Nursing teamwork and time to respond to call lights : an exploratory study

Aim: The aim of this exploratory study was to determine whether the level of nursing teamwork is correlated to call light answering time in acute care hospital patient care units. Background: Teamwork has been shown to improve productivity. In this study, we examine the relationship between unit call light response time as a measure of productivity and the level of teamwork on the unit. Method: The Nursing Teamwork Survey was administered to nursing staff on 18 inpatient units in 3 hospitals. In addition to the overall teamwork score, the NTS has 5 subscales. Call light response times were collected from electronic systems which measures the time it takes for nursing staff on a given unit to respond to patient call lights. Results: There was no significant relationship between call light response time and teamwork overall or on the five subscales. Shared mental models, which comprise the conceptual understanding of the roles and responsibilities of each team member, however was moderately correlated with call-light answering times. Conclusions: It is logical that shared mental models would be associated with call light response time since a common problem in patient units is the “it’s not my job syndrome” where nursing staff do not answer call lights for patients assigned to someone else. More research with a larger number of patient units is needed to validate these findings.


Introduction
Since the early 20 th century, nurse call light systems have provided hospital patients with an essential communication link with their caregivers.
To hospital inpatients, the call light is the primary method of contacting staff and therefore represents the most basic tool for patient empowerment.It gives patients environmental control during the stressful event of hospitalization.It is also a basic safety tool, allowing patients to communicate their needs to staff whether they require routine assistance or have an acute change in condition.Inpatients trust that when they use a call light device, someone will respond to it in a timely manner.Because call light systems are used to communicate patient needs to staff, the prompt answering of call lights directly affects patient satisfaction and perceptions of quality (1) .Surprisingly, little research has been conducted regarding how call light systems are used by patients and responded to by nursing staff members.
For nurses, the call light provides some degree of reassurance that their patients will have the ability to contact them when a need for assistance arises.
Unfortunately, the call light can also represent an interruption in workflow for nursing staff.Frequent call light requests can create a backlog of tasks for a nurse or nursing assistant attempting to get through a shift.When a call light is activated, a nurse must try to prioritize if the task at hand is the most important one, or if the call light or perhaps even other call lights need to be responded to first.In reality, one caregiver alone cannot meet the needs of multiple patients and competing call lights.Nursing staff on a patient care unit need to work together as a team to care for patients including responding in a timely manner to call light requests (2)(3) .
With the primary and total patient care models (care provided by one nurse), much emphasis has been placed on individual nurses and how they care for a patient and less acknowledgement is given to that fact that nurses should be working in teams to complete their work.Recent work on nursing teamwork has uncovered the importance of teamwork on patient safety and staff satisfaction (2,(4)(5) .No one however has utilized response time to call lights as an indicator of nursing productivity and correlated it to the level of nursing teamwork.In this study, we explore the relationship between level of nursing teamwork and time to answer patient call lights.

Call lights
In 2006, Deitrick and colleagues published an ethnographic study of the use of call lights in a 36 bed medical surgical unit.The authors state that anyone who has spent time in a hospital knows that the call bell is the patients' lifeline.It is perhaps one of the few means of control that patients have over their situation.Attention has been paid in the literature to the nature of patient call light requests.Van Handel and Krug (6) studied the call light requests on an adult orthopedic unit and found the primary reasons for call light use were requests for toileting assistance, repositioning and pain medications or to retrieve another item.In 2009, Tzeng (1) published research conducted on 27 adult patient care units in four hospitals.She found that the primary reasons for patient initiated call lights were for toileting assistance, pain medication and intravenous therapy issues.
A significant portion of the call light research and their usage focuses on the device as a tool for patient safety.One study showed that on surgical units, when call light use was high, the patient injurious fall rate was lowered (1) .In the same study, however, medical unit patient fall rates were not significantly related to more frequent use of call lights (1) .Meade and colleagues (7) found that the incorporation of hourly nursing rounds on nursing units lead to both a decreased use of call lights and a decreased patient falls by anticipating patients' needs.Similarly, a study by Athwal and colleagues (8) concluded that improvements in communication during change of shift reports led to the reduction of patient call light usage.
In 2008, Tzeng and Yin (9) reviewed the quantitative and qualitative data collected on the incidence of falls between 2005 and 2006 in an adult medical unit.The researchers concluded that patient-nurse communication broke down in 17.06% of the falls that occurred, making it the most common extrinsic risk factor for patient falls in that unit.Call lights not being answered on time (meaning quickly enough to meet the needs of an individual patient) were found to be contributing factors to a significant number of falls on the unit (9) .
Response to call lights has also been associated with patient satisfaction.Dietrick and colleagues (10) found that there were delays in answering call lights, and at other times a light was answered but the patient's request was not followed through on.Frustration regarding delays in answering the lights was one of the most frequent comments made by patients in interviews.They www.eerp.usp.br/rlaeKalisch BJ, Labelle AE, Boqin X. concluded that understanding the importance of the call light to patients is key to improving patient satisfaction.
Others have also found that call light response time is related to patient satisfaction (1,7) .
Another perspective of the reviewed research on call light usage involves nurses' perspective on call lights and their use.According to Dietrick, busy caregivers can find answering call lights to be time consuming, and some patients who frequently use call lights may be viewed as "pests."Meade (7) concluded that call lights "can impose considerable demands on nurses' time" (10) .
Tzeng (1) quantified nurses' perceptions of call lights in 27 adult care units.In that study, 49% of staff perceived that patient initiated calls mattered to patient safety, 77% agreed that these calls were meaningful, 52% thought that the call required attention by nurses, but at the same time, 53% of nurses felt that call lights prevented them from doing the critical aspects of their work.

