Real teams and their effect on the quality of care in nursing homes

Improving Sleep Using Mentored Behavioral and Environmental Restructuring (SLUMBER)

OBJECTIVES

To evaluate the impact of a mentoring program to encourage staff-delivered sleep-promoting strategies on sleep, function, depression, and anxiety among skilled nursing facility (SNF) residents.

DESIGN

Modified stepped-wedge unit-level intervention.

SETTING AND PARTICIPANTS

Seventy-two residents (mean age 75 ± 15 years; 61.5% female, 41% non-Hispanic white, 35% Black, 20% Hispanic, 3% Asian) of 2 New York City urban SNFs.

METHODS

Expert mentors provided SNF staff webinars, in-person workshops, and weekly sleep pearls via text messaging. Resident data were collected at baseline, post-intervention (V1), and 3-month follow-up (V2), including wrist actigraphy, resident behavioral observations, Pittsburgh Sleep Quality Index (PSQI), Patient Health Questionnaire-9 (PHQ-9) depression scale, Brief Anxiety and Depression Scale (BADS), Brief Cognitive Assessment Tool (BCAT), and select Minimum Data Set 3.0 (MDS 3.0) measures. Linear mixed models were fit for continuous outcomes and mixed-effects logistic models for binary outcomes. Outcomes were modeled as a function of time. Planned contrasts compared baseline to V1 and V2.

RESULTS

There was significant improvement in PSQI scores from baseline to V1 (P = .009), and from baseline to V2 (P = .008). Other significant changes between baseline and V1 included decreased depression (PHQ-9) (P = .028), increased daytime observed out of bed (P ≤ .001), and increased daytime observed being awake (P < .001). At V2 (vs baseline) being observed out of bed decreased (P < .001). Daytime sleeping by actigraphy increased from baseline to V1 (P = .004), but not V2. MDS 3.0 activities of daily living and pain showed improvements by the second quarter following implementation of SLUMBER (P's ≤ .034). There were no significant changes in BADS or BCAT between baseline and V1 or V2.

CONCLUSIONS AND IMPLICATIONS

SNF residents had improvements in sleep quality and depression with intervention, but improvements were not sustained at 3-month follow-up. The COVID-19 pandemic led to premature study termination, so full impacts remain unknown.

The mediating effect of psychosocial factors in the relationship between self-organizing teams and employee wellbeing: A cross-sectional observational study

BACKGROUND

Several benefits of working in a self-organizing team, such as higher job satisfaction and better engagement to work have been demonstrated in previous studies.

OBJECTIVE

To examine whether those employees working in a self-organizing team have higher job satisfaction and lower turnover intentions compared to those in non-self-organized teams. Further, to test whether psychosocial factors defined by the Job Demand-Control model would function as mediators.

DESIGN

A cross-sectional survey study.

SETTING(S)

Home care and assisted living facilities (with 24-h assistance).

PARTICIPANTS

Licensed practical nurses (N = 377), registered nurses, therapists and managers (N = 183), and other employees (N = 31) in services for older people.

METHODS

A survey for employees working in services for older people and who were either in the self-organized teams or in the non-self-organized teams. Data was analyzed using linear regression and mediation analyses.

RESULTS

Those employees who worked in a self-organizing team were more satisfied with their job and had lower turnover intentions compared to those in a non-self-organizing team (mean [SD] 3.9 [1.0] vs. 3.7 [1.0], p = 0.006 and 2.2 [1.2] vs. 2.5 [1.3], p = 0.006, respectively). Moreover, job demands and job strain partially mediated the effect of self-organizing teamwork on job satisfaction (Average causal mediation effect [95%CI] 0.09 [0.02-0.15] and 0.10 [0.03-0.18], respectively), as well as on turnover intentions (Average causal mediation effect [95%CI] -0.08 [-0.15 to -0.01] and -0.20 [-0.18 to -0.03], respectively).

CONCLUSIONS

In the context of older people care services, working in self-organizing teams may enhance employee wellbeing by lowering job demands and job strain, but not by improving job control. Based on the findings of this study, self-organization seems beneficial, however, it requires real autonomy for the teams and team building.

TWEETABLE ABSTRACT

Self-organizing teamwork increases job satisfaction and decreases turnover intentions via lower job demands and strain in older people care.

