The impact of RN-UAP relationships on quality and safety

Nursing assistive personnel support RNs in carrying out their responsibilities and completing their work. These individuals typically have a short training program of several weeks to 3 months, although some have no formal preparation, not even a high school diploma.1,2 The assumed model is that the RN retains responsibility and accountability for the entire care of the patient but delegates specific tasks to the unlicensed assistive personnel (UAP). The American Nurses Association points out that RNs retain ultimate responsibility, accountability, and legal liability not only for delegated work, but also for any associated errors.3 As is true of teamwork among all members of the healthcare team, the relationship among UAP, RNs, and LPNs has implications for quality of care and patient safety. For purposes of parsimony, all of the various job titles for assistive personnel (such as unlicensed assistive personnel, certified nursing assistants, nurse techs, nurse aides, healthcare assistants, and others) will be referred to in this article by the abbreviation UAP. Nurse refers to RNs. Because there were few LPNs practicing in the hospitals involved in the study, they weren't included. The responsibilities of the UAP are a combination of clinical (such as vital signs, baths, mouth care, ambulation, turning, and toileting) and nonclinical (such as keeping the environment orderly) work.2,4–12 The aim of this study was to determine the barriers that inhibit effective RN-UAP teamwork and then to ascertain if and how dysfunctional teamwork leads to problems in quality of care and patient safety. The specific study questions addressed were: What are the specific teamwork problems in the working relationships of RNs and UAP in acute care hospital settings? How do these problems lead to diminished quality of care and patient errors? Method Sample The study took place in three acute care hospitals (one academic medical center and two community hospitals) in two states. Data were collected on 15 medical-surgical patient-care units. In the first wave of data collection, a series of nine focus groups were completed with 81 RNs and 12 focus groups with 118 UAP. International Review Board approval for the study was obtained in all three facilities. Participants signed an informed consent before initiating the focus groups, which included staff from all shifts. The RNs and UAP were in separate focus groups to maximize open discussion. The second wave of data collection involved 19 individual interviews with 10 staff nurses, six UAP, and three nurse managers. These individuals worked on the study units in phase 1 of the study. Data collection A semistructured design was employed in the focus group interviews in phase 1 of data collection, which were 60 to 90 minutes in length. Focus group participants were asked to commit to confidentiality (to not quote the others in the group outside the focus group). They were assured of the confidentiality of their comments by the investigator and were encouraged to be as forthcoming as possible. In the second wave of data collection, the individual interviews employed a more structured format, focusing primarily on each of the themes identified in phase 1 of data collection and any associated quality and safety issues. Data analysis Qualitative analysis software was utilized to content analyze the tape recorded and transcribed focus group and individual interviews. These focus groups were all conducted by the author. A grounded conceptual framework approach was utilized by which empirical data are thematically categorized by induction.13 The first analysis of the transcribed focus group and individual interviews was completed by a research assistant, and the second analysis by the author. The themes from the first and second analyses, although differently grouped, extracted the same issues from the empirical material. This was taken as a confirmation of the grounding of the analysis. Barriers to RN-UAP teamwork Seven themes emerged from the focus group data: lack of role clarity, lack of working together as a team, inability to deal effectively with conflict, not involving the UAP in decision making, deficient delegation, more than one boss, and "it's not my job" syndrome. Theme 1: Lack of role clarity. There was consistent evidence across the focus groups that neither UAP nor RNs were aware of, or fully understood, each other's (or even their own) work roles and responsibilities. This lack of clarity regarding roles was reported to manifest itself primarily in two ways. First, the RNs believed that the UAP didn't unde rstand the RN role and resented the time they must spend on certain responsibilities, especially documentation. The UAP focus group participants voiced the perception that when the RN sits down to document, she's taking a break or "goofing off." UAP felt that documentation should take lower priority than completing hands-on patient-care tasks. RNs, through their comments in the focus groups, revealed that they weren't assuming a leadership role. There's a lack of acknowledgment that the RN is the leader of the UAP-RN dyad. It was clear from the focus groups that RNs fail to consistently direct and support UAP. Theme 2: A lack of working together as a team. Both RNs and UAP reported practicing almost in isolation. Both groups expressed frustration when they had tasks to do that they couldn't do themselves (such as turning a heavy patient) and found it difficult to get help from the other. UAP reported seeking out each other, often on a distant part of the unit, rather than engaging the RN they were working with. Theme 3: Lack of conflict management and feedback skills. The RNs expressed a great deal of concern about the quality of the work of many of the UAP. They pointed to a lack of appropriate training and a poor work ethic. The UAP were reported to not follow through on the directions of the RNs. Another issue was the extra work required of the RN when the UAP didn't function at a high enough level. Both the RNs and UAP expressed reluctance in giving feedback and dealing with conflicts. They both demonstrated through their conversations that they lacked conflict resolution and feedback skills. When the RNs were asked about how they dealt with a situation where UAP weren't performing well, the vast majority stated that it wasn't worth the trouble of confronting them