Nursing teamwork
The definition of teamwork utilized in this study was a group of two or more people working interdependently to achieve a common goal (11) .Teamwork has been studied in many sectors of business and industry and has been noted to be an essential component of high performance work organizations (12) .Validation of the positive effects of teamwork has come from workplaces in varied sectors of business and industry (13) .
Research from the airline industry determined that the majority of aviation accidents were caused by failures in communication and teamwork.Crew Resource Management is an educational program designed to improve the safety of air travel though teamwork training and is mandated for pilots worldwide.It has been proven to be effective in reducing human error in flight.The Institute of Medicine (IOM) ground breaking report "To Err is Human" cited evidence that at least 44,000 and perhaps as many as 98,000 deaths a year have been caused by medical errors.This report pointed to enhanced teamwork as way to reduce errors in the healthcare system (14) .
Since the IOM report was first published, the importance of teamwork in healthcare has grown.Most of the research relating to the reduction of errors in healthcare through improving teamwork however has taken place in specialty areas such as the operating room, emergency rooms, intensive care units and emergency and trauma teams (15) .Leonard and colleagues found that teamwork initiatives reduced wrong-site surgeries, improved continuity of care for patients transferred from the hospital to skilled nursing facilities, reduced nurse turnover and improved critical responses to perinatal emergencies (16) .Pronovost and colleagues documented research that links the increased use of teamwork principles in intensive care units to a reduction in error (17) .
There have been fewer studies of nursing teamwork in inpatient hospital units.Kalisch, Weaver and Salas (2) completed a qualitative study with nursing staff, which highlighted what teamwork looks like when it occurs.
Higher self-identified teamwork in the intensive care unit was found to be related to lower mortality rates (18) .
It was found that lower vacancy rates and turnover were associated with a higher level of teamwork while another study showed that when teamwork is good, staff satisfaction is higher (4) .An investigation by Brewer (19) showed that a group-type hospital culture predicted fewer patient falls with injury.An intervention to enhance nursing staff teamwork was tested which took place on a 41-bed oncology unit with 55 nursing staff members (20) .The intervention resulted in a significant decrease in patient falls, a reduced turnover and vacancy rate and higher staff evaluations of teamwork on their unit (20) .Staffing has been found to predict the level of teamwork (21) .A cross-sectional study to examine the relationship among hospital and staff characteristics and nursing teamwork showed that job title, shift, absenteeism, perceived adequacy of staffing, and unit type were significant predictors of teamwork (5) .
No studies were found which addressed the relationship between levels of teamwork and time to respond to call lights.This exploratory study examines this relationship.

Research questions
The study questions are as follows: 1) Does call light response time vary by hospital and/or type of patient care unit?
2) What is the relationship between teamwork overall and the elements of teamwork (i.e.team leadership, team orientation, back up, shared mental model, and trust), and response time to patient call lights?

Conceptual Framework
The theoretical framework for this study adapted a teamwork model developed by Salas and colleagues (22) .As can be seen in Figure 1 (11) .Thus these five elements of teamwork were utilized in this study.

Sample
To be eligible for participation in this study, hospitals had to have a call light tracking system.Three hospitals were selected and IRB approval was obtained in each facility.A total of 14 medical-surgical and intermediate/ step down patient care units within the three participating hospitals made up the sample.Two of the study hospitals were community-based facilities and a third was a university healthcare center.Hospital 1 had 3 participating units while Hospital 2 had 5 and Hospital 3 had 6 units in the study.The sample was made up of 26.9% intermediate/step down and 73.1% medical surgical units.

Measures Call light response time
Call light answering time was recorded by the patients' room call light tracking system.The patient call light system refers to the call light that a patient uses in their room, either from the bed, bedside chair or commode.The system electronically records each call light request for assistance and number of seconds it takes for the call light to be answered.It does not record when a request made by a patient is fulfilled.
Although it did not happen in this study, if a power outage or other system disruption occurred and the call lights failed to record, we would have adjusted the

Nursing Teamwork
The Nursing Teamwork Survey (NTS) was utilized to determine the level of teamwork on each patient care unit (11) .The survey was administered to the nursing staff (nurses, nursing assistants and unit secretaries) on each unit in the same month that the call light response The NTS was placed in 9 x 11 inch envelops, along with a cover letter explaining the study, their right to not participate, the assurance of anonymity and a candy bar as a token of appreciation.These envelopes were placed in staff members' mailboxes.Follow up reminders were given using posters on the units.
All responses were anonymous.Staff members placed their completed surveys in a sealed envelope and then into a locked box on their unit.Once a response of 50% was achieved for the unit, the staff was provided a pizza party.Nursing teamwork surveys were given to all nursing staff on the study units.A total of 889 surveys were received, representing a response rate of 60%.
Eleven surveys were eliminated from the pool of valid surveys because of incomplete answers or because those responders did not regularly work in the unit surveyed.

