framework describes the knowledge, skills and atti- tudes required for effective teamwork. Simply put, the model describes the components of highly effective teams. True teamwork is defined as more than parallel work and collaboration. As Salas describes, highly effective teams consistently exhibit the following knowledge, skills and attitudes:

• have a clear and common purpose • compensate for each other • regularly provide feedback to each other and the team • self-correct • anticipate each other’s actions and needs • reallocate functions • adjust their strategy under stress • coordinate without the need to communicate • value the team goals over individual goals, and • strongly believe in the team’s collective ability to succeed (Baker

et al., 2006).

Extensive research suggests that teamwork is defined by this stan- dard set of inter- related knowledge, skills and attitudes that facilitate coordinated, adaptive performance (Baker et al., 2006). There are few studies that have determined whether these standard knowledge, skills and attitudes exist in nursing- specific teams.

Effective teamwork is a valuable aspect of patient care delivery. Research has confirmed that the ability of health care to become a

     |  3KAISER And WESTERS

high- reliability organisation (HRO) is dependent on its members to effectively and efficiently coordinate their activities. Teamwork has been found to increase the productivity of nursing work, enhance job satisfaction and promote optimum quality of care. Teamwork has also been linked to decreasing nurse stress, protecting patient safety and promoting greater patient satisfaction (Kalisch & Lee, 2009). It is logical that an understanding of the structure and func- tion of nursing teams is crucial in leveraging teams to realize these outcomes.

3  | METHOD

This was a descriptive, cross- sectional study using the Nursing Teamwork Survey to measure the teamwork of nursing teams in multiple acute care environments across a large Midwestern health system. Institutional IRB review #2014- 054 was obtained prior to implementation.

The Nursing Teamwork Survey (NTS) was used to measure team- work within the nursing work environment. The tool has demon- strated validity, reliability and acceptability in previous studies (Kalisch et al., 2010). This survey tool is unique in that the team members are specific to nursing, and includes staff nurses (registered nurses and licensed practical nurses), nursing assistants, nurse managers, charge nurses and unit secretaries.

The June 2015 survey involved the participation of 74 units/ areas within 11 hospitals in the health system. Hospitals included two large 1100 bed metropolitan health centres, a 190- bed multi- specialty children’s hospital, and eight rural or suburban smaller re- gional hospitals. Nursing units included were medical/surgical units ranging from 22 to 48 beds; an acute rehabilitation unit of 20 beds; rehabilitation continuing care services; a long- term acute care unit of 25 beds; critical care units including neurosurgical critical care, cardiac critical care, surgical critical care, and a 108 bed neonatal intensive care unit; 24 bed paediatric units, and 24 bed obstetric units in the urban and regional hospitals. Surgical services, emer- gency services and more episodic teams such as interventional areas were excluded from the sample. The study included any par- ticipant who held the role of registered nurse, licensed practical nurse, nursing assistant or technician, unit secretary, clinical nurse specialist, nursing supervisor, nurse manager or nurse educator within the designated nursing areas of practice. The purpose of this broad sample was to capture a variety of nursing teams and prac- tice settings.

A convenience sample of 1,414 nursing staff employees partici- pated, constituting a 33% return rate. Probability sampling techniques were not utilized and the response rate was low. However, a sample size of 1,414 provides a ±2.6% sampling error. The ratio of sample size to the number of survey items was 26:1, exceeding the minimum recommended ratios (Osborne & Costello, 2004).

Staff nurses comprised 55% of the sample, with 53% registered nurses. Twenty- three percent were nursing assistants, 4% were unit clerks, and the remainder were nurse leaders (charge nurse, nurse

manager, supervisor, director, educator or clinical nurse specialist). The majority (86.85%) of participants was female and the highest educa- tion level of most of the participants was a bachelor degree (54.67%). A small number of participants were new to their role (6%) or new to the unit (11%) defined as less than 6 months. Interestingly, 25% of the sample respondents were not licensed nurses, although com- parison by role indicated that most of these individuals were nursing assistants. Seventy- nine percent of participants worked full- time. Fifty- three percent of participants reported working the day shift (0700–1900) and 34% worked night shift (1900–0700). Forty- eight percent did not work any overtime in the last 3 months, 87% missed one shift or fewer in the last 3 months, and 74% had no intention of leaving their position.

The survey asks the demographic items of educational level, gender, age and job title. Work- related items include work shift and years of experience. Satisfaction items relate to current position and role, staffing adequacy and level of teamwork on the unit. Thirty- three items measuring descriptors of teamwork are divided into five subscales based on Salas’ ‘Big Five’ framework of teamwork. The subscales are defined as:

• Shared mental model: All team members understand their role and responsibilities and thus respectively work together to achieve a quality work outcome.

• Team leadership: Charge nurses or managers adequately monitor, distribute and balance the workload of the nurses.

• Backup: Team members willingly aid and help one another when they recognize someone is busy or overloaded with work.

• Trust: Team members trust each other enough to communicate ideas and information and value, seek and give each other construc- tive feedback.

• Team orientation: The team works together to improve each other’s weaknesses efficiently and effectively (Kalisch et al., 2010).

The survey was deployed to approximately 4200 nursing staff within 11 hospitals and facilities in the health system via a secure email link. Surveys needed to be completed in entirety for inclusion in the study. Voluntary completion indicated consent.

4  | RESULTS

4.1 | Average level of nursing teamwork

The total teamwork system average was M = 3.614 (SD = 0.441) on a 0–5 Likert scale. There is no benchmark score for this num- ber. Compared with previous studies using the Nursing Teamwork Survey, the health system used in this study appeared to be aligned with other hospitals (Kalisch, Labelle, & Boqin, 2013; Kalisch & Lee, 2012; Pearson, Needleman, Beckman, & Han, 2015). Total teamwork differed by hospital, F (11, 1,412) = 7.50, p < .0001; service line, F (8, 1,412) = 10.4, p < .0001; and unit F (45, 1,412) = 2.31, p < .0001. Figure 1 shows the total teamwork averages for the aggregate system (n = 1,414).

4  |     KAISER And WESTERS

4.2 | Teamwork across care settings (service lines)

ANOVA found significant differences in total teamwork between care settings (service lines) F (8, 1,412) = 10.40, p < .0001. Table 1 shows the mean calculations for each of the subscales of teamwork across service lines. Rehabilitation had the highest levels of total teamwork (M = 3.840) and continuing care (long term care) had significantly lower levels of total teamwork (M = 3.288).

4.3 | Aspects of effective teams: subscales

The aggregate averages for the five subscales are shown in Figure 1. All care settings showed similar trends in subscales. The mean (M) for the total system was highest for the shared

mental model subscale (M = 4.207, standard deviation [SD] of 0.582). Team leadership was also relatively higher within nurs- ing teams (M = 3.991, SD = 0.801) than the remaining subscales, the latter showing a higher sample variance (0.339 to 0.641 re- spectively). The subscales of back up, trust and team orientation generally showed a significant drop from shared mental model and leadership across the system. The trust and backup scales showed similar frequency of behaviours (trust M = 3.790/SD = 0.725; backup M = 3.754/SD = 0.783). Finally, there was a marked drop in team orientation behaviours, with a mean of 2.324 (SD = 0.732). Regardless of the unit type or service line, the trend in subscales was constant, which is a significant finding to support the notion that nursing teams are similar regardless of the setting. Table 1 provides the averages for each subscale within each care setting.

F IGURE  1 Total teamwork averages: system aggregate

4.21 3.99

3.75 3.79

2.32

3.61

Shared Mental Model

Team Leadership

Backup Trust Team Orienta�on

Total Teamwork

Total Teamwork Averages Shared Mental Model Team Leadership Backup

Trust Team Orienta�on Total Teamwork

TABLE  1 Teamwork across service lines

Service line

Shared mental model Leadership Backup Trust

Team orientation Total Teamwork

M SD M SD M SD M SD M SD M SD

System total (n = 1,414)

4.207 0.582 3.990 0.801 3.754 0.783 3.790 0.725 2.324 0.732 3.614 0.441

Rehabilitation (n = 44) 4.487 0.480 4.375 0.347 4.318 0.513 4.231 0.567 1.790 0.539 3.840 0.265

Adult MedSurg (n = 438)

4.335 0.517 4.024 0.591 3.911 0.714 4.001 0.630 2.114 0.651 3.677 0.373

Adult progressive care (n = 204)

4.241 0.563 4.063 0.572 3.799 0.746 3.831 0.721 2.282 0.739 3.643 0.390

Adult critical care (n = 214)

4.210 0.509 3.973 0.647 3.701 0.739 3.718 0.664 2.323 0.677 3.585 0.369

Women and infants (n = 107)

4.233 0.501 3.843 0.759 3.776 0.730 3.746 0.696 2.504 0.699 3.622 0.397

Paediatric critical care (n = 145)

4.107 0.552 3.886 0.617 3.652 0.731 3.667 0.645 2.487 0.737 3.559 0.343

Paediatric MedSurg (n = 64)

4.241 0.512 4.043 0.561 3.911 0.598 3.821 0.606 2.306 0.597 3.644 0.329

Continuing care (n = 105)

3.741 0.803 3.369 0.901 3.193 0.969 3.262 0.915 2.873 0.808 3.288 0.569

M, mean; SD, standard deviation.

     |  5KAISER And WESTERS

Figure 2 displays the trends in subscales across care settings. This graph shows a consistent and significant drop in team orientation among all nursing teams.

4.4 | Differences in teams based on demographics

ANOVA was used to compare average perceptions of total teamwork characteristics based on education, gender, age, experience and work descriptors. For each of these aggregate characteristics the Bonferroni method was used to adjust for multiple testing.

There was no significant difference in the average total teamwork among males (LSM = 3.50) and females (LSM = 3.53) p > 1.0, nor were there differences by level of education (p > .41–1.0). Nursing teams on night/third shift (LSM = 3.58) reported significantly higher levels of teamwork (p < .001) than those working on day/first shift (LSM = 3.46) or evenings/second shift (LSM = 3.47). The total team- work score for those with up to 2 years of experience (LSM = 3.58) was significantly higher than those with greater than 5 years of experience (LSM = 3.39), p > .05. Work characteristics such as the amount of work missed and the amount of overtime worked had no significant differences in overall teamwork.

4.5 | Teamwork and satisfaction

The average total teamwork score for those who had no plans to leave their position within the next year (LSM = 3.52) was significantly greater (p < .001) than the average total teamwork score of those who planned to leave their position within 6 months (LSM = 3.45, p > .40) or within the next year (LSM = 3.39, p > .014). The data showed a clear correlation (p < .001) between satisfaction with position and teamwork. There was sufficient evidence to show that the average total teamwork score was highest for those with higher perceptions of adequate staffing. All levels of perceived staffing adequacy showed significant difference with a clear decline in teamwork as perceptions of adequate staffing declines. These results have implications for job retention and satisfaction.

5  | CONCLUSIONS

Generally nursing teams had similar components to those of highly effective teams in other industries as defined by the standards de- scribed by Salas (Baker et al., 2006). However, there was variation in the degree to which the nursing team expressed each of these com- ponents. In highly effective teams these scales tend to be more evenly distributed (Baker et al., 2006; Jain et al., 2008; Salas et al., 2008). This presents an opportunity for improvement to make nursing teams more congruent with prototype teams used as a model of practice.

The shared mental model subscale scored highest across the sys- tem. The shared mental model is the structure of relationships and role responsibilities within a team. High scores in this subscale means that team members are clear on the responsibilities and tasks expected of themselves and others. They feel they work well together and respect and value each other as team members. One item of particular note scored markedly low on this subscale: ‘team members are aware of the strengths and weaknesses of other team members they work with most often’. This becomes important as discussed in subsequent sub- scales. It is significant to note that nursing teams tend to know whose task and whose patient is whose but have less of an awareness of each other as team members.

The team leadership subscale also scored consistently high, which implores discussion. The predominant literature on health care teams assigns the role of team leader to the physician or other medical pro- vider. This is reflected in practice. However, satisfaction with and efficacy of the physician/provider in providing the leadership skills necessary to facilitate true teamwork is lacking. More typical of this type of team is the role of the physician/provider to make decisions based on information provided by other group members, but not nec- essarily input provided by the same (Alexanian et al., 2015).

In contrast the NTS model assigns a charge nurse or nurse man- ager the role of team leader. While nurse team leaders were perceived as much more effective than the medical leaders of interprofessional teams there remains a discrepancy between nursing teams and non- health care highly effective teams. The leadership behaviours described

F IGURE  2 Trends for teamwork subscales across care settings

1.5

2

2.5

3

3.5

4

4.5

Shared Mental Model

Team Leadership

Backup Trust Team Orientation

Total Teamwork

Rehabilitation Adult MedSurg Adult Progressive

Adult Critical Care Women and Infants Pediatric Critical Care

Pediatric MedSurg Continuing Care

6  |     KAISER And WESTERS

in the NTS are very directive toward workload and team function. High scores in this subscale mean that the team leader (charge nurse, su- pervisor or manager) monitors progress, directs changes in the plan and structure of responsibilities, and determines who should do what. Conversely, a key feature of high- functioning teams is that they are self- regulating, self- adaptable and markedly less dependent on a di- rective leader. Salas describes the importance of a dedicated leader, but in the most effective teams this aspect does not overshadow the other components. The nursing teams in this study had a prominently higher score in leadership compared with the other subscales indicat- ing a dependence on leadership versus autonomous practice.

Subscales that scored lower across the nursing teams were backup and trust. The backup scale describes team members who willingly aid and help one another with their tasks and responsibilities. In partic- ular, members monitor for and recognize when someone is busy or overloaded and assist them in their work. When the workload is heavy both team members and leadership pitch in to get things done. These behaviours were not as evident in nursing teams. While the teams value each other there is a predominant mindset of clear role delin- eation and work assignments among nursing team members. Patients are assigned to nurses and nursing assistants, and licensure often de- termines task responsibility. Even within the same level and role, units operate based on the care needed for assigned patients. Nurses feel an obligation and often pressure to get everything done for their own patient. Work left undone for the next shift is chastised and there is a constant pressure to ‘get everything done on my shift’. In the survey the least prevalent behaviours were those in which the team members themselves monitored each other and were aware of function outside of their work assignment.

The trust subscale on this questionnaire is focused on commu- nication: team members trust each other enough to communicate ideas and information and value, seek and give each other construc- tive feedback, trusting that team members will receive feedback and change as needed for the good of the team (Kalisch et al., 2010). What is seen in a lower trust subscale is the lack of self- monitoring and self- correcting through good communication found in highly effective teams. Salas observed that feedback is essential for a team to function effectively. This sort of feedback is not generally part of the typical nursing unit culture as health care tends to function in a hierarchal system of power and regulation. A levelled hierarchy tends to be a prerequisite to teamwork and the lack of this dynamic is evident in the low scores of the trust subscale.

