kierraknox.files.wordpress.com · Web viewThe University of Mary Relational Coordination Project Team (UMary Graduate EBP Project Team) would like to acknowledge the following people

Running head: RELATIONAL COORDINATION 1

Relational Coordination for Nurse Residents: Infusing the Organization

Dania Block, Esther Holliday, Kierra Knox, William Ohlson, & Shila Thorson

University of Mary

RELATIONAL COORDINATION 2

Acknowledgements

The University of Mary Relational Coordination Project Team (UMary Graduate EBP

Project Team) would like to acknowledge the following people for their assistance with this

project and Billings Clinic for allowing the UMary Graduate EBP Project Team to partner with

their organization through this educational endeavor. Special recognition is given to Claudia

Dietrich, University of Mary project advisor, who was influential to the UMary Graduate EBP

Project Team with her consistent encouragement throughout the learning process.

Billings Clinic

Laurie Smith, MSN, RN, NEA-BC, VP of Hospital Operations and Chief Nursing Officer

Curt Lindberg, DMan, MHA, Director, Partnership for Complex Systems and Healthcare

Innovation

Jeannine Brant, PhD, APRN-CNS, AOCN, FAAN, Nurse Scientist

Barb De Laurier, MSN RN, NEA-BC, Director of Professional Development and Magnet

Program Director

Jennifer Potts, Occupational Therapist Registered/Licensed, Billings Clinic Relational

Coordination Facilitator

Brooke Risa, Administrative and Technical Assistant

Cheryl Miller, MSN RN, RN-BC, Nurse Residency Program Coordinator

Kelsey Hanson, BSN RN Nursing Residency Faculty

Rebecca Clinch, Human Resources Manager

Justin Duke, MHA, Employee Engagement Analyst

Nicholas Coombs, M.STAT, Research Data Analyst


Jody Hoffer Gittell, PhD, professor at Brandeis University's Heller School for Social

Policy and Management and an expert on relational coordination and

organizational performance


Table of Contents

Executive Summary……………………………………………………………………………….9

Problem Statement……………………………………………………………………………….11

Significance of Clinical Problem………………………………………………………………...12

PICO Question…………………………………………………………………………………...15

Purpose Statement………………………………………………………………………………..16

Theoretical Framework…………………………………………………………………………..16

Review of Literature……………………………………………………………………………..18

Literature Search…………………………………………………………………………18

Synthesis of Current Literature…………………………………………………………..41

Benefits of Relational Coordination……………………………………………..41

Structure of Relational Coordination…………………………………………….42

Resources of Relational Coordination...…………………………………………46

Measurement/Effectiveness of Relational Coordination...………………………48

Project Problem Identification…………………………………………………...………………52

Internal Evidence……………………………………………………………...…………53

External Evidence………………………………………………………………..………56

Project Recommendations………………………………………………………….……………58

Project Implementation……………………………………………………….…………………58

Change Theory……………………………………………………………………..……58

Key Stakeholders……………………………………………………………...…………59

Barriers, Facilitators/Drivers, and Resistors to Change………….………………………61

Work Practices………………………………………………………………………...…64


Business Impact…………………………………………………………….……………65

Organization Planning Process ………………………………………………………….68

Implementation Plan.……………………………….……………………………………68

Project Measurement Plan….………………………………………………………...………….72

Human Subject Protection Statement……………………………………………………………83

Implementation and Measurement………………………………………………………………83

Implementation………………………………………………………………………….83

Project Outcome Measurements………………………………………………………...77

Hand Off Plan……………………………………………………………………………………92

Conclusion……………………………………………………………………………….………93

References……………………………………………………………………………….……….95

Appendix………………………………………………………………………………………,,101


List of Tables

Table 1: Relational Coordination Benefits External Data…………………………..…………..19

Table 2: Relational Coordination Benefits Level of Evidence…………………...……………..20

Table 3: Relational Coordination Structure External Data………………….…………………..25

Table 4: Relational Coordination Structure Level of Evidence…………………………...…….25

Table 5: Relational Coordination Resources External Data…………………………………….29

Table 6: Relational Coordination Resources Level of Evidence………………...……………...29

Table 7: Relational Coordination Measurement/Effectiveness External Data………………….33

Table 8: Relational Coordination Measurement/Effectiveness Level of Evidence……………..34

Table 9: Internal Data…………………………………………………………………………...54

Table 10: Internal Reported Data Pre-RC Toolkit Implementation ………………………..…...56

Table 11: Relational Coordination Overall Scores……………………………………………...91

Table 12: Retention/Vacancy Rates Post-RC toolkit implementation……...…………………...91


List of Figures

Figure 1: Relational Coordination Change Theory…………….………………………………..59

Figure 2: Transition Stages Model…………………….………………………………………...79

Figure 3: Frequent Communication…………………………………………..…………………87

Figure 4: Timely Communication………………………………………………...……………..88

Figure 5: Accurate Communication…………………………………………………….……….88

Figure 6: Problem Solving Communication…………………………………………….………89

Figure 7: Shared Goals…………………………………………………………………….…….89

Figure 8: Shared Knowledge………………………………………………………………..…..90

Figure 9: Mutual Respect………………………………………………………………………..90


List of Appendices

Appendix A: Communication for Permission to Use Relational Coordination Survey………101

Appendix B: Workshop Agenda for Nurse Residency Faculty Formal Education……………102

Appendix C: New Nurse Residency Formal Education on RC Concepts …………………….103

Appendix D: Liberating Structures ……………………………………………………………105

Appendix E: Relational Coordination Toolkit Communication Game……...…………………106

Appendix F: Relational Coordination Toolkit Visual Tools ……………...…...………………108

Appendix G: Relational Coordination Overview Handout for RC Toolkit……………………110

Appendix H: Relational Coordination Improvement Plans …………….……………………..114

Appendix I: Relational Coordination RAIL …...…….……………………….………….…....115

Appendix J: Nurse Residency Curriculum ……………………………………………………116

Appendix K: Relational Coordination Survey Tool.. ………………………………………...121

Appendix L: Relational Coordination Commitment……………………………………....…..122

Appendix M: Evaluation of RC Toolkit from NRP Residents………………………………..123

Appendix N: Letter of Support ..………...…………………………………………….……...124

Appendix O: IRB Application .…………………………………………………...…….…….125

Appendix P: Billings Institutional Review Board Letter of Exempt Status…………………..138

Appendix Q: Email Receipt of Exempt Status from Billings Clinic Nursing Research

Council…………………………………………………………………………139

Appendix R: Relational Coordination PowerPoint..…………………………….…....….……140


Executive Summary

This evidence based practice project was designed to explore if the utilization of a

relational coordination (RC) toolkit with nurses enrolled in a nurse residency program would

demonstrate an elevated RC score and a decreased vacancy rate compared to those not using the

RC toolkit over a three-month period. The UMary Graduate EBP Project Team performed a

literature review and assessment of the current gap in knowledge, which led to the development

of the RC toolkit and the inclusion of three areas to focus the efforts based on the needs indicated

by the CNO of the host organization. The RC toolkit was introduced to the nurse residency

program faculty, and then implemented with the nurses in the nurse residency program. The RC

Survey Tool measured change in RC score and the host organization provided data regarding

vacancy rates and retention rates from internal data.

The evidence based practice project draws attention to the fact that RC is well discussed

in the literature and has gained much in the way of support for improvement strategies that can

impact the quality, efficacy, and efficiency for patient care. Improving communication and

teamwork not only has a place in the healthcare setting, but in day-to-day interactions within the

communities we strive to serve. The literature supports the primary outlier for appropriate care

coordination being attributed to gaps in the communication for care delivery and the impetus for

improvement can be fostered through relational coordination.

The report evaluates the relational coordination strength and weaknesses after

implementation of the RC toolkit and found many areas of strength including frequent

communication and shared goals with preceptors. The nurse residency faculty also showed


strength with problem solving communication, shared knowledge, and mutual respect. The

leadership of the organization has shared goals and strong ties of inter-collaboration to be

preserved. Many areas of RC in the organization were found to require support and teaching.

An area identified for growth in the organization is shared goals and frequency of

communication of nurse residency faculty.

The host organization vacancy and retention rates confirm positive trends during the

implementation of the RC toolkit. Average retention rates of the host organization increased

from an average of 98.7% prior to implementation to 99.1% post implementation. Vacancy rates

in the host organization decreased from an average of 21.92% to 15.26% during the same

timeframe. The host organization results from the evidence based practice project show strong

support and implementation of the RC principles. Survey results demonstrate significant

organizational recognition of the benefits to the organization itself, the patient, and the quality

outcomes of the organization.

It is recommended that the host organization:

• Expand the RC toolkit to existing employee forces.

• Provide an education session fully explaining the concepts of RC to all preceptors and

members of leadership involved so that they worked from the same understanding and

footings of new nurse residents in the nurse residency program.

• Add examples of the stories that were shared in the new nurse residency orientation.

• Survey the participants of the evidence based practice project again in six months and

again at 12 months, just prior to completion of the nurse residency program

• Measure nurse satisfaction scores to assess the degree of nurse/job satisfaction with the


implementation of the RC toolkit.

Relational Coordination for Nurse Residents: Infusing the Organization

The value of quality relationships and communication between inter-collaborative team

members has been demonstrated and measured in many professions. Evidence based practice

has demonstrated the quality performance benefit of Relational Coordination (RC). The

advantages of RC have been applied in practice by many top-performing companies, which

include Southwest airlines, who define their business model as RC structure. As such,

Southwest Airlines continues to be recognized as a leader in their business with customer

satisfaction, safety, and fiscal return.

The host organization (Hospital in Billings Montana which requests to be addressed as

such) also identified the advantages of RC in practice. The host organization is a 280 bed,

Magnet-designated, level II trauma center with a service region of 500 miles, and newly founded

nurse residency program (NRP). The host organization welcomed the UMary Graduate EBP

Project Team consisting of Dania Block, Esther Holliday, Kierra Knox, William Ohlson, & Shila

Thorson to implement RC concepts in the training curriculum within the nurse residency

program (NRP). The UMary Graduate EBP Project Team worked closely with the host

organization to build an educational reference structure for the NRP.

Problem Statement

Healthcare organizations are complex systems with complex relationships. Building

relationships between independent practitioners to form collaborative teams, involves educating

and inspiring high performance behaviors through engagement and motivation to improve


communication and teamwork. Relational coordination concepts can be utilized to set alight the

collaborative approach and has been shown to improve coordination of care in limited venues

through anecdotal perceptions and testimonials. With only three RC content “experts” available

within Billings Clinic, or the host organization, there is a lack of expert resource to educate on

the RC concepts for project implementation. The organization’s leadership, represented by the

Chief Nursing Officer, indicated a need to disseminate RC house-wide in the organization for

better communication, teamwork, and coordination of care. In addition, despite a low turnover

rate, recruitment and retention of new nurses into the workforce has become an area of

opportunity the organization is actively engaging. The integration of RC concepts into a NRP

curriculum is positioned to help propagate the thought-process throughout the organization for

successful onboarding of nurses, improved retention, and job satisfaction.

Significance of Clinical Problem

Today’s health care system is complex and often requires various levels of

multidisciplinary involvement. The challenge is that disciplines are often loosely connected

making effective coordination of patient care difficult to achieve. The Institute of Medicine’s

(IOM) Crossing the Quality Chasm focuses on encouraging innovation to improve healthcare

delivery.

“The delivery of care often is overly complex and uncoordinated, requiring steps and

patient “handoffs” that slow down care and decrease rather than improve safety. These

cumbersome processes waste resources; leave unaccountable voids in coverage; lead to

loss of information; and fail to build on the strengths of all health professionals involved

to ensure that care is appropriate, timely, and safe.” (Institute of Medicine [IOM], 2001,

pp. 1-2).


The IOM identifies critical issues facing healthcare systems in the United States and one

of those issues is care coordination. The IOM states, “In the current system, care is taken to

protect professional prerogatives and separate roles. The current system shows too little

cooperation and teamwork...” (Institute of Medicine [IOM], 2001, p. 83). Coordinating work

through the relationship of sharing goals, knowledge, and mutual respect is imperative to quality

patient outcomes, multidisciplinary relationships, nurse retention rates, and job satisfaction.

The caliber of the nursing environment is impacted by the quality of relationships and

communication with fellow nurses, providers and other healthcare disciplines. “Nurses play a

vital role in promoting quality care in hospitals because of their unique ‘24/7’ functions that

include…coordinating care…across providers and departments” (Havens, Vasey, Gittell, & Lin,

2010, p. 936). Improvement in coordinating the delivery of health care is a known national aim

and the enhancement of coordination at the level of working relationships will undoubtedly play

a role that is significant in improving the relational experiences that nurses encounter every day.

High performance organizations are the result of high performance teams. High

performance teams in patient care are the end product of care providers sharing the insight,

goals, and information responsible for patient care and quality. This is work that is coordinated

through shared goals and relationships that share knowledge with mutual respect and frequent

communication. Patient care settings require a dependable and quality service. The higher the

collaboration of those services the more dependable the service will be with higher quality of

care. To develop and embed the relational and communication skills is a start. It is also

important to provide a resource and reference for those employees to have the tools necessary to

maintain a high functioning RC team.


The foundation of RC is solidified with a two-fold focus on relationships and

communication. Relationships in patient care are defined by shared goals, shared knowledge and

mutual respect. Communication is effective when it is frequent, timely, accurate, and focused on

problem solving. The results of which are quality performance, efficiency performance, job

satisfaction, and staff retention.

The system of RC is based on seven high performance work concepts that are the

foundations of professional relationships and professional communications. “Ideally, relational

coordination should include all participants in the key roles involved in patient care: otherwise,

some critical insight or piece of information is likely to fall through the cracks, with negative

effects on quality and efficiency” (Gittell, 2009, p. 21).

Relationships:

● Shared goals : Does each member of the group or team possess the same working goals?

● Shared Knowledge : Does each member of the group or team have insight into each

other’s job roles and responsibilities?

● Mutual Respect : Does each member of the group or team respect the other equally?

Communication:

● Frequent Communication : How often do the members of the group or team communicate

in relation to the care or situation?

● Timely Communication : How timely does each member of the group or team share time

sensitive information?

● Accurate Communication : How accurate is each member of the group or team with the

shared communication?


● Problem-Solving Communication : When communication problems arise do the members

of the group or teamwork together to problem solve?

These seven concepts are supported by twelve work practices and are essential references

in the RC toolkit. “To sustain care provider efforts over time, organizations need to invest in

strengthening their high performance work systems” (Gittell, 2009, p. 212-213). This toolkit

will be a reference for implementation and ongoing support of the RC team and the patient care

culture within the organization. “Culture is to an organization as personality is to an individual”

(Xiangiong, Bobay & Weiss, 2008).

PICO Question

The host organization had knowledge of the positive EBP results of RC and the potential

benefits of RC in the workplace. The UMary Graduate EBP Project Team was formally

extended an opportunity to explore options of RC implementation for the NRP. The next step

was to clearly define the research that will connect to the specific request of the host organization

and use all relevant information to influence the development of RC knowledge for the NRP.

The PICO format is a tool used to define the population (P), intervention (I), comparison (C),

and outcome (O) (Melnyk & Overholt, 2011). To identify and preserve the scope of this EBP

project, the PICO format was used by the UMary Graduate EBP Project Team to develop the

following statement:

P = New graduate nurses enrolled in the nurse residency program

I = Relational coordination toolkit

C = Not using the toolkit

O = Measure an elevated relational coordination score and a reduced vacancy rate.


Will nurses enrolled in the nurse residency program, with use of the relational

coordination toolkit, demonstrate an elevated RC score and reduced vacancy rate compared to

those nurses not using the RC toolkit at a three month measure?

Purpose Statement

A RC toolkit will aid in guiding and strengthening work relationships of newly licensed

nurses working in their professional role for the first time. New nurses experience transitional

shock as they are “confronted with a broad range and scope of physical, intellectual, emotional,

developmental and sociocultural changes that are expressions of, and mitigating factors within

the experience of transition.” (Boychuk & Duchscher, 2008, p. 1103). To optimize success,

nurse residency programs must train new nurses in RC in order to prepare them up for a

successful flight in healthcare’s high performance work setting. This will require nurse

residents to merge into the relational pathways of well-educated and tenured colleagues and to

perform in a highly skilled work environment.

Nursing, as a profession, is a field of broad oversight and potential with a significant

amount of specialty practice areas. Specialization in nursing is formally a post-graduate

opportunity. Rarely has the resident nurse received specialty training within a specialty field,

medical nurse residents included. Therefore, the skills requisite of the resident nurse apply not

only to the practical and professional expectations of the medical nurse resident, but also apply to

team and relational skills as well. The RC toolkit will provide a resource for the resident

medical/surgical floor nurse as an informal process (toolkit) and reference for the transmission of

communication and practice knowledge.


Theoretical Framework

The theoretical framework for this project is centered on Havens, Vasey, Gittell, and

Lin’s theory of relational coordination. Relational coordination is a form of high-quality

communication combined with high-quality relationships among health care providers in order to

coordinate their work with positive outcomes for quality, efficiency, and overall satisfaction

(Havens, Vasey, Gittell, & Lin, 2016). Hospitals have complex dynamics in which multiple

healthcare professionals work interdependently of each other to provide care to patients. Such

dynamics have the potential to lead to errors and delays in patient care. As a result, patient safety

and efficient delivery of care have become a great concern within the hospital setting. Engaging

nurses to develop and strengthen relational coordination within the complex hospital setting is

essential in improving quality patient care.

