ORIGINAL ARTICLE
Carreira, J., Santos, A. C., & Valente, C. (2026).
Structured intervention in nursing communication and cohesion: an exploratory
pilot study in a community care unit. Millenium - Journal of Education,
Technologies, and Health, 2(31), e45879
DOI: https://doi.org/10.29352/mill0231.45879
Intervenção estruturada na comunicação e coesão da equipa de
enfermagem: estudo piloto exploratório numa Unidade de Cuidados na Comunidade
Structured intervention in nursing communication and cohesion: an
exploratory pilot study in a Community Care Unit
Comunicación y cohesión del equipo de enfermería:
estudio piloto exploratorio en una Unidad de Cuidados en la Comunidad
Joaquim Carreira1, Ana Cláudia Santos1,
Catarina Valente2
1 - Unidade Local de Saúde Viseu Dão Lafões
|Local Health Unit of Viseu Dão-Lafões
2 - Instituto Piaget, Escola Superior de Saúde
Jean Piaget Viseu | Piaget Institute, Jean Piaget Higher School of Health of
Viseu
RESUMO
Introdução: A comunicação interprofissional é um pilar da segurança
do doente, exigindo estratégias estruturadas para fortalecer a coesão das
equipas de saúde.
Objetivo: Avaliar a exequibilidade e o impacto de uma intervenção estruturada na
perceção das competências comunicacionais e coesão de uma equipa de enfermagem.
Métodos: Estudo piloto exploratório, de abordagem quantitativa, realizado numa
Unidade de Cuidados na Comunidade (n=4). A intervenção incluiu três
sessões de teambuilding (baseadas no TeamSTEPPS) e a implementação de briefings
diários (modelo SBAR) durante sete meses. A colheita de dados utilizou a escala
ECIpS em dois momentos (T0 e T1). A análise centrou-se no tamanho do efeito
(Cohen’s d) e na fidelidade da intervenção através de auditoria
documental.
Resultados: Observou-se uma evolução positiva no score total da
ECIpS, com um tamanho do efeito substancial (d = 0,73). A dimensão “Liderança”
revelou o maior impacto (d = 0,70), refletindo um aumento na agência
profissional e coordenação de cuidados. A dimensão “Trabalho em Equipa”
manteve-se estável em níveis elevados (M=3,95), sugerindo um efeito de teto em
equipas experientes. A taxa de adesão aos briefings foi de 88,1%, confirmando a
viabilidade da intervenção.
Conclusão: Este estudo piloto exploratório sugere que a intervenção poderá ser
exequível e clinicamente pertinente, promovendo potencialmente o protagonismo
técnico dos enfermeiros. Dada a reduzida dimensão da amostra, estes resultados
preliminares deverão ser confirmados por futuros estudos multicêntricos que
visem consolidar a comunicação estruturada nos cuidados de saúde primários.
Palavras-chave: Comunicação; Coesão do Grupo; Cultura Organizacional; Segurança.
ABSTRACT
Introduction: Interprofessional
communication is a cornerstone of patient safety, requiring structured
strategies to strengthen healthcare team cohesion.
Objective: To evaluate
the feasibility and impact of a structured intervention on the perception of
communication competencies and cohesion within a nursing team.
Methods: An
exploratory pilot study with a quantitative approach was conducted in a
Community Care Unit (n=4). The intervention included three team-building
sessions (based on the TeamSTEPPS model) and the implementation of daily
briefings (SBAR framework) over seven months. Data were collected using the
ICHS scale at two time points (T0 and T1). Analyses focused on effect size
(Cohen’s d) and intervention fidelity assessed through a documentary
audit.
Results: Positive
changes were observed in the total ICHS score, with a substantial effect size (d
= 0.73). The “Leadership” dimension showed the greatest impact (d = 0.70),
reflecting increased professional agency and care coordination. The “Teamwork”
dimension remained stable at high levels (M=3.95), suggesting a ceiling
effect in experienced teams. Adherence to the daily briefings was 88.1%,
confirming the intervention’s feasibility.
Conclusion: This
exploratory pilot study suggests that the intervention may be feasible and
clinically relevant, potentially enhancing nurses' professional agency. Given
the small sample size, these preliminary findings should be confirmed by future
multicenter studies aimed at consolidating structured communication in primary
care.
Keywords: Communication;
Social Cohesion; Organizational Culture; Safety
RESUMEN
Introducción: La comunicación interprofesional es un pilar de la
seguridad del paciente y requiere estrategias estructuradas para fortalecer la
cohesión de los equipos de salud.
Objetivo: Evaluar la factibilidad y el impacto de una intervención estructurada en
la percepción de las competencias comunicativas y la cohesión de un equipo de
enfermería.
Métodos: Se realizó un estudio piloto exploratorio con enfoque cuantitativo en una
Unidad de Cuidados en la Comunidad (n=4). La intervención incluyó tres
sesiones de team-building (basadas en el modelo TeamSTEPPS) y la implementación
de briefings diarios (marco SBAR) durante siete meses. Los datos se recopilaron
mediante la escala ICHS en dos momentos (T0 y T1). Los análisis se centraron en
el tamaño del efecto (d de Cohen) y en la fidelidad de la intervención,
evaluada mediante auditoría documental.