Team orientation was the lowest scoring subscale. Team orienta- tion describes a commitment to the goals and integrity of the team versus personal objectives. It includes open discussion of behaviours of team members, a supportive helpful attitude of collective responsi- bility, feedback between members and conflict resolution. Teams with high team orientation are more focused on the collective work than their own responsibilities (Kalisch et al., 2010). Essentially low team orientation scores indicate an individualist versus a collectivist mind- set. This collectivist orientation of teams is the key feature of effective teams as indicated by decades of team research (Salas et al., 2008). Nurses represent the largest group of professionals who provide

patient care and have the most direct interactions with patients on a daily basis. Thus nurses have an immense influence on patient out- comes. Yet the unique structures and attributes of nursing teams are relatively unexamined particularly in settings where the majority of patient care is received. This study provides a large sample of nurs- ing teams. This study affords a distinctive description of patient care teams comprising specifically nurses. Understanding the team dy- namics of nursing professionals and their support personnel offers a unique opportunity to understand and impact those who provide the most direct patient care.

The lack of correlation between teamwork and demographic fea- tures such as gender and education shows that the factors of highly effective teams are process- orientated and modifiable. The correla- tions between teamwork and variables such as job satisfaction and role satisfaction reinforce previous findings of the positive outcomes of teamwork (Korner et al., 2015), and have implications for retention.

What is most important to this study is the description of the struc- ture and dynamics of teamwork among nursing teams in acute care settings. The disproportionately high leadership scores among acute care nursing teams combined with lower subsequent subscales show that nursing team characteristics differ from the known attributes of highly effective teams. Salas’ Big Five Framework of Teamwork model was developed by observing the characteristics of highly functioning teams. For teamwork to be effective all the concepts and coordinating mechanisms must be evident (Rochon, Heale, Hunt, & Parent, 2015). The 74 units/areas examined in this study had a very broad range and variety of skill mix, education, experience and satisfaction. Regardless of these vast differences, every nursing unit showed a similar pattern in the elements of teamwork with shared mental model and leadership scoring highest, then a marked drop to backup and trust, followed by team orientation as the least prevalent element.

The nursing teams in this study reflect members who have a clear understanding of their responsibilities, work alongside each other re- spectfully and are well coordinated by their nurse leader. The data reflect a sense of ‘parallel work’ in that individuals do their own work and collaborate, communicate and share information for specific sit- uations. However, awareness and concern for other team members presents an opportunity for improvement. Members of the nursing team work alongside each other but are focused on their own pa- tient assignments and responsibilities. There is little awareness of other team members and backup behaviours to support others in their work are not often practised. Overall teams in this survey did not have a sense of higher purpose that transcends their personal work domain.

While this study uniquely examines the teamwork of nurses there are several limitations. No sampling techniques were used and the re- sponse rate was below 40%, which is generally considered the mini- mum rate to be representative. A proportion of respondents worked in the team for less than 6 months and may not have a full under- standing of the team dynamics. The results were based on responses to a survey rather than observations of team behaviours and may be influenced by the perceptions of the respondent. Finally, no outcomes were measured in this study – it is simply a description of nursing

     |  7KAISER And WESTERS

teams and does not explore the relationship between nursing team- work and important clinical and patient outcomes.

6  | IMPLICATIONS FOR NURSE LEADERS

The benefits to be realized from effective teamwork are well docu- mented and include improved client care and outcomes, professional growth, greater job satisfaction and positive organisational outcomes. Put broadly, synergy is the primary outcome of exceptional teamwork. Synergy occurs when a team’s output exceeds what can be accom- plished individually. Two critical attributes to a synergistic group in- clude group cohesion and the pursuit of a common goal (Witges & Scanlan, 2015).

The data from this study find that this goal orientation is lacking in nursing teams. In nursing and health care it is agreed that patient well- being, safety and ‘patient- centred care’ is a mutual, widely accepted and valued goal among team members. While paramount this concept is nebulous. General management strategies support the articulation of SMART objectives and goal settings but this is rarely done in pa- tient care. Yet anecdotal stories of excellence that focus on a particular patient experience have shown that nursing teams can work syner- gistically when there is a specific goal in mind. Nurse leaders are en- couraged to set daily SMART objectives for the unit that can be clearly realized and celebrated, to facilitate this sense of collective purpose.

A high level of group orientation is the key element lacking in the nursing teams of this study. The question to nurse leaders becomes how to achieve this level of collective orientation and cohesion. Only intentional attention to teams and teambuilding can achieve this. Studies have found that teamwork can be developed through individ- ual and team competency training (Baker et al., 2006; Gaston et al., 2016; Salas et al., 2008). TeamSTEPPS® Crew Resource Management, simulation and other training methods have been widely deployed in health care and have demonstrated positive results (Gaston et al., 2016). Unit- based team building interventions related to work expec- tations, communication, decision- making and conflict resolution have been successful in creating effective nursing teams. Modifying tasks, workflow or structure can also enhance teamwork (Baker et al., 2006). Leaders can examine the conditions in which team- based work occurs and re- design accordingly. Creating interdependencies creates the conditions for teamwork to exist.

One specific way to create conditions that require interdependen- cies is to redesign staffing structures. Researchers have suggested that teams who are more familiar with each other may function better than new teams (Rochon et al., 2015). Intuitively this makes sense and nurs- ing leaders have responded by concerning themselves with retention efforts to maintain employees. An even easier solution is to schedule the same individuals together. The size of the hospital unit has been found to impact teamwork, with smaller units having better teamwork (Kalisch et al., 2013). Common staffing practices do not base sched- ules on other employees resulting in an ever- changing group of in- dividuals who comprise the nursing team. This practice may in fact inhibit teamwork and should be considered.

A comprehensive model of team performance specific to nurs- ing teams in acute and continuing care needs to be fully developed to lay a scientific understanding of what compromises effective teamwork in these settings. This study begins to contribute to this work by describing nursing teams in relationship to Salas’ model of teamwork which has been widely accepted as a prototype in both health care and other high- reliability organisations. It is presumed that the development of the components of this model will lead to increased team performance. This assumption needs to be validated with further research. Nurse leaders can use the information from this study to focus on the areas for opportunity to build highly ef- fective nursing teams.

ACKNOWLEDGEMENTS

Karen Vander Laan, PhD, MSN, RN and Sarah Geoghan, BSN, RN.

ORCID

Jennifer A. Kaiser http://orcid.org/0000-0002-7686-0213

REFERENCES

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Alexanian, J. A., Kitto, S., Rak, K. J., & Reeves, S. (2015). Beyond the team: Understanding interprofessional work in two North American ICUs. Critical Care Medicine, 43, 1880–1886. https://doi.org/10.1097/ CCM.0000000000001136

Baker, D. P., Day, R., & Salas, E. (2006). Teamwork as an essential component of high- reliability organizations. Health Research and Educational Trust, 41(4), 1576–1598. https://doi.org/10.1111/j.1475-6773.2006.00566.x

Brady, P. J., Battles, J. B., & Ricciardi, R. (2015). AHRQ commen- tary: Teamwork: What health care has learned from the military. Journal of Nursing Care Quality, 30(1), 3–6. https://doi.org/10.1097/ NCQ.0000000000000094

Brunetto, Y., Shriberg, A., Farr-Wharton, R., Shacklock, K., & Newman, S. (2013). The importance of supervisor- nurse relationships, teamwork, wellbeing, affective commitment and retention of North American nurses. Journal of Nursing Management, 21, 827–837. https://doi. org/10.1111/jonm.12111

Gaston, T., Short, N., Ralyea, C., & Casterline, G. (2016). Promoting patient safety: Results of a TeamSTEPPS® initiative. The Journal of Nursing Administration, 46(4), 201–207.

Jain, A. K., Thompson, J. M., Chaudry, J., McKenzie, S., & Schwartz, R. W. (2008). High performance teams for current and future physician lead- ers: An introduction. Journal of Surgical Education, 65(2), 145–150.

Jones, F., Podila, P., & Powers, C. (2013). Creating a culture of safety in the emergency department: The value of teamwork training. The Journal of Nursing Administration, 43(4), 194–200.

Kalisch, B. J., Labelle, A. E., & Boqin, X. (2013). Nursing teamwork and time to respond to call lights. Revista Latino Americano Enfermagem, 21, 242–249.

Kalisch, B. J., & Lee, H. (2009). Nursing teamwork, staff characteristics, work schedules, and staffing. Health Care Management Review, 34(3), 1–11.

Kalisch, B. J., & Lee, H. (2012). Variations of nursing teamwork by hospital, patient unit, and staff characteristics. Applied Nursing Research, 26, 2–9. https://doi.org/10.1016/j.apnr.2012.01.002

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Kalisch, B. J., Lee, H., & Salas, E. (2010). The development and testing of the nursing teamwork study. Nursing Research, 59(1), 42–50.

Korner, M., Wirtz, M. A., Bengel, J., & Goritz, A. S. (2015). Relationship of organizational culture, teamwork, and job satisfaction in interprofes- sional teams. BioMed Central Health Services Research, 15, 243. https:// doi.org/10.1186/s12913-015-0888-y

McCulloch, P., Morgan, L., New, S., Catchpole, K., Roberston, E., Hadi, M., … Griffin, D. (2017). Combining systems and teamwork approaches to enhance the effectiveness of safety improvement interventions in sur- gery: The Safer Delivery of Surgical Services (S3) Program. Annals of Surgery, 265(1), 90–96.

Osborne, J. W., & Costello, A. B. (2004). Sample size and subject to item ratio in principal components analysis. Practical Assessment, Research & Evaluation, 9(11), 1–9. Retrieved April 5, 2016 from http://PAREonline. net/getvn.asp?v=9&n=11.

Pearson, M. L., Needleman, J., Beckman, R., & Han, B. (2015). Facilitating nurses’ engagement in hospital quality improvement: The New Jersey

Hospital Association’s implementation of transforming care at the bedside. Journal for Healthcare Quality, 38(6), e64–e75. National Association for Healthcare Quality.

Rochon, A., Heale, R., Hunt, E., & Parent, M. (2015). Teamwork and patient care teams in an acute care hospital. Nursing Leadership, 28(2), 28–39.

Salas, E., Cook, N., & Rosen, M. (2008). On teams, teamwork, and team performance: Discoveries and developments. Human Factors, 50(3), 540–549. https://doi.org/10.1518/001872008X288457

Witges, K. A., & Scanlan, J. (2015). Does synergy exist in nursing? A concept analysis. Nursing Forum, 50(3), 189–195.

How to cite this article: Kaiser JA, Westers JB. Nursing teamwork in a health system: A multisite study. J Nurs Manag. 2018;00:1–8. https://doi.org/10.1111/jonm.12582

Nursing Inquiry. 2021;00:e12413. wileyonlinelibrary.com/journal/nin  | 1 of 10 https://doi.org/10.1111/nin.12413

© 2021 John Wiley & Sons Ltd

1  |  INTRODUC TION

Global nursing and healthcare workforce shortages, increased de- mands on healthcare systems and growing healthcare expenditure have resulted in a focus on the development of strategies to pro- vide cost- effective health care (All- Party Parliamentary Group on Global Health (APPG), 2016; National Health and Hospital Reform Commission (NHHRC), 2009). As part of these strategies, skill mix and nurse staffing are manipulated to reduce costs and provide qual- ity care to patients (Aiken et al., 2013; Jacob et al., 2015; NHHRC, 2009). Adding to this, the COVID 19 pandemic has placed further strain on the healthcare system resulting in the need to build surge workforce capacity to meet the needs of patients (Al Mutair et al., 2020; Marshall et al., 2020). Healthcare organisations have been required to reframe the delivery of patient care examining options to augment and extend the nursing and healthcare workforce. A

common strategy is a tiered healthcare team approach to patient care delivery based on the idea of experienced staff supervising less experienced or lower trained staff members working together to meet the patients’ needs (Al Mutair et al., 2020; Marshall et al., 2020). This may occur in situations where tasks traditionally per- formed by one worker are shifted to another worker (APPG, 2016).

Prior to the pandemic, pressures on healthcare systems interna- tionally had increased the reliance on the use of unregulated nursing assistant (NA) roles in the acute hospital setting (Aiken et al., 2016; Blay & Roche, 2020; Duffield et al., 2014; Kalisch, 2011). To meet pandemic surge workforce demands, healthcare teams may be addi- tionally augmented with reassigned or redeployed staff with trans- ferable skills, healthcare staff re- entering the hospital workforce, final year students in nursing, medical and allied health courses and NA roles (Al Mutair et al., 2020). It is imperative when working in the multi- skilled/ multi- tiered nursing workforce environment that

Received: 8 April 2020  | Revised: 3 March 2021  | Accepted: 12 March 2021 DOI: 10.1111/nin.12413

F E A T U R E A R T I C L E

Transparent teamwork: The practice of supervision and delegation within the multi- tiered nursing team

Felicity Ann Walker1,2  | Madeleine Ball2,3 | Sonja Cleary2 | Heather Pisani2

1Faculty of Health, Southern Cross University, Bilinga, QLD, Australia 2School of Health & Biomedical Sciences, RMIT University, Melbourne, Vic., Australia 3School of Health Sciences, University of Tasmania, Melbourne, Vic., Australia

Correspondence Felicity Walker, Faculty of Health, Southern Cross University, Gold Coast Campus, Southern Cross Drive, Bilinga, Queensland 4225, Australia Email: [email protected]

Funding information Australian Government Research Training Program Scholarship

Abstract Supervision and delegation are important leadership skills that nurses require when practising within the multi- tiered nursing team. In response to increasing demands globally on healthcare systems, Nursing Assistants are becoming more prevalent mem- bers of the nursing workforce in the acute care setting. An exploratory descriptive re- search design was used to examine supervision and delegation of Nursing Assistants in an acute hospital setting in Victoria, Australia. It was found that supervision and delegation in the context of a multi- tier nursing team required a complex assessment and decision- making process which was influenced by multiple factors. This research promotes developing transparent nursing practices and mutual understanding in the multi- tier nursing team to facilitate effective supervision and delegation based on in- formed decision- making and culture of openness and trust. Pre- registration education and continuing education and support for nurses are important to build transparent supervision and delegation practices and teamwork, empowering the nursing team to practice to their full scope of practice to provide high- quality patient care.

