ORIGINAL ARTICLE / ARTÍCULO ORIGINAL/ ARTIGO ORIGINAL

Teamwork as a nursing competence at Intensive Care Units

El trabajo en equipo y la experiencia de las enfermeras en Unidades de Cuidado Intensivo

Silvia Helena Henriques Camelo¹; Lucieli Dias Pedreschi Chaves²

¹RN, Ph.D., Professor. University of São Paulo at Ribeirão Preto College of Nursing, EERP-USP, Brazil. email: shcamelo@eerp.usp.br.

²RN, Ph.D., Professor, EERP-USP, Brazil. email: dpchaves@eerp.usp.br.

Receipt date: May 22^nd 2012. Approval date: September 19^th 2012.

Article associated with the research: The nursing work process at an Intensive Care Unit: analysis of professional competences and management strategies

Subventions: FAPESP- São Paulo State Research Foundation

Conflicts of interest: none.

How to cite this article: Camelo SHH, Chaves LDP. Teamwork as a nursing competence in Intensive Care Units. Invest Educ Enferm. 2013;31(1): 107-115.

ABSTRACT

Objective. The aim in this study was to identify how Intensive Care Unit nurses perceive professional competences in thecare team. Methodology. Qualitative multiple case study with an exploratory focus. The sample consisted of 24 nurses from Intensive Care Units (ICU) at two large hospitals. To collect the information, direct observation and - structured, non-structuredand participant - interviews were used. Results. Ninety-six percent of the participants were women, 79% were less than 40 years old, and 63% possessed less than five years of professional experience in ICU. Data analysis revealed three study categories: teamwork as a nursing management tool, improving teamwork, and interpersonal communication for teamwork. Conclusion. At the ICU where the nurses work, a teamwork strategy is observed, which demands cooperation and participation by other disciplines.

Key words: Intensive care units; nurses; interpersonal relations.

RESUMEN

Objetivo. Identificar la percepción de las enfermeras en la Unidad de Cuidados Intensivos de la competencia el trabajo en equipo profesional. Metodología. Estudio cualitativo con enfoque exploratorio, del tipo de estudio de múltiples casos. La muestra estuvo conformada por 24 enfermeras de Unidades de Cuidados Intensivos (UCI) de dos grandes hospitales. Para la toma de información se empleó la observación directa y la entrevista -estructurada, no estructurada y participante-. Resultados. El 96% de los participantes eran mujeres, un 79% tenía menos de 40 años, el 63% tenía menos de cinco años de experiencia de trabajo en UCI. El análisis de los datos permitieron identificar tres categorías de estudio: el trabajo en equipo como herramienta de gestión de la enfermería, mejorando el trabajo en equipo, y la comunicación interpersonal para el trabajo en equipo. Conclusión. En la UCI, lugar de actuación de enfermeras, se observa una estrategia de trabajo en equipo, que exige la cooperación y participación de otras disciplinas.

Palabras clave: unidades de cuidados intensivos; enfermeras; relaciones interpersonales.

INTRODUCTION

Quality, productivity and attention to the clients are dominant themes in the current context, aiming at the progress and survival of the hospital organization. In the search for better care, it is necessary to comply with the directives and principles of the Unified Health System (SUS).¹ Integrality of care, one of these principles, is indispensable to the quality of healthcare, and should be the central axis in the organization of the work in the health services, particularly in the hospitals. Integrality of care in hospital interventions can occur through the combination of hard technologies, soft-hard technologies, and soft technologies, in seeking a balanced union of instrumental rationality and communicative rationalities - and understanding these as determinants in health actions.²

It is thus fundamental to link the actions carried out within the hospital institution, such that there may be integration of the work of the various professionals in the same area, and also between teams of workers in different areas. Although the appropriate treatment of critically ill or potentiallycritically ill people exists in the context of the current Brazilian health policy,³ due to inadequate structuring of the health service networks (primary, secondary), this service has become, in recent years, one of the most problematic areas of the Health Care System. This deficiency results from the growing demand for this level of care, which has as the central rule for its existence the attendance of patients in extreme, critical and/or serious situations, requiring the workers to have specific professional qualifications.⁴

