Different strokes for different folks? Staff perceptions of team functioning in Ontario Community Health Centres
Jennifer Rayner Laura Muldoon Ontario Community Health Research Rounds January 21, 2015
Details COI - Investigators are employees of CHCs Funding from University of Ottawa Department of
Family Medicine Research Funding Program Ethics from Ottawa Health Sciences Research
Network and Bruyère Continuing Care
What are PC teams? Inter-professional teamwork in PHC is a
priority in Canada2 Know more about who team members are
than what they do or how they work together.3 Membership of PC teams vary widely
depending on the setting2 Care is by “the integrated activities of
clinical and non-clinical members of (PC) teams”4
What is team function? Multi-faceted concept and
includes the following5: Processes and psycho-social
traits of the team Links a team’s task design
(types & features of the tasks) Membership of the team Team effectiveness
Is team function important? Quality of team function linked to
innovation and effectiveness in PC6 , technical quality of care.7 Quality of team function may have more
influence over clinical behaviors in PC than individual provider or practice characteristics.8 Aspects of team function can be
improved by certain interventions.9
Why look at CHC teams? Quality of primary care delivered in CHCs is equivalent or
superior to that in other PC models in Ontario.2, 11,12,13 ICES – CHC study “If you’ve seen one CHC, you’ve seen one CHC” Provincial tour – different “feel” to the teams Little is known about CHC PC team function Quebec community-governed practices (some similar to Ontario
CHCs) had lower scores for team climate than professionallygoverned practices14
Previous Research Results Staff Groups & Teams Ontario: admin staff reported “suboptimal” team climate
more than GPs.14 US CHC physicians dissatisfied with high workloads and
administrative management.15,16 No literature on how other team members view team
functioning Organizational Features & Teams Leadership, professional governance, solo practice,
certain team cultures are associated with better team function No association previously found with size of the team or
number of sites (in PC)
Our Questions... How do CHC staff rate the
functioning of their teams? Are there differences between
different groups of staff in how team function is perceived? Are there differences between
different CHC organizations? Are there organizational features
which can explain the differences?
Methods Cross-sectional, part of proposed larger study Ethics – OHSRN/Bruyère REB All 75 CHCs invited PHC director completed organizational survey ED distributed on-line survey to PC staff ``any person who provided or supported the provision of
clinical care on a regular basis” (including administration & reception)
Organizational Survey ď‚— Adapted from CIHI ď‚— Number of sites, staffing, size,
priorities, means of communication, rurality, years of operation, patient demographics
Staff Survey ď‚— Descriptive (professional
role, full-time status, number of years employed at the CHC , working offsite from the main clinic) ď‚— 3 different scales
Team Climate Inventory Team Climate: shared
perceptions of policies, practices & procedures within team Short, validated 14 item
version Vision Innovation Participative safety Task Orientation
Organizational Justice Assesses perceptions of fairness, equity & respect Procedural Justice (PJ) – 7 items (perceived fairness) “Procedures are in place to generate standards so
that decisions can be made with consistency” Interactional Justice (IJ) – 6 items (politeness, dignity
& respect) “Primary health care team members consider your
viewpoint.”
Organizational Citizenship Behaviour
Perceptions of the presence of work related behaviors that are: discretionary not related to the formal reward system in the aggregate promote the effective functioning of the
organization.20 13 items “Help each other out if someone falls behind in his/her
work”
Analysis Staff characteristics Responses stratified by staff group (manager, physician, NP,
registered nurse, medical secretary, allied health, counselor, outreach, admin assistants) One-way Anova to determine overall difference in team
climate, organizational justice and citizenship behaviour between the different provider groups. Bonferroni posthoc analysis based on apriori hypothesis
Organizational characteristics Linear regressions relating organizational features with the various
measures of team function
Overall Results 58 CHCs (77.8%) 674 staff physicians, NPs, nurses – 57% of the respondents
Excluded “system navigators”
due to low numbers
100
CHC Staff (Ontario)
90 80 70
%
60
Yrs x10 FT (%)
50 40 30 20 10 0
NP
MD
Nurse
SW
Allied
Out
MOA
AA
Mgr
Results One way ANOVA – significant
difference between staff groups on mean scores for: Procedural Justice (p= 0.01) Total TCI (p=0.03) Innovation subscale of TCI
(p=0.011)
Team Climate Inventory 5.6 5.5 5.4 5.3 5.2 5.1 5 4.9 4.8 4.7 4.6
NP
Physician Nurse
SW
Allied Outreach
Sec
AA
Manager TOTAL
Organizational Justice 5.6 5.4 5.2 5 4.8 4.6 4.4 4.2
Physician
Nurse
Allied
Secretary
Manager
Organizational Citizenship Behaviour 5.4 5.3 5.2 5.1 5 4.9 4.8 4.7
Physician
Nurse
Allied
Secretary
Manager
Differences between groups
PJ - Organizational level results
Organizational features & team function ď‚— Association ONLY between
higher number of sites and lower team function. (TCI and OJ p<0.05) ď&#x201A;&#x2014; The different measures of team
function were highly correlated at the organizational level
1
0.5
OCB
IJ
0
TCI
OJ
PJ IJ OJ TCI OC B
Discussion TCI ratings similar to other Canadian PC studies.7,21 Citizenship behaviour and organizational justice within the range of results
reported in other settings.8,22, 23 Similar views of vision and mandate of CHC, work well together, help
each other Differences between staff types for TCI, “innovation” and PJ Different expectations?
TCI link to patient-reported access, continuity, quality of diabetes care,
patient satisfaction BUT not in every study. Recent Quebec study “modest” association between TCI and technical
quality of care
Procedural Justice NPs & physicians significantly lower than admin staff &
nurses PJ linked to improved quality of diabetes care8, better
glycemic control 22 more job satisfaction among physicians and nurses 26,27 Perceived injustice linked with poorer quality, lower
productivity of health care work 28,29 stress-related disorders among staff30
Why the different PJ ratings? CHC model – managers manage Providers don’t Many managers MAY be from nursing background? NP and physician have different expectations? MD unhappy about management in US CHCs NP unhappy about division of labour on team? NP unhappiness about wages? Part-time employees rate team higher, more resistant to change24,25 Longer duration of employment – effect? Medical secretaries left many questions unanswered – questions too
clinical? Or didn’t feel they were part of the team?
Organizational features CHCs have many organizational features in common, such as
community governance, inter-professional teams, model for remunerating staff and leadership model. Staff of a team spread across many sites may not feel cohesive,
may rate TCI and OJ lower for the entire team. (Future: assess as separate entities the “teamlets” that make up multi-site teams.)
Strengths/Weaknesses 77% CHCs participated Lots of staff – BUT no denominator Validated instruments
Conclusion All staff had positive ratings of team climate, organizational
justice and organizational citizenship behaviours Physicians and NPs had lower ratings for procedural justice. Procedural Justice has been shown to be very important in
other settings, and may be amenable to improvement through interventions. The only Org feature relating to function was number of sites
Next steps Qualitative study Working on defining the
question Differences in PJ due to
expectations of NP& MD... systematic silencing...or both? Will choose high and low
performing sites for interviews Staff of different types
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