Within the theory of RC, Havens et al. (2010) identified four key communication

components including: frequent, timely, accurate, and problem solving. Frequent communication

is essential in keeping all health care providers updated while also building relationships of

familiarity that occur with frequent interaction. Timeliness of communication has been identified

as an important component within RC since delays may result in serious errors or interruptions

of essential treatments (Havens et al., 2010). Communication must also be accurate for the same

reason; inaccurate information may result in errors and delays of treatment. Problem-solving

efforts must be focused on, rather than blame seeking. Blame seeking creates an environment of

undermining and creates a barrier rather than an environment of shared information and

collaboration.

Havens et al (2010) also identified three key relationship components within the theory of

RC, which include: shared goals, shared knowledge, and mutual respect. Those involved in


patient care must have shared goals for the work process that they are engaged in with each

other. They must also have shared knowledge in regards to what each healthcare provider’s

expertise entails so they are able to clearly see how they can work together in the care delivery

process. Mutual respect among all healthcare providers also enhances RC. It is essential to show

other members respect for the contributions they make and reinforce this respect with regard for

their time and regard for the collaborative work process (Havens et al., 2010).

Utilizing the theoretical framework of RC and subsequent studies, Havens et al. (2010)

found positive associations between RC and outcomes. Patients had decreased lengths of hospital

stays, increased perceptions of quality of care, decreased readmissions, improved reported

quality of life, better reported symptom management, and decreased reported levels of pain.

Some RC implications for nursing management as discussed by Havens et al. (2010) include

hiring providers, including physicians, that are teamwork oriented, evaluating and rewarding

teamwork performance, creating conflict resolution solutions proactively for interdisciplinary

team members, and increasing participation in interdisciplinary team rounding.

Improving the coordination of communication and collaboration between nursing staff

and other healthcare providers is essential in improving the quality of patient care. Relational

coordination is a framework that can create a positive impact on the communication and

interdisciplinary relationships among healthcare providers, especially within the hospital setting.

The nurse manager plays an essential role in initiating the implementation of this framework to

promote increased quality in patient care.

Review of Literature

Literature Search


The literature search for this project was a combination of synthesis of the current

literature and subject matter experts. Each section of the literature synthesis identified key

search terms, presented the literature in table format, identified the research methodology, the

level of evidence, and key findings. Although RC is gaining favor, research is still in its early

stages. The literature search was expanded to include similar concepts of RC including inter-

professional communication.

For the purpose of this literature review, the following search engines were used:

Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, and PubMed.

The time period from 2010-2016 was used for current literature. Additional literature from

earlier than the set timeframe was included if deemed relevant. The evidence utilized in the

development of the RC toolkit is listed in table format. The remaining resources utilized to

provide sustenance to statements made in this paper including the problem statement, discussion

of clinical significance, and clinical statement are listed on the reference page. The following

tables depict literature search results.

Table 1

Relational Coordination Benefits External Data

Key Search Terms CINAHL Medline PubMed

Relational coordination benefits 134 402 3

Communication benefits 224 316 4,791

Relationship benefits 277 190 4,525

Nurse satisfaction 1053 494 4,709

Nurse retention 485 259 1,043

Communication culture 188 386 12,434


Table 2

Relational Coordination Benefits Level of Evidence Table

Reference Citation

Research Purpose

Research Design

Sample

Data Collection Measures

Level of Evidence

Outcomes Strengths/Limitations

Study Quality

Havens, D.S., Vasey, J., Gittell, J.H., & Wei-ting, L. (2010)

Examine RC between nurses and other providers and the effect of RC on quality of patient care.

No experimental design

747 direct care registered nurses (RNs)

Survey assessing RC in 5 provider functions and 6 types of patient care units. Survey perceptions of quality of patient care using RC Survey for Patient Care.

III As RC between staff increases, adverse events with patients decrease. Some of the key dimensions identified in RC include the frequency, timeliness, accuracy, and problem solving within communic

Nurse ratings of quality of care have been reported as valid and amiable to objective data. Method for collecting data cost effective and provides participating hospitals with the opportunity to compare quality data.This was first

High


ation. Additional dimensions include the shared goals, shared knowledge, and mutual respect of the underlying relationships among the participants of the RC.

study to assess RC between nurses and providers in acute care hospital setting. The setting was rural hospitals so additional studies in a broad sample of hospitals is needed before generalization.

Williams, J. (2014).

Explore the benefits of patient/relationship continuity of care

Nonexperimental design

15 consecutive patients who underwent elective colorectal surgery over a period of 6 months within a district

Patient audit designed to establish number of contacts patients had with nurses during the preoperative, hospitalization, and post discharge.

II Continuity of care leads to a reduction in hospital readmissions, empowerment of patients, overall improvement in patient care, and increased job satisfaction for nursing staff. Continuit

Findings showed a significant lapse in continuity of care as patients were seeing a different nurse every other time/No data were available on ideal number of specialty nurse contacts.

Medium


general hospital trust

y of care helps build a trusting relationship between the patient and the nurse and it also helps to keep the nurse responsible and accountable for providing quality care.

Brinkert, R. (2010).

Prioritize research, theory, and interventions to support nurse managers and staff nurses


74 papers chosen for literature review from searches plus an additional 35 included due to previously known relevance

The terms communication, conflict, and nurse were searched in: CINAHL, Communication Abstracts, Communication and Mass Media Complete, ERIC, Medline Pubmed

V Conflict communication is an essential component of nursing. This conflict for nursing staff generally stems from the expectation of the nurse to play a multitude of roles for the patient. Conflict does not,

Limited number of studies due to space limitations.

High


(nursing journals only), Proquest ABI, Proquest Nursing and Allied Health Source, PsycINFO and Social Sciences Citation Index.

however, always result in a negative outcome to the patient. Sometimes conflict actually results in better outcomes for the patient. Nurse managers through collaboration and research on existing and emerging communication conflict efforts can establish furthering the benefits of conflict.

Twigg, D., & McCullough, K. (2014).

Provide a summary of literature and review strategies identified to promote nurse retention through


39 papers

Literature search of major healthcare related databases, CINAHL plus,

V The nursing care practice environment has a direct impact on both staff

Review shows creating a positive environment is important. Literature review

High


improving the work environment

Medline, & ProQuest. “Nurse AND practice AND environment” used in search also “retention strategies”.

nurse retention and quality of patient care. Some of the strategies to creating a positive practice environment include: nurse participation in hospital affairs, nursing foundations for quality care, nurse manager ability and support, staffing and resource adequacy, and collaborative nurse-physician relationships.

relied on authors identifying keywords that correlated. Search may have missed studies related that were not clear on the subject. Need for evaluation to determine appropriate strategies.

Cramm, J., & Nieboer, A.

Determine if Chronic Care Model improves

Regression Analysis

154 Professionals in 22

Survey of professionals in

III The use of the chronic care

The study used a contact person at

High


(2012). quality of care practices completed survey on both occasions

22 primary care practices, Netherlands that implemented Chronic Care Model starting in 2009. Professionals were surveyed in 2010 and 2011.

model improves the quality of chronic care delivery to patients. The implementation of the chronic care model also improves the RC among healthcare providers of the interdisciplinary team. The chronic care model allows for a workflow process that correlates with RC to foster a delivery of high quality care to patients with chronic health conditions

each facility. Did not examine health outcomes. The study did not have a control group. The results only have relevance for those practicing Chronic Care Model.


. It allows for interdisciplinary members to identify both acute and chronic issues and form an effective, quality treatment plan for the patient.

Hartgerink, J. M., Cramm, J. M., Bakker, T. J., Eijsden, R. A., Mackenbach, J. P., & Nieboer, A. P. (2014).

Assess the effect of RC on quality of patient care in hospitalized older patients

Cross-Sectional Study

192 respondents

Questionnaire incorporating elements of validity and reliability distributed to hospital staff. Survey consisted of 3 communication questions and 3 relationship questions.

II This study found that there was a higher incidence of RC among nursing staff and other interdisciplinary healthcare team members when providing care to geriatric patients who have complex healthcare needs. This study shows that increased

Statistical test showed hospital unit level did not affect results. Study agrees with prior research finding higher levels of RC in the profession. Supports coordination and the integration of care. Study could determine associations but not causality.

High


RC leads to increased levels of holistic care to patients.

Study unable to control all influencing factors. The success of coordinated care depends on individual and team dynamics.

Table 3

Relational Coordination Structure External Data


Relational coordination structure 138 2 18

Liberating structures 1 4 15

TeamSTEPPS 65 70 72

SBAR 101 106 103

Interprofessional collaboration 536 811 2,743

Appreciative inquiry model 2 3 164

Table 4

Relational Coordination Structure Level of Evidence Table

Referenc Resear Researc Sample Data Level Outcomes Strengths/ Study


e Citation

ch Purpose

h Design

Collection Measures

of Evidence

Limitations

Quality

Gittell, J.H., Seidner, R., Wimbush, J. (2010).

The purpose is to explore how high performance organizations contribute to performance outcomes.

Cohort Study

Convenience sample of 9 orthopedic units in major urban hospitals

Administrator interviews were used to measure high performance work practices, care provider survey were used to measure RC at the provider level, patient survey and hospitalization records used to measure outcomes at the patient level.

IV This study focuses on the structure of relationships between employees of multiple disciplines and functions in contrast to business relationships and silo responsibilities. This structure is focused on the coordination of work and work practices in a cross-functional practice with the intent of shared knowledge, mutual respect, and shared knowledge. Structure of practice success is based on six high-performance work

Study linked high performance systems to post bureaucracy theory. Formal practices are not obstacles and encourage employees to develop relationships. Study shows a relational pathway where high performance work practices add to performance. Limited by the use of interviews instead of instruments making the results less replicable. Lack of

High


practices. measures for skill and commitment. Lack of employee level controls for the study.

Gittell, J.H., Godfrey, M., & Thistlethwaite, J. (2013).

Purpose is to discuss the combination of interprofessional collaboration and relational coordination.

Opinion of authority

N/A The article is a content expertise article. No specific methods identified.

VII Successful person-centered care delivery is effective in an organizational structure that keeps focus on inter-professional coordination and relationships. The structure of these inter-professional relationships is based on the quality underlying relationships and communication. “Evidence thus far suggests that RC among care providers

Multiple sources used to support authors’ stance on subject.

Medium


promotes improved relationships with patients.” This has been evidence-supported practice in multiple industries, the greatest example being the airline industry, and should be adopted as healthcare organizational structure.

Hartgerink, J.M., Cramm, J.M., Bakker, T.J., Van Eijsden, A.M., Mackenbach, J.P., & Nieboer, A.P. (2014).

The purpose is to recognize predictors of RC among healthcare professionals delivering care to the older population.

Cross-sectional study

192 respondents that were professionals who provided care to older hospitalized patients in the Netherlands

Data was collected in 2010 using a RC survey. The survey was returned in an envelope. Participants were given 10 Euro for their participation. The survey used a 5-point scale to determine if participants agreed or disagreed to a statement. Team

IV RC structural support within the institution had a significant positive impact on patient care delivery and interdisciplinary teamwork with an increased frequency of team meetings. The stress is not just the frequency,

Both the TCI and RC survey are validated and reliable. The study design allows the author to identify associations, but not causation. Less than half (44%) of the professionals surveyed

High


Climate Inventory (TCI) was used to determine the professional’s perceptions of the team climate.

but also the frequency of the entire team to communicate in a professional interdisciplinary professional climate with the focus of improved communication.

responded. The authors could not control for all variables, such as personality.

Espinosa, J.A, & Clark, M.A. (2014).

The purpose is to promote a team knowledge view.

Opinion of authority

57 teams of four to six students engaged in a graduate-level 10-week management simulation at a Midwestern university.

Data was collected through a) student questionnaires at 3 time periods, and b) objective team financial performance.

VII Recognition and study of team knowledge and the increasing validity of shared team knowledge as important for organizational structure and success. Team members that perceived shared and overlapping team knowledge demonstrated improved task knowledge and team satisfaction.

Paper contributes to team cognition research through building on current measures. Certain team knowledge content was difficult to collect.

Medium

Chumley Purpos Nonexp Medica The study III Liberating Study was Medium


, H., & Magrane, D. (2011).

e is to gain understanding of the factors predicting student performance measures and outcomes.

erimental design

l school setting.

assessed participant satisfaction on a 5-point scale and used results to generate a 10 item dashboard.

structures develop new and open methods of communication and interaction of group settings. By using liberating structures to problem solve complex issues, communication was improved and supported.

limited to one group of individuals.

Cornell, P., Townsend Gervis, M., Yates, L., & Vardaman, J. (2014).

Purpose is to measure Situation-Background-Assessment-Recommendation (SBAR) use during shift reports and interdisciplinary rounds.

Cross-sectional study

51 shift reports in a 48-bed medical surgical unit in a suburban hospital.

The team recorded observations of shift reports including tasks, tools, and locations as a baseline. The study recorded patient review time and consistency of interdisciplinary rounds. The groups were observed a second time after paper SBAR

IV Communication is essential for patient health and safety among nurses and interdisciplinary staff. Communication should occur in a timely, efficient manner. In this study, the SBAR, which was historically used for the nurse/physician format, demonstrate

SBAR is a protocol and a tool/Process variables such as time, tools, and location are important, but do not show improvement in outcomes. Staff outcomes are not assessed. The study included confoundi

Medium


introduction, and a third time after an electronic protocol was introduced.

d a more focused communication with nursing shift report and relay of critical information between nursing and all disciplines.

ng variables.

Table 5

Relational Coordination Resources External Data


Relational coordination resources 157 345 13

Hiring tools 5 3 114

Communication resources 238 367 6.838

Relationship resources 341 294 6,565

Collaboration resources 146 182 3,034

Communication cost 90 242 8,046

Table 6

Relational Coordination Resources Level of Evidence Table

Reference Citation

Research Purpose

Research Design

Sample

Data Collection Measures

Level of Evidence

Outcomes Strengths/Limitations

Study Quality


Oh, H., & Solomon, P. (2014).

Promote role-playing as an activity to aid managers to hire, evaluate, or supervise peers.

Evidence from systematic review of train-the-trainers program, interventions to improve health care handovers, and clinical supervision training

NA No data collection measures used. The author cited sources of reference.

III Role-playing is useful in training healthcare professionals in general. Didactic instruction may be adequate to show peers how and when to apply learned information. Role-playing shows that interactive trainings are effective, improves handover skills, and helps to acquire knowledge, develop and apply skill sets, and improves confidence and independence.

Well written with sources to back up research. / No discussion of limitations or literature review.

Medium

Trepanier, S., Early, S., Ulrich, B., Cherry, B. (2012).

The purpose is to use a cost-benefit analysis to study the financial outcomes of a NRP.

Study of cost benefit analysis comparing nurse residency program to traditional orientation methods

Data from 15 hospitals in California, Florida, Georgia Nebraska, Missouri, Tennessee, & Texas.

Stepwise regression analysis done of the relationship between NRP and turnover. Analysis done to assess economic outcome

III Having a nurse residency program is a cost benefit by decreasing nurse turnover and improving competence. Nurse residency programs are a valued asset and not an expense with the potential of improving patient safety and achieving quality outcomes.

First study to study the relationship between nursing and contract labor dollars. Study may not be applicable to other settings since it used secondary data. Associatio


524 nurses in NRP (87% female, 13% male).

of a NRP viewing turnover rate and contract labor usage data. Secondary analysis

ns were not able to be seen in other years due to no relationship or small sample sizes.

McDonald, J., Davies, G., Jayasuriya, R., & Harris, M. (2011).

The purpose is to investigate the effect of organizational factors on private-public sector collaboration specifically with community health services that provide diabetes care.

Qualitative study

45 participants from 20 organizations.

Case study using qualitative methods. Data collected through semi-structured interviews.

VI The study discusses organizational factors that affect collaboration between private and public sector health services of diabetes care. Basic collaboration involves time and effort. The costs tended to be higher in organizations that varied considerably in organizational culture, size, complexity, and structure. The costs compared against benefits of the collaboration determined to organization’s inclination of if it would participate, with who, and how much. Some of these benefits included access to

Study contributes to research by listing and elaborating the benefits and costs of collaborating across organizational borders. / Sample size is limited. The study was qualitative and not focused on how much collaboration occurs.

Medium


clients, financial assistance, knowledge, and information. Organizations had a simpler instance in collaborating if their values, culture, and method of operation supported collaboration. Longitudinal research would benefit to study the effect of collaboration over time.

Men, L. (2014).

The purpose is to study how organizational leadership affects internal communication through the development of linkages between certain factors.

Evidence from systematic reviews of quantitative and qualitative literature

Employees from different positions in medium and large sized corporations. 402 participants (45.5% men and 54.5 women).

Quantitative survey. Empirically tested causal model. Pretest and preliminary online survey conducted.

V The study determines a connection among relational outcomes of employees and behavioral outcomes of employee support. Employees with good relationships with organizations participate in activities to support the organization. Employees with positive relationships are more likely to advocate, commend, defend, and endorse the

Findings add to theoretical and practical knowledge through linking leadership to communication. / Data was only collected from the employee perspective. Findings can only be generalized to similar scope hospitals. A more in depth explanation

High


organization in public. Transformational leadership and communication style should be grown to effectively and resourcefully raise internal communication determinations and benefit performance and organizational effectiveness in the future.

on how the model works is needed.

Li, Y., & Jones, C. (2013).

The purpose is to study nursing staff turnover costs.

Evidence from systematic reviews of descriptive and qualitative studies

8 studies

The literature review of studies completed between 1990 and 2010, use empirical research, and examine turnover, and the costs associated for any nursing member.

V Nursing turnover costs are hard to track. Most studies do not account for how these costs may vary over time or account for inflation. However, the literature suggests that nurse turnover is costly for organizations; the costs utilize resources and are tracked in budgets. Authors suggest it could potentially be beneficial to organizations due to cost savings related to newly hired employees typically have lower salaries than an

No studies have examined potential benefits of nursing turnover. / The study showed inconsistencies and discrepancies in the interpretation and evaluation of nursing turnover. Studies varied in the types of turnover examined, nursing personnel included, and of the timing the

High


experienced employee that departed. More research needs to be done on the effect of turnover on quality of care.

nursing staff left the organization. The studies also varied in what costs were examined and which turnover costs were reported.

