Relational Coordination: An Exploration of Nursing Units, An Emergency Department and In-Patient Transfers

Virginia Commonwealth University
VCU Scholars Compass

Theses and Dissertations Graduate School
2015
RELATIONAL COORDINATION: AN
EXPLORATION OF NURSING UNITS, AN
EMERGENCY DEPARTMENT AND IN-
PATIENT TRANSFERS
Mary Coffey
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RELATIONAL COORDINATION: AN EXPLORATION OF
NURSING UNITS, AN EMERGENCY DEPARTMENT AND IN-PATIENT TRANSFERS
A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of
Philosophy at Virginia Commonwealth University
by
Mary Coffey, MPH, RN

B.S. Nursing, Virginia Commonwealth University, 1986
Master of Public Health, Virginia Commonwealth University, 2001
Director: Jeanne Salyer, Ph.D., RN

Associate Professor, Adult Health and Nursing Systems
School of Nursing

Richmond, Virginia
August, 2015
ii
ACKNOWLEDGEMENT
The author wishes to acknowledge several people: my loving daughter, Katherine Kretz,
who has gifted me with the privilege of being her proud mother; my families of origin and choice
on which the foundation of this effort was built; my ever patient dissertation chair, Dr. Jeanne
Salyer, whose support and direction propelled me through many obstacles; my collaborator and
friend, Dr. Kathy Baker, who never stopped believing in me; and all my colleagues at VCUHS
who make me proud every day for your willingness to give of yourselves in the care of others.
iii
TABLE OF CONTENTS
Page
LIST OF TABLES ................................................................................................................... v
LIST OF FIGURES ............................................................................................................... vi
ABSTRACT ........................................................................................................................ vii
1. STATEMENT OF THE PROBLEM ................................................................................... 1
Background and Significance .................................................................................................. 6

Statement of Purpose ............................................................................................................... 9
Definition of Terms................................................................................................................10
Summary ................................................................................................................................11
2. CONCEPTUAL FRAMEWORK ......................................................................................14
Review of Literature ..............................................................................................................20

Education and Experience ..............................................................................................20
Experience ......................................................................................................................21
Input and Task Uncertainty ............................................................................................22
Relational Work Process.................................................................................................23
Reciprocal Interdependence............................................................................................26
Summary ................................................................................................................................29
3. RESEARCH METHODS ..................................................................................................32
Methods..................................................................................................................................32
Design, Setting, Sample Data Sources, and Data Collection Methods..................................32
Sample ............................................................................................................................32
Setting .............................................................................................................................33
Data Sources and Data Collection Procedures ...............................................................34
Measurement of Variables .....................................................................................................34
Sample Characteristics....................................................................................................35
Analytic Method ....................................................................................................................41
Summary ................................................................................................................................42
iv
Page
4. FINDINGS .........................................................................................................................43
The Sample ............................................................................................................................43

Descriptive Statistics ..............................................................................................................50
Relational Coordination ..................................................................................................50
Tests of Significance ..............................................................................................................54
Emergency Department Nurses Rating All Other Nurses ..............................................54
Inpatient Nurses Rating All Other Nurses ......................................................................57
Emergency Department Boarding Time .........................................................................60
Conclusions and Summary ....................................................................................................60
5. DISCUSSION OF FINDINGS ..........................................................................................63
Descriptive Statistics ..............................................................................................................64

Relational Coordination .........................................................................................................67
Emergency Department Transfers .........................................................................................73
Implications for Nursing Research ........................................................................................73
Implications for Practice and Management ...........................................................................76
Study Limitations ...................................................................................................................78
Summary and Conclusion ......................................................................................................79
REFERENCES ......................................................................................................................84
v
LIST OF TABLES
Table Page
1. Response Rate by Unit and Total Sample .....................................................................44
2. Individual Attributes of Participants (Total Sample and by Workgroup) .....................44
3. Demographic Characteristics of the Sample (n = 80) ...................................................46
4. Years of Clinical Experience and Unit Workgroup ......................................................47
5. Specialty Certification by Unit .....................................................................................49
6. Demographic Characteristics of the Sample by Unit (n = 80) ......................................49
7. Pearson’s Chi-Square by Demographic ........................................................................50
8. Units’ Rating Themselves on the Seven Dimensions of Relational Coordination…... 51
9. Results of Dunnett’s Post Hoc Tests for ED Unit Rating Units ...................................55
10. Units’ Ratings of the ED. ..............................................................................................58
11. ED Patient Admissions to Selected Hospital Units 9/9 Through 11/3/2014 .................61
vi
LIST OF FIGURES
Figure Page
1. Empirical Model of Relational Coordination’s Association With ED

Boarding Times ............................................................................................................ 13
Abstract
RELATIONAL COORDINATION: AN EXPLORATION OF

NURSING UNITS, AN EMERGENCY DEPARTMENT AND IN-PATIENT TRANSFERS
By Mary Coffey, MPH, RN
A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of
Philosophy at Virginia Commonwealth University
Virginia Commonwealth University, 2015
Major Director: Jeanne Salyer, Ph.D., RN

Associate Professor, Adult Health and Nursing Systems
School of Nursing
Emergency department (ED) crowding is a patient safety concern that has been
increasing for more than a decade. Increased visits have resulted in ED crowding, longer wait
times, ambulance diversions, and boarding of admitted patients (Hing & Bhuiya, 2012).
Numerous factors affect ED crowding. Once various extraneous issues are resolved and a bed is
available for a patient, it becomes the responsibility of nurses across unit boundaries to
coordinate the patient transfer. This study applies Relational Coordination Theory (RCT) as a
framework to provide nurses insight into the relational aspects of their work in the transfer of ED
patients to inpatient beds. Relational coordination is a mutually reinforcing process of interaction
between communication and relationships that is carried out for the purpose of task interaction.
It is useful for coordinating work that is highly interdependent, uncertain, and time constrained
(Gittell, 2002). Nurses work during ED transfers requires task interaction as they coordinate
their efforts. This study, guided by RCT, will examine relational and communication dynamics
among nurses within their own units and across unit boundaries as they interact during ED
transfers. A cross-sectional, descriptive design will explore the seven dimensions of Relational
Coordination (RC) during ED admissions and explain nurses relational and communication
dimensions that may influence ED boarding times. The results of this study provide new
information and a sound theoretical model on which to base future research.

CHAPTER 1. STATEMENT OF THE PROBLEM
The American health-care system is at a crossroads. The need for innovation and change
in the current health-care system has been universally identified as essential to improving the
nation’s health. The largest workforce component of the health-care system is nurses.
Innovation and change cannot be achieved without nursing engagement. In fact, restructuring of
current delivery systems will fail if nurses do not actively engage in the redesign and reform of
care systems. Nurses serve as the constant sentinels in the coordination and delivery of care to
patients. When The Future of Nursing: Leading Change, Advancing Health report was released
by the Institute of Medicine (IOM) in 2011, nurses were given an invitation to step from a
marginal role in health care to take the lead at the head of the reform table. The IOM, with a 40-
year foundation of providing quality reports, recognized for the first time high quality, safe,
effective, evidenced-based and patient-centered care is based on the critical role of the registered
nurse (RN). The report declared that achieving a successful health-care system in the future rests
on the future of nursing. The report concluded that nurses, in concert with other health
professionals, need to become system innovators and called for greater interprofessional
collaboration. Specifically, the report recommended as a research priority the need to identify
and test new or existing models of care teams that have the potential to add value to the health
care-system if widely implemented (IOM, 2010).
Nurses have been a quiet enabling force for change in health care in many dimensions
over the last 20 years (Aiken, Clarke, Sloane, Lake, & Chaney, 2009). During that time
1
significant relationships have emerged between individual nurse characteristics, work practice
environments, and patient outcomes. Throughout the 1980s, nursing’s work environment was
explored in an attempt to understand nursing’s work force retention and recruitment concerns.
Evidence indicated that nurse retention was directly related to a nurse’s perceived ability to
provide quality patient care (Aiken, 1989). Improvements in specific aspects of the nurse work
environment, such collaborative practice between nurses and physicians, nursing participation in
hospital governance, and adequate resources; have continued to align with better work
environments and to provide better nurse and patient outcomes. A growing body of international
literature supports these quality links between nurse work environments and better patient and
nurse job outcomes (Kutney-Lee, 2015). Providing safe patient transfers has been identified as a
challenge for nurses as they attempt to provide quality patient care. Unsafe patient transfers
plague current practice processes.
Transfer of care refers to the process of physically moving accountability of nursing care
previously provided by one nurse to another within a unit, or from one setting (the emergency
department) to another setting (an in-patient bed) and to a different set of nurses. The transfer of
care from one nurse to the next involves a transfer of information, responsibility, and authority
for patient care. Transfers are often considered error prone, affecting the continuity, quality, and
timeliness of the patient care delivery process. Problems associated with the transfer of
information have grown from accounting for 65% of sentinel events tracked by the Joint
Commission Center for Transforming Healthcare in 2007 to 80% in 2012. A sentinel event is an
unexpected occurrence that results in the risk of, or death, or injury of a patient (The Joint
Commission [TJC], 2015). The Joint Commission specifically cited communication as the most
frequent root cause of sentinel events during failed patient hand-offs. It is estimated that poor
2
communication during patient hand-offs plays a role in 80% of serious preventable adverse
events (Siefferman, Lin, & Fine, 2012). In August 2009, the Joint Commission and 10
collaborating hospitals and health systems focused on hand-off communications. These
organizations, together with the Center, examined their hand-off communications problems and
identified specific causes. A hand-off or transfer of care requires a caregiver (the “sender”) to
transmit patient information and release the care of the patient to another caregiver (“the
receiver”). The receiving caregiver accepts the patient’s information and then assumes
responsibility and accountability for providing care. On average, more than 37% of the time
hand-offs were defective and did not allow the receiver to safely care for the patient. In addition,
21% of the time senders were dissatisfied with the quality of the hand-off. They identified the
hand-off deficiencies to be caused by a culture that demonstrated a lack of teamwork and respect,
ineffective communication in which methods provided inaccurate or incomplete information, as
well as competing priorities distracting the receiver’s focus from the transferring patient (Joint
Commission Center for Transforming Healthcare, 2013). While the transfer process is plagued
with quality challenges, the often unspoken consequence of this disconnect between the sender
and receiver produces poor quality care as a patient waits to be transferred.
Emergency departments (EDs) are challenged with crowding and inadequate acute bed
capacity. The IOM has established ED crowding as a public health crisis (IOM, 2007). The
crisis is universally evident in long wait times to be seen, high “left-without-being-seen” rates,
extended ED lengths of stay, and long waiting times for inpatient bed placements (Schneider et
al., 2010). ED crowding has been associated with delays in medication administration, higher
clinical complication rates after ED evaluation, and increased mortality (Liu et al., 2011).
3
An extended wait for a bed placement is referred to as ED boarding time and will be the
focus of this inquiry. ED boarding occurs when admitted patients are unable to be transferred to
an inpatient bed. The reasons for the wait are multiple and varied. The end result of the wait,
however, is that when patients board in an ED they do not get the same level of care that they
would receive in an acute care bed (Schrader et al., 2008). ED boarding has been associated with
adverse events such as higher rates of ventilator-associated pneumonia (Carr, Hollander, Baxt,
Datner, & Pines, 2010), higher mortality rates, longer hospital stays (Singer, Thode, Viccellio, &
Pines, 2011), and higher rates of medication errors (Kulstad, Sikka, Sweis, Kelley, & Rzechula,
2010).
To address these issues, the Centers for Medicare and Medicaid Services (CMS) have
introduced ED crowding measures in their pay-for-reporting matrix. Specifically, CMS will now
consider ED boarding quality measures along with clinical processes by including throughput
measures (arrival to departure for admitted and discharged patients, decision to admit, door-to-
diagnostic evaluation, and left-before-being-seen) as they evaluate an organization’s
performance. Health-care organizations can no longer view patient admissions and ED boarding
time in isolation of the greater organizational process. A hospital’s throughput issues and ED
boarding times can no longer be considered an isolated ED issue. Organizations’ sustainability
will depend on improving current practices (Agency for Healthcare Research and Quality, 2011).
Coordination of timely admissions from the ED requires nurses to effectively collaborate
and communicate during the interdependent transfer. Relationships and communication patterns
in nursing practice have not been examined in relation to ED boarding times. The complexity of
coordinating the transfer of care is dependent on many variables that range from securing a bed
assignment, contacting and communicating the plan of care to the receiving nurse, and arranging
4
safe transport. The complexity of the environment and the challenges managed by nurses as they
face competing priorities in the provision of care for several patients can result in interrupted
efforts, missed information, and delayed interventions. Transfers add another layer of
complexity in a nurses work environment and often stress individuals as they interact,
communicate, and transfer patients. Little attention has been paid to the complex dynamics of
the relational and communication dynamics that occur during the interdependent task of
transferring care. Nurses are the primary coordinators of patient transfers. As nurses combat the
adverse outcomes associated with ED boarding times across the continuum of care, they must
examine their role in facilitating the transfers of admitted patients out of the ED. Thus, the
question that must be answered is when nurses interact with each other during the interdependent
task of transferring admitted ED boarders: What relational and communication dimensions are
present that may influence a timely patient admission?
To provide direction for nurses, health-care providers, organizations, and policy makers,
factors associated with timely ED boarder admission time is necessary. While nursing is a
subgroup of the many health-care disciplines, it remains the largest work force component and
the discipline charged with the coordination of care. In 2003, the IOM singled out coordination
of care as indispensable to improving the safety and quality of health care in the United States
(IOM, 2003). Thus, following the IOM recommendations, this study examined the work of a
nursing team’s task integration in the coordination of ED boarder transfers. Examining
relationships and communication among nurses across unit boundaries can provide insight into
nurses’ coordination of care. Innovative research is needed to explore nursing relationships with
each other as they coordinate the care for their patients. Many theories explore the dynamics of
complex environments and relational interaction. For the purpose of this study, I chose Gittell’s
5
emerging relational coordination theory (RCT) as the most comprehensive and complementary
theory to explore relationships and communication among and across nursing teams as they
coordinate the care and the transfer of care for patients boarding in an ED. This chapter presents
background and information on trends in theory development and research on RCT. It also
presents the statement of purpose for this study, definition of terms, and the hypothesized
relationships and effects among the concepts of the proposed model.
Background and Significance
Enormous effort has been expended over the last decade in attempts to identify variables
related to safe patient outcomes. Much has been written about a “safety culture.” Yet, defining
and measuring this type of culture remains difficult and elusive to design, implement, and
maintain (Blouin, 2010). Patients, providers, organizations, and regulatory agencies all engaged
in an earnest pursuit to prevent errors and stop creating harm within the health-care systems have
made little headway. Emergency department crowding is a patient safety concern that has been
increasing for more than a decade. From 1999 through 2009, ED visits increased 32%.
Increased visits have resulted in ED crowding, longer wait times, ambulance diversions, and
boarding of admitted patients (Hing & Bhuiya, 2012). In the past 10 years, despite the
challenges inherent in studying the effects of crowding, researchers have provided robust studies
linking ED crowding to quality and to outcomes. Crowding has inconstant effects on different
types of patients. Some have been found to experience significant delays without adverse effects
while others have received less effective care that lead to greater complications and mortality.
Emergency department crowding continues to be a worldwide public health problem and an
important patient safety issue (Pines & Griffey, 2015).
6
The IOM (2007) identified ED overcrowding as one of the most serious safety issues
facing hospitals nationwide. Initial position statements on this issue from TJC and the General
Accounting Office suggested overcrowding was the result of inappropriate use of emergency
services for non-urgent conditions and offered no specific policy response. More recently, these
organizations have revisited the issue and adjusted their response. Reengaged in ED crowding
issues, both organizations have evolved to an awareness that the misuse of the ED for non-urgent
care does not significantly contribute to overcrowding and boarding issues (Olshaker & Rathlev,
2006). Both organizations conclude that the inability to transfer emergency patients to inpatient
beds is the single most important factor contributing to ED overcrowding (Olshaker, 2009).
The common misperception that ED overcrowding is caused by non-urgent patients has
been dispelled by current research. Specifically, low-complexity patients do not significantly
increase ED boarding time (Schull, Kiss, & Szalai, 2007), and poor ED performance has been
shown to be significantly related to poor inpatient flow (Fatovich, Nagree, & Sprivulis, 2005).
Asplin et al. (2003), using a consensus of experts, concluded that the most often cited reason for
ED overcrowding is the inability to move admitted patients from the ED to inpatient beds. ED
workflow outcome measures that carry the highest influence on ED overcrowding are ED
boarding time, boarding burden, and hospital occupancy rate. ED throughput time increases as
hospital occupancy increases (Schull et al., 2007), and there is a strong association between
increased hospital occupancy and longer ED throughput time for admitted patients (Forster,
Stiell, & Wells, 2003).
Newer studies are beginning to assess the quality of care delivered to ED boarding
patients. Safety concerns exist that as ED staff face overcrowding many competing demands
may result in boarders not receiving the same level of care as their admitted counterparts.
7
Studies have found that ED boarding patients demonstrate higher rates of ventilator pneumonia
(Carr et al., 2007), higher mortality rates for ICU admitted patients (Chaflin, Trzeciak,
Likourezos, Baumann, & Dellinger, 2007), higher rates of medication errors (Kulstad et al.,
2010), delays in pain relief (Pines & Hollander, 2008), and longer lengths of hospitalizations
(Richardson, 2006). Liu et al. (2011) indicated that quality of care differs for boarded patients
and worsens in clinical areas where the ED environment is not equipped to manage routine care
such as the delivery of home medications and nonacute functions. ED overcrowding is
associated with health-care providers reporting decreased satisfaction (U.S. Government
Accountability Office, 2003), and poor communication related to a plan of care for their patients
(Apker, Propp, & Ford, 2007). Hospitals suffer lost revenue (Falvo, Grove, Stachura, Vega, &
Stike, 2007) associated with the increased rates of patients leaving without being seen and
ambulance diversion (Forster et al., 2003).
Numerous factors affect ED crowding and many variables affect the assignment and
availability of an inpatient bed. However, once various extraneous issues are resolved and a bed
waits for a patient, it becomes the responsibility of nurses across unit boundaries to coordinate
the transfer. The complexity of the systems and demands placed on an ED nurse to provide care
in an overcrowded environment begs the question: What can nursing do to reduce ED
overcrowding, and improve patient input and throughput? This study introduces RCT as a
framework to provide nurses insight into the relational aspects of their work. Providing quality
nursing care in today’s health-care organizations is complex. Nurses interact in many ways
across and within environmental boundaries. Transfers of patients require interdependent
interaction. Currently, ED overcrowding in most organizations is considered an ED problem
rather than a complex, hospital-wide systems problem (Emergency Nurses Association, n/d).
8
Relational coordination will introduce a hospital-wide evaluation of relational work and its
association with ED boarding time. Thus, the question that must be answered is: Is RC
significantly different within and between the ED and the nursing units where the most ED in-
patient transfers occur?
Statement of Purpose
The purpose of this inquiry is to examine the relational and communication dimensions in
work processes as RNs coordinate ED admissions and describe potential associations with ED
boarding times. RCT introduced by Gittell (2009) identifies the mutually reinforcing process of
interaction between communication and relationships that is carried out for the purpose of task
interaction. This research provides valuable information about the relational processes that occur
in the transfer of patients to inpatient beds. RCT proposes that goals are achieved by
coordinating work through relationships of shared goals, shared knowledge, and mutual respect.
Shared knowledge and a mutual understanding of a goal (the need to reduce an overcrowded ED)
is essential; however, this dimension alone is insufficient in the integration of efforts to complete
the task of transferring the patients out of the ED. Nurses must also engage in a relationship of
sharing a foundational knowledge of each other’s role in the task and demonstrate mutual respect
as they navigate the complex integration of their efforts. These three relational dimensions
(shared goals, shared knowledge, and mutual respect) establish a foundation for coordinated
team action (Gittell, 2009).
Transfer of care refers to the process of physically moving accountability of nursing care
previously provided by one nurse to another within a unit, or from one setting (e.g., ED) to
another setting (e.g., ICU) and to a different set of nurses. The transfer of care from one
clinician to the next involves a transfer of information, responsibility, and authority for patient
9
care. Problems associated with the transfer of information are a major contributing factor to
adverse events in hospitals and have grown from accounting for 65% of sentinel events tracked
by the Joint Commission in 2007 to 80% in 2012 (Joint Commission Center for Transforming
Healthcare, 2013). Coordination of patient care is enhanced when providers perceive that
coordination of patient care is enhanced and “that they have sufficient knowledge and the
confidence that their inputs will be recognized and pursued by other providers” (Haggerty et al.,
2003, p. 1221). Practice environments face complex communication behaviors as a result of
transient patient conditions, availability (or nonavailability) of clinical evidence, and distributed
nature of clinical information and decision making (Alvarez & Coeira, 2006). Units with higher
uncertainty have higher transfer duration times per patient. Higher uncertainty units discuss
fewer topics, fewer treatment options, care, and organization of work less frequently. Sharing
emotions is less often mentioned in higher uncertainty units (Mayer, Bangerter, & Aribot, 2012).
Transfers are often considered error prone, affecting the continuity, quality, and timeliness of the
patient care process. Researchers often focus on understanding transfers as a discrete
communication activity independent of other surrounding activities in the clinical workflow
(Abraham, Kannampallil, & Patel, 2012). While transferring care is an isolated care-related task,
it needs to be evaluated within the overall context of a nurse’s relational coordination and the
practice environment.
Definition of Terms
In the current investigation, the variables are as follows:
Emergency department crowding is when there are inadequate resources to meet the
patient care demands and leads to a reduction in the quality of care (Hing & Bhuiya, 2012).
10
Emergency department boarding is defined as the period of time from when a nurse
receives an in-patient bed assignment to the time the patient arrives to that inpatient bed.
Patient transfer is defined as to the process of physically moving accountability of
nursing care previously provided by one nurse to another within a unit, or from one setting (e.g.,
ED) to another setting (e.g., ICU) and to a different set of nurses (Haggerty et al., 2003).
Relational coordination is a mutually reinforcing process of human interactions between
communication and relationships that are carried out for the purpose of task integration. Team-
work is coordinated through relationships of shared goals, shared knowledge, and mutual
respect; and supported by frequent, timely, accurate, problem-solving communication.
Communication and relational dynamics provide the basis for coordinated team action under
conditions of task interdependence, uncertainty, and time constraints (Gittell, 2003). Figure 1
depicts the conceptual model of relational coordination’s association with ED boarding times.
Summary
This study will focus on nurses’ relational coordination and the seven dimensions of
communicating and sharing common goals, knowledge and mutual respect while managing ED
admissions. Specifically it will answer the question: What are the relational and communication
dimensions in work processes as RNs coordinate ED admissions and describe potential
associations with ED boarding times. It will introduce the principles of RCT as the conceptual
framework for nursing practice as nurses address the complexity of their work and tackle
overcrowding in their emergency departments. Complexity theories (Stacey, 2001) present
convincing evidence that nurses must move beyond assumptions of linear work processes and
serve as an underlying thread in RCT. RCT extends this view by moving individuals away from
the historical siloes and hierarchical roles towards a focus on task integration within complex
11
environments (Gittell, 2003). Clinical units are social objects where the team is nothing more or
less than the iterated ongoing processes in which nurses are together particularizing the
generalizations in terms of which they perceive their unit and organization (Stacey, 2001).
Relationships and interactions within and across units can expose the importance of
understanding how each makes sense of what is going on as they interact and influence each
other. These interactions within the nursing units are nonlinear social interactions. The social
construction of meaning and its definition of reality are often created in isolation of the larger
organizational goal. Nurses functioning in a complex ED environment interact and respond to
the pressures they face (Patton, 2011). RCT provides a framework for these individuals to
examine their complex work and establishes a springboard for innovation in processes that may,
through the use of human capital, sustain a reduction in ED boarding times. Instilling
accountability among nurses at the frontline of patient transfers, or more specifically,
strengthening individual nurse investment in the organizational goal of reducing ED boarding
times is crucial to organizational success. Beyond a commitment to exceptional care for
individual patient assignments and unit specific initiatives, nurses engaged in an institutional
safety goal of decreasing ED boarding and overcrowding can influence change. Organizations
that have established greater accountability among frontline nursing staff report strong quality,
safety, and patient experience outcomes (Berkow et al., 2012). Rapidly transferring admitted
patients from the ED to a hospital bed has the single greatest impact on alleviating ED crowding
and brings the greatest subjective sense of relief (Schneider et al., 2010). Nurses can drive this
initiative using relational coordination theory as they integrate the task of transferring patients
out of the ED.
12
Relational Work Practice Relational Coordination
Nurse to nurse patient transfers from
Shared goals
the ED to an in-patient bed Shared knowledge ED Boarding Time
Individual
Mutual respect
Characteristics
Frequent Communication
Education Timely Communication
Accurate Communication
Experience Problem-solving Communication
Expertise
Contingency factors
Reciprocal interdependence
Input or task uncertainty
Time constraints
Figure 1. Empirical model of relational coordination’s association with ED boarding times.