A Fresh Look at the Nursing Home Workforce Crisis: Transforming Nursing Care Delivery Models

The current State of the Science Commentary focuses on workforce challenges in the nursing home (NH) setting that lie within the purview of professional nursing-what professional nurses can do to promote high-quality person-centered care within a context of existing resources-individually and broadly across the collective profession. Historically, three models of care delivery have characterized the way in which nursing care is organized and delivered in different settings: primary nursing, functional nursing, and team nursing. Based on the existing evidence, we call for scientific leadership in the redesign, testing, and implementation of a nursing care delivery model that operationalizes relationship-centered team nursing. This integrative model incorporates successful evidence-based approaches that have the potential to improve quality of care, resident quality of life, and staff quality of work life: clear communication, staff empowerment, coaching styles of supervision, and family/care partner involvement in care processes. In addition to the needed evidence base for NH care delivery models, it is imperative that educational programs incorporate content and clinical experiences that will enable the future nursing workforce to fill the leadership gap in NH care delivery. [Research in Gerontological Nursing, 16(1), 5-13.].

The effects of organizational silence on work engagement, intention to leave and job performance levels of nurses

BACKGROUND: Reducing the level of organizational silence can play an important role in the work-related decisions of nurses. However, to date a comprehensive study investigating the effect of organizational silence on work engagement, intention to leave, and job performance levels of nurses has yet to be conducted. OBJECTIVE: This study aimed to explain the effect of organizational silence on work engagement, intention to leave, and job performance of nurses. METHODS: The sample of the study consisted of 224 nurses. The Organizational Silence Scale, the Job Performance Scale, the Intention to Leave Scale, and the Work Engagement Scale were used to collect data in this study and the Pearson correlation test and regression tests were used in the data analysis. RESULTS: It was observed that organizational silence was negatively correlated with job performance (r = –0.455) and work engagement (r = –0.242), and positively correlated with intention to leave (r = 0.440) (p < 0.01). Regression analysis also illustrated that dimensions of organizational silence have a significant effect on job performance, intention to leave, and work engagement. CONCLUSION: A decrease in the organizational silence level of nurses is effective in decreasing intention to leave and increasing work engagement and job performance levels. Nurses should be able to express their opinions clearly towards other healthcare professionals and management and management should provide this working environment for nurses. To increase work engagement and job performance levels and decrease intention to leave, meetings and educational programs that reduce organizational silence might be developed at an organizational level by management.

How do health and allied health practitioners perceive excellence in residential aged care? An exploratory qualitative study

OBJECTIVE

To identify factors that health and allied health practitioners consider central to excellence in residential aged care facilities (RACFs) with the objective of supporting improvements in monitoring, accountability and service delivery within the sector.

METHODS

In a qualitative, exploratory designed study, interviews were undertaken with seventeen participants from 10 health and allied health disciplines (general practice, dentistry, pharmacy, psychiatry, psychology, neuropsychology, physiotherapy, speech pathology, occupational therapy and palliative care) with experience of working in Victorian RACFs. The interviews focused on how practitioners perceived excellence within RACFs. Data were analysed thematically.

RESULTS

Thematic analysis yielded five themes, which correspond with different dimensions or ways of understanding excellence, including resident well-being, residences as a true home, good practice models, effective management and skilled staff, and unmet needs. Under each of these themes, participants referred to issues closely related to the concerns of their particular professions as well as those more general in nature.

CONCLUSIONS

The diversity in issues to which participants drew attention highlights the importance of obtaining the perspectives of a broad range of practitioners providing services to RACF residents to achieving excellence in the sector. Commonalities in their responses indicate the potential for a greater level of collaboration among the health and allied health professions.

Solidarity in a Community of Nursing Colleagues

Introduction

Several concepts have been used to describe the qualities of communities of nursing colleagues. Nonetheless, few studies have shed light on nursing communities by drawing on the concept of solidarity.

Objective

To explore solidarity among a community of nursing colleagues.

Methods

A qualitative research design with a reflective life world approach was selected. This study reused data from a larger Norwegian empirical study. The data from the original study consisted of qualitative interviews and follow-up interviews with 13 nurses (RNs). The research context was municipality and specialist health services. A secondary data analysis was conducted. The study was based on the SRQR reporting guidelines.

Results

The results were formulated under two themes: 1) having indispensable relationships and 2) encountering a relative absence of sympathy.