K E Y W O R D S accountability, delegation, leadership, nurse, nursing assistant, supervision, transparency

2 of 10  |     WALKER Et AL.

each team member is cognisant of their roles, responsibilities and capabilities and that appropriate delegation and supervision prac- tices are in place to ensure the quality and safety of patient care. This research aims to contribute to nursing practice through exam- ining supervision and delegation practices occurring in a multi- tiered nursing team consisting of Registered Nurses (RNs), Enrolled Nurses (ENs) and NA in an acute care setting in Victoria, Australia.

This research focuses on the question of how supervision and delegation of a NA position are practised in a multi- tier nursing team. In the situation, researched NAs were introduced to the acute hospi- tal setting, to enhance the patient experience, assist with the nurses’ workload allowing them to work up to their full scope and improve retention of nursing staff at the research setting. The NA position was additional to the mandated 1:4 nurse/ patient ratios and was used to supplement the nursing workforce. NA attended to basic care duties including patient hygiene, mobilisation, specialling at- risk patients and general duties including restocking of cupboards and checking of equipment. The NA was required to practice under the supervision and delegation of the RN at all times.

Delegation and supervision are important leadership skills for effective nursing care and teamwork. When delegating to and su- pervising another worker, nurses need to use their critical thinking skills to make an informed decision on the appropriate course of action to maintain safe and quality patient care (Bittner & Gravlin, 2009; Quallich, 2005; Standing & Anthony, 2008; Weydt, 2010). The nurse must use their assessment skills and determine whether a task is appropriate for delegation and the required level of supervision by examining the patient, the context and environment, as well as the skill level/ qualification level needed for the task. They also need to consider the competency and skill level of the person they are delegating to, as individuals have different capabilities and supervi- sion needs independent of role title. Second to this, the nurse must establish whether the person also has the capacity and resources to be able to attend to the task, taking into consideration the wider context and ward needs (All- Party Parliamentary Group on Global Health (APPG), 2016; Quallich, 2005; Weydt, 2010).

Nurses need to be aware of their accountability and responsi- bilities when delegating and supervising others, remembering that they retain accountability for their decision to delegate and for monitoring outcomes (Nurisng & Midwifery Council, 2018; Nursing and Midwifery Board of Australia (NMBA), 2007). The delegating nurse is responsible for making sure the delegated task is completed successfully and within a reasonable time frame, with feedback provided to the delegate for learning and development purposes (NMBA, 2007; Nursing & Midwifery Council, 2015; Quallich, 2005). When delegating to another worker, it is important for the RN to practice the appropriate level of supervision, which incorporates education, guidance, direction, and monitoring and evaluating out- comes (NMBA, 2007, p. 19; Nursing & Midwifery Council, 2015).

Efficient delegation and supervision in nursing practice is a com- plex process that requires the nurse to use critical thinking, rational decision- making, risk assessment processes and positive interper- sonal skills (Bittner & Gravlin, 2009; NMBA, 2007; Weydt, 2010).

Supervision and delegation are an inherent part of the nurses’ role, and therefore, it is important to examine the understanding and ac- ceptance of these practices and factors influencing them in the nurs- ing team. Evidence in the literature demonstrates the importance of the relationship between successful delegation to teamwork and quality patient care (Bittner & Gravlin, 2009; Potter et al., 2010).

1.1  |  Literature review

Internationally, nursing care is commonly delivered by a team of workers of differing levels of experience and qualifications (Kalisch & Lee, 2013; Kalisch et al., 2013). Delegation and supervision are an in- trinsic component of working as part of an effective multi- tier/multi- skilled healthcare team to deliver high- quality patient care (Potter et al., 2010). As the scope of practice of nurses and NA positions evolve to meet the pressures on the healthcare systems globally, it is important that each member of the nursing team understands and operates their role and responsibilities in the delegation and supervi- sion process. The importance of effective supervision and delegation practices in the nursing team has been recognised internationally.

Delegation is described as a process of mutual understanding of specific results expected and how those results are achieved (Potter et al., 2010). Standing and Anthony (2008) found that nurses viewed delegation as either the explicit act of instructing the NA to perform a task, or implicit delegation, whereby the NA attends to duties as part of the routine practice of their role. Magnusson et al. (2017, p. 46) reported five styles of delegation; (a) the do- it- all nurse, who completes most of the work themselves, (b) the justifier, who over- explains the reasons for decisions and is sometimes defensive, (c) the buddy, who wants to be everybody's friend and avoids assuming authority, (d) the role model, who hopes others will copy their best practice but have no way of ensuring how, and (e) the inspector, who is acutely aware of their accountability and constantly checks the work of others. Each of these styles was shown to potentially have a negative outcome and be poorly received by the NA thus impacting teamwork. The authors argue that nurses need to exercise personal authority and assertiveness for effective delegation practice and re- quire support and a safe space to enhance these skills (Magnusson et al., 2017).

Successful delegation between nurses and NAs depends on multiple factors including communication, teamwork, initiative, system support, nursing leadership, positive interpersonal rela- tionships and attitudes, work environment, ward culture, work- load and characteristics and the NA’s competence and knowledge (Bittner & Gravlin, 2009; Gravlin & Bittner, 2010; Johnson et al., 2015; Potter et al., 2010). It is important for nurses to learn skills to delegate effectively, such as critical thinking, negotiation and assertiveness to ensure patient safety and quality of patient care (Bittner & Gravlin, 2009; Magnusson et al., 2017; Potter et al., 2010; Schluter et al., 2011). Bittner and Gravlin (2009) report seven factors relevant to critical thinking and delegation between the nurse and NA which are knowledge, expectation,

    |  3 of 10WALKER Et AL.

relationships, role uncertainty, communication barriers, system support and omitted care. These findings are supported in the lit- erature (Hasson et al., 2013; Magnusson et al., 2017; Potter et al., 2010; Standing & Anthony, 2008).

The purpose of delegation is to gain work efficiency, which Potter et al. (2010) argue can only be achieved when nursing team members work together in partnership. Problematic delegation may have negative impacts on patient care and teamwork (Allan et al., 2016; Bittner & Gravlin, 2009; Johnson et al., 2015). Johnson et al. (2015) argue that poor delegation can lead to nurses and NAs work- ing in parallel rather than as an integrated team. They found that ward culture, personal working styles, skills and competencies, and effective communication were factors that informed collaborative nursing between newly qualified nurses and NAs. Ineffective del- egation practices and poor communication appear to be a source of conflict between nurses and NAs, thus effecting teamwork and quality of patient care (Johnson et al., 2015; Potter et al., 2010). Researchers argue this conflict is accentuated by a lack of under- standing and comprehension by NAs of the role and duties of the RN, with NA’s perceiving very little difference between their roles (Potter et al., 2010; Standing & Anthony, 2008).

Effective communication was shown to be essential to the del- egation process and the follow- up of completed duties (Anthony & Vidal, 2010; Gravlin & Bittner, 2010; Potter et al., 2010; Wagner, 2018). Communication issues, such as sharing information pertinent to the patient and patient care plan, understanding delegated du- ties, absence or lack of communication or reporting, and communi- cation styles were also consistent findings (Bittner & Gravlin, 2009; Gravlin & Bittner, 2010; Potter et al., 2010; Standing & Anthony, 2008; Wagner, 2018). There is a high expectation on NAs to report back abnormal findings and demonstrate prioritisation skills, which is beyond their knowledge and skill level (Bittner & Gravlin, 2009). Researchers argue that poor communication and ineffective com- munication styles have potentially negative outcomes for patient care and nursing teamwork (Bittner & Gravlin, 2009; Wagner, 2018).

The nurse and NA interpersonal relationship was found to influ- ence the effectiveness of the delegation process (Anthony & Vidal, 2010; Gravlin & Bittner, 2010). In situations where a positive rela- tionship was perceived between the nurse and the NA, delegation was enhanced (Gravlin & Bittner, 2010; Potter et al., 2010; Standing & Anthony, 2008). Mutual trust is a consistent finding for successful delegation (Anthony & Vidal, 2010; Bittner & Gravlin, 2009; Standing & Anthony, 2008). The perception of the importance of the recipro- cal nature of the nurse– NA relationship is also discussed (Standing & Anthony, 2008). Other influences on the delegation and supervision relationship considered in the literature are individual personality char- acteristics, work ethic, favouritism, the fear and frustration of working with poorly performing NAs, fear of reprimanding wayward NAs, the reluctance of NAs to accept duties, nursing confidence to delegate and the perception of nurses handing off the “dirty work” (Potter et al., 2010; Saccomano & Pinto- Zipp, 2011; Standing & Anthony, 2008).

The nurses’ acceptance of their accountability for the work del- egated to the NA was explored in the literature (Alcorn & Topping,

2009; Potter et al., 2010; Standing & Anthony, 2008). There was ev- idence that some nurses believe they should not be accountable for the actions of others (Alcorn & Topping, 2009; Hasson et al., 2013). A “red flag” in this space was reported by Hasson et al. (2013), where 46% (n = 204) of student nurse participants indicated they did not believe a nurse should have to supervise the NA, while 78% (n = 342) did not believe their nursing training had prepared them to work alongside NAs. Delegation and accountability are complicated by the variation in the scope of practice expected of the NA and nurses uncertainty about the role boundaries. Clarity and education on accountability and delegation and supervision practices were advo- cated (Bittner & Gravlin, 2009; Hasson et al., 2013; Wagner, 2018).

The movement towards diluting the nursing skill mix around the globe means nurses are responsible for the delegation and supervi- sion of lower trained workers within the nursing team. Evidence in the literature demonstrates the importance of the relationship be- tween successful delegation to teamwork and quality patient care (Bittner & Gravlin, 2009; Potter et al., 2010). It is important to under- stand how supervision and delegation are practised in the nursing team to enhance patient care and teamwork.

2  |  METHODS

In this study, an exploratory descriptive research design was un- dertaken to examine the supervision of NAs practising in an acute hospital setting, triangulating multiple sources of evidence. Nursing leaders (policymakers, managers, supervisors and educators) (n = 20), nurses (RN/EN) (n = 74) and NAs (n = 10) from 13 medical, surgical and specialty wards of a tertiary hospital in Victoria Australia participated in this research. To be included participants had to have had direct involvement in the development or implementation of the NA model, worked directly with the NA in the acute ward environ- ment (>3 months) or worked in the role of a NA (>3 months) at the hospital organisation. Recruitment and demographic information is listed in Table 1. Ethical approval for the research was obtained from the relevant University and Hospital organisation ethical review boards, and this research was conducted according to the principles and values of ethical conduct, as specified in the National Statement on Ethical Conduct in Human Research (2007).

Data were collected using semi- structured individual interviews (24), focus groups (11 focus groups with average of 6 participants) and documentary information in the period between September 2013 and March 2014. Participants were accessed and recruited via various means, including advertisement posters in the hospital, re- searcher presentations on wards, word of mouth, networking and through gatekeepers such as nurse managers and nurse educators. Recruitment was guided by the concept of data adequacy, and the accessibility and willingness of stakeholders to participate in the re- search. Interviews and focus groups were guided by semi- structured interview questions which were peer- reviewed for content valid- ity and then refined, through progressive focusing. The interview guides were developed to reflect the research aim and to collect

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information that would inform and provide a comprehensive de- scription of the topic under study.

Documentary evidence was used to augment and provide con- text to the information learned from the interview and focus group process. Both publicly and privately accessible documents were reviewed and included: organisational documents such as policies and administrative documents, academic documents such as for- mal papers and evaluations, government reports and inquiries, and government and industrial body communication and information re- leases. Interviews and focus groups were conducted by the primary researcher. They were audio- recorded and transcribed verbatim by the researcher and manually analysed. The thematic data analysis for this research consisted of data condensation, data display, and conclusion drawing and verification as outlined by Miles et al. (2014). The analytical tactics were configurational (the what), normative (the how) and field (the why) analysis as per Vincent and Wapshott (2014).

Rigour was maintained through a comprehensive description of the case and systematically following and presenting the research design as per Yin (2014). This research aimed to be relatively value neutral and free of bias, building objectivity within the research pro- cess as outlined by Miles et al. (2014) and Holloway and Wheeler (2010). Transcripts of individual interviews were sent back to

participants for verification. A sample of focus group transcripts were reviewed by the research team to verify the interpretation of the meaning expressed by participants. Triangulation of multiple sources of data was utilised to verify conclusions drawn from the data analysis. The researcher ensured that the documents collected were from a variety of sources with a variety of purposes, and in- tended audiences to maintain a balanced representation of the evi- dence available. A wide net was cast for recruitment of participants, with the aim of recruiting participants that reflected the full stake- holder population. This examination of supervision and delegation practices in the multi- tier nursing team was completed as a compo- nent of a larger research project examining a Nursing Assistant (NA) role practicing in the acute hospital setting.

3  |  FINDINGS

3.1  |  Clarity in the framework of care delivery in the practices of supervision and delegation

The importance of building a clear framework of care delivery in the practices of supervision and delegation in the context of the multi- tiered nursing team was reported in this research. Nurse

TA B L E 1 Demographics of research participants

Embedded unit of analysis

Nurse Leader Total recruitment: 20

Nurse (RN/EN) Total Recruitment: 74

Nursing Assistant Total Recruitment: 10

Role Senior Managers/ Policy Makers— 9 NUM— 6 Nurse Educators— 5

RN— 68 EN— 6

NA— 10

Age Age Range (years) No. of Participants

Age Range (years) No. of Participants

Age Range (years) No. of Participants

35– 44 45– 54 55– 64

9 8 3

18– 24 25– 34 35– 44 45– 54 55– 64

10 34 13 13 4

18– 24 25– 34 45– 54 55– 64

3 1 5 1

Gender Male 5 Male 6 Male 2

Female 15 Female 68 Female 8

Years of Experience in Current Role

Years of Experience

No. of Participants

Years of Experience

No. of Participants

Years of Experience

No. of Participants

1– 2 years 3– 5 years 6– 10 years >10 years

6 5 7 2

RN: <1 year 1– 2 years 3– 5 years 6– 9 years 10– 15 years > 15 years EN: 6– 9 years 10– 15 years >15 years unknown

RN: 6 10 16 16 15 5 EN: 1 1 3 1

1– 2 years >2 years

3 7

Additional Information

Acting Nurse Manager (ANUM)— 9 RN participants

Clinical Nurse Specialist— 11 RN participants

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leaders promoted the importance of developing clear guide- lines and education to “ensure that the RN, EN, the NA all work within their scope of practice and all three parties are aware of their roles and responsibilities when it comes to supervision and delegation and accountability” (NL8). Despite this, there were in- consistencies in the interpretations of these guidelines and how they were operationalised in practice, which had the potential to impact teamwork and the quality of patient care. It was acknowl- edged that although nurses and NA may know what tasks a NA could perform if they “put it all into an accountability supervision delegation framework, I think you might find a bit of confusion” (NL8). This may have been complicated by pre- existing “greyness” in the scope of the RN and the EN roles in the multi- tiered nurs- ing team.