Based on these reflections, the work process in an Intensive Care Unit (ICU) deserves highlighting, bearing in mind the complexity of the activities undertaken there and the need for collective, dynamic and integrated action to permit quality in the care given to the user of this service, as well as to improve the health professional's satisfaction with the object of his or her work. As a member of the health team in the context of ICU, the nurse has the role of obtaining the patient history, carrying out physical tests, undertaking treatment, advising about and teaching health maintenance and guiding the patients to continue treatment and health measures. Nurses must also combine the theoretical basis with leadership ability, the work, discernment, initiative, teaching ability, maturity and emotional stability.⁵

In this regard, nurses have various possibilities for acting, and need more than just technical competencies; they also need relational competencies that allow them to carry out their functions efficiently, combining technical-scientific knowledge, command of the technology, humanization and individualization of care. Over the years, the issue of 'professional competency' has been the focus of the attention of not only nurses but also of health service administrators, as nursing personnel represent, in quantitative terms, a significant proportion of the human resources allocated in these institutions and, therefore, directly influences the efficiency, the quality and the cost of the health care given. Competency may be defined as the acquisition of appropriate skills for accomplishing a specific task, or the ability to decide, using necessary skills and acquired knowledge, and to manage a specific situation.⁶ For this author, professional competency may be described as a linked and complex combination of skills and abilities which are the result of the conceptual and functional synthesis of theoretical aspects, linked particularly to the course contents and to the current experience.

In this way, the analysis of the competencies places special attention on the operative context and, at the same time, on the development of reflection on the development of course content and the relationship between them.

In Brazil, various studies have been undertaken on the nurse's professional competency,⁷ with more recent studies emphasizing skills and competencies which must be developed in the nurses who work in ICU^8,9 - and among these, the professional competency of working in a team stands out.⁹ This study re-affirms the concept that teamwork is a modality of collective work which is configured in the reciprocal relationship between technical interventions and the agents' interactions.¹⁰ Teamwork may be considered as a priority strategy for reversing processes of fragmentation, individualization and competition, in addition to processes which break collective alliances at work.¹¹ It is identified as a tool for the effecting of integrality in health.¹²

In ICU, teamwork appears as one of the competencies necessary for the nurses in the organization of their work. It is presented as a strategy for managing the care carried out, linking actions and knowledge from various professional categories in a search for consensus which translates into quality in the attention to the patient's health needs. The organization of the work, based in the formation of teams, has certainly been the most democratic, productive and humanized way of undertaking work in health.¹³ Thus, considering the complexity of the work of an ICU nurse, whose nursing activities represent more than 50% of the actions carried out in that location, and the challenge of making this professional fit to engage in teamwork, one may ask: are there any strategies for integrating the health team and nursing team? What is the importance of communication and relationship skills for teamwork? Does the intensive care nurse perceive teamwork as one of the competencies necessary for their work? Is the nurse prepared for working in a team?

The present study aimed to identify how nurses working in ICU perceive teamwork as a professional competency, emphasizing communication and interpersonal relationships skills in the development of this competency. The present study's relevancy lies in the possibility of identifying how the nurses who work in a highly complex sector perceive the need to develop the competency of working in a team; as well as prompting nursing managers to reflect on this professional competency, understanding its use as a strategy in re-structuring care activities which can impact on the organization of professional practices, with a view to the quality in the integral healthcare delivered in the hospital ambit.

METHODOLOGY

This is a study with an exploratory design and a qualitative approach. The research's methodological design is the case study, considered a research method with an empirical character, which investigates a phenomenon, generally contemporaneous, within a real context.¹⁴ For this work, the study was defined as a multiple case study. This type of study involves the analysis of two or more cases, which may or may not be compared. In this work, a study was made of two cases. They were not comparative and referred to two ICU(s) for adult patients, belonging to a large public teaching hospital in the state of São Paulo, a center of excellence for high complexity care - this context being reproducible in similar contexts. The purpose of the case study was the analytical generalization.