Conclusion

A sense of community among nursing colleagues seems to rely on solidarity: whatever affects one nurse affects another. The solidarity that arose from the content of commonalities involved maintaining indispensable relationships with nursing colleagues by supporting and aiding them and simultaneously enduring a relative absence of sympathy. Solidarity among the community in this study was not a peripheral concept of the general notion of solidarity, implying that the commonalities within the collegial relationships were ambiguous and could shift from something good to something relatively good and vice versa. Such a shift was evidenced by nurses’ experiences of their community.

Diversity Management as a Tool for Sustainable Development of Health Care Facilities

Organizations providing health services are often criticized because of inadequate and unsuitable management processes or procedures. Today’s challenge is focused on effective management and leadership skills in the area of health care. The aim of the research is to describe, analyze, and evaluate the current state of diversity management in details in the context of human resources management in the selected healthcare facilities. The source of the information was a questionnaire survey. The sample consists of 181 managers from various health care and health service organizations. The method of analysis of variance (ANOVA) was used for data processing. The results were processed in SPSS and Excel programs. Pearson’s coefficient was used to evaluate the cross-correlation of the variables. The level of significance was 5% on both sides. Basic awareness of diversity management in the healthcare facilities is low. Some tools of diversity management are used, but only in isolation, non-conceptually, and unsystematically. The acknowledgment of diversity concept is poor and chaotic. The basic models of this concept defining its goals, activities, programs, responsibilities, and measurements are not known. One of the strong areas of the diversity management in the healthcare facilities is the diversity of working teams. On other hand, the weak side is the diversity as part of the organization culture and diversity as a part of human resource management. The summarizing index Attitudes towards Diversity received a higher average value than the Diversity Management Implementation index. Significant variables influencing the level of aggregate indices were identified: Ownership, size of the organization in terms of number of employees, patients’ satisfaction, and employees’ satisfaction.

The Future of the Home Care Workforce: Training and Supporting Aides as Members of Home-Based Care Teams

Home health, home care, and personal care aides provide most of the paid hands-on care delivered to seriously ill, functionally impaired individuals in their homes, assisted living, and other noninstitutional settings. This workforce delivers personal care, assistance with activities of daily living, and emotional support to their patients. They are often the eyes and ears of the health system, observing subtle changes in condition that can provide important information for clinical decision making and therapeutic intervention. Despite this fact, the growing number of team-based home care initiatives have failed to incorporate this workforce into their programs. Barriers to inclusion of aides into teams include a basic lack of value and understanding on the part of clinical team members and society in general of the complex tasks that these caregivers perform, inadequate investments in training and education of this workforce to develop their knowledge and competencies, and variation in state delegation laws that limit the scope of practice and consequently the ability of aides to work effectively in teams and to advance in their careers. Building on the few programs that have successfully included aides as key members of home care teams, federal and state policymakers, educators, and health systems and providers should standardize competency-based training requirements, expand nurse delegation consistently across states, and support evaluation, dissemination, and replication of successful programs. J Am Geriatr Soc 67:S444-S448, 2019.

Collaborative capacity and patient-centered care in the Veterans' Health Administration Community Living Centers

Introduction

Previous research in acute care settings has shown that collaborative capacity, defined as the way providers collaborate as equal team members, can be improved by the ways in which an organization supports its staff and teams. This observational cross-sectional study examines the association between collaborative capacity and supportive organizational context, supervisory support, and person-centered care in nursing homes to determine if similar relationships exist.

Methods

We adapted the Care Coordination Survey for nursing homes and administered it to clinical staff in 20 VA Community Living Centers. We used random effects models to examine the associations between supportive organizational context, supervisory support, and person-centered care with collaborative capacity outcomes including quality of staff interactions, task independence, and collaborative influence.

Results

A total of 723 Community Living Center clinical staff participated in the Care Coordination Survey resulting in a response rate of 29%. We found that teamwork and collaboration-measured as task interdependence, quality of interactions and collaborative influence-did not differ significantly between Community Living Centers but did differ significantly across occupational groups. Moreover, staff members' experiences of teamwork and collaboration were positively associated with supportive organizational context and person-centered care.

Discussion

Our findings suggest that elements of organizational context are important to facilitating collaborative capacity. Additionally, investing in staffing, rewards, and person-centered care may improve teamwork.

The educational needs of nursing staff when working with hospitalised older people

OBJECTIVES

To examine nursing staffs' geriatric knowledge, perceptions about interprofessional collaboration and patient-centred care, and perceived learning needs related to working with hospitalised older people.

