Previously, the training of healthcare professionals has focused on the knowledge and skills needed by individual practitioners (Weller, Thwaites, Bhoopatkar, & Hazell, 2010). Recent trends, however, indicate a shift toward more of a focus on training for team-based healthcare delivery (Ellis, 2018). Adoption of the team-based approach has been driven by the expectation that it would result in an improved delivery process, better patient outcomes and lower costs compared to non-team approaches (Bosch et al., 2009). Given that trend, a number of articles have explored different aspects of nursing team functioning. The focus of these studies has been on the management and leadership of nursing teams (e.g., Cameron, Harbision, Lambert, & Dickson, 2012), nursing team outcomes (e.g. Kalisch, Lee, & Rochman, 2010), nursing team skills (Harper, Powell, & Williams, 2010), nursing team processes (e.g. Kalisch, Weaver, & Salas, 2009), nursing team structures (Miers, 1999) and nursing team learning practices (Timmermans, Van Linge, Van Petegem, & Denekens, 2012). While divergent in their theoretical approaches, these studies have traditionally adopted an input-process-outcome (IPO) framework, as proposed by McGrath (1964) and Hackman (1987), and applied in the healthcare context by Borrill et al. (2001), followed by numerous further applications in this field (e.g. Bae, Mark & Fried, 2010; Griffin & Hay-Smith, 2019). The IPO model is used to understand and explain team processes and performance.
The IPO model posits that inputs such as tasks and/or the composition of the team are reflected in team processes, such as communication and coordination, and will lead to team and patient-related outcomes. In this model, the commonalities of goals and vision, as well as contextual aspects, are important to consider (Xyrichis and Ream, 2008). Studies using the IPO framework in nursing team research have primarily examined team processes and team outcomes, with much less research being done on inputs. Those studies exploring inputs have traditionally focused on generational differences (e.g., Burke, Walker, & Clendon, 2015), hierarchies (e.g., Miers, 1999) and tasks (e.g. Zawawi & Nasurdin, 2017). However, few studies in health sciences (e.g. Dreachslin, Hunt & Sprainer, 2000) and other research fields (e.g. Jäger & Raich, 2011; Ancarani et al., 2016) have explored cultural diversity Following Cox (1993, p. 6), we define cultural diversity as the presence “in one social system, of people with distinctly different group affiliations of cultural significance”, and in the context of this study, social systems are represented by the nursing team constellation, and different group affiliations refer to self-perceived belongingness to an ethnic or national minority group different from that of the other member(s) of the team.
Given the increasing diversity in the profession, especially in cultural/ethnic dimensions (Dreachslin, Hunt & Sprainer, 2000), the limited number of studies on the subject is surprising. It is especially remarkable given the profound effect that the cultural makeup of healthcare teams might have on clinical decision-making (Benzeval, Judge, & Smaje, 1995). Nursing research has primarily addressed the cultural aspects on the individual level of analysis, exploring either the status of ethnically diverse nurses (e.g., Sloane, Williams, & Zimmerman, 2010) or nurses’ intercultural competencies in relation to diverse patients (e.g. Almutairi, McCarthy, & Gardner 2015).
Only nascent stream of research has explored culture-related differences (Dreachslin, et al., 2000; Jäger & Raich, 2011; Ancarani et al., 2016) in nursing teams. For example, the study by Dreachslin, Hunt and Sprainer (2000) by performing focus group interviews found that in presence of “diversity-inspired leadership”, racially/ethnically diverse nursing are characterised by more effective communication, comparing diverse team where conventional leadership is applied. The study, thus, suggests that leadership represents an important external condition for effective functioning of culturally diverse nursing teams. The study by Jäger and Raich (2011) based on a survey of nurses working in multicultural nursing teams found that these teams exhibited no difference in commitment to the team, or effectiveness compared to culturally homogeneous teams, yet they were more prone to experiencing process-related conflict, which could have consequences for the quality of service provision. Thus, the study suggested that how the conflict is managed internally in the team represents an important internal condition for effective functioning of this type of team. Finally, Ancarani et al. (2016) focusing on religious diversity as a representation of cultural diversity in healthcare teams found that there was an inverse U-shaped relationship between that diversity and team efficiency, that is, until a certain level, increasing degree of religious diversity had a positive effect on team efficiency, yet when this level was reached, any further increase of such diversity had a negative relationship with team efficiency, and this relationship was contingent on team task complexity, team task conflict, leadership climate and diversity in nationality in the team. This suggested that external conditions related to leadership surrounding the team, as well as internal conditions represented by complexity of tasks and team composition, are important aspects relevant to effective team functioning.
