The association between team resilience and team performance in nurses during COVID-19 pandemic: a network analysis

The coronavirus disease (COVID-19) pandemic has caused unprecedented public health challenges worldwide. There have been more than 161.5 million COVID-19 cases and more than 3.3 million deaths worldwide since the first cases were identified in China in December 2019 [1]. The high risk of infection and mortality because of the pandemic has caused a serious threat to the physical and mental health of healthcare workers, especially for nurses, who are closely involved in patient care [2, 3]. Nurses are front-line health workers and thus are constantly exposed to patients infected with the SARS-CoV-2 virus with little protection during the ongoing pandemic [2, 4]. Research has shown that nurses have had to face unique challenges because of the pandemic, including the threat of contracting COVID-19, unusually high workloads, and fear and worries related to being a carrier of the virus and infecting their family members [4]. Given these stressors, the psychological burden experienced by nurses is much higher than for other healthcare workers [5]. Team performance, which refers to the performance of the team at work [6], is affected by the mental wellbeing of team members. Specifically, the high psychological burden on nurses may lead to an impaired collective work [7], which might, in turn, jeopardize the safety of patients and the quality of care provided to them. For instance, a recent study noted that the working environment of healthcare teams is highly volatile and increasingly uncertain because of the nonstandard and complex working conditions resulting from the pandemic [8]. This significantly increases their chances of developing impaired work function (i.e., needle stick injuries, medication errors, and decreased work efficiency and patient satisfaction) [9]. Consequently, research focusing on the maintenance or improvement of team performance among nurses and their stress resistance during the pandemic is required [8, 10].

With the development of positive organizational behavior, researchers have begun to focus on the strengths and powers of teams, especially in the nursing scenario. Team resilience refers to a team’s ability to repair or bounce back from a potentially stressful situation [11]. It is an adaptation process in the face of adverse events that enables a team to better manage stress and thus maintain cohesion and performance [12]. Research has found that team resilience affects overall team performance and that those teams that have high levels of resilience are more likely to achieve positive team outcomes [13, 14]. However, it is worth noting that because of the complexity of the work environment, overall team performance is often evaluated by different structural components (e.g., task performance, cooperation satisfaction) [15], and there may be complex interactions among the structural components. Furthermore, different structural components of team resilience have various effects on team performance; for example, teams that have better knowledge about using resources have better overall performance than other structural components [16]. Therefore, previous studies on the relationship between team resilience and performance focusing only on the exploration of their overall relationship may not be comprehensive [13, 14]. To provide targeted coping strategies and/or interventions to improve team resilience and performance among nurses during the COVID-19 pandemic, it is important to understand the complex mechanisms between the components within and/or between team resilience and team performance.

In recent years, network analysis models have gained considerable attention as a new way of conceptualizing psychological phenomena in the field of psychological science. Rather than adding up the scores of potential variables (i.e., structural components) to describe psychological phenomena, network analysis is a potential variable-oriented approach that analyzes and documents the strength and nature of associations between potential variables from a mathematical point of view and efficiently visualizes them [17, 18]. This approach can provide the corresponding centrality and predictability indices for each potential variable and examine their importance and controllability in the overall network model [19, 20]. The central variable of the network may be regarded as a key target for the development of intervention strategies. Furthermore, network models can be used to identify bridge variables (i.e., variables that connect two psychological phenomena), which may play a role in the development and maintenance of symbiotic psychological phenomena [21]. Thus, researchers can tailor prevention or intervention strategies that simultaneously improve multiple psychological phenomena from the perspective of bridging variables. Network analysis models have been widely used in research in fields such as psychiatry and psychology [17, 18].

Recently, researchers have conducted network analyses of nurses’ work performance issues during the COVID-19 pandemic [22]. However, because nursing often requires effective teamwork [23], it is not comprehensive to analyze the network structure of nurses’ performance at an individual level, and thus, the network structure of nurse team performance should be analyzed separately. Furthermore, compared to other healthcare workers, nurses are more vulnerable to the potentially devastating effects of pandemic-related stressors [22]. Therefore, team resilience plays a pivotal role for them. If nurses have low levels of team resilience, it not only affects the overall performance of the team but is also detrimental to building a good nurse–patient relationship, reducing the effect of nursing intervention [24]. Thus, this study intends to i) examine the complex relationship between team resilience and team performance during the COVID-19 pandemic using network analysis among nurses; and ii) assess the potential impact of team grade on the observed network model; thereby providing a theoretical basis for developing targeted interventions for team resilience and team performance.

