Staff perceptions of team functioning in Ontario Community Health Centres

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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