Source: Gittell, J.H. & Douglas, A. (2012). Relational bureaucracy: Structuring reciprocal relationships into roles. Academy of Management Review, 37(4), 709
– 733.
13
CHAPTER 2. CONCEPTUAL FRAMEWORK
The purpose of this study was to examine the relational and communication dimensions
in work processes as RNs coordinate ED admissions, and describe potential associations with ED
boarding times. The purpose of this chapter is to provide a conceptual definition and
understanding of each concept in the model (see Figure 1). A review of the literature examining
research in each of the variables of interest will be presented. The conceptual-theoretical-
empirical framework (see Figure 1) for this study is derived from Gittell’s (2003) relational
coordination theory (RCT). Relational coordination is a mutually reinforcing cycle of
coordinating work through relationships and communication (Gittell, 2009).
Mary Parker Follett is the earliest scholar to introduce organizational theory as a
relational coordination process. She counted four principles essential to the success of
coordination:
1. Coordination as reciprocal relating among individuals engaged in the working
networks within the process of the work.
2. Coordination by those most directly involved.
3. Coordination in the early stages of the work.
4. Coordination as a continuous process (Follett, 1949).
Follett emphasized the importance of the individual in society frequently emphasizing the
importance of respecting and celebrating the differences among the specialized contributors to
organizational performance (Follett, 1924). Follett’s work introduced diversity of opinion as a
14
positive factor for performance improvement. She believed that separating the self from the
work process was impossible. Each human interacts with his or her own experiences, stories,
and perspectives. The situation becomes task integration as well as an integration of the
individuals involved (Follett, 1924). The key concepts of Follett's philosophy encompassed
interrelatedness, process networks, and teams producing new and innovative work processes.
She emphasized that natural leaders emerge within groups and new knowledge emerges from the
collaborative efforts of individuals. Goal and/or situations drive the action of a team and directs
their action and interaction. Managing people under Follett’s philosophy is team focused. She
felt that the most effective way to exercise authority is to emphasize the importance of the task
rather than the rights of one person over another. The primary message underpinning all of her
work is the message that relationships matter. There is a reciprocal nature in relationships in
which individuals working together influence each other. Organizational ethics are moral and
social. An organization’s ethical behavior is the result of what the individual brings to work as
well as his/her membership in the group. For this reason, Follett encouraged leaders to
encourage empowered group networks with a common purpose. She taught that a team
simultaneously focused on the individual, the group, and the environment can accomplish goals
(Metcalf & Urwick, 1949). Coordination of work is considered a relational process in which the
decisions of the individuals directly involved in the work within group networks improve
outcomes. The purpose of a team’s work can be found within the process of the work itself.
Experiences are seen as the interplay of social forces as individuals relate to a new activity
(Follett, 1924). Follett (1918) stressed the need to move away from one-way, cause and effect
relations. She introduced that teams inter-relate within situations and within their environment.
She emphasized the need to recognize this as unique to each situation and each team.
15
Stacey’s (2001) complexity theory is in communion with Follett’s inter-collaborative,
coordination, nonlinear relational approach to work processes in complexity science. In this
interdisciplinary science multiple theoretical frameworks emerge from organizational theory,
complexity sciences, psychology and sociology (Stacey, 2001). It examines systems made up of
multiple and diverse interacting agents and seeks to uncover the principles and dynamics that
affect how they evolve and maintain order. Stacey developed complex responsive process
theory, a complexity influenced theory, which focused exclusively on people and human
interaction as the primary focus in a system. Three system parameters exist in environments and
influence a team’s self-organization response: the rate of information flow throughout the
system, the nature of connections among people, and the diversity of cognitive schema (Stacey,
1996). Strong parameters support individuals to create and recreate meaning of events, provide
opportunities for higher-order learning that changes beliefs as opposed to simply knowing facts
or rules, allows creativity, provides positive feedback (supporting system changes), and provides
opportunities for reflection and evaluation of performance. Management practices influence an
organization’s system parameters. Management practices that increase the level of the system
parameters promote improved outcomes. An authoritative, directive approach, with hierarchical
(top-down) communication channels, and traditional bureaucratic approaches to management
impose barriers to the freedom of interaction needed for effective self-organization (Stacey,
1996). These barriers do not stop self-organizing behavior; they do, however, compromise the
richness of interactions required to develop useful behavior necessary to meet the demands of the
work of the team (Weick, 1993). An authoritative manager is less likely to facilitate the quality
of interactions needed for effectiveness. Self-organization will occur but the outcome is not as
likely to focus on the ultimate environmental goal (Cilliers, 1998). Finding a balance between
16
too much and too little structure where interaction, learning, and innovation are fostered is the
key to effectively managing the professional knowledge workers in the health-care system. Like
Follett, Stacey focuses on the need for workers to be empowered and actively participate in
organizational initiatives in order for innovation to emerge (Stacey, 2001). Knowledge arises in
complex responsive processes of relating between humans and is continuously reproduced and
potentially transformed. Knowledge is an active process of relating. It cannot be stored and
intellectual capital cannot be measured or managed. A relationship between people establishes
the value of an individual and highlights the capacity human relating has to the pattern of work
itself in the absence of external control (Stacey, 2001).
Gittell’s (2003) RCT extends the work of Follett and Stacey to examine the humanistic
process underlying the technical process of coordination. Gittell contends that coordination
encompasses the management of interdependence between tasks as well as between the people
who perform those tasks. Relationships and people matter. When individuals engage by
interacting with shared goals, shared knowledge, and mutual respect organizational culture
emerges with support for process improvement. Relationships of shared goals, shared
knowledge, and mutual respect help nurses focus energies on what is best for the patient.
Sharing the universal goal of decreasing ED boarding time helps nurses align their actions with
each other. Shared knowledge helps them to understand how their tasks between units and
across units fit together. Mutual respect creates an environment where nurses value and
recognize the unique contributions and input of their RN colleagues. The process is reinforcing
and as rewards are met, relationships grow (Gittell, 2003). Relational coordination contains
three relational dimensions—shared goals, shared knowledge, and mutual respect—and four
communication dimensions—frequent, timely, accurate, and problem solving that work together
17
in effective coordination of work. When individuals share goals they coordinate specific
functional goals that promote an environment in which participants engage in problem-solving
issues, rather than blaming each other. Shared knowledge enables each participant to understand
the role of others, including who needs to know what and why and when, thus enabling them to
communicate timely and accurate information. Mutual respect promotes receptivity to
communication among participants of different stations, empowering individuals to speak up and
others to listen, further contributing to the development of shared knowledge and shared goals
(Gittell, Beswick, Goldmann, & Wallack, 2015). Within the RCT of nurses’ relationships
support frequent, timely, accurate, problem-solving communication towards improved processes
and outcomes.
Focusing on relationships between roles rather than between individuals, RCT suggests
that personal relationships are not necessary for team effectiveness. The focus on roles supports
a transformational approach to goal attainment as opposed to transactions between individuals.
Individuals can come and go, but roles are securely established and defined. Nurses and units
and sharing the same goal of reducing ED boarding across unit boundaries, with shared
knowledge of the processes involved in the task integration of their transfers, while
demonstrating mutual respect for each other should produce quicker admissions (Gittell, Seidner,
& Wimbush, 2010). RCT identifies the relational work process that is inherent in the
coordination of interdependence between tasks and between people. Individuals coordinating
work through relationships of shared goals, shared knowledge, and mutual respect, supported by
frequent, timely, accurate, problem-solving communication demonstrate empirical measures of
relational coordination. Communication and relational dynamics provide the basis for
coordinated teamwork where task interdependence, uncertainty, and time constraints are present.
18
RCT reveals the inter-subjectivity of the coordination process. It pays attention to the quality of
communication and relationships among participants, as well as to the technical requirements of
the work. Relational coordination can be measured and analyzed to determine the
communication and relationships networks through which work is coordinated across functional
and organizational boundaries. The ability to identify coordination among frontline workers
(relational coordination), between frontline workers and clients (relational coproduction), and
between frontline workers and their leaders (relational leadership) allows for the development of
interventions that can improve the work of the teams (Gittell & Douglass, 2012). This study will
focus on the relationship and coordination among frontline workers, nurses, and their relational
coordination during ED patient transfers.
Relational coordination has been associated with improved outcomes in the postsurgical
context and in the chronic care context. It has provided significant associations between care
provider connections with patients and families and with health system leaders. The
enhancement of relational coordination among healthcare professionals has been positively
associated with integrated care delivery to older patients. Relational coordination’s association
with healthcare outcomes is extensive and includes increased patient satisfaction, improved
postoperative pain & functioning, improved quality of life (long term care residents), as well as
reductions in medication errors, hospital acquired infections, patient fall related injuries, length
of hospital stay, total cost of hospital stay, and costs of chronic care. Increases have been found
in patient trust and confidence in care team and professional satisfaction with care delivered by
community health nurses (Gittell et al., 2015).
19
Review of the Literature
Research question: What relational and communication dimensions are present between
inpatient RNs and ED RNs as they coordinate ED admissions? If nurses are working in an
environment where communication and shared knowledge, goals and respect related to ED
admissions are not optimal perhaps patients are experiencing longer ED boarding times. This
study explores these relational dynamics.
Education and Experience
There are multiple bodies of literature that support clinician education and experience as
important determinants of safe care. Benner (1984) referencing the Dreyfus skill acquisition
model established that strong educational preparation is the necessary base for advanced skill
acquisition. Formal education provides the basis for safe care and provides the clinician the
background knowledge to evaluate the clinical picture (Benner, 1984). Aiken et al. (2009)
demonstrated that improving nurse staffing, education, and the care environment contributes
independently to better patient outcomes. Recognizing this, however, is not complete in the
complex health-care environment. Nurses interact with multiple services and specialties in the
coordination of care. While Aiken et al. (2011) have continued to explore staffing, work
environments, and the education levels of nurses and how they all work to improve outcomes, at
least for general surgical patients, the authors acknowledge that the question of whether one
works better than the other is less significant than under what conditions they work at all. Better
staffing has shown little effect on surgical mortality and failure-to-rescue in hospitals with poor
work environments. Hospitals with better work environments demonstrate that staffing has a
significant effect. They report that that staffing in the context of a good nurse work environment,
and a more educated nurse workforce has the greatest opportunity to positively impact patient
20
outcomes (Aiken et al., 2011). Studies have not explored education and experience across
disciplines or beyond the silos within health care specialties as determinants of interdependent
coordination of care and improved patient outcomes. Nursing work environments do not exist in
isolation of the greater health care community. Exploring the relationships and coordination of
interdependent tasks (transfers) across nursing work environments may provide additional
insight into the relationship of education levels, unit types and patient outcomes (ED boarding
times).
Experience
Little is known about the ways an individual’s experience is accumulated into a structure
of routine patient transfers. These transfer structures, however, establish processes in different
situations that impact organizational consistency. Routines guide team behaviors and culture
within an organization and comprise the process of inferences drawn from experience. They can
be seen in policies, procedures, standards of practice, organizational stories, social and physical
geography, and relationships within a team. Routines exist independent of individual and are
sustained despite turnover (Levitt & March, 1988). Organizations that face complex
uncertainties rely more heavily on informally shared understandings based on team experiences
(Ouchi, 1980). Inconsistencies in inferences drawn from varied experiences may organize into a
process that is maintained by subcultures, subgroups, and subunits (Martin, Sitkin, & Boehm,
1985). Organizational challenges occur as teams tackle tasks in inconsistent ways, often leading
to unclear and arbitrary measures of success. Failure or success can occur without any real
change in a team’s performance (Hedberg & Johnsson, 1978). Higher level administrators in
these confusing situations rely more on ambiguous information than lower level managers who
rely more heavily on formal rules and real life experiences (Daft & Lengel, 1984).
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Input and Task Uncertainty
Organizational behavior theories have shifted away from the premise that there is one
best way to organize. There are several contingencies that impact organizational coordination of
work processes. Three critical contingencies are: the rate of technical change in the environment
(Burns & Stalker, 1961), the uncertainty of the environment (Lawrence & Lorsch, 1967), and the
manageability of the tasks that are performed (Mohr, 1971). The concept of uncertainty appears
as the most crucial contingency for organizational effectiveness (Thompson, 1967). The sources
of uncertainty in an organization are varied and tend to be studied as either a task or
environmental. There are also many definitions of uncertainty in the literature. A common
dimension found in most definitions is that there is a state of incomplete information. A lack of
information makes it difficult to prepare for the future (Argote, 1981). The capacity of an
organization to manage a complex, highly interdependent environment is determined by its
ability to handle the communication necessary for coordination. Information is more reliable and
available in repetitive and predictable work processes and this produces a greater tolerance for
interdependence. As teams face higher levels of variability a greater burden to communicate and
coordinate occurs. Specialization of subprograms creates greater interdependencies among
subgroups in an organization (March & Simon, 1972).
Emergency departments are an environment that is bombarded with uncertainty in many
aspects of work processes. Patients arrive with undiagnosed conditions and treatment plans
evolve as information and opinions converge. “Input uncertainty” is evident in the overall
numbers and conditions of the patient population at any point in time. Uncertainty is a function
of choices and alternatives in a given situation (Attneave, 1959). Uncertainty is greatest when
there are many alternatives that are equally likely to occur. Information provides an opportunity
for one alternative to become more likely and reduces uncertainty. Input uncertainty is
22
determined by the external environment and has an immediate impact on the tasks that the
internal environment must perform. Recognizing uncertainty as a standard characteristic of the
ED environment enables an acceptance as a condition of the organizations work (Argote, 1981).
Argote’s (1981) study of the expected relationships among input uncertainty, organizational
coordination, and effectiveness in hospital emergency units suggests the use of nonprescriptive
means of coordination is most appropriate in EDs experiencing high uncertainty. The study
supported the importance of understanding the effect of uncertain inputs (Thompson, 1967;
Weick, 1993) on the effectiveness of a hospital ED and understanding the coordination methods
most appropriate for the type of inputs they receive (Argote, 1981).
Relational Work Process
Relational organizational form is also referred to as network organizational form and
introduces the fundamental assumption that people are social beings, with an identity and
worldviews formed through interactions with other people. Follet (1918) recognized that
reciprocal interactions occur as teams engage in a work process. Their work is not a collection
of separate pieces, but a functional whole of a united integration. She urged leaders to replace
hierarchical bureaucracy with empowered group networks with a common purpose.
Organizations formed by all individuals moving together, adjusting activities, interrelating, and
working as a common unit towards a shared goal produce innovation. Through reciprocal
relating, individuals performing different roles are able to see their contribution to the whole. A
holistic understanding of their own responsibilities while engaged in interpersonal exchanges
enables higher levels of organizational performance (Follett, 1924). Behavior is internally and
externally influenced. The productivity of a team and ultimately an organization is a function of
interweaving and a response to relating. Accepting that life and life’s work is a process of an
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interlocking of individuals engaged in a relational process of integration creates an environment
where each can create a new reality. This relational, circular response, frees the individual and
the organization of the limitations of singular points of view. New modes of thinking, new ways
of acting, and innovations emerge from the collective experience (Follet, 1918).
A critical view of relational organizational form argues that organizations built on
personal relationships are vulnerable to favoritism, abuse of power, and transactional leadership
styles that drive personal favor over organizational goals (Weber, 1924). Gittell (2003) disputes
this view by focusing on roles within the relationships. The roles of the individuals are the
focus, not the individual. Weick (1993) challenges organizations to view patterns of inter-
subjectivity and sustain those patterns as people are replaced. Organizational sense making
cannot survive if individuals drive the sharing of information rather than the roles driving the
process of information sharing.
Many labels have been applied to organizational work that produces best outcomes.
Various labels such as high-performance work systems, high-involvement work systems, and
high-performance human resource management, all recognize the value of capitalizing on the
employee. Despite an agreement that human capital plays a significant role in performance,
causal mechanisms within system work remains elusive. Gittell (2003) introduces a view that
extends beyond human capital skill, motivation, and commitment as predictors of organizational
quality. She incorporates employee-to-employee relationships as another causal mechanism that
influences organizational performance. This view focuses on relationships among employees as
the primary causal mechanism that creates a positive association between work systems and
performance outcomes. The theory of relational coordination presents the position that
organizational work contributes to quality outcomes through a mutually reinforcing web of
24
communication and relationships carried out for the purpose of task integration (Gittell et al.,
2000).
Integration of individual and organizational goals. Follett (1949) writes of authority
that goes with a particular job rather than that associated within a hierarchy. She sees authority
as a function of a task. The amount of authority is based on the worker’s function or task. She
emphasizes that it is not to whom someone is responsible, but for what they are responsible. She
sums up her position on authority by stating that true authority comes from an intermingling of
forces and is a self-generating process. McGregor (1960) built off of Follett’s work and is
recognized for revolutionizing human resources thinking by positing two ways managers could
view employees: Theory X assumed workers were inherently lazy, Theory Y assumed they were
self-motivated. McGregor introduced the idea that management’s role is to create a workplace
where conditions allow people to do well and want to do well. Theory Y provided a modest
beginning for new theory in the management of human capital and has evolved from the
unionization of workers and antagonism toward authority seen in the 1930s. Theory Y has six
generalizations of research that have contributed to human resource knowledge. The
generalizations that establish its foundation and hold true in human resource science today state
that the average human finds work to be a source of satisfaction. A worker will exercise self-
direction and self-control towards an objective to which he is committed. Commitment is a
function of the rewards associated with attaining a goal. The average person learns to accept and
seek responsibility. The ability and capacity to exercise imagination, ingenuity, and creativity in
problem solving is widely distributed. In modern industrial life, an individual’s intellectual
potential is only partially utilized. The limits on human collaboration are the result of
25
management’s inability to capitalize on individual potentials. Follett and McGregor introduced
human capital into management concepts and set the stage for relational work.
Reciprocal Interdependence
Kelly and Thibaut’s (1978) interdependence model of trust stresses a reciprocating cycle
in which members of a partnership reduce uncertainty by demonstrating dependable behavior.
Reciprocal interdependence with dependable and competent interactions supports rewarding
relationships. Attribution of dependability is earned by demonstrating interdependence, sharing
common interests, and demonstrating a willingness to act out of concern for each other.
Individuals showing an intention to trust and an ability to meet their own role obligations
develop trust in a gradual reciprocation of risk taking between individuals. Every time the
process occurs in a dependable and capable exchange, fear is reduced and trust grows.
Relational coordination. Relational coordination argues that quality performance
outcomes are created by work process networks that integrate individual and organizational goals
as workers engage in reciprocal interdependent practices. More specifically, it argues that six
high-performance work practices contribute to organizational performance by supporting the
development of relational coordination, a mutually reinforcing web of communication and
relationships carried out for the purpose of task integration (Gittell, 2003). Work practices such
as cross-functional selection, cross-functional conflict resolution, cross-functional performance
measurement, flexible job design, and cross-functional boundary spanner roles can nurture the
development of relational coordination. Their impact on relational coordination is reflected in
the frequency, timeliness, accuracy, and problem-solving nature of communication among
employees and the degree to which their relationships are characterized by shared goals, shared
knowledge, and mutual respect (Gittell & Douglass, 2012). Relational coordination studies have
26
emerged in the last 10 years from Gittell’s initial conceptual development from her observations
within the airline industry to today’s significant contribution to safer and efficient health care.
Relational coordination is dynamic and daily studies are published that confirm that relationships
in work processes matter and human interactions can improve team performance.
In review of current studies, relational coordination has shown that registered nurses in
surgical, medical, intensive care, and emergency units demonstrating high levels of relational
coordination with colleagues in other departments and disciplines are associated with less
frequent family complaints, less frequent medication errors, fewer hospital-acquired infections,
and fewer patient fall-related injuries (Havens, Vasey, Gittell, & Lin, 2010). Relational
coordination among surgeons, nurses, physical therapists, and social workers has predicted
increased patient quality of care, reduced postoperative pain, and increased postoperative
functional status (Gittell et al., 2000). Relational coordination among nursing aides, nurses,
housekeeping, and dietary staff predicted greater job satisfaction for nursing aides (Gittell,
2008). In a cross-industry study of individual managers, shared goals, shared knowledge, and
mutual respect predicted high levels of psychological safety and predicted the ability to learn
from failures (Carmeli & Gittell, 2009). Acute care nurse managers' work engagement was
enhanced by their relational coordination with each other, with their administrators, and with
their physician colleagues. In addition, nurse managers' proactive work behaviors were
enhanced by their relational coordination with each other, with their administrators, and with
their physician colleagues (Warshawsky, Havens, & Knafl, 2012). Registered nurses in surgical,
medical, intensive care, and emergency units, relational coordination with colleagues in other
departments and disciplines was associated with higher job satisfaction, career satisfaction, and
professional efficacy as well as reduced burnout (Havens et al., 2010). In a study of 335 acute
27
medical care patients with 893 provider responses, relational coordination predicted lower risk-
adjusted length of hospital stay as well as lower total costs of care (Gittell, 2008).
Relational coordination has evolved into a relational model of how high-performance
work systems work by focusing on the employee skills; employee commitment; and the
coordinated, synergistic behaviors that are necessary to achieve quality performance in
interdependent work settings. Cross-functional efforts have emerged as the relational map for
effective and efficient relational networking. Cross-functional teamwork has been found to