These limited number of studies are unanimous, in that cultural differences have to be addressed and managed in the clinical context, given the increasing use of team structures in the provision of care and where joint rather than purely individual actions are of crucial importance (Shortell et al., 2001). This study sought to contribute to this nascent research by exploring cultural diversity in nursing teams and by furthering the understanding of the internal, for example, team-specific characteristics and processes, and external conditions, for example, aspects external to the team such as leadership and organisational structures under which cultural differences represent an asset or a liability for these teams.
Sweden was deemed to be a particularly relevant context for this study, given the increasing number of foreign-born individuals entering nursing and graduating with professional degrees (Swedish Government, 2000). According to Statistics Sweden (2018), the number of foreign-born workers has steadily increased in the health sector since the beginning of the century, and today, these workers account for 26% of the total healthcare sector personnel in Sweden. The cultural diversity in the sector is highest among medical doctors, where 34% are non-native Swedes, and this diversity is slightly lower among assistant nurses with 26% and nurses with 12%. Given the steady increase in this diversity, the Swedish government, based on the recommendation of the Swedish governmental agency of public management (Statskontoret, 2004), has implemented a so-called action plan for the promotion of ethnic and cultural diversity in public-sector organisations (healthcare organisations representing the largest portion of the sector) that tries to ensure equal opportunities for ethnic and cultural minorities in these organisations.
Sample characteristics.
Registered nurses | 4 | 0 | 4 (22%) |
Nurse assistants | 7 | 7 | 14 (78%) |
Native Swede | 5 | 4 | 9 (50%) |
Non-native Swede | 6 | 3 | 9 (50%) |
Years of experience in health care, median (min-max) | 10 (0,5–35) | 15 (4–33) | 10,5 (0,5–35) |
The study used a qualitative exploratory descriptive method. The data were collected through semi-structured interviews (n = 18) with registered nurses and nurse assistants in two specialised units of a regional hospital and one municipal residential care setting in the south of Sweden, in fall 2016/spring 2017. The use of individual interviews for exploring team functioning can be criticised because it captures perceptions and experiences rather than reveal the reality of interactions (cf. Froggett & Wengraf, 2004), yet it has become a commonly used method in team research, given the difficulties of access to observational data (cf. Umans, 2012). The two specialised units of a regional hospital had approximately 40 regular staff members, while the municipal residential care organisation had approximately 25 regular staff members. Registered nurses and nurse assistants represent two separate professional categories in the Swedish context (cf. Engström & Fagerberg, 2011), with differences in professional identity due to their education, work assignments and certification. The design of the study was inspired by Lincoln and Guba's (1985) approach to developing rich description, comparison, classification and conceptualisation of new knowledge in a nascent field or research (Johnstone, Hutchinson, Redley, & Rawson, 2016) and from previously disorganised and unrelated data (Patton, 2002).
Participation in the study was voluntary. The researchers informed the heads of the clinical units of the study, and they presented the project to the staff. The heads of the clinical units were not involved in any further recruitment of the staff; instead, the staff members interested in participating in the project were asked to contact the authors. The authors’ team then followed up and contacted individuals who expressed an interest in participation to agree on the time of the interview. The only inclusion criterion was individuals having a self-perception of working with individuals of a cultural background different than that of their own. In total, 18 nurses agreed to participate; two registered nurses were men, all the others were women. Their characteristics can be found in Table 1.
Semi-structured interviews were conducted, based on a predetermined interview guide (see Appendix), with open-ended questions focusing on interviewees’ experiences in culturally diverse teams. The construction of the interview guide was an amalgamation of the interview instruments used in three studies using the IPO model and focusing on teams in health sciences (Wetterneck, Hundt & Carayon, 2009), psychology (Antoni & Hertel, 2009) and organisations (Umans, 2012). The interview guide was pilot tested on one foreign-born nurse and one native-born assistant nurse, after which minor adjustments were made. Throughout the interview, follow-up and probing questions were asked when needed. The interviews lasted 30–50 minutes and were digitally recorded and transcribed verbatim by a professional transcriber.