Suter, E., Deutschlander, S., Mickelson, G., Nurani, Z., Lait, J., Harrison, L….Grymonpre, R. (2012).

The purpose is to research the effect of interprofessional interventions on quality workplace, staff satisfaction, recruitment, retention, turnover, choice of employment, and cost effectiveness.


41 peer reviewed articles and 5 IECPCP project reports

The authors reviewed 20 projects funded through Health Canada’s Interprofessional Education Collaborative Patient Centered Practice (IECPCP). Peer reviewed literature searches for relevant studies from 2004-2009

V Interprofessional interventions such as practice experiences could benefit the student and the organization. The study found interprofessional interventions to have a strong correlation with cost savings associated with patient care. The interventions contributing to cost savings included the start of interprofessional staff combinations, quality circles, consultation assistance, and increased availability of collaborative care teams. Many studies showed a

This review addresses a gap in the literature. The studies ranged from well-designed, controlled trials to studies of fair quality. The studies occurred in a broad range of settings. Detailed descriptions of interprofessional interventions were lacking.

High


were searched.

positive impact in regards to patient outcomes. The study concluded the application of interprofessional interventions improves quality of the workplace, improves provider satisfaction, and attracts graduates to rural areas or less well-liked healthcare areas.

Table 7

Relational Coordination Measurement/Effectiveness External Data


Relational coordination measurement 92 246 2

Relational coordination effectiveness 2 213 6

Evaluation tools 2,920 1,408 15,878

Measurement intent to leave 216 9,004 19

Relational coordination score 78 192 2

Nurse satisfaction measurement 4 1 284

Table 8

Relational Coordination Measurement/Effectiveness Level of Evidence

Reference

Research

Research

Sample

Data Collectio

Level of Evidenc

Outcomes

Strengths/ Limitatio

Study Quality


Citation Purpose

Design n Measures

e ns

Haggerty, J.L., Roberge, D., Freeman, G.K., Beaulieu, C., & Breton, M. (2012).

The purpose is to form and validate a measurement tool from the patient perspective on continuity of care.

Quasiexperimental

376 adult patients using primary care for a variety of health conditions, but seeing different clinicians in different settings.

The authors used literature review to identify measures to use to determine continuity of care in patients. Potential measures and measurement gaps were identified. They were adapted and surveyed participants. The instrument was then modified and given again after 6 months. The measure captures 9

III The study found it important that the measurement tool is written in terms familiar to the patient instead of those from the clinician’s perspective. Researchers should identify facets of continuity that are most significant to them and select appropriate indicators or subscales.

The continuity scopes of information transfer care plan and monitoring, self-management support, and coordination focused teamwork. The measure integrates various types of continuity and refinements from a variety of studies from a variety of conditions. The fact that the tool measures care coordination through direct experienc

High


magnitudes of continuity a patient experiences. The tool measures care from the patient perspective.

e or observation may be a strength or limitation. The study was heavily reliant on themes from the literature review, which were not in the patient voice. Previously developed items also inspired the study, which may have been inappropriate. The respondents were primarily French using English instruments.

Shaw, E., Howard, J., Etz, R., Hudson,

The purpose is to observe the effect

Qualitative study

4 primary care practices from a

Trained facilitators met with members for up to

VI Quality improvement effectiveness is consistent

The study explored three kinds of team-based

Medium


S., & Crabtree, B. (2012).

team-based reflection affects quality improvement.

QI trial, which used facilitated, team based approach to improve colorectal cancer screening rates.

11 hour long meetings. Fieldnotes and audio recordings were taken. A template was used to identify patterns and themes.

ly inconsistent. The authors suggest that quality improvement determinations would profit from using team-based reflection. Three interdependent methods of reflections were observed in the study. Organizational reflection and process reflection can be dependent on adequate relational reflection. The absence of relational reflection may be a

reflection. They are interdependent. / Small sample limits the generalizability. Cannot determine how reflection affected clinical outcomes. The study is mindful of researcher bias, and the validity and reliability of themes.


barrier to the quality improvement change process. Researchers should look for ways to purposefully implement reflective practices into efforts.

McDonald, K. et al. (2014).

The Care Coordination Atlas was developed to support measurement of care coordination across two different dimensions (domains and perspective) as well as


Multiple data sources.

The authors searched multiple sources (electronic health record systems, consumer surveys, databases of administrative claims), along with AHRQ Health Information Technology

V The atlas is a useful reference for evaluation of interventions or demonstration projects that aim to improve care coordination efforts as well as those interested in evaluating the

The atlas includes measures of patient and caregiver experiences with coordination. / Search likely missed potentially relevant studies. Limited information on feasibility and cost of measures included.

High


develop a framework for understanding care coordination measurement.

portfolio projects, information from national organizations, expert and stakeholder panels, and a comprehensive literature search.

practice of care coordination. The Atlas provides a measure selection guide that can be useful for identifying existing care coordination measures with a step-by-step guidance and correlation to the appropriate measurement tool using the Master Measure Mapping Tables.

Valentine, M., Nembhard, I., Edmondson, A. (2013).

The purpose is to review and identify survey instruments utilized to

Systematic review of quantitative studies

39 surveys measuring teamwork.

Articles published before September 2012 were used. The authors searched the ISI

I Multiple surveys have been developed with different measurements for teamwork, which

Variation in the quality of measures. Of the 39 studies, 11 met psychometric validity criteria,

High


assess teamwork.

Web of knowledge database. The assessed surveys that measured teamwork found communication, coordination, and respect to be the most commonly assessed aspects.

may lead to confusion for researchers. The authors noted that researchers tend to develop new tools instead of adapting current measurement surveys, which limits the creation of growing knowledge. There needs to be conceptual consistency between the measurement tool and the theoretical concept in the research being done. The researcher should also look

14 showed significant relationships to nonself-report outcomes. The limitation of search may have resulted in missing valuable information. Not all factors important for survey validity were assessed.


at how an already created survey can be adapted to a new setting. The survey should have satisfied the requirements for psychometric validity, resulting in greater user confidence. Finally researchers should consider the length as longer surveys may tire participants.

Arthur, N. et al. (2012).

The purpose is to provide a summary of the quantitative methods

Systematic review of quantitative studies

128 tools from 136 articles.

Key concepts were searched in Medical Subject Headings (MeSH). The article

I Interprofessional education is the opportunities when individuals of two or greater professions learn alongside

The article provides an inventory of measurement tools for interprofessional education

Medium


measuring interprofessional education or collaboration.

search was for English articles from January 2000-October 2009. A second search was done from January 2000-May 2010 to include validity and psychometrics in the terms. Additional searches were done to find relevant information.

, from and about the other to improve collaboration and quality of care. The report by the Canadian Interprofessional Health Collaborative (CHIC) provides a summary of quantitative tools measuring the results of interprofessional education or collaboration. The document gives a table of the available tools and studies pertaining to different outcome measurements in

and collaboration / The article did not provide a summary to the highlights of the tools.


interprofessional education or collaboration.

Weller, J. Shulruf, B., Torrie, J., Frengley, R., Boyd, M., Paul, A., Yee, B., & Dzendrowskyj, P. (2013).

The purpose was to investigate if a teamwork measurement tool that could correlate and assist organizations in quality improvement.

Quasiexperimental

40 intensive care teams consisting of one doctor and three nurses

The intensive care teams each participated in 4 simulated emergencies. They rated team performance using the tool. The authors tested a teamwork measurement tool with 23 items that described an observable measure of team performance and a score for overall team

III Participants scored themselves higher than external assessors did although the scores still correlated. Valid and reliable measurement tools should encourage quality improvement.

The validity of the measurement tool is supported by analysis. Participants agreed with external rankings of performance. / The study was limited to only 4 simulated events. The tool should be applied in other settings such as a clinical environment.

High


performance.The facets of communication, coordination, behaviors, and leadership were evaluated through a self-assessment after a simulation in an intensive care unit setting.

Synthesis of Current Literature

Benefits of Relational Coordination. The impact of RC has been shown to provide a

multitude of benefits to both patients and staff members within the healthcare environment. This

method of interdisciplinary interaction creates a structure of communication that allows for clear,

concise communication, effective collaboration, and the delivery of a higher quality of healthcare

to patients (Cramm & Nieboer, 2012). The specific benefits produced from the use of RC

include: mutual respect of interdisciplinary team members, reduction in hospital readmissions,

increased job satisfaction, and the creation of trusting relationships among nursing staff and

patients (Williams, 2014). Further benefits include providing an increased level of holistic, high

quality care to high-risk patient populations, such as geriatric patients (Hartgerink et al., 2014).

Key communication dimensions identified in RC include frequency, timeliness, accuracy,

and problem solving within communication. The literature revealed that there was a decrease in


the number of adverse events with patients with an improvement in these key dimensions, as

well as with an increase in the shared goals, shared knowledge, and mutual respect of the

underlying relationships among the participants of the RC (Havens, Vasey, Gittell, & Wei-ting,

2010). Prioritizing these key dimensions in communication and interaction with other

interdisciplinary team members will help increase the quality of RC that occurs in the healthcare

setting and help to achieve a higher quality of healthcare delivery to patients.

A study done by Williams (2014) showed that further quality of care could be enhanced

through RC in combination with increased continuity of care. This consists of assigning the same

staff members to the same patients on a consistent basis during the patient’s hospital stay. This

may be hard to accomplish in some settings, with rotating shifts, and fluctuations in acuity. The

study unveiled a higher level of nurse accountability for providing quality care as well as a sense

of empowerment from patients (Williams, 2014).

Relational coordination in the workplace can also have a connection with workplace

conflict. In general, with communication, conflict may follow. One study found that conflict

with interdisciplinary healthcare team members does not always need to be associated with a

negative outcome. For nursing staff, the biggest source of conflict in participating in

interdisciplinary roles is that nurses often play many different roles already, other than just that

of the nurse (Brinkert, 2010). By implementing a structured RC communication tool for

interdisciplinary team members, it allows communication and insight from different disciplines

to come together to create a treatment plan for patients that otherwise would not have been

created by one single member. The conflicts that derive from interdisciplinary team members, in

combination with their drive to see the patient thrive, helps create a better treatment plan for the

patient than they would have had prior to the team collaboration (Brinkert, 2010).


In addition to creating a more holistic care environment for patients, a nursing care

practice environment is created that increases nursing staff retention (Twigg & McCullough,

2014). With increased effective communication styles among interdisciplinary staff members

through the use of RC, nurses’ intention to stay and the quality of care provided to patients was

directly affected. Some of the strategies to creating a positive practice environment include:

nurse participation in hospital affairs, nursing foundations for quality care, nurse manager ability

and support, staffing and resource adequacy, and collaborative nurse-physician relationships

(Twigg & McCullough, 2014).

Structure of Relational Coordination. Relational coordination is “a mutually

reinforcing process of communicating and relating for the purpose of task integration”

(Relational Coordination Research Collaborative, 2016). In designing high performance

working relationships between interdisciplinary teams it is a priority to establish the structure of

RC as the foundation and structure for integration. This foundation is based upon collaborative

relationships and communication with the mission to use the tools within communication and

relationships thereby establishing high performance teams. Relational coordination structure

also improves job/work satisfaction, which in turn improves customer satisfaction leading to

increased care quality.

Inter-professional relationships that are found in complex working systems have been,

and remain common in large organizational practice. The structure modeled in organizations

like the airline industry demonstrates high functioning inter-professional relationships with a

high quality standard. To allow a silo of information within the industry allows potential

industry failure and supports the “my turf” model. A mutually reinforcing web of respect and

communication allows for the integration of tasks, goals, and expectations. Inter-professional


relationships give value to collaborative resources above skill alone. Team motivation and

commitment above individual ability, and employee-employee respect above personal

acknowledgment benefit the working structures in the care delivery model. “We argue that these

high-performance work practices contribute to performance by supporting the development of

relational coordination, a mutually reinforcing web of communication and relationships carried

out for the purpose of task integration.” (Gittell, Seidner, Wimbush, 2010). Quality care

delivery is not the care provided in the narrow scope of an individual practice with the focus on

the provider, it is person-centered care with team provision.

In providing successful person-centered care the organizational structure supports focus

on inter-professional coordination and relationships. This organizational structure of inter-

professional relationships is based on the quality within those relationships and the

communication support structure. When the members of the care delivery team can engage any

individual on the team to share information that will help in achieving the care delivery goals and

high quality care is achieved. “Evidence thus far suggests that relational coordination among

care providers promotes improved relationships with patients.” (Gittell, Godfrey &

Thistlethwaite, 2013).

Each member of the team being responsible for the care model, and at the same time

being at liberty to share that care model supports liberating relationships. Liberating structures

drive relationships that are supported by crossing the boundaries between roles and departments,

yet provide the communication and structure to channel the energy of the team. “Liberating

structures are methods that help groups change how they interact, address issues and solve

complex problems” (Espinosa & Clark, 2014). Liberating structures drive team relationships,


and team relationships have three priorities: shared goals, shared knowledge, and mutual

respect.

Shared goals are a demonstration that each member of the group or team possesses the

same patient care and working goals.

“Previous research also showed that team climate was positively related to continuously

delivering high quality care through professionals sharing objectives, commitment and

support. Team climate refers to professionals’ shared perceptions of the types of

behaviors and actions that are rewarded and supported by the team policies, practices and

procedures. When a team has a climate for teamwork, team members are willing to

provide and share resources” (Hartgerink, Cramm, Bakker, Van Eijsden, Mackenbach, &

Nieboer, 2014).

With each member of the team having shared knowledge there is insight into the other job

functions and responsibilities, providing liberating structure to the team. “Organizational social

capital has been shown to improve performance by enabling employees to access the resources

that are embedded within a given network and by facilitating the transfer and sharing of

knowledge.” (Gittell, Seidner & Wimbush, 2010). Then mutual respect is demonstrated when

each member of the group or team demonstrates the value of the shared information and respect

for each of the roles of the entire team. “Despite these different labels, their common thread is

that organizations can achieve high performance by adopting practices that recognize and

leverage employees’ ability to create value.” (Gittell, Seidner & Wimbush, 2010). An example

mutual respect and demonstrating the value of shared information can be seen during patient

rounds. “Patient rounds are a type of cross-functional meeting in which physicians, residents,


nurses, and others responsible for the care of the patient get together to discuss the patient’s case

either at the bedside or in separate conferencing area.” (Gittell, 2009, p. 162).

Communication is an essential structure within RC with four subcategories of healthy

communication identified. These are frequent, timely, accurate, and problem solving

communication. Frequent communication is essential in a fast paced care system. Frequent

communication is often complemented by non-scheduled communication opportunities that are

timely. The timeliness of this communication is just as essential for the RC structure as the

frequency is. The timeliness of meetings can be spur of the moment or schedule care rounds.

“Meetings provide a forum for interaction among people who are engaged in the same work

process.” (Gittell, 2009, p. 162).

As information is gathered, whether scheduled or unscheduled, communication of the

information continues to maintain team engagement and shared knowledge. Accurate

communication, the third form of communication, with each member of the team contributing to

this shared communication structure is “based on the expectation that members of teams with

stronger shared task knowledge would perceive more overlapping knowledge with others and

could, therefore, substitute for each other more easily.” (Espinosa & Clark, 2014). That, with

problem-solving communication, continues to build open communication structures. SBAR

(situation, background, assessment, recommendation) is a reflection of problem-solving

communication. “SBAR was intended for nurse-physician communication under urgent rounds

as well. For interdisciplinary rounds, it significantly reduced patient review time.” (Cornell,

Townsend Gervis, Yates & Vardaman, 2014).

The RC tool kit will provide the tools for resident nurses to develop ties between roles in

the place of ties between persons. High-performance teams do not silo in distinct functions, but


use tools of relationship and communication to enhance the performance of care delivery.

Fostering professional relationships with shared goals and shared knowledge, while providing

employee mutual respect will continue to develop the interdependence of the team, and the team

performance. These tools of relationships and communications are the structural foundation of

RC allowing interchangeability of employee knowledge and continuum of care without

interruption in quality care delivery or professional roles.

Resources of Relational Coordination. Collaboration and implementation of RC

practices involve time and effort regardless of the organizational setting. A study done by

McDonald, Davies, Jayasuriya, & Harris, (2011) found the costs tended to be higher in

organizations that varied considerably in organizational culture, size, complexity, and structure.

The costs compared to benefits of the collaboration determined the organization’s willingness to

participate in the project, with who, and how much. Some of these benefits included access to

clients, financial assistance, knowledge, and information. Organizations had a simpler instance

in collaborating if their values, culture, and method of operation supported collaboration.

If not already a part of the organization’s culture, transformational leadership and

communication style should be grown to effectively and resourcefully raise internal

communication determinations and benefit performance and organizational effectiveness in the

future (Men, 2014). Literature found that while implementing relational interventions has a cost,

it should benefit the organization. Employees with positive relationships are more likely to

advocate, commend, defend, and endorse the organization in public (Men, 2014). Role-playing

is a tactic that can be utilized in employee trainings to teach relational interventions. Didactic

instruction may be adequate to show peers how and when to apply learned information (Oh &

Solomon, 2014). Oh & Solomon (2014) found that role playing shows that interactive trainings


are effective, improves handover skills, and helps to acquire knowledge, develop and apply skill

sets, and improves confidence and independence.

