Over the past two decades, team-based care models have advanced the delivery of primary care.1 Primary care teams consist of two or more professionals and staff who share the goal of delivering high-quality, patient-centred care to patients and their families through collaboration and coordination.2 In general, teamwork requires each member to have role-specific competence, a shared structure to work within, and 'coordinative and adaptive capabilities'.3 Their ability to work together depends on their collective development: team training enhances team performance.4 Teams that lack common goals, leadership or training experiences present a particularly complex undertaking.2, 3 … teamwork requires each member to have role-specific competence, a shared structure to work within, and "coordinative and adaptive capabilities" Over the last 45 years, the need for interprofessional team-based training for health professions has been well documented.5 Effective team training is tailored to the specific tasks, behaviours and relationships of a health care team.5 Although there are important examples of team training in health care, they do not address the specific characteristics of primary care teamwork in the context of existing resources and culture.5 Much has been learned about primary care teamwork from the patient-centred medical home (PCMH), a team-based one-care model implemented extensively in the USA. This approach honours the tenets of primary care – comprehensive, coordinated, accessible and continuous – as well as emphasising the importance of the personal relationship between a patient and the care team members.6 The PCMH has led to improvements in patient experience, care quality, cost and team member well-being.1 Several group practices have been shown to promote team performance: goal specification, a shared understanding of team roles, quality improvement (QI) skills, team coordination, relationship-centred communication and adequate meeting time.7-10 A straightforward framework to learn, assess and improve primary care teamwork would be a valuable tool for medical professionals and trainees to learn team-related competencies. In this article, we describe a conceptual model that integrates principles of primary care team performance with research on what constitutes effective teamwork. We suggest strategies for how learners, faculty members and other stakeholders can use the model to enhance primary care team practice, training and assessment. In 2010, the Veterans Administration (VA; provides near-comprehensive health care services to eligible military veterans) adopted the PCMH care model in 900 primary care clinics. We developed the Conceptual Model of Primary Care Team Performance (CM of PCTP) at a VA demonstration site for PCMH implementation. Our workgroup includes two VA clinician-educators with team-based practice expertise in patient-centred communication and social scientists with experience in teamwork, quality improvement, coaching, and innovation development and assessment. We selected the evidence-based 'Integrative Framework of Team Effectiveness' as our starting point because of its validity and flexibility to include primary care practice characteristics.11 This framework is a synthesis of 138 models of teamwork from organisational development experts. It includes the four traditional constructs of teamwork: inputs, team performance, outputs and culture. Developers of this framework intended it to be adapted to many fields, and to serve as a foundation for team performance evaluation, the testing of new hypotheses and designing effective team training interventions. As shown in Figure 1, our model combines the key constructs of teamwork with characteristics relevant to a team-based primary care practice. Each aspect of this model contributes to what helps a team work well together, and requires a different set of knowledge and skills. Team performance in the central oval represents the essential processes that occur as a team works to coordinate patient care (Figure 1). It incorporates three related domains of team performance with effective aspects of primary care such as patient–team partnership, data-driven improvement, planned opportunities for team communication and population management.5, 9 Inputs (left side of the model) are the structural features of a team-based care model determined by practice leadership. Patient demographics define the types, roles and staffing needed on the team, as well as expected outputs of team performance. Work demands are influenced by a team's panel size, patient complexity, and level of clinical staffing.1, 5 Health professions trainees are frequently integrated into the teams; they can contribute to patient care, but may also place extra demands on team members. Outputs (right side of the model) are measurable outcomes that drive team performance and serve as benchmarks to monitor a team's care and improvement efforts. Clinical teams must be aware of and work towards relevant goals and outcomes. Patient experience, population health and cost are widely accepted as important aims of health system performance.16 Successful teamwork also contributes to individual and team viability and happiness, as reflected in measures of job satisfaction, stress, burnout and retention.17 Team perceptions of their own cohesion can provide valuable feedback on how they are working together.18 A relationship-centred culture (bottom of the model) describes the optimal work environment to promote team performance. Important contributors to culture are leadership style, performance mandates, work demands, staffing, autonomy and acceptable patterns of communication.8, 17 Patient-centredness, psychological safety, a mindset for change and reflective capacity are characteristics of a relationship-centred culture.5 These play an important role in the satisfaction, well-being, and learning ability of teams and individuals.19 A straightforward framework to learn, assess and improve primary care teamworkwould be a valuable tool for medical professionals … to learn team-related competencies We propose that the CM of PCTP can be easily recalled and applied in three categories: meeting practices – team members coordinate their work during effective meetings; task work – team members value patient-centred care, perform their roles and strive for continuous improvement; and teamwork – team members communicate with honesty and respect, and value relationships with team members. Both new and existing clinical teams can use this simple three-part framework of team performance to stimulate the quick recall of what constitutes team performance, and as a starting point to assess and improve their own team performance. The Conceptual Model of Primary Care Team Performance combines key constructs ofteamwork with characteristics of a primary care practice Teaching strategies for teams seeking to initiate or improve team-based education are described in Tables 1 to 3. We propose that the best way for new trainees to learn to practice in teams is to be immersed in a team and to be supported as they learn to practice their professional roles, with workshops to address new skills. Planning for trainees to join a care team is essential and lays the groundwork for effective learning for the whole team (Table 4). The very process of preparing for new learners will inevitably lead to better team-based patient care as team members reflect on their roles, and how and where they work and meet together. Role modelling, observation and feedback by faculty members and team members are key teaching strategies, as is continuing reflection of the care and processes of teamwork. The CM of PCTP will also assist other primary care stakeholders to learn about primary care team performance. Team members and coaches guiding teams to improve their performance can refer to the model to target areas of success and challenge. The model will provide educators with a framework to plan team training curricula and interventions. Evaluators can use the model as a roadmap to develop assessments of care outcomes, team performance, training interventions, and team member well-being. Clinical leaders may find this framework helpful to analyse the effects of changes in the structure of a primary care practice (i.e. team membership, staffing and panel size) on team performance and care outcomes. Finally, all stakeholders can promote team performance and a relationship-centred culture by clearly defining roles, communicating honestly and respectfully, and by planning for effective meetings. In summary, the CM of PCTP acknowledges the complexities of primary care team performance, yet suggests a simplified approach to its components, implementation, evaluation and potential as an improvement tool. We intend it to be used in three ways: (1) as a tool for primary care team members and trainees to readily remember, learn and practice key characteristics of team performance; (2) as a framework for the development of coaching and training interventions for primary care teams; and (3) as a guiding structure to assess and improve a primary care team's performance, care outcomes and team member well-being. … teams must have uninterrupted time and space to build relationships, reflect on howthey work together, and coordinate care