Variations in the interpretation of supervision and delegation guidelines existed at all stakeholder levels (nurse leaders, RN and EN, and NA) thus effecting horizontal (peer to peer) and vertical re- lationships (different stakeholders) and associated teamwork. NAs expected that they “were going to work side by side with a RN, so she would be giving us our instructions and our directions and she would work with us and we would be part of a team” (NA4). However, they expressed disappointment “that hasn't happened … we're very much left to ourselves” (NA4). Contrary to this, other NAs embraced the autonomy in their role and did not perceive an ab- sence of supervision and delegation by the RN “it may be unspoken but I always feel that they [nurses] are supervising me” (NA1). Where NA felt they were inappropriately supervised, they expressed frus- tration and anxiety.

Multiple factors influenced the understanding and practices of supervision and delegation within the multi- tier nursing team includ- ing the: interpretation and understanding of policy, trust, collegiality, individual work priorities, prior experience, and ward culture and ac- cepted practices. Nurse leader views on the level of supervision re- quired for a NA ranged from very conservative, one arguing “I don't think any [NA] should ever be left alone with a patient” (NL1), to a broader perspective:

A RN might ask the [NA] to do a shower while they go to tea, so they’re not there but the assumption is that when you go to tea somebody else is kind of keeping an eye on your patients.

(NL5)

Addressing these variations is essential as nurse leaders confirmed the importance of appropriate supervision and delegation “because if we don't get that right, then it dilutes the effectiveness of the [NA] role” (NL2). Nurses also held diverging views on the practice of su- pervision and delegation of the NA one nurse stating “we don't really follow them around and put them under the microscope because we consider them part of the team” (N10). Whereas another nurse ac- knowledged “we could probably do it [supervision of the NA] better” (N1). There were some nurses that perceived supervising the NA as an additional burden one RN referred to the NA as “someone else you

have to supervise and make sure that they haven't disappeared” (N9). They described being “slowed down” by supervision requirements of a NA trainee.

Due to the variability in the understanding and interpretation of the NA role boundaries, NAs were required to communicate clearly the duties they were allowed to assist with. Nurse leaders promoted building an inclusive team environment where the NA was empow- ered and “encouraged to speak up if they're unsure or if they're not able to do it” (NL4). It was recognised that “as a [NA] you have to be really strong to say “look I can't do that” (NL2). A senior nurse leader commented that “they [NAs] actually became very much the police of their own scope of practice” (NL9). In light of this, there was a concern that “some of them [NAs] may feel they don't have the right to say no to nurses because we are supervisors of them” (NL6), and “some of them [NAs] will just do it because they have been asked” (NL2). Further, concern was expressed that the NA may not identify: “‘I’m not a nurse’ just let it kind of slide, it just depends who the [NA] is” (NL3) which may have potential negative outcomes for patient care.

3.2  |  Confidence and understanding in supervision and delegation practices.

Supervision and delegation practices within the multi- tiered nurs- ing team involve a complex assessment and decision- making pro- cess. The nursing team require an understanding of each team member's roles, responsibilities, skill level and competencies of individuals. Patient condition and care needs must also be consid- ered. It was recognised that “as the RNs we are legally responsible for them [NA], so it's quite critical that our new staff and grads [New Graduate Nurses (NGN)] understand their responsibilities” (N6).

Appropriate supervision and delegation practices were identi- fied as being of such significance that it was a common understand- ing by nurse leaders that casual pool/ agency staff and NGNs were precluded from supervising and delegating to NAs, as these staff potentially had a “poorer understanding” (NL2) of requirements in a particular ward setting. In the case of the NGNs, nurse leaders argued they should not be allocated an NA to assist them as “they're [NGNs] still struggling with their own time management and prac- tice… better for them to be looked after by the rest of the team rather than NAs” (NL4). However, this did not translate into practice, as both casual pool/ agency staff and NGNs described practising su- pervision and delegation of NAs.

New graduate nurses participants acknowledged that they were regularly assisted by the NA position but felt underprepared for the leadership responsibility suggesting that further preparation for supervising and delegating to the NA would be beneficial “I’m a grad and I don't really know much about them [NA]… I find it hard, I don't know all supervision stuff and what actual tasks they can do” (N11). A lack of confidence in their ability to delegate and supervise, combined with a weaker understanding of the boundaries of the NA

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role, impacted some NGN’s willingness to delegate without direct supervision “I usually use them as my extra pair of hands. So if I’m mobilising, or if I’m doing a bed wash and I need that extra pair of hands, so I am with them” (N12). The potential negative impact of this lack of confidence and understanding was demonstrated when a NA “went out of their scope of practice because she was trying to help a NGN and the graduate didn't have the confidence to actually stop the person doing what they were doing… the problem, lack of experience with the role and lack of understanding around what the role could do lead to that issue” (NL10). This supports the need for a clear framework for supervision and delegation and ensuring that those participating have a strong understanding of each party's roles and responsibilities.

3.3  |  Collegiality, respect and trust in the delegation and supervision process

Nurses expressed greater comfort in delegating a range of duties and providing low- level supervision where higher levels of collegi- ality and trust existed between nurses and NAs. This was further strengthened where there was the perception that the NA displayed a strong work performance, high competency level and had recep- tive attitude. One RN noted “if you've asked them [NA] to do some- thing and they've done it well, then you know that you can ask them to do it again” (N2). Contrary to this, where there were lower levels of collegiality and more mistrust, nurses expressed less confidence in the NA abilities and work performance as reflected by the follow- ing “if they [NA] don't seem confident then you're not really going to leave them on their own” (N3). In these situations, nurses reported that they tended to avoid delegating tasks and provided higher levels of supervision where possible. Nurses with less confidence in the NA revealed that they preferred to use the NA “as a second pair of hands” (N4), rather than delegate duties that required the nurse to practice indirect supervision. It should be noted that there was a concern that too much trust and comfort between the nurse and NA may have a negative impact on supervision practices as “the more experienced they [NAs] become you trust them a bit more” (N5) leading to nurses becoming “quite blasé about supervision and delegation” (N6).

In the multi- tiered nursing team, nurse leaders identified the potential of nurses to inappropriately delegate tasks and take ad- vantage of the NA, expecting them to do the ‘dirty work’ or to “del- egate and forget… or a situation where the registered staff delegate off everything and then leave themselves with perhaps not much more than medication to work through (NL5). There was agreement among the nurses that “some people [nurses] rely on them [NAs] too much sometimes” (N13), “some people are NA hogs” (N14), and these nurses were inconsiderate of the needs of other nursing team members. There were further concerns that nurses will “leave those things [dirty work] because they expect the [NA] to do them” (NL11) thus potentially resulting in care being missed. The unstructured

nature of the NA workload created the potential for NA to be del- egated heavy workloads and create tension within the team should the NA refuse to accept a delegated duty.

3.4  |  Operationalising direct and indirect supervision.

Nurse leaders challenged the idea that the RNs were new to super- vision and delegation due to their responsibilities when working with ENs and student nurses “it should be similar in following the same principles as how they work with the ENs, how they work with novice and beginner nurses and nursing students as well” (NL9). One nurse leader identified that the introduction of the NA “made me understand that it did not really dawn on them [RNs] how much they were responsible for the supervision and delega- tion of ENs” (NL12).

Nurses were able to define direct and indirect supervision, but there were inconsistencies in their interpretation of when to apply the different levels of supervision. This was evident in a focus group disagreement where nurses argued whether a nurse was re- quired to remain on a ward when indirectly supervising a NA, or if this responsibility passed to the nurse covering the nurse while off the ward on break “you've always handed over to the nurse next door anyway so they're indirectly responsible” (N7). In addition to this, many nurses expressed the belief that the nurse in charge was responsible for supervising and delegating to the NA, not identify- ing their role in explicit delegation and supervision responsibilities that ensue. Participants who acted as nurse in charge rebutted this assertion, arguing they were too busy to know what the NA was doing “as an in charge I never see her because she's always out… it's more up to the girls on the floor that are working with her and alongside her” (N8).

Some nurse leaders expressed concerns about the nurses under- standing and practice of indirect and direct supervision “they [RNs] really don't understand concepts of supervision direct, indirect and accountability… I really don't think that they even think about it much the NA just comes in and does the work” (NL13). The nurse leader then provided an example of a situation where the NA had been left in a vulnerable position as the RN had “propped open the door of the drug room so the health assistant can go in and restock… they aren't thinking the NA should not be in there without a RN present” (NL13). Other nurse leaders agreed that supervision and delegation are an area that nursing could improve.

When considering how to improve supervision of NA in practice one nurse leader identified “the risk is sometimes that you can over supervise people particularly when a role is new because you're worried that people will work outside of scope” (NL14). Further to this “because supervision is generally indirect and not direct and you would argue that if you had to give direct supervision all the time there's no point having the role” (NL14). This nurse leader also indicated “I don't think supervision could be improved but I think

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possibly giving people, giving people a bit more room, bit more flex- ibility in the role”(NL14); again highlighting the divergent views on supervision and delegation practice of the NA in the acute hospital setting.

3.5  |  Understanding accountability and responsibility

The nurses’ understanding of their accountability and responsibility was intrinsically linked to their individual understanding and expec- tations of the practice of delegation. There were variations in the expectation and understanding of the nurses’ accountability when working with the NA. In theory, the nurses understood that they were accountable and responsible for the duties they delegated to the NA; however, how this was interpreted and practised in the ward environ- ment varied between individual nurses. When this issue was explored in detail in the focus groups, nurses were often divided as to what they should be held accountable for “if they've [the NAs have] been signed off on something in their training then they should be account- able for what they do” (N10); contrary to this, others argued “that's not the way it is… we are accountable… you're responsible (N11).

When the NA position was first introduced, nurses expressed concern at being accountable for another healthcare team member; however, they indicated that their experience working with the NA had dulled some of those concerns. It was argued that the NA had become embedded into the culture of the nursing team, and there- fore, the nurse was no longer mindful of their accountability and re- sponsibility, it had just become part of the daily routine as “I don't think the RNs would consciously be thinking of it [their account- ability and responsibility] it's just kind of now culturally embedded into how we practice on a day to day (NL6). There was concern that trust between the nurse and NA may result in nurses “abdicated that [accountability and responsibility of the delegated task] because we have so much faith in our NA” (NL7). One nurse leader noted “they're [nurses are] very good at delegating probably less good at supervis- ing” (NL15). There were nurse leaders that expressed concern that nurses continue to ask questions about “what accountability was, their responsibility was and they're still not clear.” (NL13). Further to this, there are some nurses that continue to have “an incredible amount of anxiety about their legal role related to supervision and delegation” (NL12).

3.6  |  Improving supervision and delegation through education and information

Nurse leaders argued that education, clarity in the supervision and delegation space, and support within the ward environment, would improve the practice and understanding of supervision and del- egation and accountability. At the ward level, the nurse managers promoted a clear support structure, further education, and clear

and consistent guidelines to ensure supervision and delegation of the NA was of a satisfactory standard. It was noted by one nurse leader that:

Being able to supervise and delegate incorporates skills such as being able to give feedback… leadership skills being able to critically appraise activities what needs to be done how to delegate those activities they’re all skills and from my experience, I don’t see many RNs having those skills.

(NL1)

Thus, impressing the importance of ongoing education in this space “we are going to have to do a revisit on the NA… I think that there is a real need for it” (NL13). This was supported by the NAs and many of the nursing participants. Educators recommended that ongoing education for the nursing team should involve practical examples and opportunities for open discussion, so nurses may gain a greater under- standing of the practical application of the principles of supervision, delegation and accountability. Those who rejected the need for further education believed that supervision and delegation were practised al- ready to satisfactory levels. Mutual understanding and transparent practices at the team level is important for supervision and delegation in the multi- tiered nursing team as nurses need to be “comfortable and confident with their scope of practice and their role in supervision and delegation and the framework they deliver care in” (NL8).

4  |  DISCUSSION

This research found that supervision and delegation practices in the multi- tier nursing team are complex and influenced by multiple fac- tors. It supports the importance of mutual understanding and trans- parency in the nursing team to facilitate appropriate supervision and delegation. It suggests that more transparent practices within the nursing team could build better shared expectations and per- formance of supervision and delegation with the aim of improving patient care, teamwork and role satisfaction. Palanski et al. (2011) define team transparency as “the sharing of information and expla- nations within a team to enable its members to carry out their re- sponsibilities within the team” (p. 203) and Horne (2012) argues that transparency requires openness, disclosure and the free- flowing sharing of knowledge. This research finds effective communica- tion is an essential part of this process, requiring the nursing team to feel empowered to openly and honestly communicate, sharing knowledge and feedback in a collegial way to maintain the quality of patient care.

In line with previous research on nursing supervision and del- egation, this study indicated mutual understanding, knowledge, skills, competence, collegiality, attitude, ward culture, communica- tion, interpersonal skills, workload, teamwork, support and initiative influenced delegation and supervision practices (Bittner & Gravlin,

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2009; Gravlin & Bittner, 2010; Potter et al., 2010; Weydt, 2010). The multiplicity of factors affecting nursing supervision and dele- gation practices within the multi- tiered nursing team culminates in a complex assessment and decision- making process requiring team members to be well informed and have access to appropriate information. Individual characteristics, skills and attitudes of team members and leaders add further complexity and inhibits a one size fits all approach. The multilayered complexity substantiates the im- portance of transparent practices so that the needs of the situation, environment and individual actors may be taken into consideration and informed decisions made.

A lack of understanding about delegation, and responsibilities and accountabilities in the delegation relationship, is associated with nurses fearing to delegate tasks and an increased risk of burnout (Quallich, 2005). This research supports the idea that nurses are more reluctant to delegate duties or provide indirect supervision in situations where they were not confident, had mistrust or lacked an understanding of the requirements of delegation and supervision. Conflict was present where there was a lack of mutual understanding as team members held mismatched expectations and understand- ing of roles and responsibilities, requirements for supervision, and workload and initiative which were further complicated by individual personalities. This supports Potter et al. (2010) finding that there are multiple sources of conflict within the nurse/NA relationship. A lack of understanding of practices and conflict within the nurse– NA re- lationship had the potential to inhibit fulfilment of the intentions of the role, which was to allow nurses to work to the upper end of their scope, improve the patient experience and improve staff retention. This is important as the APPG Triple Impact report (2016) identi- fies that it is important for nurses to work to their full potential and strengthening nursing will positively impact health, gender equality and economic growth.