METHOD

A triangulation mixed methods design was used. A survey was administered to nursing staff that contained the Knowledge About Older Patients Quiz, the patient-centered Care measure and the Modified Index of Interdisciplinary Collaboration measure. Interviews were conducted to understand nursing staffs' learning needs. Survey data were analysed using descriptive statistics. Interview data were analysed using content analysis. Survey and interview data were then compared and contrasted.

RESULTS

Twenty-two nursing staff (response rate 26%) completed surveys and 14 participated in interviews. The mean knowledge about older patients score was 22.95, indicating moderately high gerontological knowledge. The mean scores on the patient-centered Care measure and Modified Index of Interdisciplinary Collaboration were moderately high at 3.75 and 3.86, respectively. Themes developed from analysis of the interview data were as follows: complex vulnerable population, clinical care concerns and working as a team. In spite of scores on knowledge surveys, nursing staff identified learning needs related to managing the responsive behaviours of older patients with cognitive impairment, chemical and physical restraints, mobility and continence.

CONCLUSIONS

There was an incongruence between survey and interview data as nursing staff reported gaps in their knowledge despite moderately high scores on the Knowledge about Older People Quiz. Further research is needed to understand additional factors that influence nurses' educational needs.

Improving quality and safety of care in nursing homes by team support for strengths use: A survey study

Growing evidence suggests that workload has an adverse effect on quality of care and patient safety in nursing homes. A novel job resource that may improve quality of care and patient safety and alleviate the negative effect of workload in nursing homes is team support for strengths use. This refers to team members’ beliefs concerning the extent to which the team they work in actively supports them in applying their individual strengths at work. The objective was to investigate the relationships between workload, team support for strengths use, quality of care, and patient safety in nursing homes. We collected (cross-sectional) survey data from 497 caregivers from 74 teams in seven different nursing homes. The survey included measures on perceived workload, team support for strengths use, caregivers’ perception of the quality of care provided by the team and four safety incidents (i.e. fall incidents, medication errors, pressure ulcers, incidents of aggression). After controlling for age, team size, team tenure, organizational tenure, and nursing home, multilevel regression analyses (i.e. individual and team level) showed that perceived workload was not significantly related to perceived team-based quality of care and the frequency of safety incidents. Team support for strengths use was positively related to perceived team-based quality of care, negatively related to medication errors, but not significantly related to fall incidents, pressure ulcers, and aggression incidents. Finally, we found that perceived workload had a negative effect on perceived team-based quality of care when team support for strengths use is low and no significant effect on perceived team-based quality of care when team support for strengths use is high. This study provides promising evidence for a novel avenue for promoting team-based quality of care in nursing homes.

Influence of Teamwork on Health Care Workers' Perceptions About Care Delivery and Job Satisfaction

The aim of the current study was to examine the nature of teamwork in care facilities and its impact on the effectiveness of care delivery to older adults and job satisfaction among health care workers. A focused ethnography was conducted at two care facilities where older adults reside. Analysis of interviews with 22 participants revealed perceptions of teamwork and understandings about facilitators of and barriers to effective teamwork. Participants indicated that team relationships impacted care provided and job satisfaction. Participants also identified trust and reciprocity, communication, and sharing a common goal as critical factors in effective teamwork. In addition, participants identified the role of management as important in setting the tone for teamwork. Future research is needed to understand the complexity of supporting teamwork in residential settings given the challenges of culture, diversity, and individuals working multiple jobs. [Journal of Gerontological Nursing, 44(4), 37-44.].

Measuring nurses' perception of work environment: a scoping review of questionnaires

Background

Nurses’ work environment has been shown to be associated with quality of care and organizational outcomes. In order to monitor the work environment, it is useful for all stakeholders to know the questionnaires that assess or evaluate conditions for delivering nursing care. The aim of this article is: to review the literature for assessed survey questionnaires that measure nurses’ perception of their work environment, make a brief assessment, and map the content domains included in a selection of questionnaires.

Methods

The search included electronic databases of internationally published literature, international websites, and hand searches of reference lists. Eligible papers describing a questionnaire had to be; a) suitable for nurses working in direct care in general hospitals, nursing homes or home healthcare settings; and b) constructed to measure work environment characteristics that are amenable to change and related to patient and organizational outcomes; and c) presented along with an assessment of their measurement properties.