affect coordination across functional boundaries and strengthen the mutual respect dimension of
relational coordination. Cross-functional conflict resolution supports teamwork by presenting
multiple points of view from individuals’ thus adding value and building a shared understanding
to the work process. Resolving conflicts across functional teams strengthens the shared
knowledge and mutual respect dimensions of relational coordination (Gittell et al., 2000). Cross-
functional accountability moves away from traditional performance measurement practice that
places accountability on individuals within a hierarchical system. Cross-functional
accountability moves away from traditional performance measurement practice. Historically,
accountability of outcomes was placed on individuals within a hierarchical system. This
traditional view ignored the interdependent nature of work processes and supported assignment
of blame when team efforts did not produce desired outcomes. Cross-functional accountability
encourages a wider perspective and focuses on problem solving rather than finger-pointing
(Edmondson, 2004). Cross-functional rewards strengthen the shared goals of relational
coordination. Cross-functional meetings strengthen the accuracy of communication, shared
goals, and shared knowledge dimensions of relational coordination. Boundary spanners are staff
members whose primary responsibility is to integrate the work of the team around the
28
interdependent task. They strengthen the frequency and timeliness of communication and the
shared knowledge dimensions of relational coordination (Gittell & Douglass, 2012).
Relational coordination not only depends on the adoption of the six high-performance
work practices, but also on the strength of their adoption and the degree that they reach across all
involved employee functions. To test RCT in a hospital practice setting, a study of patient care
was conducted using a convenience sample of nine major urban hospitals and their nine
orthopedic units that performed a large number of joint replacements. Physicians, nurses,
physical therapists, case managers, and social workers who were involved in the care of joint
replacement patients were included in a 6-month study. The results of the study reported that the
six high-performance work practices were positively associated with relational coordination.
Physicians were significantly less engaged in relational coordination than nurses. The rest did
not differ significantly from nurses. High-performance work practices positively predicted
relational coordination. The study also indicated that high-performance work practices were
associated with higher quality of care by strengthening relational coordination among employees
in different functions. Findings also indicated that the work practices were associated with
shorter lengths of stay. The study provided evidence that formal practices can be designed to
encourage relationships between workers in different functions, producing significant quality
outcomes for organizations. The study also introduced a relational pathway through which work
practices contribute to performance measures (Gittell & Douglass, 2012).
Summary
In the last decade, work environments, as opposed to organizational initiatives, have
emerged as a focus of inquiry related to quality patient outcomes. Health-care organizations
today are faced with the challenge of new media, advanced technology, staff diversity and
29
inclusion, and workforce engagement (Gittell & Douglass, 2012). Organizations that embrace
and participate in quality initiatives traditionally focused on macro initiatives are unable to
sustain successful results. An interaction among members, the relationship between the
organization and its environment, and the significant social mission to deliver safe care requires
a partnership of efforts that must start with nurses examining their own contribution to practice
environments. Examining work environments and nurses relational coordination rather than
variability in individual nurse responses can provide organizational insight into structures and
relationships in the work processes involved in patient transfers (Verran, Gerber, & Milton,
1995). Perceptions of work stressors may differ within a given single unit and influence quality
beyond physical boundaries (McVicar, 2003). Interdepartmental teams with established strategic
direction are influencing the timing and pace of organizational change. Teams of individuals
working towards a common goal are influencing culture changes and organizations are seeing
long-lasting improvements in quality (Hughes 1996). Nurses, responsible for the coordination of
care, influence quality within their work environments. Developing an understanding of their
role-based relationship to quality can change practice and lead organizations to sustain positive
patient outcomes. Nursing practice spans a broad scope of responsibility from health promotion
and disease prevention to the coordination of care for both healing and comforting during
palliative care. Historically, however, professional tensions within and external to nursing have
undermined the nursing profession’s ability to provide and improve both general and advanced
care. Nurses are at an increased risk for work-related stress, particularly in specialty areas, such
as the ICU, and emergency rooms, where organizational expectations include saving lives while
demonstrating stoicism and perfection from the individual nurse (Meador & Jones, 2013). The
interdependent nature of nursing practice contributes to the context and environment in which
30
nurses work. Given that safe patient care is directly and positively related to the quality of staff
nurses’ work environments, reducing nurse tensions that adversely affect communication and
collaboration should improve care (Kramer, Maguire, & Brewer, 2009). Relational coordination
enables nurses to more effectively coordinate their work with each other, thus raising the bar on
higher-quality outcomes using resources more efficiently. Relational coordination and the high-
performance work practices that support nurses’ interdependent work are relevant in health care.
Relationships found in relational coordination are based on roles rather than personal ties. The
work practices of nurses across unit boundaries are expected to enhance relationships of shared
goals, shared knowledge, and mutual respect with or without personal ties. This allows for
individual interchangeability and scheduling flexibility without negatively impacting quality
measures. Relational coordination has provided health-care organizations a sustainable source of
associations in quality, efficiency, patient/family engagement and worker outcomes (Gittell,
2015).
Variables identified by Gittell include relational coordination, reciprocal
interdependence, task uncertainty, and time constraints. The final variables in the research
model will include nursing education, experience, and expertise. The relational coordination
variable will provide the dimension of measure for the relational work of nurses as they
coordinate patient transfers from ED nurses to inpatient nurses. Chapter 3 will review the
identified methodology for this study and the instruments that will be used to measure each of
the variables.
31
CHAPTER 3. RESEARCH METHODS
The purpose of this study was to examine the relational and communication dimensions
in work processes as RNs coordinate ED transfers. This chapter reviews the research methods
for the study including the design, setting and sample, measurement of study variables, the data
collection procedures, and the data analysis plan.
Methods
This study used a cross-sectional, descriptive design to answer the research question. It is
cross-sectional because variables were measured at one point in time. Since no variables were
manipulated, the design is nonexperimental. A theoretical model was used to guide the
development of an empirical model (see Figure 1).
Design, Setting, Sample Data Sources, and Data Collection Methods
Sample
The participants for this descriptive comparative were recruited from the Virginia
Commonwealth University Health System (VCUHS) using a sample of RNs. The sample was
created from a sequentially numbered alphabetical list of all RNs who met the inclusion criteria
on the four study units and was obtained from the nurse data analyst employed in the Division of
Nursing Services at VCUHS.
Inclusion and exclusion criteria. Inclusion criteria required that the RN be employed as
a direct care nurse on one of the identified study units. The identified adult clinical units were
limited to: one medical unit, one surgical unit, one step down unit, and one adult ED. Nondirect
32
care nurses on the identified units, as well as supplementary staff that work on various units were
excluded from this study.
Setting
The Virginia Commonwealth University Health System (VCUHS), a licensed 865-bed
urban, academic medical center located in the southeastern United States, is a Level I trauma
center and designated as an American Nurses Association Credentialing Center Magnet facility.
The VCUHS Emergency Department has 98,000 patient visits per year; 18,000 are seen in the
pediatric ED and the remaining 80,000 are seen in the adult ED. The ED serves as the safety net
hospital for approximately 22 counties in the state of Virginia. Emergency Medical Service
transportation is provided by 15 different agencies to the facility and four different aeromedical
agencies fly patients to VCUHS on a regular basis. There is a 42-bed adult ED, including a 4-
bed trauma bay; 15-bed adult fast track area for adults with minor illnesses or injuries; 10-bed
clinical decision unit for continued patient diagnostic evaluation, therapeutic intervention, and
observation. This study focused specifically on the 42-bed adult trauma medical emergency
department. In total, 27 separate inpatient units receive admissions from the ED. From the adult
ED, 28% of the 80,000 patients seen are admitted for inpatient stays. This equates to
approximately 50 to 60 patients daily that transfer from the adult ED to an inpatient bed. These
patients account for 45% to 50% of the health system’s daily admissions. On average 30 to 40 of
these patients are admitted to medicine or cardiology. The remainder of admissions is divided
among other service lines. Hospital outcome measures report that the coronary intensive care
unit (ICU) has the best ED to floor admission times for 2012 with 69% of their patients
transferring from the adult ED in under 60 minutes.
33
Data Sources and Data Collection Procedures
Once permission to conduct this study was obtained from the Institutional Review Board
for VCU and from the Nursing Research Council for the VCUHS, data were obtained from an
electronic survey questionnaire. A survey was appropriate for this study because it provided the
ability to gather a large amount of information about the sample in a small period of time.
Prior to distributing the survey, information was posted on the three in-patient units and
the ED informing all staff that this study was being conducted. This posting informed nurses
that the study was intended to examine patient throughput and requested that they participate and
share their observations related to transfers of patients from the ED to inpatient beds. All RNs
that met the inclusion criteria on the four units was contacted via a confidential electronic mail
(e-mail). If the nurse agreed to participate, the e-mail notification provided the nurse with a link
to the Relational Coordination Research Collaborative (RCRC) based at Brandeis University's
Heller School for Social Policy and Management. The RCRC (founded in 2011) collaborated in
this study to develop the customized study link. The study link provided each nurse with a
confidential entry to the survey and the researcher had no ability to identify any of the nurses;
however, participants were able to contact the researcher or RCRC, if desired. Auto-reminders
were distributed in Week 1, Week 2, and Week 3 after the survey was posted for
nonrespondents. Accommodation of the web-based deployment, self-registration, and weekly
status updates was managed in partnership with a RCRC staff member. The study link remained
open for a period of 3 weeks.
Measurement of Variables
In order to understand the influence of an individual nurse’s interactions with other
nurses on quality practice outcomes, it is necessary to study models that provide a theoretical
34
basis for explaining nurse relationships and the coordination of care where interdependent tasks
occur. Gittell’s (2003) model of relational coordination asserts that coordinating work through
relationships of shared goals, shared knowledge, and mutual respect achieves and sustains high
performance work systems. The model stresses that relational coordination creates a mutually
reinforcing web of communication and relationships among individuals as they engage in an
integration of tasks and together produce quality organizational outcomes. RCT proposes that an
individual’s work processes can be generalized into team performance. Individuals mutually
reinforce the interaction of relationships and coordination within their teams and across team
boundaries. Relational coordination measures provide a descriptive foundation for individuals
and teams to evaluate their coordinated collective action when working together under conditions
of task interdependence, uncertainty, and time constraints (Gittell, 2003).
Sample Characteristics
Unit/setting characteristics. Data of interest to the relational coordination dimensions
among nurses were obtained from the VCUHS Nursing Service’s data analyst and the VCUHS
decision support database. Aggregated RN characteristics by units were RNs budgeted and
actually employed full time (32 hours/week), percentage RN staff, average RN years of
employment, percentage RNs certified, percentage RNs certified in current clinical practice area,
percentage RNs full-time educated at the BSN level or higher, percentage of RNs currently
enrolled in an educational program at the BSN level or higher, percentage of RNs on the clinical
ladder and the percentage RN on each level. Unit and/or hospital characteristics included were
clinical specialty, number of beds, number of ED transfers during study period, number of ED
transfers during the 3-week period prior to study period, and RN hours per patient day.
Historically, VCUHS’s significant reports are archived in the Redwood Reporting System. The
35
reports are available on the Redwood website in a public folder. Current daily statistics are
available and updated with fresh data every hour.
Experience and expertise. A Professional Advancement Program (PAP), established by
VCUHS nurses in the late 1980s, provides common meaning and a shared language in nursing’s
culture while defining experience, expertise, and professional culture. The program is based on
Patricia Benner’s (1984) study that applied the Dreyfus model (1980) of skill acquisition to
nursing. Benner’s (1984) work and the PAP serve as the foundation of VCUHS’s Clinical
Ladder and are represented by five levels of practice as a Registered Nurse Clinician I to RN
Clinician V (Novice (I), Advanced Beginner (II), Competent ( III), Proficient (IV), and Expert
(V). All levels have the same set of practice values within competency clusters referred to as
“domains.” Nurses, through experiential learning, develop their understanding of practice in real
clinical situations. Mastery develops over time as they plan care, ask and test questions in the
provision of care to many patients. Exposure to deviations in expectations occurs as new
experiences challenge understanding. Past knowledge does not provide the foundation to
understand new outcomes. As a clinician reflects on past experiences, and examines deviations
from expectations, new knowledge forms and experience grows. New knowledge prepares a
nurse to assess and plan patient care with a greater understanding of the whole patient
experience. The pieces come together within a relationship with each patient that is no longer
grounded in rules and guidelines. Experience is not the passage of time; rather, it is the
emergence of new understandings as real situations in clinical situations bring the nurse closer to
“being all he/she can be” in the provision of patient care. A nurse’s clinical experience advances
from a Novice to Expert as he/she challenges and disputes his/her theoretical knowledge by
advancing personal theoretical understanding (Benner, 1984).
36
The Novice Nurse, or Registered Nurse Clinician I (RNCI) focuses on objective
attributes such as a patient’s weight, intake and output, temperature, blood pressure, pulse and
other measurable parameters. These measures provide the context in which the nurse evaluates a
patient’s condition. They are comfortable with rules and rely on policies and procedures as the
most relevant tasks within a set of rules. The Advanced Beginner, Registered Clinician II
(RNCII) has experienced enough real situations to have noticed (or been informed) of relevant
components of the measures within a patient’s condition. Experience with previous patients with
similar characteristics establishes a foundation for the nurse to recognize aspects of care needed.
The RCII provides experiential context to their observations with less dependence on objective
attributes (Benner, 1984).
A Competent Nurse, Registered Nurse Clinician III (RNCIII) typically has been
practicing in the same or similar clinical setting for 2 to 3 years. Of note, at VCUHS a nurse
must present a professional portfolio to a peer review process to advance to a RNCIII, IV or V.
Additional educational and certification requirements are applied at these levels. An RNCII may
practice at a RNCIII level or higher as a result of experiential learning and experience but may
opt out of formal ladder advancement. An RNCIII has begun to gain an awareness of what is
most important and what can be ignored. He/she is able to plan care that is based on
considerable conscious, abstract, analytic contemplation of the problem. Conscious and
deliberate planning is a characteristic of this level and it helps develop efficiency and
organization (Benner, 1984)
The Proficient Nurse, Registered Nurse IV (RNCIV) perceives situations as a whole.
He/she knows from experience what typical events to expect in a given situation and is able to
adjust plans as needed. The RNCIV is able to quickly access a situation and establish the most
37
accurate response to a problem. Decision making is less labored. The Proficient Nurse brings a
“perspective” to a clinical situation that “presents itself” based on past experiences. Nuances in
practice appear that are not understood by the more inexperienced nurse. An “intuitive grasp” is
demonstrated as the nurse assesses a situation and appears to bypass synthesis of aspects and
contexts. The nurse has a perceptual capacity to draw from that has been compiled over time
from past experiences. Intuitive grasp and perceptual capacity emerge after many experiences
have occurred with similar and dissimilar situations and a nurse’s theoretical understanding is
applied in practice.
The Expert Nurse, Registered Nurse Clinician V (RNCV), does not need to rely on rules
or guidelines to connect his/her understanding of a situation in most situations. They tend to
quickly assess a situation, weigh options and do “what feels right.” The Expert Nurse has an
intuitive grasp of each situation and is able to quickly focus on an accurate resolution to a
problem. They operate from a deep understanding developed from an enormous background of
experience. They apply evidence to their practice in a formal manner and practice with an
advanced degree in nursing.
Relational coordination. The Relational Coordination Survey (Gittell, 2003) is a Likert
format scale measuring the seven dimensions of communicating and relating between RNs as
they interact in the transfer of patients from the ED to in-patient beds. The seven dimensions
are: frequency, timeliness, accuracy of communication; problem-solving communication, shared
goals, shared knowledge, and mutual respect. The Relational Coordination Survey first emerged
from a study of the flight departure process (N = 354) at Continental, United, and Southwest
Airlines in the 1990s. This initial study identified that communication and relating among
employees at Southwest Airlines was dramatically different and specifically characterized by
38
high levels of shared goals, shared knowledge, and mutual respect regarding the coordination of
flight departures. The communicating and relating among all staff involved in the coordination
of flight departures supported frequent, timely, problem-solving dialogue among employees and
resulted in high-quality service and efficient use of resources (Gittell, 2003). Initial reliability
and validity of the survey was established in Gittell’s (2003) initial flight departure study and
subsequent patient care coordination study (2007). Cronbach’s alpha was .80 for the flight
departure and .86 for the patient care coordination (N=338). A single factor construct was
established with acceptable factor analyses. For this study Cronbach’s alpha was .89 for the
sample of 78 nurses.
Additional studies have provided evidence that the relational coordination construct is
generalizable to work processes (consisting of multiple providers, engaged in highly
interdependent tasks, under uncertain circumstances, with time constraints) in surgical care
(Gittell et al., 2000, Gittell, 2003, 2009), medical care (Gittell, Weinberg, Bennett & Miller,
2008), continuum of care (Weinberg, Lusenhop, Gittell, & Kautz, 2007), and the criminal justice
system (Bond & Gittell, 2010). These studies have confirmed that the survey meets
psychometric validation standards of internal consistency, content validity, structural validity
(Gittell, 2003), and inter-rater reliability (Gittell et al., 2010).
The measure is a 5-point scale (1 = never; 5 = constantly/always), and the data identify
networks of connections in an integrated work process. On the Relational Coordination Survey,
higher relational coordination scores reflect better relational coordination in interdependent work
processes. Specifically, within work group scores less than 4 are weak and greater than 4.5 are
strong; between work groups’ scores less than 3.5 are weak and greater than 4 are strong. This
study asked nurses to respond to questions measuring the seven concepts in Gittell’s (2003)
39
model of relational coordination (see Figure 1). Each RN was asked to assess the quality of their
communication and relationships specific to transferring ED patients to inpatient units. To
lessen the threat of socially desirable responses (Kluger, Reilly, & Russell, 1991) each RN will
be asked to report the behaviors of others rather than his/her own behaviors, thus aggregating the
data to the group/unit level. Individuals are more likely to overestimate their own timely
communication and less likely to do the same when receiving information from others. The
survey will ask for the nurses’ perception of typical transfer patterns rather than their perspective
of any specific patient’s transfer. This approach will reduce the risk of retrospective response
error, as the nurses will be asked to provide answers specific to current working conditions,
rather than to unique patient experiences (Gittelll, 2009).
The coordination of transferring a patient from the an adult ED to an inpatient bed
requires that nurses meet a patient’s need either directly by her own activity or indirectly by
calling in the help of others (Orlando, 1961). An individual ED nurse coordinating an efficient
and timely transfer to an inpatient unit cannot be evaluated in isolation of the larger organization,
or independent of interactions with other nurses, systems and processes. Increasingly, nurses are
working in interdisciplinary environments where resources must be deployed quickly in the
provision of safe and efficient care (Lake, 2007). Previous studies have provided evidence that
coordination between care providers is positively related to organizational quality and efficiency
(Gittell et al., 2010). However, the coordination of nurses’ work processes in the transfers from
an ED to an inpatient unit has not been explored. Specifically, this study focused on a work
process that is well understood and readily measured in health-care safety literature—patient
transfers.
40
Emergency boarding time. Emergency boarding time is defined as the time elapsed
between when an RN is informed that a bed is ready to the time the patient is physically admitted
to an inpatient bed. These data were reported from VCUHS patient tracking software. These
data reflected the ED boarding times (in minutes) for patients admitted to each of the clinical
units during the 3-week period prior to the study as well as during the 3-week study period.
Analytic Method
Data was uploaded into SPSS® (version 21) and data cleaning was initiated. Cronbach’s
alpha was computed on the relational coordination scale on ED RNs and inpatient RNs. (.89).
Descriptive statistics on the sample, setting, and model variables was also computed.
Continuous variables (age, years of experience as an RN, and years on clinical unit) were
summarized using mean and standard deviation and categorical variables (education, expertise,
ladder level, and certification) and then characterized using frequencies and percentage. Each
clinical unit was described using descriptive statistics. Categorical variables included in this
characterization were RN age, gender, RN hours per patient day, clinical specialty, number of
beds, and the number of ED transfers during the study period. Continuous variables reflecting
unit characteristics included percentage RN staff, average RN years of employment, percentage
RNs on clinical ladder, percentage RNs on each level of the ladder, percentage RNs certified,
and percentage RN full-time educated at the BSN level or higher. Emergency boarding time for
each of the units included in the study was retrieved (in minutes) and the mean, standard
deviation, and range computed.
An analysis of variance (ANOVA) was used to examine the ED nurses perspective of the
differences in relational coordination among the various units. The Dunnett’s post hoc test
provided additional information as to significant differences between the workgroups. The
41
Dunnett’s was used as it allows for “very tight Type I error control” (Field, 2009, p. 374).
ANOVA and Dunnett’s results were reported as, degrees of freedom, F values and P values.
Pearson chi-square test was then used to compare age, gender, years of experience, education,
advancing education, clinical ladder level, certification and years at an advanced level by unit.
Results were reported by χ2 and p value.
Summary
This chapter reviewed the methods employed to answer the research question and includes the
research design, sample and setting, the data collection procedures, instrumentation and
measurement of variables, and the analytic process. Study results are presented in Chapter 4.
42
CHAPTER 4. FINDINGS
The purpose of this inquiry was to examine the relational and communication dimensions
in work processes as RNs coordinate ED admissions. This chapter presents the findings.
Characteristics of the sample are described and descriptive statistics of the variables are
addressed. Significant differences in relational coordination between and among groups are
discussed.
The Sample
A total of 294 registered nurses (RNs) who met the inclusion criteria were invited to
participate in this study via electronic email notification. A confidential link to an electronic
survey was provided so that participants agreeing to complete the questionnaire could access it.
The sample was selected from the Adult ED and the four clinical units that receive the most
admissions from the ED. A total of 80 participants responded (response rate = 27%).
Demographic characteristics for the sample are included in Table 1.
Individual attributes of participants (total sample and by workgroup) are presented in
Table 2. The sample consisted primarily of females (93%) between the ages of 25 and 34 (43%).
A Pearson’s chi-square test indicated there was no significant difference in age by workgroup (χ2
[16] = 24.41, p = .08). The majority of the respondents (43%) were between the ages of 25 and
34. The second largest age group was 35 to 44 (28%) resulting in 71% (n = 56) of the
respondents being between 25 and 44 years of age. The Medical Step Down Unit (MSDU) had
43
Table 1
Response Rate by Unit and Total Sample
Work Unit Completed Invited %