The inclusion of the NA to the nursing team requires the RN to embrace their role as a leader and to be more cognisant of their re- sponsibility and accountability as a professional nurse. The Nursing Now campaign draws attention to the need to nurture nurses’ lead- ership skills and allow nurses to work to their full scope of practice to strengthen the nursing workforce (World Health Organisation. et al., 2020). This is even more important as the demands on nurses surge from the pressures of the COVID 19 pandemic. In this research, nurses accepted their accountability when delegating to others; however, how this was conceptualised differed between individuals, which was consistent with the literature (Alcorn & Topping, 2009; Hasson et al., 2013; Potter et al., 2010; Standing & Anthony, 2008). Nurses need a clear understanding of their accountability and re- sponsibility when delegating to others to ensure that appropriate supervision is provided reducing the potential for errors and neg- ative patient outcomes (Standing & Anthony, 2008). This should be supported by clear and consistent policies and guidelines.

As a leader, the nurse should role model professional behaviour acting respectfully and delegating a fair and balanced workload to the NA position. This should be supported by organisational structures and policy. The Nursing Now campaign recognises the

importance of healthcare organisations providing an “enabling en- vironment” for nurses, to promote retention and motivation in the nursing workforce (World Health Organisation. et al., 2020). Collegiality, trust and a willingness to collaborate within the nursing team are important to enhancing teamwork, role satisfaction, the quality of patient care and professionalism in the healthcare envi- ronment (Gravlin & Bittner, 2010; Padgett, 2013; Potter et al., 2010; Standing & Anthony, 2008). There was concern in this research of a potential tipping point where overconfidence, comfort and trust in collegial relationships may result in inappropriate delegation and supervision practices as camaraderies may overshadow responsibil- ities and accountabilities. It is important that there is transparency in delegation process and that team members are empowered to communicate openly and honestly ensuring the NA practices within their role boundaries and competency level with appropriate level of supervision.

Education on the roles and responsibilities of team members and the practices of supervision and delegation within the multi- tiered nursing team is important in building transparent practices and in- formed decision- making processes. Practical examples and scenar- ios were recommended in this research to assist nurses gain a deeper grasp of this. Focus should also be placed on the importance of inter- personal relationships within the nursing team and effective leader- ship skills for nursing staff (Anthony & Vidal, 2010; Gravlin & Bittner, 2010; Magnusson et al., 2017). Similar to previous research, there was concern that newly qualified nurses and nursing students were ill prepared for the demands of delegation and supervision within the clinical setting and that there was a presumption that nurses learnt these skills “on the job”(Allan et al., 2016; Hasson et al., 2013). As the Nursing Now campaign encourages nurses to embrace their role as a leader, optimising their scope of practice and maximising their impact, it is important that nurses are provided the foundation on which to build these skills and abilities through introducing these concepts at an undergraduate level and empowering continual life- long learning and practice (World Health Organisation. et al., 2020).

5  |  CONCLUSION

Supervision and delegation in the multi- tier nursing team involve a complex assessment and decision- making processes that are in- fluenced by multiple factors. Members of the nursing team need to have a strong understanding of their roles and responsibilities and the practices of supervision and delegation. This research promotes the need for developing transparency in the team environment through sharing information and explanations in decision- making processes, building a culture of openness and trust, growing aware- ness in the roles, capabilities and responsibilities of individuals, and making practices clear and evident. Transparency in the nursing team will help inform and enhance supervision and delegation practices, thus empowering the team to practice confidently within their scope of practice in providing quality patient care. This is important as poor delegation and supervision may result in negative patient outcomes

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(Potter et al., 2010; Ray & Overman, 2014; Standing & Anthony, 2008). Education is important in supporting nurses in the practice of supervision and delegation. As the prevalence of the multi- tiered nursing team increases, a greater focus should be placed on these and other leadership skills within the undergraduate education of the professional nurse.

ACKNOWLEDG EMENTS The researchers acknowledge the support of an Australian Government Research Training Program Scholarship for this re- search. We also thank the hospital setting for their support of this research.

ORCID Felicity Ann Walker https://orcid.org/0000-0001-7576-1937

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How to cite this article: Walker FA, Ball M, Cleary S, Pisani H. Transparent teamwork: The practice of supervision and delegation within the multi- tiered nursing team. Nurs Inq. 2021;00:e12413. https://doi.org/10.1111/nin.12413

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Longitudinal team training programme in a Norwegian surgical ward: a qualitative study of nurses’ and physicians’ experiences with teamwork skills

Randi Ballangrud ,1 Karina Aase ,2 Anne Vifladt 1

To cite: Ballangrud R, Aase K, Vifladt A. Longitudinal team training programme in a Norwegian surgical ward: a qualitative study of nurses’ and physicians’ experiences with teamwork skills. BMJ Open 2020;10:e035432. doi:10.1136/ bmjopen-2019-035432

► Prepublication history and additional material for this paper are available online. To view these files, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2019- 035432).

Received 31 October 2019 Revised 27 April 2020 Accepted 18 May 2020

1Department of Health Science Gjøvik, Norwegian University of Science and Technology, Gjøvik, Norway 2Center for Resilience in Healthcare (SHARE), University of Stavanger, Stavanger, Norway

Correspondence to Dr Randi Ballangrud; randi. ballangrud@ ntnu. no

Original research

© Author(s) (or their employer(s)) 2020. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ.

Strengths and limitations of this study

► In this study, the sample of both nursing staff and physicians contributes to interprofessional experi- ences in the implementation of a team training pro- gramme in a surgical ward.

► The study intervention was based on an evidence- based team training programme with a standardised curriculum.

► A longitudinal design enables data collection on three occasions.

► The sample size was small, leading to a relatively limited number of participants in the focus group interviews.

AbStrACt Objectives Teamwork and interprofessional team training are fundamental to ensuring the continuity of care and high- quality outcomes for patients in a complex clinical environment. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence- based team training programme intended to facilitate healthcare professionals’ teamwork skills. The aim of this study is to describe healthcare professionals’ experiences with teamwork in a surgical ward before and during the implementation of a longitudinal interprofessional team training programme. Design A qualitative descriptive study based on follow- up focus group interviews. Setting A combined gastrointestinal surgery and urology ward at a hospital division in a Norwegian hospital trust. Participants A convenience sample of 11 healthcare professionals divided into three professionally based focus groups comprising physicians (n=4), registered nurses (n=4) and certified nursing assistants (n=3). Interventions The TeamSTEPPS programme was implemented in the surgical ward from May 2016 to June 2017. The team training programme included the three phases: (1) assessment and planning, (2) training and implementation and (3) sustainment. results Before implementing the team training programme, healthcare professionals were essentially satisfied with the teamwork skills within the ward. During the implementation of the programme, they experienced that team training led to greater awareness and knowledge of their common teamwork skills. Improved teamwork skills were described in relation to a more systematic interprofessional information exchange, consciousness of leadership- balancing activities and resources, the use of situational monitoring tools and a shared understanding of accountability and transparency. Conclusions This study suggests that the team training programme provides healthcare professionals with a set of tools and terminology that promotes a common understanding of teamwork, hence affecting behaviour and communication in their daily clinical practice at the surgical ward. trial registration number ISRCTN13997367.

IntrODuCtIOn Teamwork is fundamental to ensuring the continuity of care and high- quality outcomes for patients in a complex clinical environment, necessitating training across professional silos.1 2 Team training has been described as a learning strategy in which a learner or group of learners systematically acquire(s) team- work knowledge, skills and abilities to impact cognition, affect and behaviours of a team.3 Teamwork is found to positively affect clinical performance.4

In hospitals, many adverse events are asso- ciated connected to surgery.5–7 A system- atic review by Johnston et al8 documented that a delayed escalation of patient care after surgical complications is associated with higher mortality rates, identifying poor communication, hierarchical barriers and high workloads as causal factors. Previous research has provided evidence for strategies such as team training to improve the surgical culture9 and have a positive effect on postop- erative patient outcomes.10–12

Several team training programmes have been developed in healthcare.13 In this paper,

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we studied the implementation of the Team Strategies and Tools to Enhance Performance and Patient Safety (Team- STEPPS) in a surgical ward. TeamSTEPPS is a publicly released, evidence- based programme based on teamwork theory14 and change theory.15 The programme was devel- oped by the Agency for Healthcare Research and Quality in collaboration with the US Department of Defense and was released in 2006.16 17 TeamSTEPPS, which is trans- ferable to any healthcare setting, intends to facilitate healthcare professionals’ teamwork by optimising team structure and the team’s communication, leadership, situation monitoring and mutual support skills. The basic assumption of the programme is that these five teamwork principles are critical for safe patient care.16

Systematic reviews have confirmed that team training affects outcomes related to the team knowledge, atti- tudes, behaviours of healthcare professionals3 18–20 and results in improved quality.3 Furthermore, increased confidence and motivation to apply learned teamwork skills in daily practice have been experienced by health- care professionals.21

Quantitative studies of the TeamSTEPPS programme have confirmed improvements in teamwork and commu- nication,22 23 patient safety culture,24–27 efficiency inpa- tient care,24 25 28 complications and mortality,29 falls23 and frequency of wrong- site/side/person surgery.22 Most of the TeamSTEPPS studies are carried out in the USA30 without any longitudinal follow- up, and there are currently only a few qualitative studies18—for example, in surgical and paediatric intensive care25 and cardiotho- racic surgery telemetry.31 However, a need persists for qualitative studies in surgical ward settings because the team structure in wards is different from that in intensive care unit (ICU) settings; physicians are not situated in the ward for extended periods, thus restricting the possibili- ties for interprofessional reflections.32 This study is a part of a larger research project, comprising mainly substudies with a quantitative design, to evaluate an interprofes- sional team training intervention in a surgical ward.33 34 In this context, a qualitative study will provide in- depth knowledge of healthcare professionals’ experiences with learned teamwork skills in a longitudinal perspective.

We aimed to describe healthcare professionals’ experi- ences with teamwork in a surgical ward before and during the implementation of a longitudinal interprofessional team training programme. The following research ques- tion guided the study: how do healthcare professionals experience teamwork skills communication, leadership, situation monitoring and mutual support before and during the implementation of an interprofessional team training programme?

MethODS Design The study used a qualitative descriptive design35 based on semistructured focus group interviews with healthcare professionals at three- time intervals.

Setting The study was carried out at a 20- bed combined gastro- intestinal surgery and urology ward at a hospital divi- sion (198 beds) in a Norwegian hospital trust. The surgical ward was selected based on practical issues and the management’s interest and motivation for improve- ment initiatives after experiencing several patient safety incidents. The study occurred from April 2016 to June 2017. At baseline (November 2015 to March 2016), the ward statistics indicated an average bed occupancy rate of 87%, a mean patient length- of- stay value of 3.46 days and an admissions rate of 192.2 patients per month. Moreover, the ward’s number of full- time positions was 13 physicians, 17.25 registered nurses (RNs), 4.95 certified nursing assistants (CNAs), 1.0 head nurse and 1.0 clinical nurse specialist.

The patient care was organised into two interprofes- sional teams, where the primary members were RNs, CNAs and physicians. The composition of the teams and their duties were predetermined by a daily worklist for the nursing staff, while the physicians had their worklist, clarifying weekly duties such as surgery, polyclinic and doctors’ rounds.

Sample A convenience sample36 of 11 healthcare professionals divided into three professionally based focus groups comprising physicians (n=4), RNs (n=4) and CNAs (n=3) were recruited from the surgical ward. The inclusion criterion for participation in the study was that healthcare professionals from the surgical ward had participated at a minimum of 1 day of the interprofessional team training programme (41 participants). The ward management decided which professional groups participated in the TeamSTEPPS training programme. A request for infor- mation about the study and researchers was distributed to all healthcare professionals, where 11 confirmed their participation, thus constituting the study sample. The sample comprised eight women and three men with varying work experiences and employment within the ward. To secure the participants’ anonymity, no specifica- tion of their background is presented.

team training programme The longitudinal interprofessional team training programme was planned and implemented according to the TeamSTEPPS- recommended ‘model of change’ and was organised into three phases16 (see table 1 and box 1). A research group initiated the programme as part of a larger research project.34 Two nurses (one leader) and two physicians (leaders) from the surgical ward had the main responsibility for the training and implementation of the programme. Before the training, the four health- care professionals conducted the TeamSTEPPS V.2.0 Master Training Course and were certified as instructors. A more detailed description of the programme can be found in Aaberg et al.37

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Table 1 Implementation of tools at phase 2 and phase 3 of the team training programme

Phase 2 Phase 3

2016 Tools Implementation arena 2017 Tools Implementation arena

May

Closed- loop Communication

Exchange of critical information

January

Debriefs Leadership

Once a week— manager with nursing staff

Task Assistance Mutual support

Distribution of workload

June ISBAR Communication

Communicating critical information

February STEP Situation monitoring

Updated in electronic care plan

August Briefs Leadership

Start of every shift March Two- Challenge Rule Mutual support

When an initial assertive statement is ignored

September Huddles Leadership

At patient safety whiteboard meetings

May I- PASS Communication

Handoffs with focus on patient safety risks

October Cross- monitoring Situation monitoring

Double control by intravenous medication administration

I- PASS, illness severity, patient summary, action list, situation awareness and contingency planning; ISBAR, introduction, situation, background, assessment, recommendation; STEP, status of the patient, team members, environment, progress towards the goal.

box 1 team training programme based on teamStePPS

Phase 1: set the stage and decide what to do—assessment and planning (January 2016–April 2016)

► Site assessment. ► A lesson about teamwork in relation to promoting patient safety was conducted with all nurses and physicians to create an awareness of the need for improvement.

► A training and implementation plan was developed. Phase 2: making it happen—training and implementation (May 2016–December 2016)

► One day of interprofessional team training in a simulation centre was completed for all healthcare professionals (n=41) in the surgi- cal ward, comprising 6 hours of classroom training (lectures, videos, role plays and discussions) and 2 hours of high- fidelity simulation.

► A change team with members from all ward professions and a for- mer patient was assigned.

► An action plan was established, based on identified patient safety issues in the ward.

► The TeamSTEPPS tool was systematically implemented every month (see (table 1)).

Phase 3: making it stick—sustainment (January 2017–June 2017) ► The initiatives from the action plan were coached, monitored and integrated.

► Implementation of a monthly TeamSTEPPS tools continued. ► Small victories were celebrated. ► TeamSTEPPS refresher courses were held after four (nurses and physicians) and 11 months (nurses).

TeamSTEPPS, Team Strategies and Tools to Enhance Performance and Patient Safety.

Data collection Ten focus group interviews of healthcare professionals were conducted before the team training implementation

(baseline=T0), with follow- up interviews after 6 months (T1) and 12 months (T2) (see figure 1).