Background: Process improvement stresses the importance of engaging frontline staff in implementing new processes and methods. Yet questions remain on how to incorporate these activities into the workday of hospital staff or how to create and maintain its commitment. In a 15-month American Organization of Nurse Executives collaborative involving frontline medical/surgical staff from 67 hospitals, Transforming Care at the Bedside (TCAB) was evaluated to assess whether participating units successfully implemented recommended change processes, engaged staff, implemented innovations, and generated support from hospital leadership and staff.Methods: In a mixed-methods analysis, multiple data sources, including leader surveys, unit staff surveys, administrative data, time study data, and collaborative documents were used.Results: All units reported establishing unit-based teams, of which > 90% succeeded in conducting tests of change, with unit staff selecting topics and making decisions on adoption. Fifty-five percent of unit staff reported participating in unit meetings, and 64%, in tests of change. Unit managers reported substantial increase in staff support for the initiative. An average 36 tests of change were conducted per unit, with 46% of tested innovations sustained, and 20% spread to other units. Some 95% of managers and 97% of chief nursing officers believed that the program had made unit staff more likely to initiate change. Among staff, 83% would encourage adoption of the initiative.Conclusions: Given the strong positive assessment of TCAB, evidence of substantial engagement of staff in the work, and the high volume of innovations tested, implemented, and sustained, TCAB appears to be a productive model for organizing and implementing a program of frontline-led improvement.