A study done by Suter, Deutschlander, Mickelson, Nurani, Lait, Harrison, L…&

Grymonpre (2012) found the application of interprofessional interventions improves quality of

the workplace, improves provider satisfaction, and reduces patient costs. Suter et al. (2012)

stated the reason for increased employee satisfaction resulted through, “a number of

mechanisms, such as positive changes in the job design and responsibilities, enhanced

interprofessional collaboration or by enhancing the quality of patient care” (p. 264). The

literature review found interprofessional interventions showed cost savings through reduction of

the following: hospital readmissions and provider appointments, length of stay, adverse events,

surgery cancellations, semi-urgent pre-operative investigations, hospital-related mortalities,

outpatient costs (Suter et al., 2012). A decrease in inpatient services in favor of more affordable

outpatient services also contributed to cost savings.

The project’s target audience is new graduate nurses participating in a newly developed

NRP. Nursing residency programs require many resources and support from their organization.

Trepanier, Early, Ulrich, & Cherry (2012) found that having a NRP shows a cost benefit to the

organization by decreasing nurse turnover and improving nurse competence. Nurse residency

programs are a valued asset with the potential of improving patient safety and achieving quality

outcomes for the organization.

The project focuses on determining if use of a RC toolkit improves nursing retention.

Nursing turnover costs are difficult to track; Li & Jones’s (2013) literature review found most

studies do not account for how these costs may vary over time or account for inflation.

However, the literature does suggest that nurse turnover is costly for organizations; the costs


utilize resources and are tracked in budgets. No studies have looked into the potential benefits of

staff turnover. The review of literature found researchers point out that the organization could

possibly benefit financially as new hires typically have a lower salary than more experienced

staff that may have departed (Li & Jones, 2013). More studies also need to be completed to

determine the effect on quality of care.

Measurement/Effectiveness of Relational Coordination. Staff resilience and care

coordination can both be attributed to an environment where trust in the team and effective

communication are seen as foundational to the culture. The process of measuring RC can be as

in depth as necessary to gain an understanding of the underlying methods supporting the

relationships. Interprofessional education and collaboration have both surfaced to improve

patient care. Interprofessional education is the opportunities when individuals of two or greater

professions learn alongside, from and about the other to improve collaboration and quality of

care (Arthur, Deutschlander, Law, Lait, McCarthy, Pallaveshi...& Weaver 2012). Collaboration

allows providers to collectively use their separate and shared knowledge to provide the best

quality of care for the patient. Both require a high degree of communication and coordination.

The literature supports a variety of measurement tools useful in measuring not only care

coordination but also teamwork and communication. The majority of the measurement tools

evaluated in the literature support the inclusion of teamwork and communication in the methods

for care coordination from the clinician’s perspective. However, to find the proper tool to

measure effectiveness and outcomes can be problematic (Arthur et al., 2012).

A number of different measurement tools have been developed. A systematic review of

surveys that measured teamwork found communication, coordination, and respect to be the most

commonly assessed aspects (Valentine, Nembhard, & Edmondson, 2013). The authors of the


review cautioned that multiple surveys have been developed with different measurements for

teamwork, which may lead to confusion for researchers. The study found that researchers tend

to create new tools instead of adapting existing surveys to meet their needs which limits the

growth of knowledge. Researchers should consider how an already created survey could be

adapted to a new setting (Valentine et al., 2013).

Certain considerations need to be taken into account when selecting a measurement tool.

The survey should have satisfied the requirements for psychometric validity, resulting in greater

user confidence (Valentine et al., 2013). The literature review found many studies did not meet

this criteria, however it should not be ignored. Valid and reliable measurement tools should

encourage quality improvement in organizations (Weller, Shulruf, Torrie, Frengley, Boyd, Paul,

Yee, & Dzendrowskyj (2013). There also needs to be conceptual consistency between the

measurement tool and the theoretical concept in the research being done (Valentine et al., 2013).

The individual who will be completing the tool should be considered, especially if it is a patient.

Time should be considered, as longer surveys can tend to tire patients. It is important that the

measurement tool is written in terms familiar to the patient instead of those from the clinician’s

perspective (Haggerty, Roberge, Freeman, Beaulieu, & Breton, 2012). The tool selected for this

project will have new graduate nurses as a targeted audience.

Haggerty, et al. (2012) identified potential measurement gaps for the continuity of care

and validated a generic measurement tool for measuring management continuity from the patient

perspective. The study identified an emphasis on relationships from resultant partnerships and

sense of security among the staff and patient as the predominant factors for the results in

perceptions (Haggerty, et al., 2012).


Shaw, Howard, Etz, Hudson, & Crabtree (2012) believe quality improvement

determinations would profit from using team-based reflection. Reflection could help staff

understand quality improvement and effectiveness better. Organizational reflection and process

reflection can be dependent on adequate relational reflection. The absence of relational

reflection may be a barrier to the quality improvement change process. According to Shaw et al.

(2012), “building an environment of trust where members of the organization can openly and

critically reflect while implementing changes can address many of the social and relational

elements that so often hinder change” (p. 8). The reflection by staff can be used as a valuable

qualitative measure of effectiveness of teamwork in relational coordination.

The successes or failures of care coordination are dependent upon perspective and can be

measured from a variety of perspectives, each with a different interpretation (Macdonald, et. al.,

(2014). Finding the correct measurement tool to meet the needs of a project is essential to the

overall evaluation of results. The Care Coordination Measures Atlas is a roadmap for finding the

appropriate measurement tool to adequately measure interventions focused on improving care

coordination. The Agency for Healthcare Research and Quality (AHRQ) sponsored study

includes both patient and healthcare clinician experiences and includes field-tested and expert

panel face validity testing metrics within the public domain (Macdonald, et. al., 2014).

Outcomes specific to the Institute of Medicine’s goals for quality of care--safety, timeliness,

effectiveness, efficiency, equity and patient-centeredness, are not identified within the Atlas but

through the evaluation process, they can be easily determined.

For the purpose of measuring RC specifically, the validated survey for measuring the

seven domains of RC provided a numerical value for each domain relative to the teamwork

relationships and communication between different disciplines. Havens, et. al., (2010) utilized


the Relational Coordination Survey for Patient Care, which was adapted from the original

Relational Coordination Survey developed and validated by Gittell in 2000. The mutually

reinforcing process of interaction among different disciplines was measured relative to the

nurses’ perceptions of RC with five other caregivers. The most compelling result from the study

was the nurses’ perceptions of quality and RC, indicating the value of relationships between care

coordination, communication, teamwork, and quality of patient care (Havens, et. al., 2010).

The UMary Graduate EBP Project Team adapted this RC survey to address nurse

residents. This survey was implemented during the fall of 2016 and results were be collated,

reviewed, and disseminated to the appropriate leadership members of the host organization for

their benefit.

Project Problem Identification

Learning about the impact communication and relationships has on patient care and

coordination for optimal outcomes requires a fundamental understanding of RC concepts.

Interviews with leadership from the host organization identified a lack of RC in many areas of

the organization and few experts to teach about the concepts to diffuse the information and help

with the integration of RC into the culture. Additionally, like the rest of the nation, the Chief

Nursing Officer (CNO) of the host organization divulged the organization has experienced a

decline in recruitment and retention of newly licensed nurses into the workforce, exacerbating an

already higher-than-historical vacancy rate over the past several years.

Relational coordination was used in a few areas of the organization with improvement in

quality outcomes of patient care. According to the CNO, despite a lack of general knowledge

about RC, many disciplines and departments have had a high level introductory overview of the

concepts but continue to struggle with infusing RC within the culture without dedicated expert


resources to help guide the teams through the learning process. From the CNO’s opinion,

liberating structures, in addition to other complexity science methodologies, such as positive

deviance discovery and action work, have shown a benefit in the previous projects.

In order to first understand what encompasses an RC toolkit, the host hospital’s

perceptions of what RC involved needed to be evaluated. Relational coordination is one facet to

complexity science theories and to fully determine the most appropriate intervention, the intent

of the RC project must be specified. Additionally, including the stakeholders and end-users in

the process helped to expound the purpose and enhance long-term engagement (Porter-O'Grady,

& Malloch, 2015).

The development of a tailor-made RC toolkit that included a step-by-step structure for

educating the educators, or training the trainers, on introducing the RC concepts in any setting

was ideal. Liberating structures, such as dialogue and action exercises successfully used in

previous RC promoting activities, implored engagement and participation. Other examples of

the liberating structure methodology include the 1-2-4 exercises, conversations of

interdependence, and fishbowl discussions, also needed to be appraised for inclusion in the

toolkit (Lipmanwicz, McCandless, and Singhal, 2013; Suchman, 2010) .

The organization’s nursing residency is in the infancy stages of development and enrolled

the first cohort of nurse residents to begin July 2016. The opportunity to influence the retention

of the enrolled new graduate nurses as they begin the onboarding journey was enriched with the

integration of RC concepts into the curriculum. The adaptation to the curriculum provided a

structured venue for learning the soft skills associated with communication, teamwork, and

relationship building to enhance the new nurses’ learning environment for successfully adapting

to a new role, in addition to fostering the culture of RC within the organization.


Internal Evidence

Existing internal evidence supported the benefit of a RC toolkit for implementation into a

nursing residency. Feedback from the CNO, nursing residency faculty, RC content experts

within the organization, current RN vacancy and retention statistics, and RN specific employee

engagement data relative to teamwork, communication, and care coordination statistics all

showed opportunities for influence driven by RC. Table 9 defines internal data acquired by the

project team, special considerations related to the project, and organization’s sources for the data.

Table 9

Internal Data

Organizational Data Need Special Considerations Source

Existing RC resources Currently no formal structure or organized toolkit available, although tools have been used separately for different projects

Curt Lindberg, Complexity Science and Organizational Development

Nursing retention rates This data is collected monthly. Will need to determine the time frame needed and communicate this to the organization. Data is collected monthly and collated on the 7th of every month.

Justin Duke, Human Resources

Nurse’s intent to leave scores

This data has not been collected yet but will be collected at baseline for the start of the nurse residency July 2016, again at 1mo, 3mo, 6mo, and 1y at completion of the program.

Cheryl Miller, Nursing Residency Program Coordinator

Nursing vacancy rates for FY16

Data is collected monthly and can be trended

Justin Duke, Human Resources

Table 10 below shows the retention and vacancy rate average, collected monthly and

reported annually, from the host organization compared to the national average for retention and


vacancy rates (Punke, 2013). Definitive national statistics for comparison rates for nurse

retention are not readily available or consistent in the literature. Additionally, discrepancies in

nationally reported data for turnover, the inverse of retention, remains inconclusive. Turnover

was reported in the table from information obtained in a report published by Nursing Solutions,

Inc (2016), a private for-profit company, to be 17.1% for 2015 compared to 16.4% in 2014,

while another study conducted in 2014 estimated the turnover rate in the United States to be

roughly 13.9% (Duffield, Roche, Homer, Buchan, & Dimitrelis, 2014; NSI Inc, 2016).

The host organization’s vacancy rate illustrated a higher value than the benchmark

comparison to other Magnet facilities. According to the host organization’s CNO, the elevated

internal vacancy rates could be attributed to the rise in patient volumes over the past several

years without efficient replacements, in addition to employee loss as a result of voluntary and

uncontrollable turnover. Vacancy rates vary across the host organization’s inpatient

medical/surgical/ortho-neuro/oncology/cardiovascular units with average vacancies of 7.4

equating to 21.92%, within a range of 3 to 12 throughout the 2016 fiscal year. Comparative

nationally, vacancy rates range from 8.4%, reported by NSI Inc. in 2016 to 17%, reported by

Duffield, et al., in 2014.

Specific internal data for retention of new nurses to the host organization was not

separately reported, although the average years of service for nurses in the host organization is

seven years averaged across the five nursing units supplied by the NRP, ranging from 3.5 to 11.1

years.

Despite the desirable high nurse retention rates of the organization, it was reasonable to

project the nurse resident retention, as measured by the nurse resident’s intent-to-stay and a

decreased vacancy rate, and is hoped to improve the longevity of the nursing workforce over


time. Such improvements may be directly related to improved communication and teamwork

prompted by healthier working relationships.

Table 10

Internal Reported Data Pre-RC Toolkit Implementation

Measure Host Organization Average National Average

Retention Rates 98.87% 82.9%

Vacancy Rates 21.92% 17%

External Evidence

After identifying the external evidence, a comprehensive review of the literature was

appraised and thoroughly analyzed. Recurring themes of evidence were identified and played a

key role in guiding the nursing practice of RC. Best evidence was gleaned and relevant clinical

actions surrounding RC in conjunction with the team’s clinical adroitness and awareness of the

clinical setting were integrated.

“Findings thus far support the empiric coherence of the concept of relational coordination

and the internal and external validity of the Relational Coordination Survey. Moreover,

research findings thus far suggest that the strength of relational coordination ties among

participants in a work process predicts an array of strategically important outcomes

including quality, efficiency, customer satisfaction and workforce resilience and

wellbeing. In healthcare studies specifically, relational coordination scores are

significantly correlated with increased quality; shorter length of stay; improved patient


satisfaction, staff satisfaction, and staff resilience; and improved clinical outcomes”

(Gittell & Suchman, 2013, p. 3).

According to the Institute of Medicine (IOM) there is a call for action in transformational

leadership affecting nursing. The Institute of Medicine (2011) stated, “all nurses must be leaders

in the design, implementation, and evaluation of, as well as advocacy for the ongoing reforms to

the system that will be needed. Additionally, nurses will need leadership skills and competencies

to act as full partners with physicians and other health professionals in redesign and reform

efforts across the healthcare system” (p. 221-222).

The American Nurses Association (ANA) supported this very idea as early as 2008 in a

policy reform publication of ANA’s Healthy System Reform Agenda. In this policy brief, direct

emphasis was placed on collaboration and its role in chronic disease management as well as

patient safety. The ANA specifically indicated that dedicated strategies for nurse retention is

critical and that work environment is “essential to sustaining the current workforce, enhancing

the success of recruitment programs, and, more important, improving patient outcomes and

overall satisfaction” (American Nurses Association [ANA], 2008, p. 11).

DeNisco and Barker (2016) point out that the Joint Commission’s mission is to

deliberately improve upon quality and safety and that they have placed focus on “improve(ing)

communication and collaboration among providers, staff, and patients” in order to preserve

patient safety (DeNisco & Barker, 2016, Chapter 6). Identifying personal collaboration as a

necessary component in preventing medical errors, offers further support to the evidence that

there is a pronounced need for implementing RC among high performance healthcare staff,

specifically nurses. DeNisco and Barker (2016) and the Joint Commission (2008) add that

collaboration among high performing teams encourages work satisfaction and a positive work


environment. It lends to feeling accomplished and adding value to the team (DeNisco & Barker,

2016).

Project Recommendations

The host organization has a current average retention rate of 98.87%, which is above the

national average. However, the host organization’s average vacancy rate of 21.92% is also

above the national average of 17%. Research has established that RC can have a positive impact

on professional communication, professional relationships, staff retention, and quality of care.

Recommendations for the development and implementation of the RC toolkit in the NRP

program can assist with the organization’s request for improving care coordination,

communication, and teamwork through collaborative means and education.

Project Implementation Plan

Change Theory

The concept of change theory in regards to the project was a vital element. The project

was focused on forming a RC toolkit to train new graduate nurses enrolled in a NRP. The use of

change theory was necessary as the project intends to study change in the organizational

structure and relational dynamics in order to assess if it results in improved nurse retention and

vacancy rate. Gittell, Schein, and Edmonson have developed a relational model of

organizational change that relates directly to the project. The relational model of organizational

change is depicted in Figure 1. The model consists of relational, work process, and structural

interventions (Spreitzer & Cameron, 2011). The UMary Graduate EBP Project Team also plans


to incorporate resilience theory. The study on resilience theory by Benjamin & Black (2012)

focuses on teachers, but the same concepts could be applied to any employee, particularly nurses.

Figure 1-Relational coordination change theory

The relational model of organization had a great influence on project recommendations

and the implementation plan. The relational interventions, work process interventions, and

structural interventions are ideas the organization focused on in the toolkit created for new nurse

residents. The second phase of RC and leadership shows how RC should look in action. The

final step of the theory is performance outcomes. The project focused specifically on the worker

engagement portion (nurse retention and intent to leave). Based on what was observed during all

phases assisted in the development of recommendations.

Key Stakeholders

Traditionally, key stakeholders are affected by actions, objectives and policies. In this

project they were also affected through relationships of shared goals, knowledge, and mutual

respect creating the core of relational coordination. Each improves clinical outcomes when those


relationships include communication that is frequent, timely, accurate, and oriented around

problem solving. These very relationships existed among those having key roles in patient care

and they were considered to be the key stakeholders of this process. The host hospital is

committed to a high standard of quality and forges ahead to excel in the area of high performing

teams for the purpose of achieving optimal clinical outcomes and enhanced working

relationships. The host hospital respects and values each individual noting that stakeholders

contribute as team members. The host hospital also recognizes that flexibility, trust, and

cooperation are essential to relationships in their organization. Stakeholders are frontline staff

including nurse residents, nurses, and CNA’s, patients, physicians, nurses, therapists, case

managers, dieticians, pharmacists, social workers, and organizational leaders but truly include

any individual having conversations of interdependence.

It is crucial for stakeholders to recognize that their educations (formal and informal) do

differ from their colleagues and that their individual “training, socialization and expertise”

(Havens, Vasey, Gittell, & Lin, 2010, p. 928) take on a unique and specific focus. It is important

for each stakeholder to remain mindful of the exclusive training and education each brings to the

table. This degree of mindfulness will be essential in avoiding individual silos that can hamper

effective communication.