All the interviews occurred in a meeting room at the hospital during the daytime. A pilot interview was conducted to validate the thematic interview guides developed from a literature review on teamwork (online supplementary files 1 and 2). The interviews were conducted as a dialogue and started with a clarification of the study aim. The thematic interview guides, including the four teamwork skills at T1 and T2, were used to ensure that all themes were explored during each focus group interview. The participants were encouraged to complete an open collective activity with a reflection on common experiences.38 The same questions were posed to all focus groups, and follow- up questions were used to encourage the participants to elaborate and/or clarify their responses.39 One moderator and one observer (who made field notes) were responsible for conducting the interviews, with the third author (AV) as a moderator at T0 and the first author (RB) as a moderator at T1 and T2. At T0, the interview referred to generic questions about teamwork at the ward (see online supplementary file 1); at T1 and T2, the interview questions referred to learned teamwork skills based on the TeamSTEPPS framework (see online supplementary file 2). The field notes were approved by the participants after the interview. The interviews lasted from 25 to 60 min (mean=33 min). All the interviews were digitally recorded, transcribed verbatim and anonymised before the analysis.

Data analysis Based on the aim and research question of our study focusing on healthcare professionals’ experiences with teamwork skills during a team training programme, a

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T0 Interview, April 2016 Profession (focus groups 1–3)

T1 Interview follow up after six months, November 2016 Profession (focus groups 4–7)

T2 Interview follow up after 12 months, June 2017 Profession (focus groups 8–10)

RNs (n=4) CNAs (n=2) Physicians (n=3)

RNs (n=3) CNAs (n=2) Physicians (n=2) Physicians (n=2)

RNs (n=3) CNAs (n=2) Physicians (n=1)

Start of team training programme, May 2016 Figure 1 An overview of participants, and times of the interviews in relation to the implementation of a team- training

programme; n=11 healthcare professionals (four physicians, four RNs and three CNAs). CNA, certified nursing assistant; RN, registered nurse.

Table 2 Description of the four TeamSTEPPS teamwork skills

Communication Structured process by which information is clearly and accurately exchanged among team members

Leadership Ability to maximise the activities of team members by ensuring that team actions are understood, changes in information are shared and team members have the necessary recourses

Situation monitoring Process of actively scanning and assessing situational elements to gain information or understanding, or to maintain awareness to support team functioning

Mutual support Ability to anticipate and support team members’ needs through accurate knowledge about their responsibilities and workload

Agency for Healthcare Research and Quality. TeamSTEPPS V.2.0: Core Curriculum.16

TeamSTEPPS, Team Strategies and Tools to Enhance Performance and Patient Safety.

deductive manifest content analysis approach grounded on Elo and Kyngäs40 was used. The data were analysed according to the TeamSTEPPS framework,41 42 focusing on the four teamwork skills of communication, lead- ership, situation monitoring and mutual support. The description of the four teamwork skills is shown in table 2.

The analysis process was organised according to three phases: preparation, organising and reporting. The first (RB) and third (AV) authors conducted the first two phases with input from the second author (KA), while all three authors conducted the third phase. In the preparation phase, each interview was defined as one unit of analysis, and data from T0, T1 and T2 were analysed separately. All the interviews were read several times by all three authors to become familiar with the data, and, guided by the aim and research questions, the researchers obtained intimate knowledge of the participants’ experiences with teamwork skills. In the organisation phase, the authors established a structured analysis matrix, with columns representing the categories of communication, leadership, situation monitoring and mutual support. Based on the concep- tual description of each TeamSTEPPS teamwork skill in the TeamSTEPPS programme (see table 2),16 all the data were reviewed for content and coded according to the four teamwork categories (without using any software

tool), first individually by RB and AV, and then together by all three authors until agreement was reached. Exam- ples from the codebook at T1 are shown in table 3. The matrix revealed 514 codes representing the four team- work categories. In the reporting phase, the results were described using the contents of each of the four team- work categories. Quotations were used to enhance and illuminate the categories.43 To help secure a presentation of results representing the information provided by the participants, continuous discussion among the authors was prominent throughout the reporting phase. Finally, the results were reported according to the Consolidated Criteria for Reporting Qualitative Research (online supplementary file 3).44

Patient and public involvement Patients or the public were not involved in the design, conduct, reporting or dissemination plans of our research.

reSultS teamwork at t0 The healthcare professionals’ experiences of the four teamwork skills in the surgical ward before the team training programme (T0) are described in table 4.

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Table 3 Codebook examples from the qualitative deductive content analysis at T1

Communication Leadership Situation monitoring Mutual support

T1:RN,24. Everyone participates using a closed loop.

T1:RN,94. We allocate the tasks now so that they are distributed more evenly.

T1:RN,80. We have become more vigilant about medication administration.

T1:RN,35. When you know the purpose, you have a greater understanding for reporting a second time concern.

T1:CNA,5. On the classroom training day, we learnt to repeat messages—for example, when we take the phone—which is already done.

T1:CNA,36. The ward management is aware that the whiteboard meetings will take place.

T1:CNA,30. The most important thing about the whiteboard meetings is that there is a proper review of patients after the doctor’s rounds.

T1:CNA,56. It is not so easy to say so if there is something that we disagree about, compared with when there is something positive.

T1:Ph1,26. Seemed like the nurses were confident about how to present patient information to us.

T1:Ph2,84. If one is to think we are a team, it is natural that the physician who does the round is the leader.

T1:Ph1,69. Whiteboard meetings generate awareness about—for example, safety routines, nutrition, medication administration, etc—that is, such things that are good to check.

T1:Ph,43. It is now easier to ask each other since we know each other better after being in classroom training together.

CNA, certified nursing assistant; Ph, physician; RN, registered nurse.

teamwork during the 12-month (t1–t2) interprofessional team training programme A summary of healthcare professionals’ experiences with the four teamwork skills during the 12- month team training programme is described in table 5.

Communication, t1–t2 The RNs experienced a common set of tools that promote patient safety. Everyone emphasised the ‘closed loop’ tool as important to ensure a common understanding within the team. Using the tool, the RNs detected misunder- standings that could have caused consequences for the patient. Both the CNAs and RNs emphasised that, after the 12- month implementation of the team programme, they used the ‘closed loop’. They perceived the tool as important, simple to use and promoting patient safety, as exemplified by a CNA:

If there is a phone call and you receive a message then you repeat the message … to make sure you have got it right—don’t you? (T2:CNA,2)

The RNs found it valuable to have a common under- standing of communication skills with physicians at the surgical ward. However, they experienced that physicians from other wards, who were not included in the Team- STEPPS programme, expressed the feeling that the RNs were criticising them when using the ‘closed loop’.

During the implementation period, both the physicians and CNAs experienced the RNs as being more confident in their information exchange and found ‘introduction, situation, background, assessment, recommendation (ISBAR)’ useful when communicating important or crit- ical information over the phone. The RNs experienced the use of ‘ISBAR’ as somewhat challenging but easier to use when they had enough time. The physicians high- lighted that their medical education taught them how to

provide information systematically. However, they became more aware of systematic communication and repeating messages:

Well, I think everyone … everyone involved has re- flected … and raised one’s consciousness regarding it [communication] to a greater extent than if they didn’t attend the course. (T2:Ph,11)

With ‘ISBAR’, it had become more natural for the RNs to take an active part in patient treatment. They referred to common, established expectations toward more active participation, with ‘ISBAR’ focusing on their perception of the problem and how to handle it. One RN said:

When we call about a deteriorating patient … I pre- viously thought I shouldn’t mention anything regard- ing my ideas on the causes of deterioration. I always thought that was the physician’s task. (T2:RN,13)

The ‘handoff’ tools for information exchange during shifts had been introduced late and were not properly integrated at the ward. One RN said:

Well, then at least you will need sufficient time to re- flect before starting to use them [tools]… and that is not always the case, right. (T2:RN,45)

Even though it is an easy … an easy tool, I actually think it is one of the hardest as well. (T2:RN,46)

leadership, t1–t2 The RNs experienced that TeamSTEPPS had led to an increased awareness in using ‘huddling’ and ‘briefing’ at the patient safety whiteboard meetings. One RN explained:

We use huddling at the patient safety whiteboard meetings regarding the redistribution of tasks if

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Table 4 Teamwork skills at T0

Teamwork skills categories

Communication All healthcare professionals were mostly satisfied with the information exchange within the ward, with the nurse team leader possessing a central position. A busy schedule allowed the RNs, who often had patient responsibility within both teams, to acquire patient information in different ways, from participation in regular team meetings to ad- hoc meetings with the team leaders. The CNAs appreciated the ‘quiet handover’ used between shifts. When calling up the physicians on duty, the RNs often checked the phone list ahead of the phone call to be prepared, indicating that some physicians needed to have more background information than others. The physicians also emphasised the importance of proper and relevant information from the RNs who can be trusted.

Leadership The two core teams each had a team leader throughout the week, allowing the team leader to become better acquainted with a patient’s medical history and thereby increasing continuity and simplifying the hospital discharge. Not all of the RNs enjoyed being team leaders due to a heavy workload; however, the physicians were satisfied with the arrangement.

Situation monitoring

The physicians became familiar with the patients during rounds and through the patient’s medical record, mostly discussing patient- related issues in physicians’ meetings. Similarly, the RNs discussed issues related to patients’ care in nurse meetings, although this may also have resulted in contact with the physicians. Both RNs and CNAs had an active role in the observation of the patients and updating each patient’s care plan, and they were encouraged to stay bedside during the rounds. The Modified Early Warning Score (MEWS)* was recently applied, and the physicians were pleased with the new routines, which was highlighted as an excellent tool to quickly determine the degree of illness of a patient. Moreover, the ward was in the initial phase of using a patient safety whiteboard; thus, these meetings did not work optimally with a frequent absence of physicians.

Mutual support The RNs and CNAs stated that they were flexible in helping each other in the event of an uneven distribution of work, both within the team and between the teams. However, the teamwork was dependent on openness and that team members spoke out when they needed help. They felt listened to and respected by the physicians. All three healthcare professionals groups stated that knowing each other and having fun together strengthened a good working environment and good teamwork. The physicians highlighted that, for the best interest of the patient, good teamwork requires nurses with medical knowledge, clinical experience and continuity with the patient. Nonetheless, the RNs experienced that they did not always have the expected response from the physicians, and the physicians stressed that a large workload requires prioritisation of multiple issues at one time, which may affect the teamwork. According to the RNs, this rarely causes conflicts among healthcare professionals in the ward. Nevertheless, there have been real conflicts, and some have been perceived as a personal attack.

*MEWS is a tool for bedside evaluation of the systolic blood pressure, pulse rate, respiratory rate, temperature and Alert, Reacting to Voice, Reacting to Pain, Unresponsive score.57

CNA, certified nursing assistant; RN, registered nurse.

anyone feels they have too much work, while others have available capacity. (T2:RN,58)

The redistribution of work tasks resulted in a more even workload between the two core teams at the ward.

At T1, the mid- day nurse meeting was led by the RN team leaders, whereas the physicians initially led the interprofessional patient safety whiteboard meetings. The RNs experienced it as natural that the physicians led the meetings whenever they were present. However, at T2, the mid- day nurse meeting was replaced with the interprofessional patient safety whiteboard meeting, led by the RN team leader. The physicians could not always attend the patient safety whiteboard meeting due to activ- ities in the operating theatre, being called for and so on. While whiteboard meetings occurred daily, the weekly ‘debriefing’ occurred on Fridays. The ward head nurse usually led the ‘debriefing’, which was experienced as useful, as exemplified by a CNA:

It is good to talk things through, expressing issues that are on your mind when it has been a busy week … also experiencing that debriefing can be funda- mental for change. (T3:CNA,30)

The physicians were more uncertain whether the team training programme had led to an increased awareness of team leadership.

Situation monitoring, t1–t2 The use of the term ‘situation monitoring’ was new for healthcare professionals. The RNs realised that they had always monitored the work system without being aware of the term. By using the tools, they detected patient safety incidents that could have resulted in unnecessary harm to the patients. Cross- monitoring of the intravenous medication administration had been implemented. The RNs experienced the use of situation monitoring skills depended on their role in the team. As team leaders, they

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Table 5 Experiences with teamwork skills at T1 and T2 of the team training programme

Categories T1 (6 months) T2 (12 months)

Communication Increased awareness in using the closed loop and ISBAR tools.

* ———————————————————→

Challenges with using ISBAR when communicating critical information (RNs).

RNs are more confident in information exchange using ISBAR. ISBAR forms a basis for a more active role for RNs in decision- making.

Challenges still exist when using ISBAR during busy shifts.

The included tools are seen as a common initiative to promote patient safety.

———————————————————→

Misunderstandings in work practice are discovered when using the tools.

The tools provide information in a more systematic manner.

Handoff not properly incorporated.

Leadership Distribution of work tasks using huddling. ———————————————————→ RN team leader runs the mid- day nurse meeting.

Mid- day nurse meeting replaced with patient safety whiteboard meeting.

Physician runs the interprofessional patient safety whiteboard meeting when present, otherwise an RN.

RN runs the interprofessional patient safety whiteboard meetings.

Head nurse runs the Friday debriefing, evaluating the weekly activities.

Situation monitoring Double control in intravenous medication administration using cross- monitoring.

———————————————————→

Risk assessment at whiteboard meetings provides awareness of new and/or important patient issues.

Risk assessment at interprofessional patient safety whiteboard meetings established on weekdays, challenges on weekends.

Nursing plans less prioritised due to patient safety whiteboard meetings.

———————————————————→

MEWS prioritised. MEWS a well- established routine.

Mutual support Transparency and openness across the healthcare team.

———————————————————→

Legitimate to express safety concerns. ———————————————————→ Use of the Two- Challenge Rule to resolve disagreements.

———————————————————→

Increased awareness of speaking up for the patients.

Increased awareness of giving and receiving feedback.

*The arrow expresses continuity in healthcare professionals’ experiences throughout T1 and T2. CNA, certified nursing assistant; ISBAR, introduction, situation, background, assessment, recommendation; MEWS, Modified Early Warning Score; RN, registered nurse.

had to scan what was going on at the ward; however, if they were situated inside the patient room, they lost sight of other ongoing issues.

Six months into the team training programme, health- care professionals experienced a better functioning of the patient safety whiteboard meetings, though still not optimal because physicians did not always attend. After 12 months, everyone experienced the meeting as a useful and well- established arena to monitor patient risks. They

also experienced that the meeting created an awareness of tasks that needed attention, as described by a physician:

Yes, fall prevention, nutrition, medication reconcili- ation. Well, that’s the type of issue that … it’s con- venient to check, reminding us of issues that need attention. (T1:Ph,69)

Despite the benefit of the whiteboard meetings, they were not prioritised on busy shifts during the weekends.