Emergency Department (ED) 31 105 30
Medical Intensive Care (MICU) 12 76 16
Medicine Unit (MU) 9 28 32
Medicine Step-down (MSU) 16 48 33
Surgery Step-down (SSU) 12 37 32
Total 80 294 27
Table 2
Individual Attributes of Participants (Total Sample and by Workgroup)
Age (in years) Gender

≤ 24 25-44 45-64 Male Female Total
Unit (%) (%) (%) (%) (%) (%)
ED 0 18 13 3 28 31
(0) (22) (16) (4) (35) (39)
MSU 3 12 1 2 14 16
(4) (15) (4) (1) (18) (20)
MICU 0 11 1 1 11 12
(0) (14) (1) (1) (14) (15)
MU 1 5 2 0 9 8
(1) (6) (2) (0) (11) (10)
SSU 2 10 0 0 12 12
(3) (12) (0) (0) (15) (15)
6 56 17 6 74 80
Total (8) (69) (23) (8) (93) (100)
44
the youngest nurses with 4% being < 24 years old. The ED had the most nurses who were > than
55 years old (8%). A Pearson’s chi-square analysis indicated there was no significant difference
by gender and unit workgroup (χ2 [4] = 2.50, p = .64). The majority of the respondents across all
workgroups were female (93%). Overall, more males worked in the ED (4%) than on the other
units.
Pearson’s chi-square indicated there is a significant difference in years of clinical
experience by unit workgroup (χ2 [52] = 78.95, p = .009). This difference is most reflected in the
respondents who indicated that they had more than 20 years of clinical experience (n = 10,
12.5%); the ED unit comprised 26% of those with more than 20 years of experience (n = 8).
The second largest group for years of experience was that of 12-15 years (10%); within all units,
the ED (16%) and MICU (17%) unit comprised the largest representation of all workgroups.
The majority of the nurses in this study who had practiced for less than 5 years (41%) are
practicing at an Advanced Beginner, RNCII level (61, 77%). The majority had a BSN (68%),
and they are not currently engaged in a program to advance their nursing education (64%). Of
those enrolled in an educational program, the majority are in a Master’s degree program in
nursing (20%). Fourteen are Competent Nurses, RNCIII (18%) and four (5%) are Proficient,
RNCIV. Of the nurses formally advanced up the practice levels, 80% (n = 19) have done so in
the last 5 years. Thirteen percent, however, have been practicing above the Advanced Beginner
level, RNCII for more than 16 years. The majority of the respondents (59%) do not hold a
specialty certification. The certified nurses (40%) are practicing in the area of their clinical
specialty (see Tables 3 and 4). The BSN (68%) prepared nurses were primarily working in the
ED accounting for 24% of the overall total.
45
Table 3
Demographic Characteristics of the Sample (n = 80)
Variable Frequency %
Work Unit Adult Emergency Department 31 30
MICU 12 16
MU 9 32
MSU 16 33
SSU 12 32
Years of Practice as an RN ≤ 5 years 33 41
6 – 10 years 23 29
11 – 15 years 8 10
16 - 20 6 8
> 20 years 10 13
Education Diploma 2 3
Associate’s Degree 16 20
BS/N 54 68
MS/N 8 10
Pursuing Degree No 47 64
BS/N 9 11
MS/N 16 20
DNP 0 0
PhD 1 1
Level of Expertise II 61 77
III 14 18
IV 4 5
Years at Advanced Ladder Level < 1 year 4 17
1-5 years 15 63
6-10 years 1 4
11-15 years 1 4
16-20 years 3 13
Specialty Certification Yes 32 40
No 47 59
Certified in current practice area Yes 32 40
No 46 58
46
Table 4
Years of Clinical Experience and Unit Workgroup
Experience as a clinical nurse
Units
Experience ED MSU MICU MU SSU Total
1 – 5 years Count 5 6 5 6 5 5
% within units 12.9 43.8 50.0 0.0 58.4 34.0
% of total 12.6 7.5 6.3 14.0 6.3 34.0
6 – 10 years Count 11 4 2 3 3 23
% within units 35.6 25.1 16.7 33.3 25 28.9
% of total 11.4 5.1 2.5 3.8 3.8 28.9
11-15 years
Count 5 0 2 0 1 8
% within units 16.1 0.0 16.7 0.0 8.3 10.0
% of total 6.3 0.0 2.5 0.0 1.3 10.0
16-20 years
Count 3 0 1 1 1 6
% within units 9.7 0.0 8.3 11.1 8.3 7.5
% of total 3.8 0.0 1.3 1.3 1.3 7.5
More than 20
years Count 8 0 0 2 0 10
% within units 25.8 0.0 0.0 22.2 0.0 12.5
Total % of total 10.0 0.0 0.0 2.5 0.0 12.5
Count 31 16 12 9 12 80
% within units 100.0 100.0 100.0 100.0 100.0 100.0
% of total 38.8 20.0 15.0 11.3 15.0 100.0
The ED also had the largest number of nurses educated below a BSN level with Associates (9%)
and Diploma (3%) degrees. The majority of the respondents were not advancing their nursing
degree (68%). Of those that were advancing their degrees, Medical Unit (MU) (2%) and
Medical Intensive Care Unit (MICU) (2%) indicated the fewest. Overall, the majority of nurses
in school were advancing their education at the master’s level (20%). The ED represented the
47
largest contribution to the overall percentage of those enrolled in school with 6% seeking a BSN
and 8% seeking an MS. The majority of the respondents were not advanced on the Clinical
Ladder (77%). Those who had advanced beyond a RN Clinician II did so at the RN Clinician III
level (18%). MSU comprised the largest contribution to the overall RN Clinician III
advancements (6%). The ED (5%) provides the next greatest contribution to the RN Clinician III
respondents. The MICU did not have any respondents practicing above an RN Clinician II level.
N5 (3%) and the ED (3%) shared the largest contribution at a RN Clinician IV level within all
units. The majority of the respondents practiced at a RN Clinician II level (72%). Of the
respondents who had advanced, the majority had done so in the last 2 years (9%). Four percent
of the respondents had practiced at an advanced level for 16 to 20 years. The ED comprised
14% of the overall 4% while MU contributed 13%. MSU and Surgery Step Down Unit (SSU)
did not have any nurses who had practiced beyond a RN Clinician II level. The MICU did not
have any nurses beyond a RN Clinician II. The majority of the respondents were not certified
(60%). SSU comprised the greatest deficit in certification with 83% indicating that they were
not certified. Of the nurses that responded that they were certified, the majority (8%) had been
for 2 years. The MICU comprised the majority of the 8% certified in the last 2 years (33%). The
ED nurses comprised the largest overall contribution to the total with 22%. Of all the
respondents that held certification the majority attained it in the last 1 to 5 years (34%).
Specialty certification by unit, demographic characteristics of the sample by unit, and Pearson’s
chi-square by demographic are displayed in Tables 5-7.
48
Table 5
Specialty Certification by Unit
Units
ED MSU MICU MU SSU Total
Certified 17 11 6 3 10 47
% within unit 55 69 50 38 83 60
% of total 22 14 8 4 13 60
Table 6
Demographic Characteristics of the Sample by Unit (n = 80)
Units
ED(%) MSU(%) MICU(%) MU(%) SSU(%) Total(%)
Education:
Diploma 2 (3) 0 (0) 0 (0) 0 (0) 0 (0) 2 (3)
Associate 0 (0) 3 (4) 13 (16) 0 (0) 16 (20) 16 (20)
Bachelor 0 (0) 2 (3) 8 (10) 2 (3) 12 (15) 54 (68)
Master 0 (0) 2 (3) 5 (6) 2 (3) 9 (11) 8 (10)
Enrolled:
Not 20 (25) 9 (11) 9 (11) 7 (9) 9 (11) 54 (68)
BSN 5 (6) 1 (1) 1 (1) 1 (1) 1 (1) 9 (11)
MSN 6 (8) 6 (8) 1 (1) 1 (1) 2 (3) 16 (20)
PhD 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 1 (1)
Ladder level:
II 25 (32) 11 (14) 12 (15) 4 (5) 9 (11) 61 (77)
III 4 (5) 5 (6) 0 (0) 2 (3) 3 (4) 14 (18)
IV 2 (3) 0 (0) 0 (0) 2 (3) 0 (0) 4 (5)
Years > 2
Not > 2 20 (27) 11 (15) 10 (13) 4 (5) 9 (12) 54 (72)
< 1 year 1 (1) 2 (3) 0 (0) 1 (1) 0 (0) 4 (5)
1 year 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 1 (1)
2 years 2 (3) 2 (3) 0 (0) 1 (1) 2 (3) 7 (9)
4 years 1 (1) 1 (1) 1 (1) 0 (0) 1 (1) 4 (5)
7 years 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1)
11-15 years 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1)
16-20 years 2 (3) 0 (0) 0 (0) 1 (0) 0 (0) 3 (4)
49
Table 7
Pearson’s Chi-square for Demographics by Unit
Demographic χ2 df p
Nursing educationa 7.801 12 .800