Transforming Care at the Bedside (TCAB) is a program designed by the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement to engage frontline staff in change processes to improve the work environment and patient care on nursing units. Originally designed and piloted in a small number of hospitals, TCAB is being disseminated through large-scale quality improvement (QI) collaboratives facilitated by professional organizations, such the New Jersey Hospital Association's Institute for Quality and Patient Safety (NJHA). This article presents the results of an evaluation of the NJHA dissemination effort. The evaluation team used an observational mixed-method evaluation design and multiple data sources to assess implementation of TCAB by nursing units in these facilities. The results show that most of the participating units successfully implemented the TCAB improvement processes. Nursing teamwork and three nursing-sensitive outcomes improved significantly over the course of TCAB, and TCAB unit managers attributed important improvements to their unit's participation. These findings suggest that TCAB is a viable mechanism for engaging frontline nursing staff in valuable QI activities. Other hospitals interested in furthering the culture and capacity for QI among frontline nursing unit staff should consider a TCAB collaborative for achieving these goals.

OBJECTIVES:The American Association of Colleges of Nursing recommends that nursing schools transition their advanced practice registered nurse (APRN) programs to doctor of nursing practice (DNP) programs by 2015. However, most schools have not yet made this full transition. The purpose of this study was to understand schools' decisions regarding the full transition to the DNP.METHODS:Key informant interviews and an online survey of nursing school deans and program directors were performed.DISCUSSION:The vast majority of schools value the DNP in preparing APRNs for the future of the health care system. However, other important factors influence many schools to fully transition or not to the postbaccalaureate DNP, including perceived student and employer demand, issues concerning accreditation and certification, and resource constraints.CONCLUSION:Multiple pathways to becoming an APRN are likely to remain until various factors (e.g., student and employer demand, certification and accreditation issues, and resource constraints) yield a more favorable environment for a full transition to the DNP.

Background: The 'spillover effect' of academic-practice partnerships on hospital nursing staff has received limited attention. In 2007, the Department of Veterans Affairs (VA) created the VA Nursing Academy (VANA) to fund fifteen partnerships between schools of nursing and local VA healthcare facilities. In this paper, we examine the experiences of the VA staff nurses who worked on the units used for VANA clinical training.Methods: We used survey methods to collect information from staff nurses at all active VANA sites on their characteristics, exposure to the program's clinical training activities, satisfaction with program components, and perspectives of the impact on their work and their own plans for education (N = 314). Our analyses utilized descriptive statistics and bivariate and multivariate regression.Results: Results show that staff nurses working on VANA units had moderately high levels of exposure to the program's clinical education activities, and most reported positive experiences with those activities. The vast majority (80 %) did not perceive the presence of students as making their work more difficult. Among those who were enrolled or considering enrolling in a higher education program, over a quarter (28 %) said that their VA's participation in VANA had an influence on this decision. The majority of staff nurses were generally satisfied with their experience with the students. Their satisfaction with the program was related to the level or dose of their exposure to it. Those who were more involved were more satisfied. Greater interaction with the students, more information on the program, and a preceptor role were all independently associated with greater program satisfaction.Conclusions: Our study suggests that academic-practice partnerships may have positive spillover effects on staff nurses who work on clinical education units. Further, partnerships may be able to foster positive experiences for their unit nurses by focusing on informing and engaging them in clinical training activities. In particular, our results suggest that academic-practice partnerships should keep unit nurses well informed about program content and learning objectives, encourage frequent interaction with students, involve them in partnership-related unit-based activities, and urge them to become preceptors for the students.

In 2004, members of the American Association of Colleges of Nursing (AACN) voted to endorse a position statement identifying the doctor of nursing practice (DNP) degree as the most appropriate degree for advanced-practice registered nurses (APRNs) to enter practice. At the same time, AACN members voted to approve the position that all master's programs that educate APRNs to enter practice should transition to the DNP by 2015. While the number of DNP programs for APRNs has grown significantly and steadily over this period, at this time, not all nursing schools have made this transition. To better understand why, the AACN contracted with RAND to investigate schools' progress toward this goal and the factors that facilitate or impede this transition. This article describes the results of a mixed-method RAND study undertaken between October 2013 and April 2014 that sought to understand schools' program offerings to prepare APRNs to enter practice and the reasons for those offerings, as well as the barriers or facilitators to nursing schools' full adoption of the DNP.