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Both the RNs and CNAs were responsible for updating the patient safety whiteboard according to their patients’ needs and realised that the increased whiteboard focus negatively affected the updating of the nursing plans.

During the team training programme, the ‘Modified Early Warning Score (MEWS)’ became a well- established and systematic routine appreciated by all healthcare professionals. Nevertheless, the physicians experienced that some nurses did not relate the ‘MEWS’ measure- ments to the patient’s condition, only using ‘MEWS’ as a recipe. Some experienced that the RNs called them without getting into the patient’s anamnesis from the medical record seen as their common information exchange system. It was expected that both RNs and CNAs scored their patients with ‘MEWS’ and exchanged the results with the team leader. They now measured the patient’s pulse and blood pressure more frequently, although it was described that the parameters might be overlooked, as pointed out by one CNA:

Well, it is worth mentioning regarding MEWS that people tend to forget to measure the pulse them- selves. They see the number and then refer to this … without acknowledging that the pulse can be as irregular and deviating as ever. (T2:CNA,47)

Mutual support, t1–t2 The RNs perceived mutual support to the teamwork skill creating the most influential changes at the ward, also considered the most effective to implement. At T1, RNs experienced increased transparency and openness across the healthcare team. Colleagues raised problems more directly. It became more legitimate to express concerns and speak up because the contents could be addressed in relation to the tools and strategies of the training programme. With a common understanding in place, it was easier to use a tool such as the ‘Two- Challenge Rule’. A physician referred to an episode, where the RN disagreed with him and used the tool:

There was a patient with … urine retention with 300 mL of residual urine and you are not supposed to send them home without a catheter … but on that occasion I meant that we could do so. And she [RN] was absolutely right in her judgment … there are routines for not having that much [residual urine], and since I thought it was right I tried to explain it. (T1:Ph,61)

Moreover:

It was, of course, ok, she did what she was supposed to do and it is commendable that they raise it, that they are not afraid of voicing it. (T1:Ph,62)

The physicians emphasised that it became easier to collaborate on patient treatment with mutual and open communication, and they felt that the team programme had impacted this. At T2, the ‘Two- Challenge Rule’ was

used frequently, a strategy they probably used prior to the programme, but as an RN expressed it:

Yes we did it [open communication, Two- Challenge Rule] … it was just that we did not have a notion for it. (T2:RN,40)

Hence, increased awareness of using different mutual support tools had been created:

You don’t accept the response you are given; you rather rephrase the question once or twice if neces- sary. (T2:RN,102)

Both the RNs and CNAs had become more aware of the importance of feedback. They evaluated the tools as useful when adverse events occurred and, in that context, experienced a high degree of support across the inter- professional team. They experienced colleagues being less concerned with raising issues through feedback, and, according to RNs, the ‘go to the leader’ mentality when dissatisfied was less prominent. The RNs had also seen inexperienced RNs who now dared to speak up for the patient. However, they still felt that healthcare professionals held back on different occasions, implying a continued room for improvement within giving and receiving feedback.

DISCuSSIOn We aimed to describe healthcare professionals’ experi- ences with teamwork in a surgical ward before and during the implementation of a longitudinal interprofessional team training programme. The results described that RNs, CNAs and physicians were highly satisfied with the team- work at the ward before the team training programme. Nevertheless, they experienced that the implementation of the programme, where they were trained together, led to greater awareness and knowledge of their common teamwork skills. Changes were described related to more systematic information exchange, increased conscious- ness of team leadership balancing activities and resources, increased use of situation monitoring tools and a common understanding of accountability and transparency.

Communication: towards a systematic information exchange When RNs used the communication tool ‘ISBAR’, the physicians experienced a more systematic exchange of patient information, which was highly appreciated. The RNs experiencing challenges using the tool in the first phase and eventually became more confident. This finding is in accordance with results from a study in surgical wards, where both nurses and physicians perceived ‘ISBAR’ as effective in obtaining a structure of the contents of patient reports.45 Nurses and physicians traditionally communicate using different styles appro- priate to the needs and processes of their respective professions.46 47 This gap may be bridged using ‘ISBAR’, establishing a common communication style. Hierar- chical culture has been experienced by nurses as having

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a negative effect on interactions with some physicians.31 According to De Meester et al,48 the use of ‘ISBAR’ may flatten the hierarchical structure by nurses experiencing being empowered, thereby resulting in more effective communication channels. The RNs in our study referred to a positive change with expectations towards more active participation in patient decision- making. Open commu- nication with a common language of how to present key patient information can prevent misunderstandings and communication failures.49 Interprofessional teamwork is generally found to motivate and empower staff when team members feel their roles are acknowledged.50

leadership: balancing activities and resources Leadership was seen as an essential teamwork skill to increase the continuity of patient care, with an even distri- bution of work tasks and debriefing as essential activities. According to Salas et al,14 team leadership coordinates and organises team members’ activities. Considering that the team leader possesses knowledge of team resources,51 they have the opportunity to ‘balance the workload within the team’.16 In this study, the redistribution of work tasks was completed at the daily patient safety whiteboard meeting led by the RN team leader. At these meetings, the use of the tool ‘huddling’ was implemented and found useful when balancing work tasks within and between the two ward teams—the intention using huddles.16 The leader’s overview of team activities is essential, with the weekly debriefing meeting described as ‘fundamental for change’ due to the opportunity for healthcare profes- sionals to share their experiences related to patient care as a basis for improvement in procedures or work routines.

Situation monitoring: towards a conscious use of tools and interprofessional meetings Our study confirmed that using the term ‘situation moni- toring’ was new for healthcare professionals at the surgical ward, although they realised they had previously used the skill unconsciously. According to Benner,52 knowledge development in healthcare consists of spreading practical knowledge and the mapping of existing practical knowl- edge developed through clinical experience, to which the team training programme may have contributed. RNs, CNAs and physicians all experienced increased attention towards situation monitoring skills throughout the use of MEWS, as well as at the daily interprofessional patient safety whiteboard meetings established during the team training programme period. These meetings were expe- rienced as useful opportunities to monitor patients and create an awareness of necessary tasks. This finding is in accordance with Sehgal et al,53 where nurses were seen as responsible for accurate and updated information on whiteboards, whereas the goals for the day should be created jointly by nurses and physicians. The physi- cians in the current study appreciated that the nursing staff referred to MEWS when calling them. Early warning scores are known to have a good prognostic value for patient deterioration and have been shown to improve

patient outcomes, partly because they facilitate communi- cation among healthcare professionals.54 Like the physi- cians, the nurses also saw the importance of gathering the MEWS but also emphasising the importance of using their clinical eye and mind. In their integrative review, Massey et al55 found that assessing and knowing the patient, nurse education and the use of specialised equipment were all factors with an impact on ward nurses’ ability to recognise patient deterioration.

Mutual support: towards accountability and transparency In our study, mutual support was considered the most effective teamwork skill to implement and, according to the RNs, contributed to the most comprehensive positive change at the ward during the team training programme. This was despite healthcare professionals referring to a ward culture with open communication, including before the training programme. Mayer et al25 found that, by using pre- implementation and post implementation interviews of staff in surgical ICUs, the informants described an overall improved mutual support with a more positive team morale across physicians and nurses post imple- mentation. In a qualitative study conducted by Baik and Zierler,31 the nurses reported improved changes in inter- professional relationships and being more satisfied with their work because they felt included as a member of an interprofessional team training intervention. In our study, both physicians and nurses experienced that when having a common understanding, it was easier to use tools such as the ‘Two- Challenge Rule’. Both RNs and CNAs described that they had become more aware of giving each other feedback. When adverse events occurred, they experienced a high degree of support across the interprofessional team, a situation that is in accordance with Weller et al,56 who interviewed a surgical team in an operating room and described a positive change in information sharing and improved confidence, as well as a greater awareness of the other team members and working environment, after conducting a simulation- based team training programme.

limitations There are several limitations in our study that need to be recognised. The results may be influenced by the relatively limited number of participants in each of the focus group interviews and a possible bias in the sample of participants based on possible positive perceptions of teamwork at the surgical ward. The study is not suitable for generalisation; however, the results based on our qualitative design provide a deeper understanding of the health professionals’ experiences with learned teamwork skills that may be relevant at other hospital wards. Due to time pressure and workload in their daily practice at the surgical ward, the healthcare professionals had to repeat- edly change their interview times, which may have affected the results. Two groups of two physicians participated in the interviews after 6 months, whereas only one physi- cian had the opportunity to participate after 12 months.

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A larger group of physicians might have provided other experiences with the teamwork skills that may also impact the results because mostly the nursing staff attended the refresher courses. The results may also be influenced by the patient safety initiatives recently initiated at the ward ahead of the team training programme, such as the MEWS and patient safety whiteboard meetings.

COnCluSIOn Our study suggests that, during a team training programme, healthcare professionals were provided with a set of tools and terminology that promoted a common understanding of teamwork, hence affecting behaviour and communication in their daily clinical practice at a surgical ward. The findings contribute to the qual- itative evidence base of the implementation of team training programmes. More specifically, the study docu- mented the role of a systematic information exchange, a consciousness of leadership and situation monitoring skills and the importance of creating a culture of account- ability and transparency in a surgical ward. Further research should study the effect of the implementation of the TeamSTEPPS programme in hospitals, including various departments. Moreover, a study on the long- term sustainability of team training programmes on healthcare professionals’ behaviour is necessary.

Contributors RB, KA and AV were responsible for the study design. RB and AV performed the data collection. RB, KA and AV contributed to the analysis of the data, drafting of the manuscript, critical revision of the manuscript for important intellectual content and final approval of the version to be published. All the authors read and approved the final manuscript.

Funding This study was supported by the Norwegian Nurses Organisation (15/0018), the Norwegian University of Science and Technology in Gjøvik and the University of Stavanger.

Competing interests None declared.

Patient consent for publication Not required.

ethics approval The study was approved by the Norwegian Center for Research Data (Ref. 46872) and permission was given by the head administration in the participating hospitals. The Committee for Medical and Health Research Ethics of South- East Norway reviewed the study (Ref. 2016/78) and responded that approval was not necessary according to Norwegian law, since the study did not involve patients. Information and an invitation to participate in the study were given to healthcare professionals in written and verbal forms, referring to the principle of autonomy addressed by confidentiality and voluntariness. Written consent was obtained from the healthcare professionals who agreed to participate. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement No data are available. No additional unpublished data are available from this study.

Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.

OrCID iDs Randi Ballangrud http:// orcid. org/ 0000- 0003- 0403- 0509 Karina Aase http:// orcid. org/ 0000- 0002- 5363- 5152 Anne Vifladt http:// orcid. org/ 0000- 0001- 6594- 9725

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Columbia Gas of Massachusetts – Project Issue Analysis – AD642 Individual Assignment 2 ©2020 Richard Maltzman, Master Lecturer, Boston University Metropolitan College It was late in the afternoon of September 13, 2018. Professor Rich Maltzman looked up, startled, as three sharp raps on his car window interrupted the online course he was teaching from his car. Why from his car? Everyone in the town of Andover (Massachusetts, USA) had already been told to get out of their their homes, and they awaited word from the police – should they leave the town altogether? Yes! The three raps were from the Professor’s wife, and she was animatedly and urgently conveying the message: “we have to LEAVE TOWN. NOW!” The urgency was coming from the breaking story so well-summarized by the podcast series, “Fire in the Valley”. Fires and explosions were occurring in over 100 structures in the Merrimack Valley region of Massachusetts, north of Boston, in particular in the City of Lawrence and the towns of North Andover and Andover, Massachusetts, where the Professor and his family reside.

It was hard for residents to get the important details. Local news stations were covering the story, but the information was scattered and hard to decipher meaningfully. The Twitter feed from Columbia Gas of Massachusetts, the utility that operates the natural gas lines that were involved had this post on their web page for hours during the incident:

This was of little help – and if it wasn’t so sad, it would actually be funny. The local police were doing a better job posting advice and making announcements and sending out reverse 911 calls to residents. This is what triggered the raps on the windows and yielded the decision for Professor Maltzman to prematurely end his class, which ironically was about qualitative decision making. This tweet from the authorities made things much more clear:

So, the Professor and his family headed to Cape Cod to stay with relatives – they were very lucky to have this option available. Others were not so lucky. See this video from Rabbi Howard Mandell who tells his story, which starts with a 6- foot flame emanating from his boiler’s gas supply.

What happened here?

A tremendous write-up of the story comes from an article from the June, 2019 issue of Popular Mechanics – an article entitled, “The Day the Town Blew Up”.

Here the key extract:

…On the Salem Street side of the O’Connell South Common (in Lawrence, Massachusetts), a public park, a contractor removes a length of cast-iron pipe, caps it, and sets it aside.

Feeney Brothers Utility Services (“Providing Underground Utility Services since 1988”) has a permit to open up a two-foot-wide, 340-foot-long stretch of Salem Street, for the purpose of “completing gas main tie-ins and retirement of dual cast-iron gas mains.” Feeney Brothers is a family-owned operation with seven hundred employees. They’ve worked extensively not only for Columbia Gas but also for the region’s other major natural-gas supplier, Eversource. In recent years, gas utilities in Massachusetts have increasingly relied on contractors to carry out projects like this.

It’s usually cheaper.

The job today is to install new polyethylene pipeline and tie it into a new distribution main, also plastic. The Feeney Brothers contractor may or may not be aware that a regulator sensing line— a gauge that measures gas pressure—is attached to the pipe he had discarded. But it’s important to note that he and his crew are performing their duties as directed, under Columbia Gas supervision, and correctly following the steps in the work package Columbia Gas developed and approved. Columbia Gas’s work order doesn’t mention the sensor and was not prepared by a professional engineer. Until four years ago, a technician from the Meter and Regulation Department would have been assigned to the site to monitor pressure readings on the affected section of gas main, but Columbia Gas, for undisclosed reasons, has ended this practice.

The sensor on the discarded length of pipe thinks it’s still measuring the gas pressure in a vast underground network. In fact, it is measuring nothing: The pipe has been disconnected from the network. The sensor might as well be attached to a hot dog. But the sensor doesn’t know any of that, and there is no other sensor in this segment of the network to contradict it.

The sensor sends a message to the regulator valves in this segment of the network: Boost the pressure! Which they do. But the sensor, because it’s still attached to the dead piece of pipe,

doesn’t detect any of that. Instead, it registers a pressure drop, all the way down to 0.01 psi. More pressure, it tells the valves, until they have opened completely, and two distribution systems that were supposed to be segregated, cordoned off from each other, are instead tied directly into each other for twenty-six minutes.