Remembering that stakeholders in this project are primarily health care professionals, the

host hospital chose to incorporate RC into their NRP as a response to the IOM’s report of Health

Professions Education: A Bridge to Quality which suggests that educational encounters be

revived in an effort to reshape the future of healthcare (Havens et al., 2010). The

implementation of RC into their NRP has become the gateway that allows new nurses to

establish crucial relationships with other stakeholders including physicians and advanced


practice providers who have statistically been considered the “weakest link”. Gittell (2009)

states that the “provider team tends to be systematically weaker” even though they play a key

role in the direction and delivery of patient care (Gittell, 2009, p. 21). Remaining aware that

each discipline comes from different training avenues will be essential in the success of each

stakeholder’s ability to function as part of a high performing team.

The stakeholders in these high performing work systems have identified the importance

of adopting practices of collaboration and partnerships and understand that solo acts are no

longer acceptable or beneficial to quality care. In today’s ever changing healthcare system,

every member of the interdisciplinary team is charged with achieving optimal outcomes for the

patient. Stakeholders must bring their various professional backgrounds to work together

through the health care continuum for the good of the patient, the family, and the community.

Barriers, Facilitators/Drivers, and Resistors to Change

Relational and communication barriers in the workplace are an expectation. There are

ever-present challenges when working within a given profession. Successful results in care

delivery and staff retention are the end product of working through barriers in relationships and

communication. The challenge of overcoming these barriers in medicine is compounded more as

the result of working within interdisciplinary relationships. Interdisciplinary teams lend

themselves to multiple professional silos. Silos of responsibilities between multiple disciplines

result in poor communication, conflict, avoidance of potential communication, and confrontation

challenges that result in reinforcing those barriers and diminishing the potential for collaborative

work. At fault are professional cultures, personalities, education, and professional roles, with

multiple other social and professional excuses that are contributors; but what are the actual

barriers to communication? Significant communication barriers are the result of social and


professional expectations that do not take into consideration that professional roles are still filled

by people, and as Alfred Adler stated, the only normal people are the ones you don’t know very

well. Therefore it is important to recognize that if people are involved, barriers will exist.

Medicine and nursing are often viewed as the central drivers of healthcare teams. It is of

value to primarily consider these professions in the effort to diagnose barriers in relational

coordination. Barriers of interprofessional collaboration are "(1) gender, power, socialization,

education, status, and cultural differences between professions; (2) lack of a payment system and

structures that reward inter-professional collaboration; (3) the misunderstanding of the scope and

contribution of each profession and (4) turf protection." (DeNisco, S. & Barker, 2016 p. 129).

Professional identity is the end product of sociological processes and historical identity

development. As professions have struggled to define their unique roles, values, and practice

compasses, these profession practices have effectively created a silo of professional roles. This

side effect of professional identity has, in effect, left a gap in professional collaboration and a

loss of overlapping care and competencies.

Further barriers of care coordination are economic factors and staff turnover. With

resource challenges and staff retraining there are frequent interruptions in team coordination and

relationships. Priorities are to remove barriers in relationships and communication; the earlier

the walls of division are removed in the professional career, the more successful professional

collaboration will be. "There is some data that suggests that the earlier nurse residents are

exposed to interdisciplinary practice within the curriculum; the more likely they are to practice

within an interdisciplinary model following graduation." (Pecukonis, Doyle & Bliss, 2008).

Relational coordination is dependent on inter-professional communication and

relationships. Strong relationships are the result of strong leadership and facilitators. Facilitators


are role models that are willing to recognize personal biases and prejudices while promoting the

direction of the team. Facilitators direct professional culture through example for the care

delivery team. Five keys elements to professional relationship facilitation are: (1) model the

way, (2) inspire a shared vision, (3) challenge the process, (4) enable others to act, and (5)

encourage the heart.

In modeling the way, the leader must primarily have a full understanding of their own

values and live life in such a way to inspire those values in others. An effective facilitator can

see and inspire future vision in others and is willing to challenge the current process and be open

to innovation, take risks, and recognize the benefits and shortcomings of potential change.

Through openness and team support, facilitators encourage others to act and build collaborative

relationships. Facilitators recognize team success and provide reinforcement to support those

breakthrough events.

Facilitators are also able to accept challenges to personal and team viewpoints. In

supporting each member of the team, they encourage each member to contribute by profession

and knowledge. When facilitators foster an environment of open communication they ensure

that all aspects of care are considered and receive proper attention. Facilitating a strong team is

the result of recognizing the strengths of the individual members of the team with each working

for a common goal. Examples of rules for effective team communication are:

● One person speaks at a time

● Raise your hand if you have something to say

● Listen to what other people are saying

● No mocking or attacking other people's ideas

● Be on time coming back from breaks (if it's a long meeting)


● Respect each other

Work Practices

1. Select for teamwork: Interview for soft skills, emotional intelligence, teamwork

attitudes, personality traits, etc. Do not hire with the sole focus of a technical skill set. Team

development is a significant indicator in patient care outcomes. Hiring and evaluation tools are

in place to evaluate the longevity and team investment of the employee.

2. Measure team performance: Measure the team, not the individual performance. A cross-

functional approach to performance measures provides a sense of shared goals and knowledge as

well as mutual respect for all the members of the team. Identify the parties for each patient care

responsibility to recognize the team, not the individual.

3. Reward team performance: Reward the team, not the individual. Individualized rewards

are associated with poor levels of communication where shared rewards strengthen patient care,

improve patient outcomes, and strengthen relational coordination.

4. Resolve conflicts proactively: High performance teams have conflict; it is the result of

high performance teams with high levels of task interdependence. To recognize the conflict

early and use it in constructive resolution across all functions reflects care coordination.

5. Invest in frontline leadership: Supervisors on the front line are needed in the roles of

coaching and feedback to foster relational coordination. This coaching and feedback are to

direct care providers to coordinate directly with each other and support team dependence.

6. Design jobs for focus: Care teams designed for specialty care areas have elevated levels

of effective care delivery. The most effective care delivery has a core focus area but retains

flexible boundaries between them.


7. Make job boundaries flexible: To increase the flexibility of job boundaries threatens

professional roles of security. To improve patient outcomes, rigid healthcare boundaries and

status roles impair coordination of patient care outcomes.

8. Create boundary spanners: Reaching peak team and care performance by implementing a

cross-functional role to coordinate care and resolve problems that arise from division of labor.

9. Connect through pathways: Invest in protocols and care pathways that codify best

practices, individual capabilities can be transformed into organizational capabilities.

10. Broaden participation in patient rounds: Supporting patient rounds is a form of cross-

functional meeting that encourages physicians, residents, nurses, and all invested parties to share

involvement and responsibility of patient care.

11. Develop shared information systems: The team dependency on a clear communication

infrastructure improves team communication with relay of care progress, knowledge, and care

goals.

12. Partner with suppliers: Support coordination across organizational boundaries. As the

patient care is extended to the next level of care, be that a home care, rehabilitation, or other; the

care plan and relationship of care extended out from the original care team continues the RC

process.

Business Impact

The National Center for Interprofessional Practice and Education holds that high

performing teams maximize the “experience, outcomes and costs of health care” and the overall

performance of the organization (Vega & Bernard, 2016, para. 10). The business impact of RC is

more than metric as it means that healthcare workers, specifically new nurses, may be happier in

their careers leading to longevity in their organization, achieve a higher level of job satisfaction


and patients can be increasingly satisfied with the care they receive and benefit from an

improved quality of life. Relational coordination will have a profound impact on the

organization through the measured advantages reflective of high performance teamwork and

through allowing new nurses from the NRP to benefit from enhanced communication skills and

improve on team collaboration efforts.

The infusion of RC into the healthcare organization at the NRP level offers a plethora of

possibilities that may undoubtedly benefit the healthcare organization (HCO) for years to come

in terms of improved nurse retention, improved job satisfaction, and improved patient

satisfaction. Each of these benefits impacts the host organization’s vision of being a national

leader in providing the best clinical quality, patient safety, service and value. Working

systemically will provide incentive for nursing and other stakeholders to identify mutual goals

and achieve them as a unified body. “Good health is the sum of many things, so it takes nurses

working with experts in many other fields to strengthen well-being for all” (Campaign for

Action, 2016, para. 1).

In a 2010 study surrounding nurse retention, nurse residency programs were identified as

a means to retaining new graduate nurses. In order to assure that registered nurses are ready to

practice and will remain an employee and even stay with their career will mean that new nurses

must be thoughtfully transitioned into the role of professional nurse (Ulrich et al., 2010).

Focusing on working relationships will allow new nurses to achieve effective relational pathways

in high performing work environments and will foster the confidence needed to feel and be

successful. Equipping nurses to lead collaborative efforts has the potential to improve patient

health and to offer a level of professional satisfaction.


According to Nursing Solutions, Inc. (2016) the average cost of turnover for a bedside

RN is $48,050 causing healthcare organizations to address their “talent acquisition efforts” and

protect “their human capital investment” (Nursing Solutions, Inc., 2016). Siedlecki and Hixson

(2015) suggest that nurses hold strong views on communication, collaboration of patient care and

being respected professionally (Siedlecki & Hixson, 2015). This supports that RC practices will

have meaningful impact on the decision for nurses to remain employed with their current

organization or to seek employment with an organization that value their views.

The U.S. healthcare system has been faced with dramatic changes in how reimbursement

is achieved and in how healthcare is delivered. Healthcare, across the spectrum, has been

challenged with improving care while reducing costs. The need for efficient high quality care

organizations is rising and RC is being utilized in an effort to meet that need. Healthcare models

that use evidence based approach and highlight “nurse-led, team-based care” ensures “continuity

of care, prevention and avoidance of complications and close clinical treatment and

management” (Naylor, 2011, p. 1).

Furthermore, the Affordable Care Act points out that patient must be well informed and

included in the decision-making processes surrounding their care. Relational coordination and

like concepts of interprofessional collaboration, is an important movement in the connection of

nurses and quality patient care and is supported by The Robert Wood Johnson Foundation’s

Interdisciplinary Nursing Quality Research Initiative (INQRI). In exploring the effects of

collaboration between healthcare professionals INQRI has identified that effective

communication among teams and having shared leadership “improves quality of care and patient

outcomes” (Naylor, 2011, p. 2). Patient involvement will further drive RC in the “process of

care delivery, design and improvement to result in high value care delivery” (Gittell, Godfrey, &


Thistlethwaite, 2013, p. 212). Finally, Gittell confidently states that RC impacts both efficiency

and financial outcomes, increases employee productivity, increases profit growth, improves

operational excellence, reduces turnaround time, reduces length of hospital stay, reduces total

cost of hospital care, reduces inpatient hospitalizations and reduces total cost of chronic care

(Gittell, 2009).

Organization Planning Process

The organization’s mission of integrated health care, education and research, and vision

to be a national leader in providing the best clinical quality, patient safety, service, and value, can

be complemented through the integration of RC into the culture. By improving the care

coordination across the spectrum of the patient’s experience through enhanced communication

and teamwork, the organization will be closer to achieving their mission and vision of national

leadership in care provision. Relational coordination not only enriches the care coordination

efforts, it can provide the mechanism for engaging employees to create value (Gittell, Seidner,

and Wimbush, 2010). Furthermore, there is evidence to support the causal mechanism of

employee-employee relationships as the primary connection between high performance work

systems and performance outcomes (Gittell, Seidner, and Wimbush, 2010). Roussel, Thomas

and Harris (2016) explained the relationships that are created and fostered within an organization

are translated into the care provided to the patients and community as perceived by their

awareness of the existing synergies.

Implementation Plan

The literature review and assessment of the current gap in knowledge led to the

development of the RC toolkit and the inclusion of three areas to focus the efforts based on the

needs indicated by the CNO of the host organization. Implementation of the RC toolkit into the


learning process for newly licensed nurses enrolled in the NRP provided a unique opportunity to

incorporate RC concepts into the onboarding process. Taking a grassroots approach to the way

communication and teamwork was viewed by new nurses and infusing RC concepts gave them

an opportunity to strengthen their work relationship skills while effectively blending their

knowledge and newly gained talents with the skills and knowledge of their seasoned colleagues

in a variety of care units. This infusion of RC into the organizational culture began with sharing

information and education on the RC concepts with the NRP faculty. Although all NRP faculty

members have had a brief introduction to the RC concepts through testimonials from a variety of

other projects within the organization, education from internal experts has not formally occurred.

The host organization utilizes a rolling action item list (RAIL) for addressing the needs of

a project as a communication tool for the team to use that includes identified tasks, deadlines,

primary responsibility, and status of the task. UMary Graduate EBP adopted this dynamic and

evolving organizational tool to help facilitate the needs of the implementation plan for the RC

toolkit (see Appendix I). The first step in the NRP faculty’s formal training was clarification of

the RC concepts that helped set the stage for the project’s desired purpose. The second step was

to educate the NRP faculty on the use of liberating structures as a means to insight and engage

dialogue and learning through action. Thirdly, was to assist in understanding the value of RC

and liberating structures on the learning process when integrated into the NRP curriculum.

As part of the education for the NRP faculty, a formal meeting invitation scheduled for

September 14th, 2016 was sent to the two faculty members by the UMary Graduate EBP team.

This one-hour meeting addressed educational objectives (see Appendix B) and the use of the

liberating structures that were utilized in a practice format as a means to “train the trainer” (see

Appendix D). Additional exercises were determined from this initial educational phase and will


determine subsequent training sessions. The underpinning of the faculty educational plan was

conceptually based on complexity science.

“Clinical practice, organization information management, research, education, and

professional development are interdependent and are built around multiple self-adjusting

and interacting systems. In complex systems, unpredictability and paradox are ever

present and some things will remain unknowable. New conceptual frameworks that

incorporate a dynamic, emergent, creative, and intuitive view of the world must replace

traditional reduce-and-resolve approaches to clinical care and service organization”

(Roussel, Thomas, & Harris, 2016, p. 106).

After the NRP faculty was sufficiently prepared per their own verbalized perception of

competence in RC concepts, the NRP curriculum incorporated the RC content as an additional

mechanism for learning the soft skills associated with care coordination, communication, and

teamwork. The host organization’s NRP faculty developed the curriculum. The first exposure to

the RC concepts for the nurse residents occurred on September 28, 2016 during a two-hour

introduction on team building and RC. A member of the UMary Graduate EBP Project Team

facilitated this two-hour introduction with assistance from the NRP faculty. Ongoing feedback

from the new employees to the faculty through the RC Survey Tool helped guide future NRP

cohort curriculum development.

This timeline was chosen based on the learning spectrum of a new nurse indicated in

Figure 2. New nurses are adapting to many changes in a very short period of time. They

experience periods of both highs and lows as they navigate between being a student to beginning

their career. They tend to be narrowly focused on the tasks of being a clinical nurse in the

orientation phase for the first two months. Due to the influx of information delivered to them,


the soft skills associated with care coordination, communication, and teamwork are presented

after they have established their work routine and can focus their attention on learning other

necessary skills.

Figure 2-Transition Stages Model

(Boychuk Duschscher, 2008)

Issues commonly cited as troublesome for newly graduated nurses at various points in

time throughout the initial 12 months relate to a lack of clinical knowledge and confidence in

skill performance, relationships with colleagues, workload demands, organization and

prioritization as they relate to decision making and direct care judgments, and communicating

with physicians” (Boychuk Duschscher, 2008). Relational coordination concepts can help

improve their confidence in a variety of clinical and critical thinking scenarios as an adjunct to

the curriculum fundamentals. The NRP curriculum is a dynamic and fluid process presented

during the infancy and initial cohort of nurse residents based on their ongoing clinical and soft

skill needs. To introduce and help get the RC project underway, The UMary Graduate EBP

Project Team met with the organization’s team of Executive Directors, Directors, and CNO on


August 11th, 2016. This meeting utilized a professional presentation by members of the UMary

Graduate EBP Project Team to discuss the theory of RC, the impact of leadership support for

RC, as well as addressing the RC toolkit implementation plan.

A formal meeting invitation was sent to the three NRP faculty members, scheduled for

September 13th, 2016, to address educational objectives that were utilized in a practice format as

a means to “train the trainer”. Additional exercises were determined from this initial educational

phase and guided subsequent training sessions.

After the faculty was sufficiently prepared per their own verbalized perception of

competence in RC concepts, the NRP curriculum incorporated the RC content as an additional

mechanism for learning the soft skills associated with care coordination, communication, and

teamwork. The host organization’s NRP faculty developed the curriculum. The first exposure to

the RC concepts for the nurse residents occurred on September 28, 2016 during a two-hour

introduction on team building and RC. A member of the UMary Graduate EBP Project Team

facilitated this two-hour introduction with assistance from the NRP faculty. At the completion of

the introduction to the RC concepts, a commitment to promote RC within the organization was

presented to each NRP student (see Appendix L). Ongoing feedback from the nurse residents to

the faculty through the RC Survey Tool helped guide future NRP cohort curriculum

development.

Project Measurement Plan

The implementation of RC can provide many benefits to healthcare organizations. By

providing a toolkit reference for the nurse residency program as a methodology for improving

interdisciplinary communication among nursing, physicians, therapists, social workers, and other

members of the care delivery team, the outcome was measured in longevity of staff, improved


vacancy rates, staff retention, improved work practice, improved care delivery, and improved

quality outcomes. The success of the implementation depended largely on organizational efforts

and commitment as well as available resources, support, and effective planning. The outcomes of

implementing RC at the host hospital was projected to result in better communication among

staff members, increased teamwork, and coordination of patient care, increased quality of patient

care, increased staff satisfaction, and staff retention. The organization’s leadership, represented

by the CNO, indicated an opportunity to help the organization successfully recruit and retain new

staff members. Relational coordination concepts provided the host organization with an excellent

opportunity, through their nurse residency program, to allow these organizational changes to

occur with their workforce

The Relational Coordination Survey Tool (See Appendix K) is the source of

measurement that was used to determine whether or not RC concepts have been integrated into

specific units in which student nurses in the NRP work. Due to the timeline of the project, the

final results will not be obtained until three and six months after the nurse residents have started

their rotations. For this particular EBP project the nurse residents started in September 2016.