The present study's population was made up of 24 nurses, and the inclusion criteria were: nurses directly involved in care in the selected units, who had undertaken their activities for more than six months. Data collection occurred between January and April 2011.

Two sources of evidence were used for the data collection: observation, and semi-structured interviews recorded with the study population. The observations were structured, and occurred on the occasion of the field visits for the interviews. The data from observation, recorded in field diaries, was added to the data from the interviews, so that these might be considered jointly in the process of the analysis. The categories were organized based on the identification of the regularities and differences in the data. In this way, the corpus of the analysis of this study was made up of material transcribed from the recordings of the interviews, combined with the records of the observations made.

Thus, the method of content analysis, centered in the technique of thematic analysis, was used for the analysis of the present study's data. This modality of analysis seeks the center of the meaning of a communication, whose presence or meaning signifies something to the object of analysis.¹⁵ So as to proceed to the thematic analysis, the questions' content was organized, following the sequential phases proposed by Minayo: pre-analysis, the exploration of the material, and the treating of the results.¹⁵

This project was evaluated and approved by the Ethics Committee of the Clinical Hospital of Ribeirão Preto Medical School, University of São Paulo, under Protocol n°9951/2010. Before data collection was started, the subjects were guided regarding the research's objectives, and those who agreed to participate signed the terms of Free and Informed Consent, in line with Resolution no 196/96 of the National Health Council.¹⁶

RESULTS

The present study's results allow one to outline the ICU nurses' profile, according to the variables: 95.8% of the participants were female, 79.2% were aged forty or under, 66.7% had graduated since 2001, 33.5% had up to four years' work in the institution, and 37.5% had between one and four years of work experience in the ICUs. The analysis of the data made it possible to construct three categories related to teamwork: teamwork as the nurse's managerial tool in the ICU; improvement for the teamwork; communication and interpersonal relationship in the teamwork.

In relation to the first category, in this investigation, primarily, the nurses (N) highlighted the need to work as a team, bearing in mind the complexity of the care delivered in ICU, as shown in the following discourses. [...] the ICU doesn't function without teamwork, there are always disagreements, the team is very big [...] (N14) [...] teamwork is essential, principally here in the ICU, because it isn't going to work, how is a nurse, auxiliary or a doctor going to deal with a cardiac arrest on their own? It isn't going to work, here you have to go for teamwork [...] (N 39). [...] we have to work as a team, we have to work as much with the medical team as the nursing team, the patients are very seriously ill [...] (N22).

The discourses and field observations alike also showed teamwork as part of the nurse's work. [...] the issue of teamwork is eminently part of the nurse, it's the nurse who knows how to manage the relationship between the medical professional and the auxiliary nurse professional, it's the nurse who knows how to keep the service running in harmony [...] (N 32). [...] the nurse has to know how to work in a team, if the nurse is an individualist he won't manage to work, the one depends on the other [...] (N 12) [...] the teamwork here, I think, is predominant really, it's multidisciplinary work - the doctor, the physiotherapist. this is a competence I developed most here [...] (N 09).

In relation to the improvement for teamwork, the statements show that the nurses who work in the units investigated improved their knowledge in relation to the competency of working as part of a team after graduating, in the daily routine of their work. I had a notion of how to work in a team, which became stronger here... before I had a view, but now - as a real nurse - if you don't work as a team, things don't work, I have to demand this of the team (N01). The teamwork is much greater here in the unit, I had already worked a little in ICU before too, so I had already had an on-call doctor 24 hours, the physiotherapist, but not so much, here I developed much more, sometimes you see that it is harder, sometimes it's better, it's good, so you learn to deal with the differences, with the different professions, I learnt that too, I developed it much more here (N05). I developed the teamwork totally here, in the four years I've been here... I've succeeded in really managing the team I work with, because you have to bring the team to work along with you (N06).

