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Healthcare team functioning requires coordination and collaboration between multiple practitioners towards a common goal of delivering safe and quality patient care (Lemieux-Charles & McGuire, 2006). Communication patterns, leadership, mutual support, and situation monitoring are all processes of effective teams (Weaver et al, 2010). However, despite the growing focus on developing interprofessional teams, minimal focus is given to the contextual and cultural forces influencing healthcare team functioning. Negative relationships amongst providers can affect teams in clinical settings, which in turn can undermine patient safety (Carpenter, 1995). Sources of poor team cohesion can be rooted in unequal distributions of power and the inability to express oneself without fear (Leonard, Graham & Bonacum, 2004; Edmondson, 1999).
The Interprofessional Critical Care Simulation (ICCS) experience at VCU is one program that aims to foster positive relationships by giving nursing and medical students an opportunity to work together in a simulated environment before they graduate. Each academic year, senior nursing students (~150) and fourth-year medical students (~170) participate in a series of three two-hour simulation workshops over a two-week period. Students are grouped into 48 interprofessional teams of approximately 6-7 members, and each team is assigned to one faculty facilitator for the series. Four faculty facilitators (two nurses and two physicians) conduct the workshops in the simulation centers in the School of Nursing or in the School of Medicine.
During the 2015-16 academic year, we asked medical and nursing students to complete a self-reported paper survey measuring team cohesion (Jung & Sosik, 2002), perceived power distance (Yoo, Donthu & Lenartowicz, 2011), and psychological safety (Edmondson, 1999) at the end of the ICCS course. Each scale was validated in prior research, however power distance was tailored to measure perceptions of power on the team compared to the original measure regarding an individual’s beliefs regarding how power should be distributed. The mediation model was tested with 1000 bootstrapping samples and controlling for semester through SPSS Version 23 (Armonk, NY) Process Macro, model 4 (Hayes, 2013).
After data cleaning efforts, 243 (76% response rate) post-surveys were included in analyses. There were 134 (55%) nursing students and 98 (40%) medical students in our sample. The majority of respondents were female (n=135; 56%) and identified as Caucasian (n=151; 62%).
Our partial mediation, Rsq=0.30, F(2,227) = 47.94, p<.001, revealed that as power distance increased 1.0 unit, psychological safety decreased 0.28 units, however as psychological safety increased 1.0 unit, team cohesion increased 0.40 units. In addition to this indirect relationship, the direct relationship illustrated that as power distance increased 1.0 unit, team cohesion decreased 0.19 units, total effect = -0.30 [-0.40, -0.20], indirect effect= -0.11 [-0.18, -0.05].
Facilitators of such interprofessional activities should shape team interactions so power is equally distributed amongst medical and nursing students, and support environments where students feel safe to speak up. Creating a safe space where learners clearly understand their roles and responsibilities on an interprofessional team will impact the affective nature of team dynamics. Future research can focus on the impact of facilitator leadership on team dynamics and influences of context and culture when transitioning to the clinical learning environment.
We aimed to identify the impact of power distance (the unequal distributions of power) between medical and nursing students on team cohesion through psychological safety (the belief one can speak up without the fear of negative consequences) during their participation in the ICCS course. Our partial mediation model hypothesized that team cohesion increased as power distance decreased, both directly and indirectly through psychological safety.
We aimed to identify the impact of power distance (the unequal distributions of power) between medical and nursing students on team cohesion through psychological safety (the belief one can speak up without the fear of negative consequences) during their participation in the ICCS course.
Carpenter, J. (1995). Doctors and nurses: Stereotypes and stereotype change in interprofessional education. Journal of Interprofessional Care, 9(2), 151-161.
Edmondson A. (1999). Psychological safety and learning behavior in work teams. Adm Sci Q, 44(2), 350-383.
Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach Guilford Press.
Jung, D. I., & Sosik, J. J. (2002). Transformational leadership in work groups: The role of empowerment, cohesiveness, and collective-efficacy on perceived group performance. Small Group Research, 33(3), 313-336.
Lemieux-Charles, L., & McGuire, W. L. (2006). What do we know about health care team effectiveness? A review of the literature. Medical Care Research and Review : MCRR, 63(3), 263-300.
Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality & Safety in Health Care, 13 Suppl 1, i85-90.
Weaver, S. J., Rosen, M. A., DiazGranados, D., Lazzara, E. H., Lyons, R., Salas, E., . . . Barker, M. (2010). Does teamwork improve performance in the operating room? A multilevel evaluation. The Joint Commission Journal on Quality and Patient Safety, 36(3), 133-142.
Yoo, B., Donthu, N., & Lenartowicz, T. (2011). Measuring hofstede's five dimensions of cultural values at the individual level: Development and validation of CVSCALE. Journal of International Consumer Marketing, 23(3-4), 193-210.
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