This survey tool was previously used by the host organization and permission was granted to

utilize and make changes to this survey tool for the purposes of this project (see Appendix A).

The RC survey tool consisted of seven questions in which staff members can answer questions

relative to their perceptions of the degree to which RC occurs. The RC survey tool has been

utilized in a variety of areas with participation from staff members representing nurses, physical

therapists, nurse residents, physicians, dieticians, social workers, and speech therapists. The RC

survey tool was used to survey four workgroups that are involved in the learning experiences for

the NRP nurse residents: 1) NRP faculty, 2) NRP nurse residents, 3) unit preceptors from the


inpatient medical/surgical/ortho-neuro/oncology/cardiovascular departments responsible for the

orientation needs of the NRP nurse residents, and 4) unit leadership triad consisting of the

manager, clinical coordinator and education clinician from all of the five nursing inpatient units

that are included in the NRP. The survey was sent out via email to all of the workgroups for

determining the RC score within the workgroups and across the workgroups. An employee of

the host organization collated the data and the results were be presented to the UMary Graduate

EBP Team for interpretation.

Measurement data was obtained from retention rates and vacancy rates from the host

organization’s internal data sources. Retention rates and vacancy data from the 2016 fiscal year

were used as baseline measurements. This measurement data was compared to nurse residents’

retention and corresponding decrease in vacancies three months after the RC toolkit

implementation and could be useful in assisting managers to implement action plans that can

help retain nursing staff. Thus, the formative survey tool was administered to the nurse residents

after three months due to information retention and potential sensory overload issues that may

occur with beginning a new job. It was suggested to have the survey completed again in six

months to assist in measuring change created by the implementation of the RC concepts and

toolkit. It was also highly recommended to have nurse satisfaction scores measured although the

UMary Graduate EBP Project Team was not be able to review this particular measure. All data

sets were collected by the NRP faculty with results being shared and evaluated as a team effort

with human resources, recruiting personnel, and affected department managers. With successful

RC toolkit implementation, nursing residency retention rates, and improved

communications/relationships as measured by the RC survey was expected to demonstrate the

following:


● Increase nursing staff retention for the hospital with RC adoption

● Improve nurse retention among resident nurse and reveal a decreased vacancy rate

● Demonstrate a professional advantage with enhanced communication skills and

professional relationships among and between disciplines as evidenced by an elevated

RC survey score.

Human Subject Protection Statement

This EBP project had a goal of improving communication, teamwork, coordination of

care, and staff satisfaction among interdisciplinary team members through the use of RC. This

project required the protection of any human subjects that are involved. An institutional review

board (IRB) proposal was submitted to the University of Mary for review and approved. The

risks and benefits of participation in this study were reviewed in the IRB application in Appendix

O.

Implementation and Measurement

Implementation

The implementation of the RC toolkit occurred seamlessly over a two week time

period. The education of the RC concepts and the introduction to the RC toolkit for the NRP

faculty was well received and offered the opportunity to collaborate and interact throughout an

hour-long teaching session. In collaboration with the NRP faculty, new ideas were generated to

help emphasize the concepts for the NRP residents. The NRP faculty recommended having

examples or stories of RC in real-life scenarios. The agenda was followed and the NRP faculty

expressed appreciation for the conciseness the agenda provided as well as the handouts that were

made available for this step of the implementation plan.


The education provided to the NRP residents was very well received and the degree in

which the group participated in the activities was exciting. The concepts were addressed in

detail according to the agenda provided for the curriculum and many questions were answered

for clarification. The communication “game” was conducted with three groups of four residents.

Five important pieces of information that might be included within the shift report were given to

one individual from each group and provided in turn through the rest of the group similar to the

childhood game Telephone. Additionally, the NRP faculty and UMary EBP project graduate

team member provided numerous interruptions during this process as is par for the course in the

workflow of a bedside nurse. This was not an initial part of the implementation plan but added

another level of a real-life scenario the NRP residents may face in their career. Interestingly,

none of the three groups were able to express all five of the important pieces of information at

the end of the activity. The NRP residents were very engaged during the activities and had their

own examples of situations where the RC concepts were utilized and ultimately improved the

care of the patient because communication and teamwork were highly effective.

At the conclusion of the education for both the NRP faculty and residents, an evaluation

of the content and presentation was completed (see Appendix M). Approximately six weeks

after the initial presentation to the NRP residents, the RC survey was launched. The launch date

was scheduled for October 26th, but due to increased email security measures put in place by the

host organization, the survey was sent to the spam folder and not readily available. A member of

the UMary EBP project team worked with the host organization’s information systems

department and LearningBridge.com to correct this process but was not able to be corrected until

two weeks after the scheduled survey launch. Once the interruption was identified, an additional

email was sent to all identified members of the workgroups to retrieve the email with


corresponding survey link from the spam folder. As a result of this, the host organization is now

aware of the inconvenient process and is working to remedy the process with the vendor and

internal parties.

Several opportunities became apparent during the implementation process. The current

curriculum was amended to incorporate RC related allegories and adjusted to incorporate the

communication game. Another recommendation made through this process was to provide

education on the RC concepts to the preceptors and leadership workgroups prior to the survey

being launched as many were unclear what he/she was being asked by the survey because of the

lack or limited amount of prior knowledge relative to the RC concepts.

Project Outcome Measurements

The RC toolkit was relayed to the NRP faculty on September 14, 2016. The graduate

team’s Project Lead worked with the faculty to support the concepts of RC to be taught to new

cohorts of NRP residents and engaged in role play and scenarios for teaching strategies to NRP

faculty. The Project Lead followed up two weeks later with the NRP residents to review and

reinforce what they had previously learned about the RC concepts.

On September 28, 2016, the UMary Graduate EBP Project Lead met with 11 NRP

residents for follow-up and survey presentation. There was strong support and feedback from

the residents. It was noted that the stories and scenarios taught to the NRP nurse residents had a

significant benefit to the RC toolkit and allowed for practical application of RC. With the

measured results of the RC toolkit exceeding expectations, the host organization extended strong

support and encouragement for the RC toolkit and the continued use of the toolkit. Survey

results demonstrate strong support and positive trends to the concepts of RC implementation for

the NPR.


Survey results came from 29 out of 49 (59%) of the participants that completed the

Relational Coordination survey. For inter-rater reliability, the only results used were those from

completed surveys. The breakdown of those completing the survey were:

• 10 Leadership staff (71% of Leadership group)

• 9 Nurse Residency nurse residents (82% of Nurse Residency group)

• 2 Nurse Residency faculty (100% of Nurse Residency Faculty group)

• 8 Preceptors (40% of Preceptor group)

The survey results legend designates green as strength in RC connection (there are few, if

any, areas of RC weakness with easy identification and isolation of the areas of disconnect, and

requires minimal support for RC expansion and education). The color red designates areas of RC

weakness (reflective of multiple areas of RC improvement, most, if not all, aspects of RC have

disconnect; some connections may not require a high level of relationship). Finally, the color

yellow is recognized as having moderately functional ties in RC connections (there remain areas

of ongoing attention and support to encourage RC growth, this is a positive indicator, ongoing

reinforcement areas of RC weakness).

In measuring the survey results by the group, areas of identified RC strengths were, per

the legend, noted in green. The number is indicative of how the group has scored others within

the same group on each of the seven domains. Those green strength areas by group were:

• Preceptor: frequent communication and shared goals

• Nurse Residency Faculty: problem solving communication, shared knowledge and

mutual respect

• Leadership: shared goals

Group weaknesses that were identified in red for RC growth were:

• Nurse Residency Faculty: frequent communication and shared goals


• Nurse Residency: shared goals

All other group areas of the host organization demonstrated a moderate composite score

in yellow.

Connection survey results between groups was also measured using the same color

legend and were demonstrated with arrows. The areas of identified RC strengths were identified

in green (strong ties of inter-collaboration to be maintained). The areas of identified RC

moderate connectivity identified were in yellow (areas of moderated RC ties that needs

reinforced). The areas of identified RC weaknesses were identified with red (many or all areas

of RC require support and teaching).

Figure 3 Frequent Communication

Green:

Leadership to Nurse Residency Faculty and Preceptor

Nurse Residency Faculty to Preceptor

Nurse Residency to PreceptorRed: None identifiedYellow: All other areas of Frequent

Communication, representing areas of RC growth potential.


Figure 4 Timely Communication

Green: Preceptor to Nurse

ResidencyRed:

Leadership to Nurse Residency Faculty and Preceptor

Nurse Residency to Leadership Preceptor to Leadership and

Nurse Residency Faulty Nurse Residency Faculty to

PreceptorYellow: All other areas of Timely

Communication ·

Figure 5 Accurate Communication

Green: Leadership to Nurse Residency

Faculty and PreceptorRed: Nurse residency to PreceptorYellow: All other areas of Accurate

Communication. ·


Figure 6 Problem Solving Communication

Green:

Preceptor to Nurse ResidencyRed:

Leadership to Nurse Residency Faculty

Yellow: All other areas of Problem

Solving Communication ·


Figure 7 Shared Goals

Green: None identified

Red: Leadership to Nurse Residency

Faculty, Nurse Residency, and Preceptor

Nurse Residency Faculty to Nurse Residency and Preceptor

Preceptor to Nurse Residency Faculty

Yellow: All other areas of Shared

Goals ·

Figure 8 Shared Knowledge

Green:


Nurse Residency Faculty to Nurse Residency


and Nurse Residency Preceptor to Nurse Residency

Faculty and Leadership Nurse Residency to Leadership

Yellow: All other areas of Shared

Knowledge ·

Figure 9 Mutual Respect

Green:

Preceptor to Nurse Residency Faculty and Nurse Residency


Faculty Nurse Residency and Preceptor

to LeadershipYellow: All other areas of Mutual

respect


Figure 10 displays the overall RC scores for each of the 7 dimensions and provides an

average RC score for the UMary EBP project implementation. The RC scores are relatively high

on the spectrum and demonstrate the inclusion and adaptation of the RC concepts to the work

currently occurring within the NRP curriculum and total program. While there are areas that

scored lower than others, the information provides a glimpse into the success of the NRP as it

currently stands.

Table 11 Relational Coordination Overall Scores RC Dimension Between Workgroups Within WorkgroupsFrequent Communication 4.7 4.5Timely Communication 4.3 4.5Accurate Communication 4.8 4.2Problem-solving Communication 4.9 4.7Shared Goals 4.4 4.1Shared Knowledge 4.2 4.6Mutual Respect 4.8 4.7Relational Coordination 4.6 4.5

Table 12 below shows the comparison data between the pre- and post-RC toolkit

implementation for the retention and vacancy rate average of the host organization. The increase

for retention rates and reduction in vacancies for the host organization indicates positive results,

although with only two data points for comparison, a trend is not demonstrated.

Table 12Retention/Vacancy rates post RC toolkit implementation

Measure

Host Organization Average July 1, 2015 through

June 30, 2016

Host Organization Average July 1, 2016 through November 30, 2016

National Average

Retention Rates 98.87% 99.11% 82.9%

Vacancy Rates 21.92% 15.26% 17%


As is noted in the primary survey results, the RC toolkit, implemented to the NRP

residents of the host organization, has demonstrated positive RC survey support. The host

organization survey results demonstrate the benefit of ongoing promotion and strong support for

the RC principles to the point that the scale of measure was adjusted to reflect elevated levels of

RC results. There is organizational recognition of the benefit of RC to the organization itself, the

patient, and to the quality outcomes with the use of the RC toolkit and infusion of the RC

concepts. The retention rate and vacancy tables confirm positive trends with implementation of

the RC toolkit.

Hand-off Plan

Expanding the RC toolkit to existing employee forces could yield similar expected

retention results; an increased percentage of staff retention rates throughout all hospital

professions could be measured with full relational coordination adoption and toolkit usage. The

graduate EBP team has suggested to the host organization that survey be completed again in six

months and just prior to the completion of the nurse residency program, which is 12 months.

This could assist in measuring progress that the implementation of RC can create. It is also

recommended to have nurse satisfaction scores measured to assess the degree of nurse and job

satisfaction with the implementation of RC. The organization would gain profitable information

by collecting data that pertains to retention and vacancy rates each year that the RC toolkit is

utilized. Year-to-year comparisons can then be made offering essential data about the effects

that RC has on the retention rates of new nurse participating in the nurse residency program.

Such information would be advantageous to a nurse retention committee and or human

resources.


Finally, there were two salient recommendations made by members of the host

organization that would enrich and assist in making RC and the RC toolkit more lucrative for

them. These recommendations were to:

1. Provide an education session fully explaining the concepts of RC to all preceptors

and members of leadership involved so that they worked from the same understanding

and footings of new residents in the nurse residency program. At the time this project

was launched education was given only to the nurse resident faculty and new nurse

residents.

2. Add examples of the stories that were shared in the new nurse residency orientation.

The story examples pertained specifically to the host organization, which added a layer of

personification and provided realistic illustrations of how practicing and implementing

RC can be beneficial. The story examples can be designed to reflect true instances in any

department of the organization and carry additive value that emphasizes the benefits of

RC.

The handoff plan has been formally delivered and fully discussed with the organization.

All of the host organizations questions have been answered in detail and the graduate EBP team

has extended an offer to answer any further questions should they arise. The host organization

has expressed their gratitude for being provided an EBP that has the ability to enhance their care

outcomes and nurse retention rates.

Conclusion

Relational coordination is well discussed in the literature and has gained much in the way

of support for improvement strategies that can impact the quality, efficacy, and efficiency for

patient care. Improving communication and teamwork not only has a place in the healthcare


setting, but in day-to-day interactions within the communities we strive to serve. The literature

supports the primary outlier for appropriate care coordination been attributed to gaps in the

communication for care delivery and the impetus for improvement can be fostered through RC.

Changes in healthcare trends have prompted outside-of-the-box strategies for soliciting

engagement and ownership of the healthcare model; to be focused on integration and

collaboration, while promoting efficiency and resilience. In the complex system of healthcare

delivery, RC can be a low-to-no-cost initiative any organization can utilize in their quest for

excellence, quality, and value.

The implementation of RC with the NRP provides a unique alternative to improvement

strategies that have been unit-dependent and exclusively integrated. Because the NRP residents

are assimilated into a variety of different patient care areas, the spread of RC into the varying

departments can be infused into the culture through system-wide integration with the residents

leading the charge versus the isolated approach.

The RC toolkit provided the host hospital with the requested plans needed for future

implementations. The host organization vacancy and retention rates confirm positive trends

during the implementation of the RC toolkit. An evaluation of the implementation of the toolkit

found strengths and weaknesses of the host organization’s RC skills. The faculty of the NRP

showed strength with problem solving communication, shared knowledge, and mutual respect.

Many areas of RC in the organization were found to require support and teaching. These

weaknesses have been addressed in recommendations to the host organization for future

utilization of and expansion of the RC toolkit. The host organization results from the evidence

based practice project show strong support and implementation of the RC principles. Survey

results demonstrate significant organizational recognition of the benefits to the organization


itself, the patient, and the quality outcomes of the organization. Through perseverance and

dedication to incorporating RC into the culture of the organization, the patient remains at the

center of focus and fulfills empowerment for staff to assert new process into the care delivered.

References

American Nurses Association. (2008). Healthy system reform agenda [Policy Brief]. Retrieved

From http://www.nursingworld.org/Content/HealthcareandPolicyIssues/Agenda/

ANAsHealthSystemReformAgenda.pdf

Arthur, N., Deutschlander, S., Law, R., Lait, J., McCarthy, P., Pallaveshi, L., Roots, R., Suter, E.,

& Weaver, L. (2012). An inventory of quantitative tools measuring

interprofessional education and collaborative practice outcomes: A report by the

Canadian Interprofessional Health Collaborative (CIHC).

Vancouver, BC: Canadian Interprofessional Health Collaborative.

Benjamin, T., & Black, R. (2012). Resilience theory: Risk and protective factors for novice

special education teachers. Journal of American Academy of Special Education

Professionals, p. 5-27.

Billings Clinic. (n.d.). http://www.billingsclinic.com/about-us/mission-vision-values/

Boychuk Duchscher, J. E. (2008, October 17). Transition shock: The initial stage of role

adaptation for newly graduated registered nurses. Journal of Advanced Nursing, 65,

1103-1113. http://dx.doi.org/10.1111/j.1365-2648.2008.04898.x

Brinkert, R. (2010). A literature review of conflict communication causes, costs, benefits, and

interventions in nursing. Journal of Nursing Management, 18, p. 145-156.

Campaign for Action. (2016). Fostering interprofessional collaboration. Retrieved from

http://campaignforaction.org/issue/fostering-interprofessional-collaboration/


Chumley, H., & Magrane, D. (2011). Energizing a faculty medical education retreat with

liberating structures. Medical Education, 45, p. 529-530.

Cornell, P., Townsend Gervis, M., Yates, L., & Vardaman, J.M. (2014). Impact of SBAR on

nurse shift reports and staff rounding. MEDSURG Nursing, 23(5), p. 334-342.

Cramm, J., & Nieboer, A. (2012). In the Netherlands, rich interaction among professionals

conducting disease management led to better chronic care. Health Affairs,

31(11), p. 2493-2500.

DeNisco, S. M., & Barker, A. M. (2016). Advanced practice nursing (3rd ed.). Burlington, MA:

Jones & Bartlett Learning.

Duffield, C. M., Roche, M. A., Homer, C., Buchan, J., & Dimitrelis, S. (2014). A comparative

review of nurse turnover rates and costs across countries. Journal of Advanced

Nursing, 70(12), 2703-2712. doi:10.1111/jan.12483

Espinosa, J.A., & Clark, M.A. (2014). Team knowledge representation: A network

perspective. Human Factors, 56(2), p. 333-348. Doi:

10.1177/0018720813494093.