Advancing degreeb 11.255 12 .507
Ladder level c 14.760 8 .064
> Clinician II d 23.206 28 .723
a
14 cells (70%) have expected count less than 5.
b
c
d
35 cells (87.5%) have expected count less than 5.
Descriptive Statistics
Relational Coordination
Nurses rating their own units. The nurses were asked to rate the relational coordination
dimensions on their own home unit (see Table 8). The first dimension was frequent
communication. A mean score of 3 would be most desirable, indicating that the nurses within
their own units participated in frequent communication with each other at just the right amount.
All the units, including the ED, rated themselves as communicating too often or closer to much
too often. The ED (mean = 4.77; SD =.65) and the MICU (mean = 4.83; SD = .58) nurses rated
themselves the closest to communicating much too much. The MU nurses rated themselves
closest to too often (mean=4.22, SD=1.20). None of the nurses rated their own units frequent
communication dimension with ED transfers at just the right amount.
The second question asked about the timeliness of communication with each other about
ED transfers. A mean score of 5 would be most desirable, indicating that the nurses rated their
own unit as always participating in timely communication about ED transfers. The inpatient
50
Table 8
Units' Rating Themselves on the Seven Dimensions of Relational Coordination
Frequent communication
Not nearly Not Just the right Too Much too
Unit enough enough amount often often Mean SD
ED 0 1 1 3 30 4.77 .65
MSU 0 0 2 1 13 4.69 .70
MICU 0 0 1 0 11 4.83 .58
MU 0 1 2 0 6 4.22 1.20
SSU 0 1 0 0 11 4.75 .87
Timely communication
Unit Never Rarely Sometimes Often Always Mean SD
ED 0 1 5 14 12 4.16 81
MSU 0 0 0 13 3 4.19 .40
MICU 0 0 3 7 2 3.92 .67
MU 0 0 4 5 0 3.56 .53
SSU 0 0 4 7 1 3.75 .62
Accurate communication
ED 0 0 5 18 9 4.13 .67
MSU 0 0 0 12 4 4.25 .45
MICU 0 0 1 8 3 4.17 .58
MU 0 0 3 4 2 3.89 .78
SSU 0 0 4 7 1 3.75 .62
Problem-solving communication
Always Mostly Neither blame Mostly Always
Unit blame blame nor solve solve solve Mean SD
ED 1 2 6 14 9 3.88 1.01
MSU 0 2 1 11 2 3.81 .83
MICU 0 1 0 9 2 4.00 .74
MU 0 0 1 7 0 4.00 .50
SSU 0 0 4 5 3 3.92 .79
Shared goals
Unit Not at all A little Somewhat A lot Completely Mean SD
ED 2 1 4 12 13 4.03 1.21
MSU 0 0 4 8 4 4.00 .73
MICU 0 0 1 7 4 4.25 .62
MU 0 0 4 5 0 3.56 .53
SSU 0 0 2 8 2 4.00 .60
51
Table 8 - continued
Shared knowledge
Unit Nothing A little Some A lot Everything Mean SD
ED 0 1 4 11 15 4.29 .82
MSU 0 0 4 8 4 4.00 .73
MICU 0 1 2 6 3 3.92 .90
MU 0 0 3 3 3 4.00 .87
SSU 0 2 1 5 4 3.92 1.08
Mutual respect
ED 0 1 5 10 15 4.26 .86
MSU 0 0 5 7 4 3.94 .77
MICU 0 1 1 8 2 3.92 .79
MU 0 0 3 4 2 3.89 .78
SSU 0 0 2 7 3 4.08 .67
nurses each felt that they did a better job within their units than with the ED. The SSU nurses
rated themselves highest (mean=4.75; SD=), indicating that they always participate in timely
communication among themselves. The ED (mean = 4.16, SD=.81)) and MSU (mean=4.19,
SD=.40) rated themselves as more than often but not always. The MICU (mean=3.92, SD =.67)
and MU (mean=3.56, SD =.53) nurses rated themselves as more than sometimes but less than
often.
The third survey item asked about accurate communication during the transfer process.
A mean score of 5 would, again, be most desirable, indicating that the units felt they always
participate in accurate communication with each other. If the mean score is closer to 1, the
nurses felt they never provide accurate communication and if closer to 5, they always provide
accurate communication. A rating of 4 indicated that they felt they often provide accurate
communication with each other. The ED (mean = 4.13; SD = .67), MSU (mean = 4.25; SD =
.45) and MICU (mean = 4.17; SD = .58) rated themselves as often to always participating in
accurate communication within their own work groups. SSU (mean = 3.75; SD = .62) and MU
52
(mean = 3.89; SD = .78) rated themselves as sometimes too often. SSU (mean = 3.75; SD = .62)
rated their accurate communication within their unit as lower than the other units but still often.
The fourth dimension is problem-solving communication when difficulties arise during a
transfer. For this survey item, a mean score of 5, again, would be most desirable, indicating that
when there is a problem with an ED transfer, the nurses on their own units work together to solve
the problem rather than blaming each other. A score of 5 would indicate that the nurses feel they
always work together to solve the transfer problem. If the mean score is closer to 1, the nurses
always blame others for the problem rather than seeking resolution. All the units rated
themselves as working together to mostly solve the problem rather than assigning blame.
The fifth dimension is shared goals. For this survey item, a mean score of 5 would be
most desirable, indicating that when nurses are engaged in an ED transfer within their own unit
they completely share the same goal. If the mean score is closer to 1, the units feel that they do
not share the same goal with their co-workers; in fact, not at all. All the units rated themselves
as sharing the same goal a lot. The MICU rated themselves the highest (mean = 4.25; SD = .62)
indicating that they share the same goal closer to completely.
The sixth dimension is shared knowledge. For this survey item, a mean score of 5, again,
would be most desirable, indicating that when ED patients are transferred nurses working on the
same unit know everything about the work that is required of their co-workers to complete the
task. A score of 5 would indicate that the nurses know everything about the work that is required
and share the same knowledge. If the mean score is closer to 1, the co-workers know nothing
about the work that is required and do not share the same knowledge. All the nurses within the
same units rated themselves as knowing a lot about the work required. The ED (mean = 4.29;
SD=.82) nurses rated themselves the highest and a little higher than a lot.
53
The final RC dimension is mutual respect. For this survey item, a mean score of 5 would
be most desirable; indicating that when nurses receive an ED transfer they feel their co-workers
respect the work they do during the transfer. A score of 5 would indicate that the nurses feel
completely respected within their unit. If the mean score is closer to 1, the nurses feel that their
colleagues do not respect their work. A mean score of 3 would indicate that their co-workers
somewhat respect their work. The ED (mean = 4.26; SD = .86) and SSU (mean = 4.08; SD =
.67) indicated the highest rating for respect within their units. MU (mean = 3.89; SD = .78) was
the lowest, however, they still felt respected.
Tests of Significance
Emergency Department Nurses Rating All Other Nurses
The first dimension of RC aims to determine how the ED workgroup rated the other four
units (MICU, MU, MSU, and SSU) regarding the frequency in which nurses in each of these
groups communicate with the ED about patient transfers. Results of the ANOVA were found to
be significant (F [4, 81] = 5.577, p = .001). Due to this finding, the Dunnett’s post hoc test was
run to determine which individual workgroup pairings produced significant differences in mean
ratings (Table 9). Significant differences were found in the ED unit ratings for the MU (p =
.005) and the MSU (p = .001). This finding indicates that the two units received lower ratings
from the ED unit as to frequency of communication, enough so to be significantly lower than the
other two units. The ED unit staff felt that the MU and MSU should communicate more
frequently.
The ED Unit was then asked to rate the other units timely communication during patient
transfers. Results of the ANOVA was significant (F [4, 78] = 3.916, p = .006). Dunnett’s post
hoc analysis found the MU to be rated significantly lower than the other three units for timely
54
Table 9
Results of Dunnett’s Post Hoc Tests for ED Unit Rating Units
Mean 95% Confidence Interval
RC Dimension Workgroup# Workgroup# Difference Std. Error Sig. Lower Bound Upper Bound
Frequent MICU ED -.18627 .28603 .937 -.9113 .5387
Communication MU ED -1.07516* .31932 .005 -1.8846 -.2658
MSU ED -.97794* .25825 .001 -1.6325 -.3233
SSU ED -.67112 .29548 .095 -1.4201 .0778