Results

The search yielded 5077 unique articles. For the final synthesis, 65 articles met inclusion criteria, consisting of 34 questionnaires measuring nursing work environments in different settings. Most of the questionnaires that we found were developed, and tested, for registered nurses in a general hospital setting. Six questionnaires were developed specifically for use in nursing home settings and one for home healthcare. The content domains covered by the questionnaires were both overlapping and unique and the terminology in use was inconsistent. The most common content domains in the work environment questionnaires were supportive managers, collaborative relationships with peers, busyness, professional practice and autonomy.

Conclusions

The findings from this review enhance the understanding of how “work environment” can be measured by an overview of existing questionnaires and domains. Our results indicate that there are very many work environment questionnaires with varying content.

Electronic supplementary material

The online version of this article (10.1186/s12912-017-0256-9) contains supplementary material, which is available to authorized users.

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

Background

Dementia with challenging behaviour (CB) causes significant distress for caregivers and the person with dementia. It is associated with breakdown of care at home and disruption in care homes. Challenge Demcare aimed to assist care home staff and mental health practitioners who support families at home to respond effectively to CB.

Objectives

To study the management of CB in care homes (ResCare) and in family care (FamCare). Following a conceptual overview, two systematic reviews and scrutiny of clinical guidelines, we (1) developed and tested a computerised intervention; (2) conducted a cluster randomised trial (CRT) of the intervention for dementia with CB in care homes; (3) conducted a process evaluation of implementation of the intervention; and (4) conducted a longitudinal observational cohort study of the management of people with dementia with CB living at home, and their carers.

Review methods

Cochrane review of randomised controlled trials; systematic meta-ethnographic review of quantitative and qualitative studies.

Design

ResCare – survey, CRT, process evaluation and stakeholder consultations. FamCare – survey, longitudinal cohort study, participatory development design process and stakeholder consultations. Comparative examination of baseline levels of CB in the ResCare trial and the FamCare study participants.

Settings

ResCare – 63 care homes in Yorkshire. FamCare – 33 community mental health teams for older people (CMHTsOP) in seven NHS organisations across England.

Participants

ResCare – 2386 residents and 861 staff screened for eligibility; 555 residents with dementia and CB; 277 ‘other’ residents; 632 care staff; and 92 staff champions. FamCare – every new referral (n = 5360) reviewed for eligibility; 157 patients with dementia and CB, with their carer; and 26 mental health practitioners. Stakeholder consultations – initial workshops with 83 practitioners and managers from participating organisations; and 70 additional stakeholders using eight group discussions and nine individual interviews.

Intervention

An online application for case-specific action plans to reduce CB in dementia, consisting of e-learning and bespoke decision support care home and family care e-tools.

Main outcome measures

ResCare – survey with the Challenging Behaviour Scale; measurement of CB with the Neuropsychiatric Inventory (NPI) and medications taken from prescriptions; implementation with thematic views from participants and stakeholders. FamCare – case identification from all referrals to CMHTsOP; measurement of CB with the Revised Memory and Behaviour Problems Checklist and NPI; medications taken from prescriptions; and thematic views from stakeholders. Costs of care calculated for both settings. Comparison of the ResCare trial and FamCare study participants used the NPI, Clinical Dementia Rating and prescribed medications.

Results

ResCare – training with group discussion and decision support for individualised interventions did not change practice enough to have an impact on CB in dementia. Worksite e-learning opportunities were not readily taken up by care home staff. Smaller homes with a less hierarchical management appear more ready than others to engage in innovation. FamCare – home-dwelling people with dementia and CB are referred to specialist NHS services, but treatment over 6 months, averaging nine contacts per family, had no overall impact on CB. Over 60% of people with CB had mild dementia. Families bear the majority of the care costs of dementia with CB. A care gap in the delivery of post-diagnostic help for families supporting relatives with dementia and significant CB at home has emerged. Higher levels of CB were recorded in family settings; and prescribing practices were suboptimal in both care home and family settings.

Limitations

Functionality of the software was unreliable, resulting in delays. This compromised the feasibility studies and undermined delivery of the intervention in care homes. A planned FamCare CRT could not proceed because of insufficient referrals.