BACKGROUND:The nursing profession is exploring how academic-practice partnerships should be structured to maximize the potential benefits for each partner. As part of an evaluation of the U.S. Department of Veterans Affairs Nursing Academy (VANA) program, we sought to identify indicators of successful partnerships during the crucial first year.METHODS:We conducted a qualitative analysis of 142 individual interviews and 23 focus groups with stakeholders from 15 partnerships across the nation. Interview respondents typically included the nursing school Dean, the VA chief nurse, both VANA Program Directors (VA-based and nursing school-based), and select VANA faculty members. The focus groups included a total of 222 VANA students and the nursing unit managers and staff from units where VANA students were placed. An ethnographic approach was utilized to identify emergent themes from these data that underscored indicators of and influences on Launch Year achievement.RESULTS:We emphasize five key themes: the criticality of inter-organizational collaboration; challenges arising from blending different cultures; challenges associated with recruiting nurses to take on faculty roles; the importance of structuring the partnership to promote evidence-based practice and simulation-based learning in the clinical setting; and recognizing that stable relationships must be based on long-term commitments rather than short-term changes in the demand for nursing care.CONCLUSIONS:Developing an academic-clinical partnership requires identifying how organizations with different leadership and management structures, different responsibilities, goals and priorities, different cultures, and different financial models and accountability systems can bridge these differences to develop joint programs integrating activities across the organizations. The experience of the VANA sites in implementing academic-clinical partnerships provides a broad set of experiences from which to learn about how such partnerships can be effectively implemented, the barriers and challenges that will be encountered, and strategies and factors to overcome challenges and build an effective, sustainable partnership. This framework provides actionable guidelines for structuring and implementing effective academic-practice partnerships that support undergraduate nursing education.

Background: Inpatient quality deficits have important implications for the health and well-being of patients. They also have important financial implications for payers and hospitals by leading to longer lengths of stay and higher intensity of treatment. Many of these costly quality deficits are particularly sensitive to nursing care.Objective: To assess the effect of nurse staffing on quality of care and inpatient care costs.Design: Longitudinal analysis using hospital nurse staffing data and the Healthcare Cost and Utilization Project State Inpatient Databases from 2008 through 2011.Subjects: Hospital discharges from California, Nevada, and Maryland (n = 18,474,860).Methods: A longitudinal, hospital-fixed effect model was estimated to assess the effect of nurse staffing levels and skill mix on patient care costs, length of stay, and adverse events, adjusting for patient clinical and demographic characteristics.Results: Increases in nurse staffing levels were associated with reductions in nursing-sensitive adverse events and length of stay, but did not lead to increases in patient care costs. Changing skill mix by increasing the number of registered nurses, as a proportion of licensed nursing staff, led to reductions in costs.Conclusions: The study findings provide support for the value of inpatient nurse staffing as it contributes to improvements in inpatient care; increases in staff number and skill mix can lead to improved quality and reduced length of stay at no additional cost.

The Center for Medicare and Medicaid Innovation within the Centers for Medicare & Medicaid Services (CMS) has funded 108 Health Care Innovation Awards, funded through the Affordable Care Act, for applicants who proposed compelling new models of service delivery or payment improvements that promise to deliver better health, better health care, and lower costs through improved quality of care for Medicare, Medicaid, and Children's Health Insurance Program enrollees. CMS is also interested in learning how new models would affect subpopulations of beneficiaries (e.g., those eligible for Medicare and Medicaid and complex patients) who have unique characteristics or health care needs that could be related to poor outcomes. In addition, the initiative seeks to identify new models of workforce development and deployment, as well as models that can be rapidly deployed and have the promise of sustainability. This article describes a strategy for evaluating the results. The goal for the evaluation design process is to create standardized approaches for answering key questions that can be customized to similar groups of awardees and that allow for rapid and comparable assessment across awardees. The evaluation plan envisions that data collection and analysis will be carried out on three levels: at the level of the individual awardee, at the level of the awardee grouping, and as a summary evaluation that includes all awardees. Key dimensions for the evaluation framework include implementation effectiveness, program effectiveness, workforce issues, impact on priority populations, and context. The ultimate goal is to identify strategies that can be employed widely to lower cost while improving care.