Communication and the relationship were also emphasized in the results, as fundamental elements of teamwork, as shown in the following discourses. [...] there has to be teamwork and I think that to have that, there has to be communication, which is fundamental and clear, clear communication, because otherwise you go nowhere if it's 'do this', or 'who does that?' (N 24). [...] with communication with doctors, you have to be alert, because the procedures progress very fast, we have to get information from the doctors and pass it on to the team, and know how to guide the nursing team (N 10.) [...] in my opinion, one of the most important things is having good relationships, because in ICU there is an involvement with several areas, so if you don't have a good relationship, and plenty of flexibility the whole deal grinds to a halt (N 27). [...] working in a team...working in an interdisciplinary way nowadays, too, if you can't manage to work with the physiotherapist, with the nutritionist, with the doctor, if you don't have a harmonious relationship with all these professionals, including the technicians and auxiliaries, you won't be able to do anything; if you don't have a good interpersonal relationship, sometimes this is the most important thing (N20). [...] the good relationship between the professionals from different areas, knowing how far your duty extends, and your role, and where somebody else's starts, because no matter how much we all work together, everybody has their role, the nurse manages all this... so the more the team is integrated, the better it will be for the work to pay off. (N31).

DISCUSSION

The social and professional profile of the nurse in ICU

The results evidenced that 79% of the sample's participants were aged between 23 and 33, thus determining a population of young nurses. The majority are female, this predominance in nursing being shared by other authors,¹⁷ reproducing the historical characteristic of nursing, a profession exercised almost exclusively by women since early times. This predominance also occurs among the workers in hospital, principally in nursing, which can be explained relating to the archetype, attributed to women.¹⁸ In relation to the year in which they had finished their nursing course, by far the majority had concluded the course within the previous 10 years. The time which has passed since graduation can be indicative of the length of the nurse's experience in the job market and of his or her relative maturity.¹⁹ The Bachelor's degree reveals the nurse's competencies and skills, rather as the time since graduation, in a specific epoch, reflects the knowledge and aptitudes valued in a specific period.²⁰

Regarding length of service in the institution, it is worth emphasizing that eight (33.5%) nurses had up to four years of working in the institution and nine (37.5%) nurses had between one and four years of working in the ICUs. This data is similar to that of another study, where 54% of the nurses had up to five years' service in the institution.¹⁹ Professional experience, institutional involvement and the stability acquired through the length of service are factors which encourage professionals to remain in an organization; further, length of service in an institution may be associated with the institution's work proposal and individual satisfaction.¹⁹

The present study's results showed that a large proportion of nurses had been working in the units for less than three years. However, when one looks at these workers' training, it may be ascertained that 16 (66.5%) nurses had some type of specialization, with eight (50%) of these in intensive care. It is worth highlighting that four (25%) of the nurses with some sort of specialization had master's degrees. This data is similar to that of another study, which reported the existence of nurses with ^{stricto sensu master's degrees} -Stricto sensu master's degrees focus on the formulation and testing of new theories, rather than pre-existing theories. Translator's note- (13%), doctorates (2%) and in the process of doing master's degrees (5%).²⁰ These results seem to indicate a concern among nurses with seeking other experiences, besides those taught on the undergraduate course, which may prepare them to provide care to seriously ill patients better and with greater safety.

Teamwork as a strategy of the ICU nurse

Teamwork is a strategy for organizing work in the hospital institution and, in the Intensive Care Unit, it must cover the articulation of the actions and the knowledge of varying professional categories so as to achieve the integral care for its clientele's health needs. The strategy of working as a team does not presuppose abolishing the specific characteristics of the tasks, as the technical differences show the possibility of how the division of the work contributes to improving the service delivered, to the extent that the specialty allows the improvement of the knowledge and technical performance, in a specified area of work, as well as greater production.¹⁰

The nurse's work in a ICU is characterized by complex care and managerial activities which demand technical and scientific competency, and where decision-making and adoption of safe practices are directly related to people's life and death.²¹ In this context, it is of the uttermost importance for the nurse to develop knowledge, skills and attitudes which are coherent with quality care and - in the present study - it was ascertained that the strategy of teamwork is considered one of the competencies necessary for a nurse, so as to achieve the expected results in a sector where highly complex nursing care is undertaken. The nurse, having the competency of working in a team, can construct a global vision of each situation through the interlocution between the different professionals involved in the therapeutic response monitoring, contributing to achieving the best prognosis for the hospitalized patients.