Timely MICU ED -.46237 .29503 .379 -1.2103 .2856
MSU ED -.56653 .26713 .133 -1.2437 .1106
SSU ED .05279 .30455 1.000 -.7193 .8248

Accurate MICU ED -.62903 .26768 .079 -1.3076 .0495
MSU ED -1.25403* .24236 .000 -1.8684 -.6396
SSU ED -.94721* .27631 .004 -1.6477 -.2467

Problem-Solving MICU ED -.37097 .33497 .690 -1.2201 .4782
MSU ED -1.05847* .30328 .003 -1.8273 -.2896
SSU ED -.96188* .34577 .026 -1.8384 -.0853

Shared Goals MICU ED -.56452 .34352 .334 -1.4354 .3063
MU ED -1.84229* .38258 .000 -2.8121 -.8724
MSU ED -1.12702* .31103 .002 -1.9155 -.3385
SSU ED -1.33724* .35460 .001 -2.2362 -.4383

Shared MICU ED -1.13333* .28690 .001 -1.8607 -.4060
Knowledge MU ED -2.07778* .31924 .000 -2.8871 -1.2685
MSU ED -1.61250* .26003 .000 -2.2717 -.9533
SSU ED -1.66364* .29607 .000 -2.4142 -.9131

Mutual Respect MICU ED -.43333 .31544 .503 -1.2330 .3663
MU ED -2.26667* .35099 .000 -3.1565 -1.3769
MSU ED -1.26667* .28589 .000 -1.9914 -.5419
SSU ED -1.81212* .32552 .000 -2.6374 -.9869

*. The mean difference is significant at the 0.05 level.
a. Dunnett t-tests treat one group as a control, and compare all other groups against it.
55
communication (p = .004). The ED Unit indicated that timely communication with the MU
occurred rarely or sometimes; whereas the other units received mean ratings ranging from
sometimes to often or always.
Accurate communication regarding patient transfers between the ED Unit and the
inpatient units was examined as the third dimension. AVOVA findings were significant (F [4,
78] = 10.426, p = .000). Post hoc Dunnett’s found significantly lower ratings for accuracy of
communication for MU (p = .000), MSU (p = .000), and the SSU (p = .004). These units
received mean ratings in the lower categories of sometimes to often, while the MICU had mean
ratings in the area of often to always.
When asked, When there is a problem with patient transfers between the ED and other
units, do nurses on these units blame others or work with you [the ED Unit] to solve the
problem? the ED provided mean ratings that were significantly different (F[4, 78] = 6.303, p =
.000). Results of the Dunnett’s found significantly lower mean ratings (mostly blaming or
neither blaming or solving) for the MU (p = .000), MSU (p = .003), and the SSU (p = .026).
Therefore, the analysis provides support that the ED Unit rates the MICU as the only unit
engaged in behaviors intended to solve patient transfer problems rather than blaming each other.
When asked if their inpatient colleagues share their goals during patient transfers
ANOVA findings were significant (F [4, 78] = 8.456, p = .000). Significant findings from the
Dunnett’s found three units to be rated lower than the MICU for shared goals. The MU (p =
.000), the MSU (p = .002), and the SSU (p = .001) had mean ratings in the range of a little to
somewhat for how the ED nurses felt they shared goals concerning patient transfers. However,
the MICU had the highest mean ratings, ranging from somewhat to a lot.
56
Another survey item asked ED nurses to indicate how strongly they felt their inpatient
colleagues knew everything about the work that is required of them during the task of patient
admission (shared knowledge). Findings of the ANOVA indicated low ratings for all four
workgroups (F [4, 77] = 18.242, p = .000). The four workgroups all were consistently rated low
by the ED Unit, as found in the post hoc results (MICU, p = .001; MU, p = .000; MSU, p = .000;
SSU, p = .000). The majority of mean rankings for all four workgroups was in the categories of
a little to some for shared knowledge.
The final RC dimension asked whether the ED nurses felt that colleagues in the other
units respected the work they do with patient transfers. ANOVA results were significantly
different, and demonstrated lower mean ratings for three of the workgroups (F [4, 77] = 16.057,
p = .000). The MICU was the only group with nonsignificant rating, where mean ratings were
reported in the areas of somewhat to a lot, indicating that the ED Unit recognized the MICU had
an understanding of, and respect for, the work they do. However, lower mean ratings of a little
to somewhat were indicated for the MU (p = .000), the MSU (p = .000) and the SSU (p = .000).
The ED nurses feel that the majority of their inpatient colleagues do not respect their work, not at
all.
Inpatient Nurses Rating Emergency Department Nurses
Nurses on the inpatient units were asked to rate the ED nurses on the seven RC
dimensions (Table 10). For the initial dimension, frequent communication, the MU indicated
that frequent communication was just the right amount of communication with the ED (mean =
3.78; SD = .97). The MICU nurses indicated that communication was actually too often (mean =
4.67; SD = .78). The ED was rated highest by SSU as providing timely communication more
than often but less than always (mean = 4.25; SD = 1.14). Overall, the units reported that the
57
Table 10
Units' Ratings of the ED
Frequent communication
Unit Not nearly Not Just the right Too Much too Mean SD
enough enough amount often often
MSU 1 0 6 2 7 3.88 1.20

MICU 0 0 2 0 10 4.67 .78
MU 0 0 5 1 3 3.78 .97
SSU 0 1 3 0 8 4.25 1.14
Timely communication
MSU 0 2 4 9 1 3.56 .81
MICU 0 1 3 7 1 3.67 .78
MU 0 3 3 3 0 3.00 .87
SSU 0 1 3 0 8 4.25 1.14
Accurate communication
MSU 0 5 8 3 0 2.88 .72
MICU 0 3 1 7 1 3.50 1.00
MU 0 4 4 1 0 2.67 .71
SSU 0 3 4 4 1 3.25 .97
Problem-solving communication
Always Mostly Neither blame Mostly Always
Unit blame blame or solve solve solve Mean SD
MSU 0 7 5 4 0 2.81 .83
MICU 0 3 2 5 2 3.50 1.09
MU 1 5 2 1 0 2.33 .87
SSU 0 5 4 2 1 2.92 1.00
Shared goals
MSU 1 5 4 6 0 2.91 1.00
MICU 0 1 4 7 0 3.50 .67
MU 3 1 5 0 0 2.22 .97
SSU 1 4 4 3 0 2.75 .97
Shared knowledge
Unit Nothing A little Some A lot Everything Mean SD
MSU 1 4 10 1 0 2.69 .70
MICU 0 2 6 4 0 3.17 .72
MU 2 3 4 0 0 2.22 .83
SSU 1 5 4 1 1 2.67 1.07
Mutual respect
MSU 0 4 8 4 0 3.00 .73
MICU 0 1 2 7 2 3.83 .84
MU 5 0 3 1 0 2.00 1.23
SSU 3 2 5 2 0 2.50 1.09
58
often communicated with them in a timely manner. MU, however, rated the ED as only
sometimes providing timely communication (mean = 3.0; SD = .97). The MICU (mean = 3.50;
SD = 1.00) rated the ED higher than the other units indicating that they felt that accurate
communication occurred sometimes and often. MU (mean = 2.67; SD = .71) rated accurate
communication from the ED the lowest indicating that it occurred rarely and sometimes.
When there is a problem with a transfer the unit nurses were asked if the ED nurses try to
solve the problem rather than blaming others. MU (mean = 2.33; SD = .87) rated the ED the
lowest on this item indicating that they feel the ED is more likely to mostly blame others when a
problem occurs. MICU (mean = 3.50; SD = 1.09) rated the ED the highest indicating that they
share similar views as the ED on this dimension and feel that ED nurses are likely to work with
them to solve issues. None of the units, however, rated the ED as always working with them to
solve the problem.
When nurses are engaged in a transfer from the ED they were asked if their colleagues
completely share their same transfer goal. The MICU (mean = 3.50; SD = .67) rated the ED
closest to sharing their same goal somewhat to a lot. MU (mean = 2.22; SD = .97) rated ED the
lowest indicating that they share the same goal only a little. MSU (mean = 2.91; SD = 1.00) and
SSU (mean = 2.75; SD = .97) were somewhat closer to feeling that the ED nurses share their
same goal during transfers.
The unit nurses were asked if their ED colleagues know everything about the work that is
required of them as they try to receive ED patients (shared knowledge). The MICU (mean =
3.17; SD = .72) feels that the ED knows some about the work that is required for the MICU to
receive a patient. MU (mean = 2.22;SD = .83) rated shared knowledge the lowest indicating that
they feel that ED nurses only know a little about what is required for them to receive a patient.
59
MSU (mean = 2.69; SD = .70) and SSU (mean = 2.67; SD = 1.07) rated the ED a little higher in
understanding the work required of their inpatient colleagues.
The unit nurses’ final assessment of the ED nurses is on mutual respect. MU’s (mean =
2.00; SD = 1.23) rating of mutual respect with the ED was the lowest indicating that they do not
feel that the ED respects their work during transfers beyond a little. MSU (mean = 3.00; SD =
.73) and SSU (mean = 2.50; SD = 1.09) indicated that the ED respected them somewhat. The
MICU (mean = 3.83; SD = .73) indicated the highest level of respect from the ED at a lot
Emergency Department Boarding Time
ED boarding time is reported as the time elapsed between when a physician enters a
request to admit a patient and when the patient arrives on a designated unit. Data collection
occurred over a 3-week period of time and during that time 676 patients were transferred from
the ED to the selected units. The mean boarding time for all patients was 311.5 minutes. The
standard deviation for each unit’s ED boarding time was not available by each transfer and the
total standard deviation was calculated to be 107.9. The majority of the ED transfers were
admitted to the MSU unit (30%) and experienced the longest boarding time (minutes = 410
minutes). The MU (25%) had the second highest volume of admissions and these patients
experienced the second longest ED boarding time (minutes = 375). The MICU (15%) had the
lowest boarding time (minutes = 167). The SSD (22%) provided the shortest boarding time
among all the non-ICU units (minutes = 294). Table 11 displays ED patient admissions to
selected hospital units and the mean ED boarding time (in minutes) for each.
Conclusions and Summary
The results of this investigation were presented in this chapter. The participants were
similar in age, education, ladder level, enrollment in school, and current level of certification.
60
Table 11
ED Patient Admissions to Selected Hospital Units