and it was doubtful that it would help anyway. The RNs verbalized a strong reluctance and a lack of skill in giving negative feedback to UAP, partly because they feared retaliation from UAP who would refuse to care for their patients but also because they detested conflict and would "avoid it at all costs." The UAP also expressed a reluctance to give feedback and deal with conflicts with each other and the nurses. Theme 4: Not engaging UAP in decision making. The focus group participants noted that UAP aren't involved in decisions about patient care and unit management. It starts by not having a report together at the beginning of each shift and continues with a lack of communication throughout the shift. UAP felt that the RNs didn't often listen to them. Another subtheme was RNs commanding UAP rather than asking in a respectful manner. Focus groups stated that RNs often communicate in a top down, disrespectful manner. The UAP felt devalued and diminished, and were unwilling to be team players because of it. When UAP aren't drawn into decisions about patient care, they don't develop an ownership of the goals of the nurse, unit, and organization. This ownership is essential for accountability. Communication was reported to largely take place through written means. Theme 5: Deficient delegation. RNs complained that they were the only ones capable of performing all of the tasks and responsibilities. Deficient delegation skills were consistently evident in the focus group discussions. RNs weren't able to describe effective delegation when asked. The RNs repeatedly voiced practices that were the opposite of effective delegation. The UAP also didn't understand their role in the delegation process. Theme 6: More than one boss. The focus group members pointed to the fact that UAP and RNs don't work with the same individuals regularly, which is a deterrent to giving feedback. Instead of assuming the role of leader and delegator, both UAP and RNs expressed the belief that the other doesn't understand their workload. The typical assignment method described in all of the focus groups involved UAP working with two or more RNs. This structure contributed to the problem of not only holding UAP accountable, but also ensuring an appropriate UAP workload. Theme 7: "It's not my job" syndrome. RNs reported separating their work from that of UAP and focusing almost exclusively on completing "their work" rather than assuming leadership over the entire care of the patient. On the other hand, some UAP ignored the direction of the RNs or engaged in dysfunctional politics to get their intended results. The practice of isolating aspects of work as being the sole responsibility of another person or job category is known as the "it's not my job" syndrome. RNs voiced the opinion that they shouldn't have to take patients to the toilet, get them water, or help them ambulate. They noted that they have a great deal of work that only they can do. The UAP expressed extreme frustration about the fact that RNs didn't do certain tasks even if it was logical and better for the patient for them to do so. The UAPs also believed that nurses won't do what they consider "dirty work." Quality and safety Table 1 contains examples of the findings in phase 2 of this study. The interviewees were asked to identify issues of quality and safety they've actually seen or participated in related to the seven themes that emerged from the focus groups in phase 1 of the study. The interviewees identified many examples of quality and safety problems with each of the themes, suggesting that the lack of effective working relationships between these two nursing care providers is resulting in diminished quality and increased errors.Table 1: RN and UAP working relationships—Impact on quality and safetyTable 1: RN and UAP working relationships—Impact on quality and safetyImplications for nurse managers There has been a tendency to overlook and not give a great deal of attention to the relationship between RNs and UAP, yet it's of critical importance as can be seen from the quality and safety problems that result from poor teamwork. The first step in addressing this issue is to highlight its presence along with the actual and potential errors and safety problems that exist on any given unit. To engage staff members in the resolution of this problem, data are needed; otherwise, there's a tendency for staff members on any given unit to deny that they have this problem and subsequently avoid addressing it. After the teamwork issues are identified and recognized, staff members need to be asked if they're willing to work on their teamwork problems. This is an essential step. Change will only occur if there's a commitment on the part of a significant number of staff members to work on the problem. The next step is to engage staff members in the development of a vision of how they would like to work together in the future, and then appoint a small leadership committee made up of RNs, LPNs, UAP, and unit secretaries. The selection should be done carefully to include a combination of change-oriented, innovative staff and more resistive individuals. This leadership group needs to use the data obtained from the survey and/or focus groups, as well as their own observations, to develop ideas that will promote more effective teamwork. It's helpful at this point to use brainstorming to promote new and creative ideas. Categorizing potential improvements into structure and process changes will help clarify and organize interventions. Some type of teamwork training is almost always needed. The training required should be built on the diagnostic data obtained earlier. In our experience, feedback, conflict resolution, and listening are essential components. RNs also need delegation and coaching training, and there's a need for role clarification for both RNs and UAP. New models of care are also needed to eliminate the problem of UAP with more than one boss. One idea is to create a three-person team consisting of two RNs and one UAP to care for a group of patients together. The UAP would need to be present at report as an integrated member of the team. All three team members would need to monitor one another, give feedback to each other, and back up one another. The shortage of nurses means that more, not less, assistive personnel will be employed in healthcare settings. It's critical that they're facilitated to work effectively together with RNs.