Improvement for teamwork

The analysis of the interviewees' data and the data from the observations carried out in the ICU(s) made it possible to say that the organization of the nurses' work in the ICU is a systematic process and that it sets in motion relationships of support and collaboration, producing the articulation of their work with that of other professionals - such as auxiliary nurses and nurse technicians, doctors, physiotherapists, and nutritionists - so as to produce quality care. This fact demands the development of the competency of teamwork not only in nurses, but also in the other health professionals. Health professionals with differing training and lengths of service can contribute to the development of teamwork in different ways.²² The development of the professional nurse can occur in the daily work routine, through punctual training or specialization/post-graduate courses. A program for preparing and training human resources in health should be an investment to be made by the training colleges, as well as by the health institutions' managers, as an important instrument for developing professionals in the face of transformations taking place in this work setting. It is known that the training process allows the acquisition of motor and intellectual skills, as well as the development of cognitive strategies and attitudes, which can make the individual more competent to perform various roles in the organization.²³

Communication and interpersonal relationships in teamwork

Considering the process of teamwork in the ICU context, communication favors appropriate and productive interactions. For the integration of different professional categories and fields of knowledge around a common objective, efficient communication between the team members is essential, so as to identify difficulties and promote the best plan for the solution of impasses. To this end, communication can be visualized as a tool for change and improvement of the care. Evaluating, planning and communicating are processes present in the everyday of work in ICU, and are necessary for any action or decision.²⁴ Communication is considered a key point in nursing care and must be used as a channel for information, in which there is guidance and clarification of doubts, and these must be clear and objective. Communication is a principal factor for improving the link between people, influencing the interpersonal relationship between the professionals in a team, principally in a closed unit such as ICU.

The discourses showed that the interpersonal relationship between the various members of the team can be decisive for the teamwork in these units to occur. The good relationship between the people involved in the nursing care is essential for the teams to provide mutual help in the care and also at times when the health professionals themselves need emotional support, when it is difficult to deal with a client's pain, or the loss of a client.²⁴ Despite discussions about teamwork being common in work environments, in the area of health many professionals still have difficulties in understanding it and accomplishing it in practice - even knowing that it is only through the articulation of actions and interaction between team members that one can progress to work which manages to meet the multidimensional needs of the individuals being cared for.²⁵

Conclusion. The work in ICU requires new competencies of the health professionals, who encounter technological changes and their clientele's demands, both of which cause transformations in their work process. The present study's results showed the nurses to be predominantly young and female, and to be considering the need for developing competencies based in scientific knowledge, so as to be able to manage the care for highly complex patients with safety and quality. The nurses who participated in this study perceived teamwork as an essential competency for carrying out their roles, and recognized the need to develop and improve it in the daily routine of their work. Employing institutions have co-responsibility and commitment to the development of their staff and must evaluate the return on their investment in terms of the services' quality and the care to the clientele.

In ICU, the strategy of working as a team is a proposal that emphasizes cooperation and incorporates the health professionals' participation, strengthening the multiprofessional work; it can contribute to the integral care given, thus becoming an imperative strategy for the management of people. To this end, it is believed that discussion concerning teamwork as a competency for nurses who work in critical care/intensive units allows one to analyze aspects which are relevant to these professionals' training, in terms of competencies and skills which are necessary while acting as an agent who must recognize the multiple dimensions involved at this level of care and interdisciplinary activity.

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