9/9 through 11/3/2014 (n = 728)
Mean ED Boarding
Patients Time (min.)
Nursing Unit admitted
Medicine 181 375
Medicine ICU 111 167
Medicine Step-down 221 410
Surgery Step-down 163 294
Overall-summary n = 676 Mean =311.5
SD = 107.9
The only significant demographic difference was found in the nurses’ level of experience. ED
nurses were significantly more experienced than the nurses on the inpatient units (χ2 (52) =
78.95, p = .009).
The results indicate significant RC concerns across ED and inpatient boundaries. While
nurses feel that their own units are doing well and rated RC dimensions highest on their own
units the ED nurses rated several of their inpatient colleagues significantly low in several RC
dimensions. The inpatient nurses rated the ED low in several RC dimensions but none are
significant. Specifically, the ED feels that the MU is significantly low in all seven RC
dimensions. They rated the MSU significantly low in all but timely communication. A ll four of
the inpatient units were significantly low in understanding the work that the ED nurses must do
as they transfer patients (shared knowledge). The MICU was only significantly low in the shared
knowledge category, suggesting a reciprocal relationship that positively influences their
interactions in the other six dimensions. The two medicine units (MU and MSU) tend to share
the same perspective when asked about the ED nurses, however, the study did not indicate
61
significance. The MU and MSU feel that the ED nurses do not understand or respect their work
either.
When units rate themselves their RC dimensions scores are much more positive. The ED
nurses and the SSU nurses rated their own units as having the overall highest RC dimensions.
The MSU and MU rated themselves as the overall lowest. All the inpatient units feel that
communication is frequent and timely with the ED. They feel they are weakest with problem-
solving communication and sharing transfer goals. While the units and ED share similar poor
perspectives on their RC dimensions, the ED views their inpatient colleagues as significantly
lower. Chapter 5 will present a discussion of these findings and addresses the limitations;
implications for practice, theory and research, and recommendations for future research.
62
CHAPTER 5. DISCUSSION OF FINDINGS
The purpose of this research was to determine if relational coordination dimensions are
significantly different between ED nurses and inpatient nurses as they transfer ED boarding
patients. Health-care organizations continue to face adverse quality outcomes associated with
ED crowding. Quality metrics identified as predictors of crowding, diversion, wait times, and
boarding continue to increase despite managerial imperatives to reduce each (Liu et al., 2011).
ED nursing care is under surveillance and increasingly monitored, measured, reported, and
scrutinized with a focus on these quality and efficiency metrics (Borbasi & Jackson, 2005). An
inability to transfer a patient to an inpatient bed remains the single most important contributing
factor to ED crowding (Olshaker, 2009). This study examined the relational and communication
dimensions present in nursing practice as ED nurses collaborate with floor nurses to transfer
patients. Their knowledge, expertise, intentions, and interpretations of the task were examined
within the context of experiential learning (Benner, 1984). Gittell’s (2009) relational
coordination philosophy provided the theoretical foundation by examining the coordination of
transfers through nursing’s relationships of shared goals, shared knowledge, and mutual respect.
This chapter presents a synthesis of the main empirical findings summarized in Chapter 4. It
describes the nursing workforce and their relational coordination during ED transfers. Strengths
and potential limitations of the current study will be discussed as well as recommendations for
future research presented.
63
Descriptive Statistics
The only significant demographic difference in this study was found in the nurses’ level
of experience. ED nurses were significantly more experienced than the nurses on the inpatient
units. The significant difference in years of clinical experience by the ED nurses as well as
having the overall highest percentage practicing beyond an RN Clinician II level (8%) by
Benner’s (1984) concept would indicate that the ED nurses in the study are most likely
practicing at an expert level. They would no longer require analytical principles such as a rules
or guidelines to direct their practice. Benner (1999) defines four key aspects of expert nursing
practice: (a) an ability to read a situation and respond quickly, (b) an embodied know-how, (c)
seeing the big picture with an anticipated trajectory and not just the immediate clinical situation,
and (d) working with and acting through positive relationships with others. These aspects in
their practice would guide the ED nurses’ behavior when coordinating ED transfers. They would
demonstrate an ability to quickly focus on the accurate region of the ED crowding issue and seek
resolution specific to diversion, wait time, or boarding without wasting time or considering other
less helpful possibilities (Benner, 1984). Transferring a patient to an inpatient unit may be only
one route considered when addressing ED crowding; however, once the expert nurse considers
all options, she may settle on this as the best. One less patient may increase resources to address
all crowding issues, but is reflected only in the measure of boarding time. Reducing diversion
and wait times may only be secondary gains not easily captured in ED quality metrics. While the
expert ED nurse organizes her behaviors by anticipating the bigger clinical issues faced with ED
crowding, the floor nurse may coordinate the transfer in isolation of the bigger picture.
The study indicated that the majority of the nurses with less than 5 years’ experience
(41%) worked on the inpatient units. The MU and MSU nurses comprised the most respondents
64
with fewer than 5 years of practice (75%). A nurse at this level would be considered a novice or
advanced beginner (Benner, 1984). They generally would require help setting priorities and tend
to operate on prescribed guidelines. Sorting out what is most important in their work would
require direction. Typically, a novice nurses have limited or no experience in managing highly
complex situations, with multiple interruptions and demands exceeding their capability to
respond, and a need to constantly reorder priorities while staying focused on the task to
coordinate a transfer (Benner, Hughes, & Sutphen, 2008). While engaging with the ED nurse
(the expert nurse), they may face an interaction in which their colleague would see beyond
guidelines and may rush or short cut their novice processing. The ED nurse may actually
expedite problem solving and prioritize the transfer by providing verbal direction. This directive
may be perceived as a status differential rather than evidence of expert knowledge and ultimately
challenge communication and divide efforts (Gittell, 2009).
Inpatient novice and advance beginner nurses would be expected to be beginning to
demonstrate an ability to synthesize previous experiences and to see recurrent and meaningful
patterns in their practice; however, visualizing the whole picture is developmentally beyond their
reach. The complexity inherent in the coordination of an ED transfer requires an ability to
manage many contingencies with speed and flexibility. A reliance on general guidelines to
navigate a transfer may fall off an inpatient nurse’s priority list as she navigates caring for her
current patients in the form of conflicting goals, obstacles, unpredictability, poorly designed
work flow, rapid changes, missing data, the engagement with other patients and practitioners.
Complexity forces the nurse to depart from her preferred formal and ideal response into an
uncharted cognitive reality (Ebright, Urden, Patterson, & Chalko, 2004).
65
Though the majority of the nurses had limited experience, they did report having a
bachelor’s degree (68%), which is higher than the overall nursing workforce at the VCU (66.4%)
and the country (45%) (Health Resources and Services Administration, 2013). Nursing
education ensures that a nurse’s advancement from novice to expert will be efficiently navigated
from a foundation of theory and principles to experiential learning. This sample of primarily
BSN nurses, young by industry standards, would be expected to have the foundational
knowledge through their formal BSN preparation, to ask the right questions and look for the
correct problems as they advance their knowledge through experience (Benner, 1984). Their
BSN preparation, however, will not influence their practice in isolation of experience or work
environment. Nurses with many years of experience compared to those with fewer years may be
relatively desensitized to complex work environments and consequently have higher coping
thresholds (Manski-Nankervis, Furler, Young, Patterson, & Blackberry, 2015). Higher education
and healthy work environments together have the greatest opportunity to positively impact
patient outcomes (Aiken et al., 2011). The majority of the sample was female (93%) and
younger (25 to 34 years) than the overall population of nurses at VCU (48 years) and in the
United States (45 years). Most (68%) were not pursuing additional nursing education beyond
their current level. They also were not specially certified in their practice area (60%). The
majority (72%) were not practicing beyond Benner’s advanced beginner level (RN Clinician II)
on the formal clinical ladder. A well-functioning nursing team requires foundational education,
effective communication for experiential learning to occur as well as a social climate that
supports shared clinical judgment and strong relational skills (Benner, 1999).
66
Relational Coordination
Relational coordination is a mutually reinforcing process of human interactions between
communication and relationships as task integration occurs. As nurses coordinate an ED
transfer, the mutually reinforcing webs of communication and relationship impact the process
(Gittell et al., 2000). Relationships among nurses matter in the transfer of ED boarding patients.
Specifically, accurate, problem solving, frequent, timely communication, supported by
relationships of shared goals, shared knowledge, and mutual respect provide the basis for
coordinated ED transfers.
None of the RC rankings in this study, within inpatient unit boundaries were significantly
different. Several RC rankings of inpatient RC dimensions as perceived by the ED were
significantly different. All inpatient units were rated significantly below having some knowledge
related to the ED nurses work during transfers. The two medicine units were rated by the ED as
significantly less than a positive interaction in six to seven dimensions. At best, the inpatient
nurses rated the ED’s RC dimensions as only moderate and weak in all seven dimensions except
frequent communication. Inpatient unit’s indicated that frequent communication’s rating
indicated a strong RC score, however, as it relates to ED transfers nurses felt it occurred too
often and much too often. They did not view the strength in this communication dimension as a
positive influence during ED transfers. RC scores were reported as only slightly higher when
nurses rated their own units. The MU and MSU rated their overall RC score as weak and lower
than the other units self-rated.
All the units felt that the ED nurses provided frequent and timely communication
(moderate to strong) and rated these as higher than the other 5 RC dimensions. These ratings
indicate that the floor nurses feel that there is too often or much too often communication from
67
the ED related to ED transfers. Perhaps organizational pressure aimed at ED crowding and
throughput initiatives along with associated monitoring of the individual and unit performance
has amplified the ED nurses need to over communicate during transfers (Van Eyk, Baum, &
Houghton, 2001).
The CMS announced the inclusion of median time from admit decision time to time of
ED departure for admitted patients as a quality measure under the Hospital Inpatient Quality
Reporting Program initiative. Hospitals will be required to report their measures to CMS in
order to receive the full Medicare payment update. The metric was also endorsed by the
National Quality Forum in 2008 and 2011 and is currently one of several reviewed by
researchers and administrators to assess changes in ED crowding and patient throughput.
Eventually, it will be reported publicly (Medicare Program Federal Register, 2012). While
administrators and clinicians recognize the Institute of Medicine's (IOM's) six dimensions of
quality (safety, effectiveness, patient-centeredness, efficiency, timeliness, and equity) may all be
compromised when patients are boarded in the ED, solutions appear to be focused on frequent
communication that is not perceived as helpful to ED or inpatient nurses.
Excessive managerial pressure to move patients may actually be impeding the exchange
of information, diminishing the synergy from interaction and creating anxiety and tension
between the ED and floor nurses (McKeon, Oswaks, & Cunningham, 2006). Managing
knowledge workers, whose expertise must develop in the care of particular patients, using a
static command-and-control approach, blunts direct learning and limits the development and
sharing of innovation and initiative in practice. The fact that nurses do not always actualize their
intent should not result in a top down approach designed to drive outcomes. Micromanagement
tactics do not drive expert nurses to overlook the nuances in a patient’s condition in order to
68
meet the time commitment established by external directives. They view these directives as
guidelines and open for discussion. The novice nurses, however, may recognize the directives as
priorities and encounter stress as they struggle to provide safe care to their current patient
population while navigating numerous interruptions during the transfer process. Over
communicating during ED transfers by considering it a task divisible by measurable units may
actually be reducing the efficiency and effectiveness of the process (Benner et al., 2008).
Finding a balance between too much and too little communication where interaction, learning,
and innovation are fostered is the key to effectively managing the professional nursing
knowledge workers. Knowledge arises in an experiential process of relating between nurses and
is continuously reproduced and potentially transformed. Knowledge is an active process of
relating. It cannot be stored and intellectual capital cannot be measured or managed. A
relationship between the nurses establishes the value of each and highlights the capacity human
relating has to the task of transferring the patients in the absence of external control (Stacey,
2001). Designing nurses’ work during ED transfers so that they have the continuity and context
for developing trusting relationships with each other and an opportunity to demonstrate astute
clinical judgments based on knowing their patients provides the safest and most cost-effective
care (Benner et al., 2008).
Overall the floor nurses rated the ED lowest on shared knowledge and mutual respect and
the ED agreed by rating all the units lowest on the same. The ED especially does not feel that
the two medicine units (MU and MSU) know what is required of them to transfer a patient do not
respect the work that the ED nurses do, do not provide accurate information, tend to blame rather
than problem solve and do not share the same goals. The two general medicine units feel the
same towards the ED nurses. They feel that the ED nurses do not understand or respect their
69
work either. The ED feels that the SSU may provide frequent and timely communication, but
they, like their general medicine colleagues do not provide accurate information, tend to blame,
do not share goals, or respect. These poor RC dimensions and lack of interrelatedness among the
nurses within the transfer process prevents new and innovative solutions to the ED boarding
issues. The lack of understanding and respect across unit boundaries prevents collaboration.
Organizational throughput initiatives cannot engage bedside nurses as leaders with their
colleagues and crowding will remain an independent ED issue (Stacey, 2001).
The nurses on the medicine units (MU and MSU) felt that the ED provided accurate
communication a little less than often. Incomplete information exchange increases uncertainty in
the work environment (Lawrence & Lorsch, 1967). Environmental uncertainty is inherent in
emergency departments at any point in time. ED patients may be transferred with undiagnosed
conditions and incomplete treatment plans. Coordinating the work of the unit from incomplete
information and undefined patient conditions limits the floor nurses’ ability to deploy appropriate
resources to provide care for the transferred patient (Argote, 1981). Novice nurses may struggle
with adjusting their priorities as they face urgency without clear protocols (Benner, 1984). The
capacity of both areas to manage their complex, highly interdependent environments is
determined by their ability to handle the communication necessary for coordination. Reliable
information produces a greater tolerance for interdependence. As the ED and floor nurses face
higher levels of variability a greater burden to communicate and coordinate occurs.
Specialization in these units creates greater interdependencies between them to accomplish the
transfer (March & Simon, 1972). Accurate information is at best, only sometimes or often
accurate during ED transfers. The floor nurses’ inability to view the big picture produces
mistrust and increases uncertainty during ED transfers. They may consider ED nurses’ behavior
70
as undependable as unexpected situations create modifications and alter transfer plans. A lack of
interdependent trust between the units does not support rewarding relationships and attribution of
dependability is not earned. ED nurses are frequently navigating complexities that reduce their
ability to demonstrate interdependence, share common interests, and demonstrate a willingness
to act out of concern for the less experienced floor nurses. Nurses on the floor may not show an
intention to trust and an ability to meet their own role obligations as they fail to develop trust in a
gradual reciprocation of risk taking during transfers. Every time the process occurs in an
undependable exchange, fear increases and trust fades (Kelly & Thibaut, 1978). The conditions
of task interdependence, uncertainty and time constraints inherent in ED transfers are not
conducive to predictable or dependable exchanges. Acceptance of this emphasizes the
importance of understanding the effect of uncertain inputs (Thompson, 1967; Weick, 1993) on
ED transfers and the coordination methods most appropriate for the novice/advanced beginner
nurse to assimilate into practice (Argote, 1981). The use of critical pathways and protocols may
be helpful to the advanced beginner and competent-level clinicians but must be viewed as
guidelines, not mandates for the proficient-expert nurse. The expert nurse must be encouraged to
consult and question mandates as she assimilates new alternatives into his/her practice. The
expert views pathways and protocols as prompts for memory and dialogue. The nuanced
responses to the changes in a specific patient are the mark of expert nurse practice that typically
goes beyond formal rules and guidelines (Benner et al., 2008)
The weakest RC dimensions consistently reported by the ED nurses (at a significant
level) among their inpatient co-workers were a lack of accurate information sharing, an inability
to problem-solve without blaming, not sharing transfer goals and not respecting or understanding
the work requires of the ED nurses. The MU and the MSU rated themselves as having the
71
weakest RC with them. A level of passive engagement is apparent as the nurses on the two
medicine floors (MU and MSU) rated themselves as weak on problem-solving communication
and shared goals during ED transfers. Low problem-solving communication and ambiguous
expectations on the units impacts each nurse’s individual prioritization of the task. The
reciprocal nature of the work on the unit and their RC scores indicate that the nurses talk a lot
about transfers but they do not influence each other to accomplish the task. The ED crowding
issue does not drive the action of a nurse on these units. The relational process during the
coordination of the transfer is driven by the decisions of the nurse directly involved in the
transfer. His/her coworkers do not encourage or discourage the coordination of the transfer.
Experiences gained during ED transfers are unique to each interaction and occur in the interplay
of social forces between an ED nurse and a floor nurse during the task (Follett, 1924). The lack
of a shared goal associated with ED transfers ensures that nurses on MU and MSU are not
moving together, adjusting activities, interrelating, and working as a common unit to transfer
patients. While the nurses on the unit may each perform different roles during the coordination
of an ED transfer they are unable see their personal contribution to the whole (Follett, 1924).
In all seven RC dimensions the MICU rated the ED nurses higher than the other units
rated the ED, and the ED rated the MICU higher than it rated the other units. Though the ratings
MICU were not significantly different and are considered weak, the reciprocal RC dimensions
are apparent. The highest ratings occur in all but shared knowledge. This may be, in part, a
result of a different quality matrix assigned for ICU transfers. Once a decision is made to admit
a patient, an inpatient transfer should occur within 4 hours. An ICU admission is expected to be
quicker and completed within 2 hours. The acuity of an ICU patient would also be expected to
deploy more resources to expedite a transfer and reduce ED boarding time.
72
Emergency Department Transfers
None of the inpatient units successfully met the quality metrics related to ED transfer
times during this study period. The general floors have an admission threshold of 4 hours and
the ICU patient is expected to be in a bed within 2 hours once the decision to admit has been
made. The MICU was the closet to meeting their goal in 2.78 hours. The second closest was the
SSU in 4.9 hours. The MU (6.25 hours) and the MSU (6.83 hours) had the longest time
intervals. The MSU (221) and the MU (181) transferred more patients from the ED than did the
other units. The MICU and ED had higher RC dimensions compared to the ED and others. The
MICU and SSU nurses reported higher internal RC dimensions than the other units. Overall, the
MICU and SSU had better RC ratings by the ED nurses and lower ED boarding times than the
other units.
Implications for Nursing Research
The model did establish statistically different RC scores between the ED and the inpatient
nursing units that receive the most ED admissions. It also provided some descriptive findings
that warrant further investigation. The next step in theory development should include the
examination of causal relationships between nursing experience and all seven RC dimensions
during interdependent work with other nurses. Establishing focus groups to explore the lived
experience of nurses within units and across boundaries could provide greater insight into the
seven relational coordination dimensions examined in this study. Continuing to explore and
clarify relational dynamics between nurses during ED transfers may continue to validate the
utility of the relational coordination theory in nursing’s work processes.
73
Nursing teams face high levels of task interdependence, uncertainty and time constraints.
As nurses experientially learn and advance their practice, their ability to understand their role,
interpret the intentions of others, and measure their value and power within the bigger picture
evolves (Benner, 1984). This study examined ED transfers; however, given the relational nature
of coordinating care, future research should examine nursing experience and RC dimensions on
various performance outcomes (Gittell, 2012).
The ED nurses poor perspective of their inpatient colleagues RC dimensions warrant a
follow up qualitative study to explore themes that may emerge. The RC dimensions across ED
and inpatient units that require further investigation are accurate communication, problem
solving communication, shared goals, shared knowledge, and mutual respect. The ED and floor
nurses do not feel that they communicate with each other accurately about the status of ED
transfers. They do not feel that they know what work is required of each other and do not
understand or respect the nurses or the work done by the nurses’ on the other units.
Within unit RC dimensions that require further investigation are shared goals and
problem-solving communication. Nurses within their own teams do not feel that they share the
same goals related to transferring ED patients and they do not share responsibility to resolve
issues as they occur during transfers.
Future theory development should examine the causal relationships between these RC
dimensions, nursing experience, and situational awareness during ED transfers. Others have
begun to take steps in this direction. Riley, Davis, Miller, and McCullough (2010) examined
team responses and described situational awareness as the ability to actively assess and discern
changes in the environment. Environmental issues are perceived and managed differently by
nurses based on their developmental level (Benner, 1984). Examining causal relationships
74
between experience, situational awareness and RC dimensions during ED transfers is another
next step in advancing our understanding of nursing’s relational work.
Weak problem-solving communication indicates that future theory development should
explore the causal relationships between nursing experience and directives during ED transfers.
Others have begun to take steps in this direction. Daft (2007) identifies the value of
decentralized structures in which authority is shifted to the level of service and leadership is
characterized by shared decision making, mutual goal setting, and employee empowerment.
Benner (1984) would propose that this leadership style would create stress and insecurity for the
rule-governed and inflexible, inexperienced nurse who is seeking rules and guidelines. Both
realities must be explored within an organization. Nurses are governed by managerial rules and
norms. Nursing work is increasingly driven by managerial imperatives that can lead to
intergroup conflict as the ED is accountable for ED quality metrics (Smith, Pearson, & Ross,
2002). Individual nurses, both expert and less experienced, along with their teams struggle to
define their role, contribution, and behavior within the context of the larger organizational
directives.
Recognizing the RC is expected to improve the quality and efficiency performance of
nurses’ work as they transfer patients; theory can be developed by measuring RC as the
independent variable and ED transfer time as the dependent variable. Careful attention would
need to identify and control for the multiple confounders associated with ED transfers. ED
transfers would require more accurate time measures beyond this study’s RFA to bed interval.
Jody Gittell (2012) is actively engaged in studies that are producing evidence that RC is a
predictor of quality and efficiency performance. Because transferring ED boarders out of
crowded EDs is a critical component of ED efficiencies and patient care, resolving barriers that
75
decrease the success of this exchange is essential. Therefore, future studies are needed to
examine associations that incorporate longitudinal data and datasets that include objective
measures capturing, nursing experience, complex work environments and relational coordination
dimensions. Because ED crowding is associated with poor patient outcomes nurses need to
continually ensure that each individual’s contribution and every work environment is conducive
to effective relational coordination in all seven dimensions as ED boarding patients are
transferred.
Implications for Practice and Management
The findings in this study suggest that, if RC is to have a beneficial influence on ED
performance, nurses on all of the studied units must become more aware of RC and the various
dimensions that exist and currently influence the task of transferring an ED patient to an
inpatient bed. Awareness, however, is not enough. Nurses must also target appropriate
interventions and assess the impact of interventions on their ability to improve the transfer
process.
Jody Gittell (2015) argues that efforts to build teamwork will benefit from both teamwork
measures that diagnose issues (RC) in the current state as well as teamwork interventions that
address and respond to the opportunities. She has proposed that partnering the validated RC
teamwork dimensions survey with the interventions of the Team Strategies and Tools to Enhance
Performance and Patient Safety (TeamSTEPPS) program may provide both diagnostic measures
and targeted interventions to improve team performance. The training may produce positive
changes in RC and associated outcomes. She offers that the training’s impact on RC and
associated outcomes may be greater and more sustainable when the diagnostic RC measures are
used to target and inform content and interventions. She suggests that the training on RC and
76
associated outcomes will be greater and more sustainable when it moves beyond changes in
interpersonal relationships to create longer-lasting changes in role relationships.
This study has provided the diagnostic insight into the current state of the ED and floor
nurses RC dimensions during ED transfers. TeamSTEPPS, a validated evidence-based patient
safety program developed by the Department of Defense, the Agency for Healthcare Research
and Quality, and researchers focused on improved teamwork and communication in health care
was released in 2006. This program may provide nursing leaders the specific tools for training,
and recommended strategies to target ED transfer opportunities. The four skills taught in the
program are communication, leadership, situation monitoring, and mutual support. Nurses
supporting the philosophy that every nurse, regardless of unit or experience, is as important as
any other nurse would be an improvement to the current state. All nurses taking responsibility in
the provision of timely feedback to each other (within and across boundaries) as well as
resolving conflicts related to transfers would improve the current blaming environment.
Communication that is open, offered freely with each nurse sharing an obligation to speak up
regardless of unit or experience may improve the shared knowledge and mutual respect
dimensions. Sharing situation monitoring as nurses remain fully engaged and aware of
everything that is occurring during the transfer process may result in each knowing; the status of
the patient, who is available to address the situation, the urgency of the situation, what equipment
is necessary and available, and what facility or environmental issues may need to be addressed.
Leadership, communication, and situation monitoring among all nurses should lead to an
environment of mutual support in the transfer process. Nurses may start to help each other
complete the transfer. Professional barriers may break down permitting everyone to contribute,
within the limits of their ability and knowledge, in the process of safe and effective patient
77
transfers out of the ED. Evidence supports that the knowledge, skills, and attitudes, that
comprise the core of TeamSTEPPS program, can improve safety and outcomes. Successful
implementation should assist the transition of ED nurses from functioning as individual experts
in the ED to performing as members of expert teams within the organization (Epps & Levin,
2015). Health-care leaders will need to promote and influence the adoption and implementation
as a system wide culture change to influence relational dynamics across unit boundaries.
Study Limitations
Despite its contributions and strengths, this study is limited in several ways. First, this
study is limited by the use of survey alone. The rich voice and perspective of the nurses
surveyed are not present. The relational dynamics inherent in the communication and
coordination of patient transfers are available only by the interpretation of a Likert scale. Adding
a qualitative component to the study would have provided more insight into the complex
dynamics of the nurses’ integrated work.
The anticipated sample size was not met on each unit. The study identified the minimum
sample size for each of the four units and the adult ED to be 15-30 registered nurses. This
number was required to detect a medium effect size based on Cohen’s (1992) guidelines for
calculating the number of participants necessary for achieving sufficient power. The ED is the
only unit that achieved the desired sample size. This study should be repeated with a larger
sample.
The study was limited to one research setting. VCUHS is a large, urban, academic
hospital. It is one of 256 acute care hospitals in the country designated as part of the Council of
Teaching hospitals (American Hospital Association, 2011). The nursing workforce has achieved
their Magnet status from the American Nurses Credentialing Center and several units have been
78
recognized as Beacon Units. Along with this recognition comes a high degree of measured and
reported nursing sensitive indicators. Expectations are well defined and practice is monitored
and scrutinized. These environmental factors influence the nursing work environment. The
findings of the study may not be generalizable to all nursing environments.
Another limitation of the study was that the nursing workforce faced a unique stressor
while the survey was deployed. VCU was designated as one of two of the state’s Ebola hospitals
should a case be identified in the state and the patient could not be transferred to one of the four
nationally recognized biocontainment facilities. The organization had an emergency
preparedness process in place but the acute Ebola crisis called upon nursing teams that were
predominantly in medicine and in the emergency department. Seventy people were trained in the
ED and 20 in the MICU/ICUs. The rest of the nursing staff were expected to engage in three
learning modules related to care of the Ebola patient. This acute deployment of resources and
demand on the nursing staff left little time for attention to this study.
The final limitation in the study is that it does not determine if RC is associated with ED
boarding quality metrics. It has not established any causal links between variables. It has
provided observations related to the RC dimensions present in nursing practice as ED boarding
patients are transferred. It has proposed relationships between RC and ED transfers. It did not
examine extraneous factors or rule out the many confounding variables associated with
transferring a patient from the ED to an inpatient bed.
Summary and Conclusion
In conclusion, the major findings in this study is that nurses within their own units
perceive their relational coordination dimensions to be positive while across boundaries this
perception is not confirmed by their colleagues on other units. Nurses within their own units feel
that they all share the same goals, knowledge a lot as well as respect each other a lot. They
79
perceive that their communication about ED transfers is often and mostly tends to problem solve
rather than blame when faced with problems. The ED nurses do not share this healthy
perspective of the relationships and communication once their inpatient colleagues engage in
transfers across unit boundaries. The ED nurses perceive that the floor nurses (MU, MSU and
SSU) communicate infrequently, are rarely timely, only sometimes accurate and they mostly
blame others during problem solving issues. ED nurses feel that their inpatient colleagues know
little about the ED’s nurses’ work during transfers and do not share their goal of transferring the
patient to the floor nor respect the role of the ED nurse in the process. Inpatient nurses rate the
ED nurses lower than themselves in the RC dimensions but not as low as they are rated by the
ED. Floor nurses feel that the ED nurses communicate too frequently about transfers. They are
only a little to somewhat timely in their communication, sometimes accurate, neither solve or
blame problems. The same goal of transferring a patient is shared a lot by the MICU nurses but
only a little by the MU nurses. They feel that the ED nurses know only a little about the work
required of the MU nurses and somewhat about everybody else. The inpatient nurses on the MU
feel that the ED nurses respect them a little while the MICU nurses feel respected a lot. This
suggests that the relational work during ED transfers has identified weak RC dimensions that
may be influencing ED crowding. Nurses and nursing units can no longer function in silos
within the larger organization. If nurses are to serve as system innovators barriers to
communication and weak relationships must be improved across health-care systems.
Emergency department crowing, boarding and transfers may all improve if nurses on these units
seven relational coordination dimensions can be influenced to match in a positive perception of
each other’s relational coordination dimensions during ED transfers.
80
The study also suggests experience plays a role in the variability of a nurse and a nursing
unit’s engagement during an ED transfer. The study suggests that floor nurses, functioning with
less experience suffer particular vulnerabilities during ED transfers. It also suggests that the ED
nurses perceive the transfer issues as less of a priority for their inpatient colleagues. Expert
nurses, able to guide their level of attentiveness and apply interventions as required, face unique
stressors when coordinating transfers with their less experienced colleagues. Additional quality
metrics applied to the ED environment may be increasing stress for this population of nurses.
The study highlights the possibility that work environments and managerial attention may limit
the rich possibilities that expert nurses could offer as innovative leaders contributing solutions to
ED crowding issues. Nurses, units, work environments, hospital culture, resources, demands,
and constraints establish a foundation for nursing to either remain weak within their RC ties or
improve these dimensions and potentially improve ED transfers.
The RC scores between the ED and floor nurses suggest that there is much room for
improving the relational and communication dynamics across unit boundaries. An interaction
among nurses, the relationship between the units, and an engagement with the larger
organization’s ethical mission to deliver safe care requires a partnership of efforts that must start
with nurses examining their own contribution to ED crowding. Teams of individuals working
towards a common goal can influence culture (Hughes 1996). The interdependent nature of
nursing practice contributes to the context and environment in which nurses work. Given that
safe patient care is directly and positively related to the quality of staff nurses’ work
environments, reducing nurse tensions that adversely affect communication and collaboration
should improve care (Kramer et al., 2009).
81
Nurses are knowledge workers who must attend to skill as well as efficiency.
Relationships found in RC are based on roles rather than personal ties. The work practices of
nurses across unit boundaries are expected to enhance relationships of shared goals, shared
knowledge, and mutual respect with or without personal ties. Relational coordination enables
nurses to more effectively coordinate their work with each other, thus raising the bar on higher-
quality outcomes using resources more efficiently. The margins for error in nursing practice are
small. Transferring care between individuals across unit boundaries is riddled with challenges.
Interlocking of ED and floor nurses’ relational process of integration at the point of an ED
transfer may produce an environment where each can create a new reality. This relational,
circular response, frees the individual and the organization of the limitations of singular points of
view. New modes of thinking, new ways of acting, and innovations may emerge from the
collective experience (Follet, 1918).
82
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Relational Coordination: An Exploration of Nursing Units, An Emergency Department and In-Patient Transfers