To the best of our knowledge, this is the first study to characterize the team resilience and performance network of nurses during the COVID-19 crisis. The present analyses showed that node monitoring had the highest centralities in the entire network, followed by node anticipation, cooperation satisfaction, and cooperation, all of which emerged as core variables in understanding the team resilience and team performance network of nurses. Node cooperation satisfaction and learning had the highest levels of bridge centrality in the entire network, which were considered as bridge variables linking team resilience and performance. Additionally, some important strong edges identified in the current network were the connections between node monitoring and cooperation, node anticipation and monitoring, and leadership and monitoring.

Network analysis revealed that monitoring was the most urgently needed expertise of nurse teams during the COVID-19 crisis. Monitoring is defined as the capability of team members to monitor each other’s or the team’s performance, as well as what happens when faced with unexpected situations [25, 35], which helps promote team effectiveness in unexpected situations. The pandemic is an unexpected situation for nursing teams. Therefore, to maintain or promote team performance, monitoring is unequivocally necessary for nurse teams during the COVID-19 pandemic. On the one hand, nurses can monitor the performance of a team to which they belong to gain insight into their team’s mishandling of work processes and correct the resulting errors; on the other hand, nurses can circumvent underperformance by self-reflecting on their own performance (i.e., self-monitoring), such as “what went well” and “what could have done better” [36]. Furthermore, previous research has found that team performance is positively associated with teamwork quality, and monitoring is an important prerequisite for effective teamwork [37, 38]. Thus, to improve team performance among nurses during the COVID-19 pandemic, monitoring may indeed be the most urgently needed ability for nurse teams, and this may be a critical intervention target for nurse managers to improve both team resilience and team performance among nurses during the COVID-19 pandemic.

Anticipating was identified as another urgently needed capability for nurse teams in this study. As the pandemic led to nonstandard and complex working conditions, nurses have experienced increased uncertainty in the course of their work [8]. To ensure quality of care and patient safety, it is necessary to develop nurses’ anticipating capacity so that they are more adept at making accurate judgments about unexpected situations. Furthermore, cooperation satisfaction and cooperation were found to be the core variables in the team resilience and performance network of nurses. This finding was similar to that of Schmutz et al. (2019) [39], who concluded that cooperation is a critical capability for healthcare teams to maintain or promote team performance in unexpected situations. As such, strengthening nurses’ cooperation capability should be incorporated within programs designed to improve team resilience and performance.

There are two strong bridge variables in this study: cooperation satisfaction and learning. These findings suggest that when team performance is poor, interventions targeting “cooperation satisfaction” will not only improve team performance but may also improve overall team resilience. However, when team resilience is poor, interventions targeting “learning” will not only improve team resilience but may, in turn, improve overall team performance. Previous studies on the influences of team performance and team resilience found that cooperation satisfaction was a critical factor affecting team performance and team resilience, which could substantiate our findings [14, 40]. Moreover, in studies assessing team performance and resilience [16, 25, 26], cooperation is an evaluation criterion for team performance and resilience in company workers. As for “learning,” it is a critical factor that affects not only team resilience but also team performance among healthcare staff [41, 42]. Given the significant differences in team characteristics and work contexts among the participants, the above variables are plausible candidates as signature bridge variables for simultaneous improvements in team resilience and performance among nurses.