While the initial ambition was to conduct repetitive interviews, due to re-organisation in two out of three units, sometimes, after the first waves of the interview, this was not deemed possible. Two authors of the paper were responsible for data collection. One of these authors was a female native-born specialised nurse holding a master's degree in nursing and with extensive experience in conducting qualitative research in healthcare settings. The other author was a male foreign-born researcher with a PhD in social sciences and with extensive experience in conducting qualitative research in healthcare settings. Native-born nurses and assistant nurses were interviewed by the native-born author of the paper, while foreign-born professionals were interviewed by the foreign-born author, an arrangement that was deemed to facilitate more open discussion on the sensitive issues related to cultural differences and experiences. The third author of the paper was a native-born female, a specialised nurse by profession with a PhD in caring sciences and extensive experience in conducting qualitative research in healthcare settings. At the time of the data collection, all three authors were employed at a Swedish university as teachers/researchers. Thus, the authors had different cultural backgrounds, gender, as well as work experience, and all had experience of working in culturally diverse teams in different contexts. These later experiences were of both a positive and negative nature, yet in the interview situation, the author maintained an agnostic attitude without revealing their past experiences.
The number of conducted interviews (n = 18) in our study was determined on the basis of theoretical saturation. According to Low (2019), theoretical saturation is achieved when the respondent's answers do not provide new elements or knowledge. In our study, the saturation point was reached at approximately the 15th interview. However, given that the interview meetings were pre-booked before the saturation point was attained, we proceeded with collecting three additional interviews.
The study was conducted in accordance with the Declaration of Helsinki on ethical principles (World Medical Association, 2008). In accordance with Swedish law (SFS 2003:460, 2003; SFS 2008:192, 2008), formal approval was not sought because the data collected were of a non-biomedical nature. Prior to the interviews, the interviewees were given clarifying information about the aim of the study, their right to withdraw at any time with no personal consequences and the voluntary nature of their participation. Oral informed consent was obtained. All materials collected and personal data relating to the interviewees were treated confidentially, stored safely and available only to the authors of this paper.
The interview texts were analysed by inductive qualitative content analysis (Elo & Kyngäs, 2008); the first two authors conducted the analysis and alternated between the whole and parts of the texts. In the preparation phase, the texts were read and re-read as a whole. Impressions and reflections about the wholeness and important elements in the text were discussed. Then, all parts of the text were divided into meaning units consisting of sentences related to the aim. In the organising phase, the meaning units were open coded, with notes and headings in the margin; they were then collected on a coding sheet. The codes were critically interpreted and compared in a discussion by the authors. From this, a number of themes with sub-themes emerged. Drawing on relevant literature (e.g. Dreachslin, Hunt & Sprainer, 2000; Borrill et al. 2001; Jäger & Raich, 2011; Ancarani et al., 2016) and the authors’ experience of the context, emergent themes were aggregated to form domains. Finally, all the texts were re-read and compared with the outcome of the analysis to ensure that the themes covered the contents of the texts and codes.
In line with Lincoln and Guba (1985), the authors ensured the studies’ credibility and dependability by inspecting the field notes for potential personal bias. The field notes were taken immediately after each interview and contained both descriptive and reflective information (cf. Duffy, 2009). All the authors discussed the themes, sub-themes and the domains with each other until they reached consensus.
The analysis revealed three broadly defined domains related to the functioning of culturally diverse nursing teams: triggers, team process and contingencies. ‘Triggers’ refer to aspects that enable and/or disable the teams in their work. ‘Team process’ refers to interactions that are a function of the triggers. Finally, ‘contingencies’ represent the contextual dimensions and dimensions external to the team that enable and/or disable the flow between triggers and team processes. A summary of the results and analysis is depicted in Figure 1.
The analysis revealed five themes within the triggers domain that either enabled or disabled the team process. These triggers were of an internal team nature and characterised different dimensions of team functioning.
So we have rules. . . . if they [immigrants] come here they have to adjust to those rules that exist, so that it doesn’t result in a conflict. Everyone here follows the rules
Summary of the analysis.
For me it is positive when we all are different, from different countries and with different experiences. I think it is rewarding. One wants to learn, and to thrive and develop
Yet I think, [that] often those from other countries are extremely well meaning. They are kind and good. But [they] can almost be too kind and good. It becomes almost baby-like for the patients . . . it can be very tough . . . I think. Since they help way too much
I can say that when one works with someone foreign, like me. They have more feelings and are more sentimental. While a Swede is a bit . . . they think . . . they are somewhat colder, not like us
I think it is exciting and fun meeting other cultures. But it can be a bit difficult at times and to get the understanding of each other when one starts to mix in religions. . . . Well, some women have problems with taking care of male patients . . . and that can create some issues
Opinions were divided on the relation between diversity in age and cultural diversity in nursing teams. The interviewees thought that when different generations worked with each other, it enhanced the competence base in teams. They also revealed that the same diversity led to an age-related hierarchy that distorted the exchange flows.