Data Analysis
NTS data was entered into SPSS statistical software, version 16.The level of analysis for this study was the patient care unit.There were six teamwork variables: overall teamwork, trust, team leadership, team orientation, back up, and shared mental model.The overall teamwork score was calculated as an average of all of the subscales.A score for each of these teamwork variables was calculated at the patient unit level.
After preliminary analyses, call light response time was a non-normal distribution and linearity between call light response time and teamwork variables were violated.Thus, Spearman's Rank Order Correlations were performed to test the relationship among study variables-call light response time and the five teamwork subscales and the overall teamwork score for each unit.
Average call light time in seconds for the unit for the month were calculated and compared with unit-level teamwork subscales and overall teamwork scores.

Study Results
RNs made up 68% of the respondents to the NTS while 22% were nursing assistants and 6.5% were unit secretaries.They were predominately female and under the age of 55 years.About half of the respondents had five years or less experience, and 60% were educated at the associate degree or lower level.In terms of age, 37% were under age of 35 years.

Teamwork by hospital
The differences of 6 teamwork variables were showed in Table

Response time and teamwork
The results of the analysis of the correlations among trust, team orientation, backup, shared mental model, team leadership and overall unit teamwork and response to call light time were performed.Three elements of teamwork--trust, team orientation and shared mental model--showed a degree of negative correlation; that is, the higher the teamwork scores, the lower the call light answering times.However, these relationships were not significant.Shared mental model demonstrated the highest correlation to call light answering time but it did not reach a significant level The fact that the strongest correlation was between shared mental model (conceptual understanding of the roles and responsibilities of each team member) and response time fits with findings of other studies we have conducted how nurses work.Nursing staff members often do not answer call lights for patients not assigned to them (23) .This is referred to as "it's not my job syndrome," and we have found that it is common in acute care hospital patient care unit teams.Dietrick et al. (10) observed that "the first and most problematic issues in call light issue is that of answering the light includes [deciding] whose job it is to answer the bells" It is logical that working together as a team to care for all the patients on a unit would enable nursing staff to respond to call lights faster.
Since the trends are in the direction of a relationship between call light response time and teamwork, repeating this study with a larger sample size of units may yield significant results.Other important variables need to be added to the study such as staffing levels, physical layout of the units, amount of experience of the staff, patient acuity and others

Study Limitation
This exploratory study was limited by the number of patient units and hospitals included in the study, which does not allow for generalization of the study findings.
A larger scale study may yield different results.Another limitation is that because this was an exploratory study,

Figure 1 -
Figure 1 -The "Big Five" framework of teamwork data to reflect only those days in the month where the light systems were functioning normally.Total call light use by unit per month was derived with the following computation: [(Counts of total call light use / Number of covered days) x Total number of covered days] Total patient days for the month The average response time in seconds for the month of the study was utilized.
time was collected.Measures of content, criterionrelated (concurrent) and construct (contrast-group and convergent) validity yielded positive results.Content validity was established by a panel of experts.Concurrent validity showed significant correlation between teamwork scores and an imbedded question related to overall satisfaction with teamwork (r=0.633,p<.001).The exploratory factor analysis on a random half of the sample predicted a 33-item five factor solution while the confirmatory factor analysis on the remaining half of the sample confirmed the factor structure (CFI=0.884,RMSEA=.055,SRMR=.045).Contrast group validity showed that a non-inpatient unit did not answer the questions in the same way (r wg(j) =0.25) as the inpatient units (r wg(j) >0.90).Convergent validity of the teamwork tool was measured with correlations with the teamwork subscale of the Safety Attitudes Questionnaire (r=0.76,p=.01).The NTS demonstrated good test-retest reliability (r=0.92,p<.05) and internal consistency (α=0.94).The NTS contains a total of 33 questions with each question being answered on a five point Likert response scale (1=rarely, 2=25% of the time, 3=50% of the time, 4=75% of the time and 5=always).

(
r=-334, p=.243).Back up behaviors, team leadership and teamwork overall demonstrated no significant relationship to call light answering time.DiscussionThis exploratory study examined the relationship between call light answering response time and nursing teamwork.No significant differences were found between nursing teamwork overall and the five subscales of teamwork and call light answering time.One subscale, shared mental models (referring to the extent that team members have the same understanding of who is to do what and when) had the highest correlation to shorter response times to call lights.
we did not collect staffing levels, physical layout of the unit, patient acuity and other potentially important variables for the study.Teamwork was measured by self reports of the staff (who completed surveys) as opposed to observations of teams in action.On the other hand, reliably capturing team behaviors through observation has proven to be a difficult process, requiring multiple trained observers with extensive training.

Table 1 -
Differences of teamwork across hospitals