A wave of high-pressure gas rushes into the regional gas-main system that serves Lawrence, Andover, and North Andover. In the older cast-iron segments of the network, the pressure rises to at least 6 psi, twelve times what the pipes are capable of handling.

At 4:04 p.m., the first high-pressure alarm is received by the NiSource monitoring station—in Columbus, Ohio. A second alarm is received at 4:05 p.m.

In the control room in Ohio, the NiSource employees have no capacity to control, let alone shut down, the gas flow. They can only contact the Meters and Regulations Group at Columbia Gas, which at 4:06 p.m. dispatches its entire team of inspectors to investigate—a total of two people, or approximately one per 2,494.75 miles of pipe.

The result of this over-pressurization: 141 fires, 5 explosions, 21 serious injuries, 1 death, many people displaced and/or without heat or the ability to cook - for months, and the bankruptcy of Columbia Gas of Massachusetts.

This was the incident. How about the cause?

The NTSB incident report summarized the case in the following way:

NTSB investigators learned that, until about 4 years ago, Columbia Gas required that a technician monitor any gas main revision work which required depressurizing the main. The technician—typically from the Meter and Regulation department—would use a gauge to monitor the pressure readings on the impacted main and would communicate directly with the crew making the change. If a pressure anomaly occurred, the technician could quickly act to prevent an overpressurization action. Columbia Gas offered no explanation as to why this procedure was phased out.

Although the Columbia Gas monitoring center in Columbus, Ohio, received high-pressure alarms and reported the event to the Meters and Regulations department two minutes after receiving the first alarm, there were no technicians prestaged or positioned to immediately close valves when the overpressurization occurred. Had Columbia Gas adequately performed MOC (Management of Change) and placed personnel at critical points along the system, Columbia Gas could have immediately addressed the issue and mitigated the consequences of the event. Therefore, the NTSB recommends that NiSource apply MOC processes to all changes to adequately identify system threats that could result in a common mode failure. Additionally, the NTSB recommends that NiSource develop and implement control procedures during modifications to gas mains to mitigate the risks identified during MOC operations. Gas main pressures should be continually monitored during these modifications and assets should be placed at critical locations to immediately shut down the system if abnormal operations are detected.

NTSB Recommendations In November 2018, the NTSB issued a series of “urgent” safety recommendations. The report contained four recommendations for NiSource, the parent company of Columbia Gas, and one for the state, seeking elimination of the professional engineer licensure exemption for public utility work and a requirement for a professional engineer’s seal on public utility engineering drawings.

The NTSB report recommends NiSource do the following:

• revise the engineering plan and constructibility review process across all subsidiaries; • review all records and documentation of natural gas systems; • apply management of change processes to all changes to identify threats that could

result in a common mode failure; • develop and implement control procedures during gas main modifications to mitigate

risks.

See below for important references and resources.

References and Resources

NTSB Incident Report

Popular Mechanics article, “The Day The Town Blew Up”

Boston Magazine article on the real story of the Merrimack Valley explosions

Fire in the Valley – Podcast – Four episodes

Episode 1: The first minutes of a disaster

Episode 2: “I had never gone toward explosions before”

Episode 3: The sun rises after a disaster

Episode 4: Making the Valley whole again

Merrimack Valley Gas Explosions Case Study

(REDACTED)

Executive Summary

On September 13, 2018, excessive pressure in natural gas lines owned by Columbia Gas

caused a series of explosions and fires in Massachusetts's Merrimack Valley region. The system

over-pressure ultimately damaged 131 structures, hospitalized 21 individuals, and killed one

person. (National Transportation Safety Board, 2019) Columbia Gas of Massachusetts did not

offer any advisories, and police and firefighters were doing a better job evacuating people from

their homes. It ultimately left thousands of households displaced without heat or the ability to

cook for months and bankrupted Columbia Gas of Massachusetts.

Although the accident can be attributed – on face value - to technical errors, these errors

shine a light on more profound organizational complacency within Columbia Gas, not the least

of which involve a gap in good project management practice and responsibility. A thorough

investigation conducted by the NTSB provided many technical recommendations to Columbia

Gas. To protect against future disasters, however, changes must be made from the project

management perspective. The three top identified top issues are cost-cutting in safety efforts,

lack of coordination internally and with local governments, and a culture of complacency.

I will discuss how these three major issues led to the subsequent disaster, solutions, pros

and cons, and these two overall recommendations: adding safety to the performance criterion

for project managers and developing a precise emergency plan with routine drills.

Background

On September 13, 2018, excessive pressure in natural gas lines owned by Columbia Gas

caused a series of explosions and fires in Massachusetts's Merrimack Valley region. The system

over-pressure ultimately damaged 131 structures, hospitalized 21 individuals, and killed one

person. (National Transportation Safety Board, 2019) Columbia Gas of Massachusetts failed to

proactively communicate with the local population. The people of Merrimack Valley were

getting their news instead from the local law enforcement agencies. This disaster ultimately left

thousands of households displaced without heat or the ability to cook for months and bankrupted

Columbia Gas of Massachusetts.

The disaster's technical causes could be traced back to replacing aging cast iron gas pipes

with polyethylene pipes. Contractors followed the work package that Columbia gas developed

and approved. The contractors removed a length of pipe without the very important step of

disconnecting a pressure sensor that was still attached to the removed pipe section. The pressure

sensor began reading a pressure drop that opened valves in the gas network until they were open

completely. Alarms were triggered at NiSource, Columbia's parent company, in Ohio. However,

they had no remote control of the valves and could only respond in person, and by the time the

valves were shut and brought back in control, the damage had already been done. (Maltzman,

2020)

Although seemingly technical in nature, this disaster points to multiple systemic issues

linked to project managers' failures and top management at Columbia Gas. The three issues

discussed in this paper are cost-cutting in safety efforts, lack of coordination internally and

with local governments, and a culture of complacency.

Issues Identification

Issue 1 – Cost Cutting in Safety Efforts

Ironically, the modernization project that set off the disaster was to replace the old pipes

with newer, safer, polyethylene pipes. However, the mitigation of risk through this

modernization created a secondary risk that revealed cost-cutting measures that made the process

unsafe. As it is cheaper to hire a contractor to replace the pipes, Columbia Gas outsourced labor

on this project. (Penn, 2019) By engaging a third party, Columbia Gas would have less oversight

over the project with contractors working on an unfamiliar system. Furthermore, Columbia Gas

typically had a technician from the Meter and Regulation Department assigned to the site to

manage the pressure readings. This practice was ended four years ago. (Penn, 2019) Columbia

Gas did not provide any reasons for ending the procedure, but it seems evident that it is a cost-

cutting measure, undertaken (in the author’s opinion) without proper consideration of the

downside.

However, even if Columbia Gas were directly working on the project, the accident may

have still happened. The NTSB investigation revealed the work package was signed off by an

engineer-in-training, not a licensed professional engineer. The office working on the project only

had two licensed engineers, and they only dealt with signing off on more extensive projects,

which this pipeline replacement was not (National Transportation Safety Board, 2019). This

seems to be a workflow process problem – something a project manager should consider.

Finally, there was a lack of documentation of the sensors resulting in them being

excluded from the work package. Had the engineers had the resources to review and provide that

information to the construction workers diligently, they would have accounted for the regulator

sensing lines.

Issue 2 – lack of coordination

Had the significant increase in gas pressure been detected and promptly acted upon, the

damage would have been significantly reduced. The first alarm that warned of high pressure

went off at 3:57 pm. It was not until 4:30 pm that technicians arrived at the first regulator station

to cut off the high-pressure gas flow - and not until 7 pm later that evening that the high gas

pressure was brought back in control. The NTSB investigation showed that Columbia Gas was

not prepared to respond to the emergency. Their emergency documents did not provide clear and

actionable steps for responding to this large-scale emergency event. (National Transportation

Safety Board, 2019). Although not per se related to this particular project, the project manager

could ‘step up’ and question why a particular project does not have these emergency steps.

Furthermore, information was not provided to municipal governments and emergency

first responders. The NiSource Emergency Manual states that when an over-pressurization of the

system occurs, there "may be a need" to communicate with local government officials and

emergency management agencies as well as fire and police departments. Had firefighters and

police been given the actionable information in a timely fashion, evacuations and precautions

could have begun. This communication could have potentially prevented multiple injuries and

the single death that occurred. Further, better communications could have prevented the

embarrassing situation of leaving the Twitter feed posting the company receiving a safety award

rather than providing the local population with vital, urgent information about the disaster as it

unfolded.

Issue 3 – lack of safety culture

Massachusetts Department of Public Utilities provided documentation on enforcement

action against Columbia gas for the preceding five years. Many of the incidents show a history of

improper maintenance, documentation, and inspection of their gas lines.

In Columbia Gas' pursuit of higher profit, minimum resources were placed into making

sure the gas lines they operated could be as safe as possible. A lack of safety culture also reveals

a culture of complacency. This culture can be seen in their lack of thorough risk assessment and

planning for emergency events. Investment into classes and exercises for their on-site engineers

would have also made the response less hectic and more unified.

Furthermore, had safety been a higher priority, the planning process would have included

a thorough check for safety issues. At the time, Massachusetts' state did not require a

professional engineer to sign off on the project plans. Columbia gas, therefore, did the bare

minimum to be following regulatory guidelines. Had also safety been taken into account during

their review and planning process for modernizing their gas lines, the potentially deadly issue of

over-pressure would have come up and been a more significant part of the review process for the

construction plans. Again, although this is not the specific role of the PM, the PM can and

should be the person to highlight these issues to management.

Proposed Solutions Table

Issues # - Solution # Solution

1-1 Re-invest in safety heavily. Create an executive-level office to

advocate for safety across the entire company's operation. Use this new

people's power to conduct a thorough review of engineering and

planning processes to refocus on safety.

1-2 Add safety as a performance target criterion to protect against

sacrificing quality over budget and time constraints.

1-3 Modify company policy concerning project planning and review so that

it goes above and beyond the regulatory requirements set forth by the

government.

2-1 Develop a precise and thorough emergency action plan that includes

Columbia Gas, local governments, and emergency first responders.

Make sure different monitoring stations are adequately staffed so that

no one person is entirely swamped when an emergency incident occurs.

2-2 Plan routine drills that practice potential emergencies. Make sure that

emergency first responders are included. Conduct reviews of these

drills to see if there are any improvements to be made

2-3 Conduct a review of how different departments and regional offices

communicate with each other. Create a communications plan that

allows information, especially in an emergency, to be communicated

timely.

3-1 Create a company-wide safety program that educates people on safety

practices and standards that must be respected. Also, put in place a

mechanism to make sure violations are dealt with transparently and

timely.

3-2 Make training classes for new hires, especially in the technical

department, mandatory.

3-3 Bring in new board members, executive-level hires with extensive

experience working in organizations that focus on safety. Such as the

NTSB or OSHA.

Pros and Cons Matrix

Solution Pros Cons

1-1: Create

executive-level

office overseeing

safety

 Does not add to current

employee's responsibilities.

 Dedicated teams can dig deeper

and provide more unbiased

recommendations.

 It will take time to set

up.

 Without strong

backing from board

members, may not

have enough influence

to provide long-

lasting change

1-2: Add safety as a

performance

criterion

 Limit the pressure for project

managers to meet budget and

time constraints at the cost of

safety

 Quality over cost constraints

 There is a subjectivity

to how safety factors

in and can be

confusing for project

managers

1-3: Modify

company policy to

exceed regulatory

requirements

 Columbia Gas becomes a leader

over a follower regarding safety

regulations.

 Reduces the possibility that

Columbia Gas will be fined.

 Increased margins

required may turn the

company to be less

competitive with other

companies that follow

the bare minimum

 Takes increased time

before project start

2-1: develop a

precise emergency

plan

 Reduces the need for the on-site

managers to make high-pressure

decisions in the moment

 The plan could be too

rigid, leading to

secondary risks

2-2: Conduct

routine drills  Make sure employees practice

the emergency plan.

 Practice coordination with local

emergency first responders

 Expensive and time-

consuming

 May inadvertently

create more

complacency by

allowing people to

feel too comfortable

2-3: Review how

departments

communicate

within the company

 Create pathways for company-

wide improvement that will

have long-term benefits for

safety and productivity

 Would require drastic

changes to

communications

systems that could be

expensive or time-

consuming to

implement

3-1: Create a

safety-program  Invests in future profits by

reducing costs for disaster

events

 Will take time to

translate into

employees' attitude

3-2: Create training

classes for new

hires

 Improve technical qualifications

within the team

 Provide another perk for

employment

 Costly and time

consuming to create

and complete

3-3: Bring on board

safety-oriented

board members and

executives

 Enables new exchange of

information and practices

 Changes may take

time to trickle down

to the whole company

Solutions Ranking Table (Top Solutions in green)

Solution Likelihood of

Success

Difficulty

Implementing

Solution

Score

Solution

Rank 1-5, 5 highest 1-5, 5 least difficult Likelihood of

success times

difficulty

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Recommendations

From the solutions ranking table above, we can see two stand-out solutions. They have a

high likelihood of success with low difficulty: adding safety to the performance criterion for

project managers and developing a precise emergency plan with routine drills. These are

incredibly urgent as there is no good emergency plan currently in place, and Columbia Gas

cannot sustain another mismanaged emergency, and of course the people of the Merrimack

Valley have had enough in terms of fires and explosions in and around their homes.

These aren’t the only changes – there are also more long-term changes, these changes

will be useful but will require significant resources and time before positive results appear. These

changes are necessary to reinstate their customers' trust in the company as one that safely

manages their natural gas. These changes include creating long term safety programs, more

comprehensive technical training, and making an executive-level office overseeing safety within

the company.

Lastly, a review of the company's communication and corporate culture will shed light on

where Columbia Gas has become complacent. This review is a massive undertaking but will

reveal safety downfalls and inefficient and redundant parts of the company to reorganize to bring

this ancient company forward into the more competitive landscape. These changes, prioritized

and implemented immediately, will significantly reduce any potential future disasters and

mismanagement.

References

Maltzman, R. (2020). Columbia Gas of Massachusetts – Project Issue Analysis – AD642

Individual Assignment 2. Boston.

National Transportation Safety Board. (2019). Overpressurization of Natural Gas Distribution

System, Explosions, and Fires in Merrimack Valley, Massachusetts, September 13, 2018.

Washington, DC: Pipeline Accident Report NTSB/PAR-19/02.

NiSource Inc. (2020, December 1). Home - NiSource. Retrieved from Nisource:

https://www.nisource.com/home

Penn, N. (2019, June 3). The Day the Town Blew Up - Andover Masssachusetts Gass Explosion.

Retrieved from Popular Mechanics:

https://www.popularmechanics.com/technology/infrastructure/a27309627/andover-gas-

explosion/

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