The theme that emerged within the team process domain is entitled We are two or three working [together], depending on what happens during the night. It could be that the patient has been awake the whole night so we let her/him sleep a bit longer. It all depends on how [the] situation looks in the day ahead, and how we solve it. So we make joint decisions about it
Another sub-theme within this domain was It is important that one can speak good Swedish, [. . .] I’m talking about everyday Swedish. It is important that one has it
We socialise outside work, many of us. We have very nice “after works” and other activities; it is a great team. It includes people of many different ages and [both] genders
Finally, the fourth sub-theme and a sub-process that emerged was labelled It is very important that one, one has it clear for oneself. That one helps others and that assistant nurses’ views are as important as those of the nurses and doctors, for that matter. We are very clear here that all are on the same level. That no one is bigger or better than another. So, we discuss it a lot, and stand for that
The interviews suggest that different processes were closely intertwined and reinforced a team's ability to work as one unit. The interviews further revealed that this ability represented an important and desirable outcome of work in culturally diverse nursing teams.
The analysis revealed six themes representing contingencies. These contingencies, representing external aspects, were revealed to be important enablers and disablers of the relationship between triggers on team processes. For example, That [foreign] doctor. He just comes and looks at my name badge and sees that I am the assistant nurse. So he doesn’t greet me. He just goes away
She [department head] believes us when we say we can’t manage, we can’t, we need help or extra things, or that we don’t manage. She listens. So it is good. And she is visible. It is also good for the patient's kin to have a face, to know who is a boss
The specificities of the work I would say that we are like a family. There is someone that is like one's sister, and another that one sees as a mother
The data further suggested that culturally diverse nursing teams were enabled by superiors arranging thoroughly coordinated activities. Here, the interviews discussed how clear and transparent planning helped teams to coordinate from within. At the same time, a lack of resources from superiors, that is, concerning further education for the staff and new skills acquisition, had a disabling role. These two aspects formed a theme called At times, many things happen here. Like last week . . . It was terrible; we just ran, ran, ran. We didn’t have much time for cooperation, or to talk with the nurse or assistant nurse. But otherwise, I think that we are well coordinated, actually
It is important to understand the patient as well as possible. And if one has a colleague that comes from a similar or close culture, well, then it is a plus. Then we [native Swedish personnel] understand it better. There are many [patients] that come here that can speak Swedish or English
Numerous contingencies were perceived to play both enabling and disabling roles and represented a context for the triggers and the processes taking place in culturally diverse nursing teams. The enabling aspects appeared to neutralise some of the disabling aspects of the triggers and team processes. Similarly, the disabling aspects appeared to reduce the enabling aspects in the triggers and team process domains.
The analysis of the data revealed how triggers and team process are embedded in the context represented by different contingencies (Figure 1). Our findings depicted in Figure 1 suggest that, external to the team ‘contingencies’ and internal team ‘triggers’ enable and/or disable different teams’ processes (see Figure 1).
The results of this study contribute to the field of cultural diversity in nursing teams and an understanding of the internal, that is, triggers, and external, that is, contingency, conditions under which cultural differences represent an asset or a liability for such teams. The data revealed that three distinct domains come into play in culturally diverse nursing teams:
Our data provide some indications that the trigger domain's enabling and disabling aspects relate to teams’ ability to make joint decisions. This is also reflected in team processes of communication, socialisation, support and recognition and is supported in the nursing literature dealing with teams (cf. Xyrichis and Ream, 2008; Ortega et al., 2013). Our study, however, aggregates these processes and, relying on the team literature (e.g., Hill, Offermann & Thomas, 2019), suggests that they can be conceptualised in terms of team cohesion, a process that is also reflected in the nursing literature (e.g. Quoidbach & Hansenne, 2009) and that represents a shared bond that drives team members to stay together and want to work together (Casey-Campbell & Martens, 2009).
Finally, and as suggested, our findings in respect of contingencies might be the primary contribution of our study, in that they reveal clinical context-specific properties that are related to the triggers associated with shaping cohesive and culturally diverse nursing teams. Our study found that the combination of team-and organisation-specific contexts, as well as leadership styles and patient complexity are key factors in enabling and disabling the functioning of culturally diverse teams. The emergence of these contextual specificities resonates well with the findings in group research (Yamak et al., 2014) where identification of the team external factors is considered to be a way forward in understanding the conditions under which culturally diverse teams in organisations perform best. Our findings also represent a more nuanced picture of how contingencies are related to the triggers that enable and disable team cohesion.