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NURSING UNITS, AN EMERGENCY DEPARTMENT AND IN-PATIENT TRANSFERS

Mary Coffey, MPH, RN

Director: Jeanne Salyer, Ph.D., RN

Virginia Commonwealth University

LIST OF TABLES ................................................................................................................... v

LIST OF FIGURES ............................................................................................................... vi

ABSTRACT ........................................................................................................................ vii

1. STATEMENT OF THE PROBLEM ................................................................................... 1

Background and Significance .................................................................................................. 6

2. CONCEPTUAL FRAMEWORK ......................................................................................14

Review of Literature ..............................................................................................................20

3. RESEARCH METHODS ..................................................................................................32

The Sample ............................................................................................................................43

5. DISCUSSION OF FINDINGS ..........................................................................................63

Descriptive Statistics ..............................................................................................................64

1. Response Rate by Unit and Total Sample .....................................................................44

2. Individual Attributes of Participants (Total Sample and by Workgroup) .....................44

3. Demographic Characteristics of the Sample (n = 80) ...................................................46

4. Years of Clinical Experience and Unit Workgroup ......................................................47

5. Specialty Certification by Unit .....................................................................................49

6. Demographic Characteristics of the Sample by Unit (n = 80) ......................................49

7. Pearson’s Chi-Square by Demographic ........................................................................50

8. Units’ Rating Themselves on the Seven Dimensions of Relational Coordination…... 51

10. Units’ Ratings of the ED. ..............................................................................................58

1. Empirical Model of Relational Coordination’s Association With ED

RELATIONAL COORDINATION: AN EXPLORATION OF

By Mary Coffey, MPH, RN

Virginia Commonwealth University, 2015

Major Director: Jeanne Salyer, Ph.D., RN

patients to inpatient beds. Relational coordination is a mutually reinforcing process of interaction

information and a sound theoretical model on which to base future research.

care-system if widely implemented (IOM, 2010).

plague current practice processes.

collaborating hospitals and health systems focused on hand-off communications. These

ineffective communication in which methods provided inaccurate or incomplete information, as

and receiver produces poor quality care as a patient waits to be transferred.

diagnostic evaluation, and left-before-being-seen) as they evaluate an organization’s

boarding times can no longer be considered an isolated ED issue. Organizations’ sustainability

Coordination of timely admissions from the ED requires nurses to effectively collaborate

present that may influence a timely patient admission?

nursing team’s task integration in the coordination of ED boarder transfers. Examining

relationships and effects among the concepts of the proposed model.

Background and Significance

Emergency department crowding continues to be a worldwide public health problem and an

important patient safety issue (Pines & Griffey, 2015).

The common misperception that ED overcrowding is caused by non-urgent patients has

been dispelled by current research. Specifically, low-complexity patients do not significantly

Stiell, & Wells, 2003).

such as the delivery of home medications and nonacute functions. ED overcrowding is

associated with health-care providers reporting decreased satisfaction (U.S. Government

ambulance diversion (Forster et al., 2003).

in an overcrowded environment begs the question: What can nursing do to reduce ED

across and within environmental boundaries. Transfers of patients require interdependent

interaction. Currently, ED overcrowding in most organizations is considered an ED problem

patient transfers occur?

team action (Gittell, 2009).