Conclusions

A Cochrane review of individualised functional analysis-based interventions suggests that these show promise, although delivery requires a trained dementia care workforce. Like many staff training interventions, our interactive e-learning course was well received by staff when delivered in groups with facilitated discussion. Our e-learning and decision support e-tool intervention in care homes, in its current form, without ongoing review of implementation of recommended action plans, is not effective at reducing CB when compared with usual care. This may also be true for staff training in general. A shift in priorities from early diagnosis to early recognition of dementia with clinically significant CB could bridge the emerging gap and inequities of care to families. Formalised service improvements in the NHS, to co-ordinate such interventions, may stimulate better opportunities for practice models and pathways. Separate services for care homes and family care may enhance the efficiency of delivery and the quality of research on implementation into routine care.

Future work

There is scope for extending functional analysis-based interventions with communication and interaction training for carers. Our clinical workbooks, video material of real-life episodes of CB and process evaluation tool resources require further testing. There is an urgent need for evaluation of interventions for home-dwelling people with dementia with clinically significant CB, delivered by trained dementia practitioners. Realist evaluation designs may illuminate how the intervention might work, and for whom, within varying service contexts.

Trial registration

Current Controlled Trials ISRCTN02553381 (the ResCare trial) and ISRCTN58876649 (the FamCare study).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 15. See the NIHR Journals Library website for further project information.

A Practice Improvement Education Program Using a Mentored Approach to Improve Nursing Facility Depression Care-Preliminary Data

Depression is common in nursing facility residents. Depression data obtained using the Minimum Data Set (MDS) 3.0 offer opportunities for improving diagnostic accuracy and care quality. How best to integrate MDS 3.0 and other data into quality improvement (QI) activity is untested. The objective was to increase nursing home (NH) capability in using QI processes and to improve depression assessment and management through focused mentorship and team building. This was a 6-month intervention with five components: facilitated collection of MDS 3.0 nine-item Patient Health Questionnaire (PHQ-9) and medication data for diagnostic interpretation; education and modeling on QI approaches, team building, and nonpharmacological depression care; mentored team meetings; educational webinars; and technical assistance. PHQ-9 and medication data were collected at baseline and 6 and 9 months. Progress was measured using team participation measures, attitude and care process self-appraisal, mentor assessments, and resident depression outcomes. Five NHs established interprofessional teams that included nursing (44.1%), social work (20.6%), physicians (8.8%), and other disciplines (26.5%). Members participated in 61% of eight offered educational meetings (three onsite mentored team meetings and five webinars). Competency self-ratings improved on four depression care measures (P = .05 to <.001). Mentors observed improvement in team process and enthusiasm during team meetings. For 336 residents with PHQ-9 and medication data, depression scores did not change while medication use declined, from 37.2% of residents at baseline to 31.0% at 9 months (P < .001). This structured mentoring program improved care processes, achieved medication reductions, and was well received. Application to other NH-prevalent syndromes is possible.

Functions of behavior change interventions when implementing multi-professional teamwork at an emergency department: a comparative case study

BACKGROUND

While there is strong support for the benefits of working in multi-professional teams in health care, the implementation of multi-professional teamwork is reported to be complex and challenging. Implementation strategies combining multiple behavior change interventions are recommended, but the understanding of how and why the behavior change interventions influence staff behavior is limited. There is a lack of studies focusing on the functions of different behavior change interventions and the mechanisms driving behavior change. In this study, applied behavior analysis is used to analyze the function and impact of different behavior change interventions when implementing multi-professional teamwork.

METHODS

A comparative case study design was applied. Two sections of an emergency department implemented multi-professional teamwork involving changes in work processes, aimed at increasing inter-professional collaboration. Behavior change interventions and staff behavior change were studied using observations, interviews and document analysis. Using a hybrid thematic analysis, the behavior change interventions were categorized according to the DCOM® model. The functions of the behavior change interventions were then analyzed using applied behavior analysis.

RESULTS

The two sections used different behavior change interventions, resulting in a large difference in the degree of staff behavior change. The successful section enabled staff performance of teamwork behaviors with a strategy based on ongoing problem-solving and frequent clarification of directions. Managerial feedback initially played an important role in motivating teamwork behaviors. Gradually, as staff started to experience positive outcomes of the intervention, motivation for teamwork behaviors was replaced by positive task-generated feedback.

CONCLUSIONS

The functional perspective of applied behavior analysis offers insight into the behavioral mechanisms that describe how and why behavior change interventions influence staff behavior. The analysis demonstrates how enabling behavior change interventions, managerial feedback and task-related feedback interact in their influence on behavior and have complementary functions during different stages of implementation.