The theoretical contributions of this study lie in the complex picture it reveals of the functioning of culturally diverse teams and its nuanced picture of the interrelation of triggers and contingencies related to team process. The study further contributes to and develops the IPO model in health care (e.g., Borrill et al., 2001) by highlighting the importance of external contingencies found at different levels of analysis. The practical contributions are twofold. First, the study suggests a way for culturally diverse teams to achieve cohesion that can be reflected in both unit and patient outcomes (cf. Van Bogaert et al., 2017) by, for example, focusing on factors that enable their process and openly discussing or avoiding disabling factors. Second, the study puts forward some managerial implications by identifying which structural and organisational aspects improve or aggravate team functioning. For example, managers of the nurses and nursing assistants working in culturally diverse teams could reinforce the enabling elements of the contingencies, that is, by being more active and supportive leaders who stimulate integrative activities. Alternatively, these managers could consider establishing different for a where professionals of different cultures could have open discussions to find commonalities, for example, common values and purposes. This paper also provides an insight for the health professionals into how culturally diverse teams work and highlights what makes culturally diverse teams function better or worse.
The findings of this study have several implications for a broader range of health professionals. For example, our findings highlight how different hierarchical structures in culturally diverse teams could serve as both enablers and disablers of team process. This suggests that health professionals working in increasingly multi-professional and culturally diverse teams should be aware of their own professional and cultural status vis-à-vis other team members while emphasising the former trying to deemphasise the latter. Moreover, our findings imply that members of one profession might require training for understanding the values common for the members of other professions. Through such training, professionals might gain in awareness of shared rather than divergent professional values and thus could better position themselves in reaping the benefits of work in increasingly culturally diverse multi-professional teams. Our findings have further implications for allied health professionals who are increasingly involved in team-based provision of care in cooperation with health professionals. In such constellations and in the presence of cultural diversity in these teams, the role of coordination and integrative leadership might be of particular importance because coordination might be required to highlight the interdependency between the professions, while integrative leadership might further strengthen the feeling of the team being a coherent unit rather than a collection of different profession with divergent aims.
This study has a number of limitations, which can also be seen as opportunities to be explored. The relatively small study sample does not allow for the emergence of more robust results. Yet, the analytical generalisation presents results that could be further explored by qualitative, and even quantitative, methods. A further limitation of the study relates to the recruitment for the interviews and potential peer and leadership pressure to participate in the study, but this issue was partly alleviated by direct contact between interested participants and the researcher. However, we cannot discount the possibility that leaders of the unit, as well as the peers positively reinforce interviewees for study participation. Moreover, the study might suffer from non-participation bias, which could mean that only the most dissatisfied or most satisfied voices were represented. Yet, these concerns were partly alleviated by the relatively balanced narratives of participating interviewees. Another limitation relates to the way data were collected, that is, by individual interviews that might not capture the complexity of interactions one would have captured through participant or non-participant observations. At the same time, the individual interviews allowed for open dialogue about sensitive subject matter, while a researcher making observations might have distorted the typical flow of nursing teams’ work. One way forward would be to conduct studies using multiple methods, in which the interviews are interlaced with observations to produce a richer and multidimensional picture of the functioning of culturally diverse teams. We further acknowledge the limitation associated with over-representation of one of the two professions, that is, assistant nurses were overrepresented compared to nurses, which could have consequences for the narrative presented in the paper.
Our findings might provide inspiration for future research. For example, a future study might explore further the mechanisms through which specific team triggers relate to specific team processes. Moreover, future research could further explore the external factors and their relation to the functioning of culturally diverse nursing teams. Our finding could further encourage scholars to inquire into other multi-professional teams in the healthcare context and explore how differences in interprofessional hierarchies and multiple professional structures and intertwined identities interact with cultural differences presented in the teams. Future studies could also explore culturally diverse teamwork using methods that would give a deeper insight into these teams’ functioning. For example, observational studies or shadowing could provide a more nuanced understanding of the interactions within these teams, as well as the instruments they use to make their work more effective. Finally, future studies should consider exploring patient perceptions and experiences of culturally diverse nursing team functioning, to get an additional insight into how these teams operate.