The current study found some strong connections between “monitoring” and “cooperation,” between “anticipating” and “monitoring,” and between “leadership” and “monitoring;” all these connections underscore the important relationship between monitoring and other team capabilities. To the best of our knowledge, this finding has not been previously reported and may be unique to our study sample (i.e., Chinese nursing teams); this requires further investigation. Indeed, there is a strict hierarchy of leadership between superiors and subordinates because of the traditional nursing management culture in China (hospitals in China have a hierarchical management system for nurses, that is, based on clinical nursing competency, hospitals divide nurses into different hierarchical levels. High-hierarchical-level nurses often play leading roles in work, whereas low-hierarchical-level nurses carry out high-hierarchical-level nurses’ orders) [43]. For nurse teams in each department, the process of cooperation within the team, the process of honing the anticipating capability of the team, and the leadership style within the team are all monitored by the supervisors. Moreover, the study was conducted in Shandong Province, China, which has deeper roots in hierarchical management culture [43]. That is, staff from Shandong were more powerful than those from other regions, and in this case, the process of cooperation within the team, the process of honing the anticipating capability of the team, and the leadership style within the team tends to be more strictly monitored by supervisors. Furthermore, these findings may provide several potential intervention pathways to improve the monitoring capability of nurse teams. The predictability of “monitoring” was found to be 97.7%, suggesting that it is highly influenced by its neighboring variables in the current network. This finding suggests that intervention in “monitoring” can be achieved not only by intervening in “monitoring” itself or by affecting other relevant factors not included in the current network but also by intervening on strong neighboring variables (i.e., “cooperation,” “anticipating,” and “leadership”).

This study has several strengths. First, this was a multicenter study and the results might be more generalizable than those of a single-center study. Second, the team resilience and performance network had adequate stability and accuracy, as shown by bootstrapping analyses. Furthermore, the NCT analysis showed that team resilience and team performance network structure did not vary by team grade.

In addition to the strengths mentioned above, this study also has several limitations. First, because this study used cross-sectional data to build an observed network model, it was not possible to infer a causal relationship between the nodes of team resilience and team performance. Longitudinal data can be used to assess the dynamics between nodes of team resilience and team performance over time. Second, the current findings are limited to Chinese nursing teams in a pandemic scenario. Hence, team resilience and performance networks in non-pandemic contexts and/or other populations may differ from the network structure of this study. Finally, the variable patterns of team resilience and performance in this study were specific to the instruments used for analysis. There is often a discrepancy among self-report tools for assessing variables of team resilience and team performance. Therefore, different assessment tools can lead to different network structures.

To conclude, this study revealed that monitoring, anticipation, cooperation satisfaction, and cooperation are the most urgently needed capabilities for nursing teams and can be regarded as potential clinical intervention targets for maintaining or promoting both team resilience and team performance among nurses during the COVID-19 pandemic. Interventions targeting bridge variables (cooperation satisfaction and learning) may contribute to simultaneously improving team resilience and performance. These results also identify a strong connection between monitoring and most other team capabilities (cooperation, anticipation, and leadership), which requires further research.

Recently, the issue of team performance during a pandemic has been the focus of nursing management. To solve this issue, understanding the dynamic and reciprocal relationships between team resilience and performance, especially during pandemics, is undoubtedly important. Nurse managers and hospital administrators can use the network to gain insight into the relationships within and between communities (i.e., team resilience and team performance), thereby tailoring interventions that maintain or improve nurses’ collective stress resistance and performance and improving the quality of nursing services.

Specifically, nurse managers and hospital administrators should consider investment in improving the capability of nurses to monitor each other’s or the team’s performance during the COVID-19 crisis: for example, organizing regular seminars or team meetings, characterized by active listening and effective communication, and facilitating nurses’ communication and reflection on “what went well” and “what could have done better” to look for positive work practices [44]. In addition, developing the capability of nurses to anticipate unexpected situations during the COVID-19 crisis should also be considered. On the one hand, managers can organize regular in-situ simulation trainings and debriefings, characterized by managing different situations and cases, helping nurses understand practice and adapt to routine and unexpected situations, thereby building the best coping strategies that foster the development of resilient behaviors, such as anticipating, when facing similar situations. On the other hand, managers can mix experienced and inexperienced people to enable experienced nurses to teach novices how the health care system works and how the organization adapts to and copes with expected and unexpected situations, allowing them to take resilient action proactively in routine and unexpected situations [44]. Additionally, establishing an environment that encourages cooperation and learning among nurses can benefit nurses greatly. Therefore, in the course of their daily work, managers can encourage nurses to participate in and contribute to cooperation and learning by making it an integral part of their evaluations in order to create a positive cooperation and learning climate.

Hospital education departments can also use this information to design curricula for nurses to manage stress and performance during health crises and provide effective care to patients who are also affected by these crises. In addition, social or health policymakers can use this information to develop support programs or improve existing programs focused on stress management for nurses.