Gittell, J. H. (2009). High Performance Healthcare: Using the power of relationships to achieve

quality, efficiency and resilience. New York: McGraw-Hill.

Gittell, J.H., Godfrey, M., & Thistlethwaite, J. (2013). Interprofessional collaborative practice

and relational coordination: Improving healthcare through relationships. Journal

of Interprofessional Care, 27(3), p. 210-213. Doi: 10.3109/13561820.2012.730564.

Gittell, J.H., Seidner, R., Wimbush, J. (2010). A relational model of how high-performance

work systems work. Organization Science, 21(2), p. 490-506. Doi:

10.1287/orsc.1090.0446.


Gittell, J. H., & Suchman, A. L. (2013). An overview of relational coordination. Retrieved from

http://rcrc.brandeis.edu/aboutrc/Overview%20of%20Relational

%20Coordination.pdf.html

Haggerty, J.L., Roberge, D., Freeman, G.K., Beaulieu, C., Breton, M. (2012). Validation of a

generic measure of continuity of care: When patients encounter several

clinicians. Annals of Family Medicine, 10(5), p. 443-451.

Hartgerink, J.M., Cramm, J.M., Bakker, T.J., Eijsden, A.M., Mackenbach, J.P., &

Nieboer, A.P. (2014). The importance of multidisciplinary teamwork and team

climate for relational coordination among teams delivering care to older patients.

Journal of Advanced Nursing, 70(4), p. 791-799. Doi: 10.1111/jan.12233.

Hartgerink, J. M., Cramm, J. M., Bakker, T. J., Eijsden, R. A., Mackenbach, J. P., & Nieboer, A.

P. (2014). The importance of relational coordination for integrated care delivery

to older patients in the hospital. Journal Of Nursing Management, 22(2), 248-256.

doi:10.1111/j.1365-2834.2012.01481.x

Havens, D.S., Vasey, J., Gittell, J.H., & Wei-ting, L. (2010). Relational coordination among

nurses and other providers: Impact on the quality of patient care. Journal of

Nursing Management, 18(8), p. 926-937. Doi: 10.1111/j.1365-

2834.2010.01138.x

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st

century. Retrieved from http://www.nap.edu/catalog/10027/crossing-the-quality-chasm-a-

new-health-system-for-the

Institute of Medicine. (2001). Report brief: Crossing the quality chasm. Retrieved from


http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/Crossing-

the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health.

Retrieved from http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-

Nursing-Leading-Change-Advancing-Health.aspx

(https://rcrcconnect.org/resource-center/intervention-database/)

McDonald, J., Davies, G., Jayasuriya, R., & Harris, M. (2011). Collaboration across private and

public sector primary health care services: benefits, costs, and policy

implications. Journal of Interprofessional Care, 25, p. 258-264.

McDonald, K., Schultz, E., Albin, L., Pineda, N., Lonhart, J., Sundaram, V., Smith-Spangler, C.,

Brustrom, J., Malcolm, E., Rohn, L., & Davies, S. (2014). Care coordination

atlas (Version 4) (Prepared by Stanford University under subcontract to American

Institutes for Research on Contract No. HHSA290-2010-00005I). AHRQ

Publication No. 14-0037- EF. Rockville, MD: Agency for Healthcare

Research and Quality.

Men, L. (2014). Why leadership matters to internal communication: Linking transformational

leadership, symmetrical communication, and employee outcomes. Journal of

Public Relations Research, 26, p. 256-279.

Naylor, M. D. (2011, June). Viewpoint: Interprofessional collaboration and the future of health

care. American Nurse Today, 6(6). Retrieved from

https://americannursetoday.com/viewpoint-interprofessional-collaboration-and-the-

future-of-health-care/


Nursing Solutions, Inc. (2016).

http://www.nsinursingsolutions.com/Files/assets/library/retention-institute/

NationalHealthcareRNRetentionReport2016.pdf

Oh, H., & Solomon, P. (2014). Role-playing as a tool for hiring, training, and supervising peer

providers. The Journal of Behavioral Health Services & Research, 41(2), p. 216-

229.

Pecukonis, E., Doyle, O., & Bliss, D. L. (2008). Reducing barriers to interprofessional training:

Promoting interprofessional cultural competence. Journal Of Interprofessional Care,

22(4), 417-428.

Porter-O'Grady, T., & Malloch, K. (2015). Quantum Leadership: building better partnerships for

sustainable health. Burlington, MA: Jones & Bartlett Learning.

Punke, H. (2013). Physician, nurse vacancy rates high in hospitals. Retrieved from

http://www.beckershospitalreview.com/hospital-physician-relationships/physician-nurse-

vacancy-rates-high-in-hospitals.html

Relational Coordination Research Collaborative. (2016). Transforming Relationships for High

Performance. Retrieved from http://rcrc.brandeis.edu/

Roussel, L., Thomas, P. L., & Harris, J. L. (2016). Management and leadership for nurse

administrators. Burlington, MA: Jones & Bartlett Learning.

Shaw, E., Howard, J., Etz, R., Hudson, S., & Crabtree, B. (2012). How team-based reflection

affects quality improvement implementation: A qualitative study. Quality

Management Health Care, 21(2), p. 104-113.

Siedlecki, S. L., & Hixson, E. D. (2015, August 31). Relationships between nurses and


physicians matter. The Online Journal of Issues in Nursing, 20(3).

http://dx.doi.org/10.3912/OJIN.Vol20No03PPT03

Spreitzer, G., & Cameron, K. (2011). The Oxford handbook of positive organizational

scholarship. New York, NY: Oxford University Press.

Suter, E., Deutschlander, S., Mickelson, G., Nurani, Z., Lait, J., Harrison, L., Jarvis-Selinger, S.,

Bainbridge, L., Achilles, S., Ateah, C., Ho, K., & Grymonpre, R. (2012). Can

interprofessional collaboration provide health human resources solutions?

A knowledge synthesis. Journal of Interprofessional Care, 26, p. 261-268.

Trepanier, S., Early, S., Ulrich, B., Cherry, B. (2012). New graduate nurse residency program:

A cost-benefit analysis based on turnover and contract labor usage. Nursing

Economic$, 30(4), p. 207-214,

Twigg, D., & McCullough, K. (2014). Nurse retention: A review of strategies to create and

enhance positive practice environments in clinical settings. International Journal

of Nursing Studies, 51, p. 85-92.

Ulrich, B., Krozek, C., Early, S., Ashlock, C. H., Africa, L. M., & Carman, M. L. (2010,

December). Improving retention, confidence, and competence of new graduate nurses:

Results from a 10-year longitudinal database. Nursing Economics, 28, 363-375. Retrieved

from https://www.nursingeconomics.net/ce/2012/article28363375.pdf

Valentine, M., Nembhard, I., Edmondson, A. (2013). Measuring teamwork in health care

settings: A review of survey instruments. Medical Care, 00, p. 1-15.

Vega, C. P., & Bernard, A. (2016, February 11). Interprofessional collaboration to improve

health care: An introduction. Medscape. Retrieved from

http://www.medscape.org/viewarticle/857823


Weller, J., Shulruf, B., Torrie, J., Fregley, R., Boyd, M., Paul, A., Yee, B., & Dzendrowkyj, P.

(2013). Validation of a measurement tool for self-assessment of teamwork in

intensive care. British Journal of Anesthesia, 111(3), p. 460-467.

doi:10.1093/bja/aet060.

Williams, J. (2014). Potential benefits of relationship continuity in patient care. British Journal

of Nursing, 23(5), p. S22-S25.

Xiangiong, F., Bobay, K., & Weiss, M. (2008). Patient safety culture in nursing: a dimensional

concept analysis. Journal Of Advanced Nursing, 63(3), 310-319.


Appendix A

Communication for permission to use the Relational Coordination survey

From: Lindberg, CurtSent: Monday, May 23, 2016 6:07 PMTo: Block, DaniaSubject: Re: RC surveyNo, we are members of the Relational Coordination Research Collaborative (RCRC) and no further permission is necessary.CurtSent from my iPhoneOn May 23, 2016, at 5:52 PM, Block, Dania <[email protected]> wrote:

Hi Curt,Do I need to get permission from anyone (like Jody or the RCRC) to use the RC survey for work conducted in my capstone project? Thanks.Dania Dania Block RN BSN CNMLDirectorMedical-Surgical ServicesBillings [email protected] 781


Appendix B

Workshop agenda for Nurse Residency faculty formal education

Relational Coordination Primer – Nurse Residency FacultySeptember 14th, 2016

7:15 – 8:00 am

Time

Topic Notes

7:15 Opening Remarks RC is about ingredients of good teamwork. Don’t shy away because of academic sounding name. You’ll find you know more about the ingredients of collaboration than you realize

7:20 Stories of Great Teamwork

In small groups of 4-5 people invite someone to tell a story about great collaboration and teamwork. The other group members play the role of journalists. Ask probing questions – tell me more about this, who was involved, what seemed to support the good teamwork, can you clarify this, etc.

7:30 Primer on Relational Coordination

§ Genesis of RC – Gittell’s airline research§ The 7 dimensions§ Summary of RC research in healthcare§ Couple quick stories that illuminate change inspired by RC dimensions and the difference improved RC made in important outcomes (i.e., timely rehab services in ICU, early morning rounds and extubation)§ How RC has spread at the Clinic

7:40 Making Sense of Stories Through 7 RC Dimensions

§ Small groups reconvene and asked to reexamine stories for presence/absence of RC dimensions§ Circulate handout with 7 dimensions and example of survey questions and results§ Reflections on the stories and a bit about a few stories shared with the full group

7:55 Thoughts on Using Relational Coordination

§ Ask for suggestions about how RC could be used/spread to their departments or the organization§ Circulate Billings Clinic RC book chapter to those interested

Note: Cycle of storytelling, RC orientation and interpretation of stories using RC dimensions, all in small groups, worked very wellHandouts:§ Four RC slides with survey results examples§ Gittell book chapter about Billings Clinic’s early RC effortsRoom Set-up & Equipment:§ Circle of chairs


§ Flip chartAppendix C

New Nurse Residency formal education on RC concepts

Relational Coordination – New Nurse Residency Workshop PlansSeptember 28th, 2016

08:00-10:00 am

Time Topic Notes

1:30

(15 min)

Stories of Great Collaboration

Use brief version of Appreciative Interviews to get participants engaged and talking about their experiences with great teamwork.

1:45

(20 minutes)

Celebrity Interview of Dania Block

Cheryl interviews Dania and asks for questions from audience

2:05

(30 min)

Relational Coordination Mapping

Use process to acquaint participants with RC, identify key relationships they may be involved in as the bedside nurse. Ask participants to base assessment on relational coordination dimensions.Do this work in 3 or 4 small, mixed groups.Share maps and reflect on what they show.

2:35

(15 min)

Some Background on Relational Coordination and What’s Going on at Billings Clinic

Provide additional background on Relational Coordination theory and association with outcomes in healthcare.Curt reviews RC activities at Billings Clinic.Conclude by asking attendees to reflect on what they’ve learned about RC, their own experiences with teamwork, and the RC maps they created. What did they notice? What struck them?

2:50

(15 min)

Does It Make Sense to Use Relational Coordination to Enhance Teamwork?

Invite participants to share questions, concerns about possible use of RC in the bedside setting. Ask them for thumbs up/down. Make it clear it is their decision.

3:05

(30 min)

If Yes, Plan Next Steps Use 1-2-4-All process to plan initial steps.

Handouts:· Four RC slides with survey results examples· Gittell book chapter about Billings Clinic’s early RC effortsRoom Set-up & Equipment:


· Circle of chairs· Access to wall space where 4 small groups can meet and construct RC maps· Flip chart (with self-stick paper or masking tape)· Markers (with at least four colors in each)· Refreshments


Appendix D

Liberating Structures


Appendix E

Relational Coordination Toolkit Communication Game

Building Communication Skills Game

By Lyndsay Swinton

Effective communication in business is essential. Use this fun communication skills game to improve communication within your team.

Communication Skills Game Purpose - to illustrate the importance of clear communication, and allow the group to explore their communication style and make improvements as necessary.

Materials and Preparation - 2 matching sets of children's building blocks (e.g. Lego), with 10 blocks and 1 baseboard in each set. Using one set of blocks, build a random object using the 10 blocks, onto the baseboard. Optional - 2 bags to contain each set of building blocks.

Time - 45 mins

Group Size - minimum 3 people, up to about 7. (You can have duplicate exercise running in parallel if group is larger, but will need more sets of building blocks).

There are 4 roles in this communication skills game.

Person A - director Person B - runner Person C - builder Person(s) D - observer(s)

Person A is given the built-up set of blocks, and is the only person who can see the object. It is the director's job to give clear instructions to person B, the runner, so that person C can build an exact replica of the model.

Person B listens to the director's instructions and runs to a different part of the room to where person C is sitting. The runner then passes on the building instructions, without seeing the building blocks, to Person C, the builder. The runner can make as many trips as required within the time allowed for the exercise.

Person C listens to the runner's instructions and builds the object from the set ofbuilding blocks. The builder is the only person who can see the object under construction, and building materials.

Person(s) D observe the communication game, and make notes about what works, what doesn't work, and how people behaved under pressure etc., to pass onto the group later. Set a time limit for the exercise of 10 minutes.


When the time is up, allow the group to compare the model and the replica, and see how closely it matches. Generally, the replica will bear little resemblance to the original, which usually causes heated discussion!

Allow the group to reflect on how the exercise went, and agree 1 thing they did well, 1 thing that didn't work, and 1 thing they would do better next time.

Run the exercise again, either switching or keeping original roles, and see if any improvements have been made. Make sure you de-construct the "original" model and create a new design!

This simple communication skills game can be run many times without losing learning potential. Teams can add layers of sophistication to their communication by making use of aids such as diagrams, codes, standard procedures and using active listening techniques.

By Lyndsay Swinton Owner, Management for the Rest of Us


Appendix FRelational Coordination Toolkit Visual Tools



Appendix G

Relational Coordination Overview Handout for RC Toolkit

An overview of relational coordination Adapted from “New Directions for Relational Coordination Theory” by Jody Hoffer Gittell

Published in “Oxford Handbook of Positive Organizational Scholarship,” eds. Kim Cameron and Gretchen Spreitzer, Oxford University Press (2011).

Dimensions of relational coordination

Relational coordination theory makes visible the social processes, the human interactions

that underlie the technical process of coordinating complex work. It describes the management of

interdependence not only between tasks but also between the people who perform those tasks.

Relational coordination theory starts by conceptualizing the coordination of work as taking place

through a network of relationships among participants in a work process. The theory specifies

three attributes of relationships that support the highest levels of coordination and performance:

§ shared goals that transcend participants’ specific functional goals

§ shared knowledge that enables participants to see how their specific tasks interrelate

with the whole process, and

§ mutual respect that enables participants to overcome the status barriers that might

otherwise prevents them from seeing and taking account of the work of others.

These three relational dimensions reinforce and are reinforced by specific dimensions of

communication that support coordination and high performance, namely frequency, timeliness,

accuracy and, when problems arise, a focus on problem-solving rather than blaming. Knowledge

of each participant’s contribution to the overall work process enables everyone to communicate

in a timely way across functions, grounded in an understanding of who needs to know what,

why, and with what degree of urgency. Shared knowledge also enables participants to


communicate with each other with greater accuracy, based on an understanding of how their own

tasks relate to the tasks of others functions. Shared goals increase participants’ motivation to

engage in high quality communication and predispose them towards problem solving rather than

blaming when things go wrong. Mutual respect increases the likelihood that participants will be

receptive to communication from their colleagues irrespective of their relative status, thus

increasing the opportunity for shared knowledge and problem solving. This mutual

reinforcement between relationship and communication forms the basis for coordinated

collective action. The relational dimensions of relational coordination are not personal

relationships of “liking” or “not liking” but rather are task-based relationship ties. They are

conceptualized as ties between work roles rather than personal ties between discrete individuals

who inhabit those work roles.

Approach

A relational approach to coordination is more effective than more mechanistic

approaches, enabling participants to achieve better results for customers while engaging in less

wasteful and more productive utilization of resources. How? In contrast to the traditional

bureaucratic form of coordination that is carried out primarily by managers at the top of

functional silos, relational coordination is carried out via direct contact among workers at the

front-line, through networks that cut across functional boundaries at the point of contact with the

customer. Relational coordination improves performance of a work process by improving the

work relationships between people (shared goals, shared knowledge, mutual respect) who

perform different functions in that work process, leading to higher quality communication. Task

interdependencies are therefore managed more directly, in a more seamless way, with fewer

redundancies, lapses, errors and delays. Relational forms of coordination are particularly useful


for achieving desired performance outcomes under conditions of reciprocal interdependence,

task and input uncertainty and time constraints. When tasks are reciprocally interdependent the

actions of each participant affect and are affected by the actions of others. It takes a high degree

of relational coordination for participants to be able to mutually adjust their actions in response

to each other’s actions and outcomes. When task and/or input uncertainty is high, relational

coordination becomes even more important, enabling participants to adjust their activities with

each other “on the fly” as new information emerges in the course of carrying out the work.

Finally, as time constraints increase, as in high velocity environments, relational coordination is

essential for enabling participants’ rapid real-time adjustments in response to each other and to

newly emergent information without wasting additional time to refer problems upwards for

resolution.

Organizational structures

Relational forms of coordination are fundamentally shaped by organizational structures.

In organizations with traditional bureaucratic structures that tend to reinforce functional silos,

relational networks exhibit strong ties within functions and weak ties between functions,

resulting in fragmentation and poor handoffs among participants at the front-line of production

or service delivery. In contrast, organizations with structures that foster relational coordination

build cohesiveness and broader contextual awareness (participants’ awareness of how their work

fits into and influences the larger whole). Such structures include the selection of participants

based on their capacity for cross-functional teamwork, measurement and reward systems based

on team performance across functions, venues for proactive cross-functional conflict resolution,

work protocols that span functional boundaries, and job designs that feature flexible boundaries

between areas of functional specialization and boundary spanning roles to support the


development of networks across functional boundaries. These crosscutting structures represent a

redesign of traditional bureaucratic structures, and together they constitute a relational work

system that strengthens cross-functional networks of relational coordination without sacrificing

the benefits of the division of labor. Relational coordination theory calls for the redesign rather

than the replacement of formal structures, specifically redesigning these structures to reinforce

and strengthen relational processes across functional boundaries where they tend to be weak. In

so doing, relational coordination theory contributes to the development of high performance

work systems that strengthen the ability of employees to manage their own handoffs and work

interfaces. Such systems are distinct from but complementary to other high performance work

systems that reinforce employee commitment to the organization or that build individual

employee knowledge and skills.

Outcomes

Though relational coordination theory is at a relatively early stage of development, a

considerable body of research-based evidence already backs it. Findings thus far support the

empiric coherence of the concept of relational coordination and the internal and external validity

of the Relational Coordination Survey. Moreover, research findings thus far suggest that the

strength of relational coordination ties among participants in a work process predicts an array of

strategically important outcomes including quality, efficiency, customer satisfaction and

workforce resilience and well-being. In healthcare studies specifically, relational coordination

scores are significantly correlated with increased quality; shorter length of stay; improved patient

satisfaction, staff satisfaction, and staff resilience; and improved clinical outcomes (e.g. pain and

functional status 6 weeks after knee and hip replacement).

Appendix H


Relational Coordination Improvement Plans

It is not possible to anticipate what improvement strategies are indicated or how to

maximize changes based on results without first soliciting ideas from the nursing staff or before

knowing survey results. However, to offer an interpretation of the types of actions that may

emerge from the results, here are examples of what has been achieved in other healthcare

organizations:

· Train staff in facilitating meetings and use processes to engage staff

· Provide more opportunities and time for staff to participate in learning activities, like case

conference, that are broadly interdisciplinary and help build relationships

· Train staff in crucial conversation skills

· Include more representatives from other disciplines in regular meetings and task forces

· Offer targeted educational workshops

· Increase participation of staff in discussions about key issues and goal setting

· Recruit staff with well-developed collaborative skills

· Create protocols that highlight the roles and importance of contributions from a variety of

professional disciplines

Appendix I


Relational Coordination RAIL


Appendix J

Nurse Residency Curriculum

Sample Agenda:

Session # When/Hrs Scheduled Topics Credits 2016 2017

Session 1(W1D1)Clinic Meeting Rm (AM) Sim Lab PM Computer lab available

Thursday 8 hours

Welcome, Icebreakers, Expectations, Overview, Research, Role Transitions, Sim101, Baseline Scenario, Self-Assessments, Review MS StandardsDebrief

7 July 21July 28Aug 11Sept 1Oct 6Nov 3Dec 15

Feb 9Feb 23April 6May 4June 1July 21July 23Sept 11Oct12Nov 16

Session 2(W1D2)Sim Lab all day

Friday8 hours

Head to Toe AssessmentsUnit RoutinesSBARAbnormal Head to ToeSkills StationsDebrief

7.5 July 22July 29Aug 12Sept 2Oct 7Nov 4Dec 16

Feb 10Feb 24April 7May 5June 2July 21July 28Sept 12Oct


13Nov 17

Session 3(W2D1)Sim Lab all day

Monday8 hours

DebriefAbnormal RespiratoryIS useMedsRT skillsChest Tube ManagementTrach Care/LaryngectomyCPAP/BiPapIV/Lab draw experience

7.5 July 25Aug8Aug 15Sept 5Aug 9Nov 7Dec 19

Feb 13Feb 27April 10May 8June 5July 24Aug 7Sept 18Oct 16Nov 20

Session 4(W2D2)

Tuesday4 hours

MD Office/IV experience 0 credit (not education)

July 26Aug 9Aug 16Sept 6Oct 10Nov 8Dec 20

Feb 14Feb 28April 11May 9June 6July 25Aug 8Sept 19Oct 17Nov 21


Session 5(W3D1)Sim labDebrief RoomOr Conference Room

Monday8 hours

DebriefCardiac-Irr HRMeds/LabsRemote TeleChanges in Pt ConditionCAT – Role and CallingDocumentation IssuesFirst 5 Minutes of CPR

7.5 Aug1Aug22Sept 12Oct 16Nov 14Dec 26

Feb 20Mar6April 17May 15June 12July 31Sept 25Oct 23Nov 27

Session 6(W3D2)8:30-10:30Clinic Room10:30-12:30 Sim Lab

Tuesday4 hours

DebriefPrioritizationDelegationIsolationFalls

4 hours Aug 2Aug 23Sept 13Oct 18Nov 15Dec 27

Feb 23 Mar7April 18May 16June 13Aug 1Sept 26Oct 24Nov 28

Session 7M2Clinic Room or HCC

Monthly4 hours

DebriefACESResiliencySelf-CareMindfulness

4 hours Aug 31Sept 21Dec 21

Mar 15June 7Aug 30Dec 20


Session 8M3ComputerLab OpenTests?

Monthly4 hours

DebriefRelational Coordination and Care CoordinationOversedation (Narcan)EtCO23 Month Assessments

4 hours Sept28Jan 18

Jan 18Apr 12July 5Sept 27

Session 9M4Sim Lab

Monthly4 hours

DebriefNeuro (Braces)Pain (opioid naïve)TeamStepps

4 hours Oct 26

Feb 15May 17Aug 2Oct 25

Session 10M5SimLab

Monthly4 hours

Debrief (Generational Differences)GI/Wound/Ostomies (not AM)TRALICalling MDs

4 hours Nov 30

Mar 22June 14Sept 6Nov 29

Session 11M6Computer Lab Tests

Monthly4 hours

Debrief (Cultural Diversity) DM/Sepsis Case StudiesCI troubleshootingCPI6 month Assessments

4 hours Dec 28

April 19July 12Oct 4Dec 27

Session 12M7Classroom

Monthly4 hours

Debrief (Personal Accountability)End of Life/GerontologyCompassion FatigueEthics (Atul)

4 hours -- Jan25May 24Aug 9Nov 1

Session 13M8

Monthly4 hours

Debrief (Lateral Violence)

4 hours -- Feb 22


Classroom Finding Your VoicePN PuzzleResearch 101Project Identification

June 21Sept 13Dec 6

Monthly4 hours

Debrief (Professional Dev)5 yr plan (Portfolios)Teamwork CPRs teamQI work

4 hours -- March 29July 19Oct 11


Monthly4 hours

Debrief (communication)Nursing/Healthcare EthicsCoaching/Mentor OthersDifficult Communication

4 hours -- Apr 22Aug 16Nov 8


Monthly4 hours

Debrief (Leadership)Next StepsLeadershipPutting it all together

4 hours -- May 31Sept 20Dec 13

Session 17M12ClassroomSim LabTests

Last Monthly4 hours

Debrief (Wrap Up)Simulation FinalData Collection FinalProjects/EBP/Posters/Case StudiesGraduation Ceremony

1 hours -- Jun 22Oct 18


Appendix K

Relational Coordination Survey Tool

Frequent Communication How frequently do people in each of these groups communicate with you about the learning experiences of the Nurse Residency Program?

Timely Communication How timely is their communication with you about the learning experiences of the Nurse Residency Program?

Accurate Communication How accurate is their communication with you about the learning experiences of the Nurse Residency Program?

Problem Solving Communication When there is a problem with the learning experiences of the Nurse Residency Program, do they blame others or work with you to solve the problem?

Shared Goals Do people in these groups share your goals for the learning experiences of the Nurse Residency Program?

Shared Knowledge Do people in these groups know about the work you do with the learning experiences of the Nurse Residency Program?

Mutual Respect Do people in these groups respect the work you do with the learning experiences of the Nurse Residency Program?


Appendix L

Relational Coordination Commitment


Appendix MEvaluation of RC Toolkit from NRP residents


Appendix NLetter of Support


Appendix OIRB Application






University of MaryINSTITUTIONAL REVIEW BOARD

Part 2: Human Subjects Review

1. PURPOSE FOR THE PROJECT: The purpose of the relational coordination (RC)evidence based practice (EBP) project is to assist a healthcare organization with implementation of RC into the curriculum of a nurse residency program (NRP). The project setting will be the NRP of a 280-bed hospital with a service area of 500 miles in the upper mid-west. The organization’s Chief Nursing Officer (CNO) has expressed a need to integrate RC into the organization’s culture. Integration of RC concepts has proven time and resource exhaustive due to the limited internal RC experts within the organization available to provide education. The organizational leadership presses forward in their quest to be a national leader in quality, safety, service, and value, and through this EBP project they have chosen to take on the Institute of Medicine’s recommendation to improve coordination of the delivery of healthcare. The development and incorporation of a RC toolkit within the NRP curriculum could help meet the organization’s needs to retain nurses, improve job satisfaction and improve patient outcomes. This is an EBP project as identified in Part 1 of the application. The projected outcome of this project is to introduce RC concepts into the NRP curriculum to aid communication and teamwork. The UMary Graduate EBP Project Team expects this addition to the learning and onboarding process for newly licensed registered nurses to improve nurse retention, and intent-to-stay through focused education of soft skills in the work environment. The development of a RC toolkit for the nurse residents of the NRP may positively impact the coordination of care through learning how to develop and foster professional working relationships early in their career. It is hoped that the nurse residents will then become an RC vessel carrying these skills with them into the work environments. The foundation of RC is the coordination of work through collaborative relationships. Research in RC began in the airline industry and extended into healthcare in 2000. Research findings consistently show coordination of care among healthcare disciplines is enhanced when staff share knowledge and goals, treat each other with mutual respect, and communicate frequently, timely, and accurately, while focused on problem solving in the absence of blame. Outcomes of the RC project could affect a variety of quality measures within the organization, including but not limited to length of stay, readmission rates, and patient and staff satisfaction. Relational coordination is measured through a seven-item RC questionnaire that will be used with this EBP project. 2. PROTOCOL: The host organization fully supports the UMary Graduate EBP Project Team. Attached is a letter of support written by the organization’s CNO.


The project participants will be newly licensed nurses enrolled in the NRP. The NRP nurses will be hired by the medical/surgical/oncology/cardiovascular units of the host organization. A UMary Graduate EBP Project Team member is highly involved as a leader within the organization in the NRP curriculum. The UMary Graduate EBP Project Team is scheduled to meet with the organization’s team of Executive Directors, Directors, and CNO on August 11th, 2016. This meeting will utilize a professional presentation by members of the UMary Graduate EBP Project Team to discuss the theory of RC, the impact of leadership support for RC, as well as addressing the RC toolkit implementation plan. A formal meeting invitation will be sent to the three NRP faculty members, scheduled for September 14th, 2016, to address educational objectives that will be utilized in a practice format as a means to “train the trainer”. Additional exercises will be determined from this initial educational phase and will guide subsequent training sessions. After the faculty has been sufficiently prepared per their own verbalized perception of competence in RC concepts, the NRP curriculum will incorporate the RC content as an additional mechanism for learning the soft skills associated with care coordination, communication, and teamwork. The curriculum has been developed by the host organization’s NRP faculty. The first exposure to the RC concepts for the nurse residents will occur on September 28, 2016 during a two-hour introduction on team building and RC. This two-hour introduction will be facilitated by a member of the UMary Graduate EBP Project Team with assistance from the NRP faculty. Ongoing feedback from the nurse residents to the faculty through the RC Survey Tool will help guide future NRP cohort curriculum development. 3. BENEFITS: The participants in this EBP project are the newly licensed nurse residents enrolled in the NRP and the NRP faculty. Individuals involved in this EBP project will not experience any personal benefits other than the satisfaction that they have participated in a project that may benefit patient care. The benefits of this EBP project will affect the newly licensed nurse residents enrolled in the NRP. Additionally, it can be expected that there may be “spillover” effects resulting from the EBP project involving other healthcare professionals of the interdisciplinary team and in patient outcomes. The organization has incorporated a new NRP to aid in nurse retention, with a formal mentorship through the onboarding process of the organization’s culture, values, goals and expectations.


4. RISKS: The participants in this EBP project are the newly licensed nurse residents enrolled in the NRP and the NRP faculty. The risks associated with this project are minimal; because there will be no greater harm than what is already encountered by nurse residents, and other members of the multidisciplinary team in the workplace. In order to mitigate the risks associated with the implementation of the RC toolkit, the nurse manager of each department where the RC toolkit is implemented, and RC group leader, will be in charge of closely following throughout the project implementation phase. The project will also be proposed to the IRB at the host facility for approval for implementation prior to initiating the EBP. Approval by the IRB will ensure there is minimal risk to participants and the project is conducted as stated by those leading the EBP project. 5. USE OF DATA: Internal measurements of nursing retention and vacancy rates will be supplied in aggregate from the host organization and evaluated by the UMary Graduate EBP Team. Retention rates and vacancy data from the 2016 fiscal year will be used as baseline measurements. The retention and vacancy data shared from the host organization will be compared to nurse residents’ retention three months after the RC toolkit implementation. The host organization will establish any additional data collection intervals following project handoff. Currently, the host organization collects monthly internal data to measure nursing vacancies and retention rates. Suggested intervals beyond the initial RC three-month measure are at six months and at one year. The data demonstrating retention numbers and vacancy rates will be delivered to the host organization at the final report. The UMary Graduate Team has been provided the baseline data of nursing retention and vacancies from the host organization. The data will establish a baseline of nursing retention and vacancies pre-implementation of the RC project. Relational coordination has the potential to provide a multitude of benefits to other healthcare organizations, employees, and patients. It is the hope of the UMary Graduate EBP Team that the infusion of RC into the NRP curriculum will enhance communication and teamwork at the bedside, improve nurse retention, diminish vacancies, and demonstrate a high intent-to-stay for the newly hired RNs. This method of interdisciplinary interaction creates a structure of superlative communication affecting the delivery of high quality care to patients. It is also anticipated that there may be an obvious improvement to job satisfaction and enhanced working relationships that can be assessed throughout the organization’s already existing staff satisfaction surveys.


6. CONSENT FORM: This EBP project is an organizational initiative. Employees who are affected by recommendations of the project are expected to participate, thereby removing the choice to participate; therefore, informed consent is unable to be collected.


University of Mary INSTITUTIONAL REVIEW BOARD

Part 3: Human Subjects Informed Consent

This EBP project is an organizational initiative. Employees who are affected by recommendations of the project are expected to participate, thereby removing the choice to participate; therefore, informed consent is unable to be collected.


University of MaryINSTITUTIONAL REVIEW BOARD

Human Subjects ReviewPart 4: Institutional Review Board Action

Project Title: Relational Coordination Project ID#: ____________

Project Advisor/Principle Investigator: Claudia Dietrich/Dania Block

______The Institutional Review Board approves this project for the ethical use of human subjects.

Additional Comments:

______The Institutional Review Board does not approve the proposed project based on the following reasons:

Recommendation:

Signatures:

________________________________________ ______Approve ____Not ApprovedIRB Chair Date ________________________________________ ______Approve ____Not ApprovedIRB Member Date ________________________________________ ______Approve ____Not ApprovedIRB Member Date ________________________________________ ______Approve ____Not ApprovedIRB Member Date ________________________________________ ______Approve ____Not ApprovedIRB Member Date

From: Carol Olson Sent: Monday, August 22, 2016 5:22 PM


To: Claudia M. DietrichCc: Billie MadlerSubject: Re: OFFICIAL COMMUNICATION: IRB 639082216 Relational Coordination August 22, 2016 Claudia DietrichUniversity of MarySchool of Health Sciences RE: IRB Proposal 639082216 Relational Coordination Dear Investigator, The University of Mary Institutional Review Board has reviewed the above referenced study. The chair has determined that this study is being conducted for the purpose of action research in cooperation with a sponsoring organization and therefore, qualifies for exemption status. If no changes in protocol are made, the IRB authorizes this study as exempt action research. This exemption is valid for 12 months from today’s date. Conditions of Approval: There are six (6) conditions attached to all approval letters. All six conditions must be met, or the IRB’s approval may be suspended.

1. No subjects may be involved in any study procedure prior to the IRB approval date or after the expiration date. (Principal Investigators and Sponsors are responsible for initiating Continuing Review proceedings.)

2. All unanticipated or serious adverse events must be reported to the IRB.3. All protocol modifications must be IRB approved prior to implementation, unless they

are intended to reduce risk. This includes any change of investigator or site address.4. All protocol deviations must be reported to the IRB within 14 calendar days.5. All recruitment materials and methods must be approved by the IRB prior to being

used.6. The IRB must be notified upon completion of the project.

Principal investigators are responsible for making sure that studies are conducted according to the protocol and for all actions of the staff and sub-investigators with regard to the protocol. As a principal investigator, you may have multiple and possibly conflicting responsibilities to the IRB, the research subjects, and any sponsor. If you have any questions or concerns about this approval, please contact the Assistant Vice-President for Academic Affairs, the IRB Chairperson, in the Office of Academic Affairs.Carol H. Olson, PhD, OTR/L, FAOTAProfessorChair, Institutional Review BoardUniversity of Mary7500 University Dr.Bismarck, ND 58504


T: 701-355-8156F: [email protected]


Appendix P

Billings Institutional Review Board Letter of Exempt Status


Appendix Q

Email receipt of exempt status from Billings Clinic Nursing Research Council


Appendix R

Relational Coordination Power Point Presentation

Documents

kierraknox.files.wordpress.com · Web viewThe University of Mary Relational Coordination Project Team (UMary Graduate EBP Project Team) would like to acknowledge the following people