Resultados: Se observaron cambios positivos en la puntuación total
de la ICHS, con un tamaño del efecto sustancial (d = 0,73). La dimensión
“Liderazgo” mostró el mayor impacto (d = 0,70), lo que refleja un
aumento de la agencia profesional y la coordinación de los cuidados. La
dimensión “Trabajo en equipo” se mantuvo estable en niveles altos (M = 3,95),
lo que sugiere un efecto techo en equipos experimentados. La tasa de adherencia
a los briefings fue del 88,1%, confirmando la factibilidad de la intervención.
Conclusión: Este estudio piloto exploratorio sugiere que la intervención
podría ser factible y clínicamente relevante, potenciando de forma preliminar
la agencia profesional de los enfermeros. Dado el reducido tamaño de la
muestra, estos hallazgos preliminares deberán confirmarse mediante futuros
estudios multicéntricos orientados a consolidar la comunicación estructurada en
la atención primaria.
Palabras Clave: Comunicación; Cohesión Social; Cultura
Organizacional; Seguridad
INTRODUCTION
Patient safety is
unequivocally a strategic priority for modern health systems, constituting a
fundamental cornerstone for Universal Health Coverage (World
Health Organization, 2023). However, despite technological and
scientific advances, the occurrence of adverse events remains a persistent
reality, frequently rooted in systemic failures of human interaction (Mujuru & Peisah,
2024; Weller et al., 2024; World Health Organization, 2023). Therefore, interprofessional communication
cannot be reduced to mere behavioral or 'soft' competence; it is a critical
determinant of organizational effectiveness and clinical safety (Alhur et al., 2024; Dietl et al., 2023). Studies indicate that
communication breakdowns and disciplinary fragmentation are significant barriers
to excellence in care, underscoring the need to transition from an individual
competence model to a collective and patient-centered safety culture, where
responsibility is shared across the entire team (Mujuru & Peisah, 2024; Weller et al., 2024; World Health
Organization, 2023).
This imperative for
cohesion takes on specific and challenging contours within the context of
Primary Health Care (PHC) in Portugal, specifically in Community Care Units
(CCUs) (Carrapiço et al., 2025; Souza & Sá, 2013). The reform
of PHC in Portugal emphasized teamwork as a vector of change; however,
challenges concerning the relative isolation of nurses and the need to
transform nominal proximity into effective cooperation persist (Neves, 2012). Practice within these units requires
more than a mere juxtaposition of knowledge, demanding true interdisciplinarity
to mitigate care fragmentation and address the complex needs of the community (Dalla Nora et al., 2018; Neves, 2012).
The quality of team
dynamics impacts more than patient health outcomes; it is a determining factor
for occupational health and professional retention. Evidence suggests a strong
positive correlation between leadership effectiveness, team cohesion, and job
satisfaction (Fernandes et al., 2021; Inês & Pacheco, 2021).
Conversely, teams characterized by poor communication and low levels of mutual
support tend to fragment, thereby increasing the risk of burnout and the
intention to leave the profession (Bragadóttir et
al., 2023).
In
a scenario of human resource scarcity, fostering a psychologically safe and
collaborative work environment is essential for the sustainability of
healthcare organizations (Fernandes et al., 2021).
To address these
challenges, evidence-based intervention strategies drawn from the principles of
high-reliability industries have emerged, including briefings (or huddles) and
teambuilding. Daily briefings, consisting of short, structured meetings to
share critical information and align goals, have proven effective in enhancing
situational awareness and reducing adverse events (Pimentel et al., 2021;
Stychno & Kulczycka, 2023). Simultaneously, teambuilding interventions
focused on role clarification and establishing common goals have proven
effective in improving team functioning and, consequently, care quality,
although their application in non-acute settings still warrants further
systematic exploration (Haugstetter et al., 2024;
Weller et al., 2024).
Despite the robust
evidence regarding the impact of these strategies in hospital settings, a notable
gap remains in the literature concerning their application and effectiveness
within the specific context of PHC (Kanno et al., 2023; Ribeiro et al., 2021).
In Portugal, although the importance of clinical governance and care
integration is well-recognized, there is a scarcity of studies assessing the
impact of structured communication and cohesion interventions in CCUs
(Carrapiço et al., 2025; Souza & Sá, 2013). Specifically, it remains
unclear whether the combined implementation of teambuilding and daily
briefings, as an integrated communication strategy, is feasible and capable of
producing measurable improvements in interprofessional communication and team
cohesion within the organizational reality of Portuguese CCUs.
The present study
aims to bridge this gap by analyzing the impact of implementing briefings and
teambuilding strategies on team cohesion and communication within a CCU.
Ultimately, this work seeks to contribute to the definition of new health
governance practices and, by extension, the enhancement of patient safety.
1. STATE OF THE ART
1.1 Interprofessional Communication Models and Patient Safety
Effective interprofessional communication is widely recognized as a
structural component of quality and safety in healthcare. Current literature
defines interprofessional collaboration not merely as the coexistence of
different professionals, but as a dynamic process involving the coordination of
distinct disciplinary cores to produce comprehensive care (Kanno et al., 2023).
Historically, healthcare communication has been vulnerable to
fragmentation. Transitioning from linear, hierarchical models toward complex,
bidirectional, 'closed-loop' systems is essential to ensure that critical
information is not only transmitted but accurately received and understood (Ashour et al., 2025;
Stychno & Kulczycka, 2023). The absence
of this confirmation is frequently cited as a significant contributing factor
to errors of omission and adverse events.
Within the context of patient safety, communication acts as a
preventive barrier against error. According to the World Health Organization’s
Global Patient Safety Action Plan 2021–2030, most harm is preventable and
results from systemic failures rather than individual incompetence (World Health Organization, 2023).
Evidence emphasizes that barriers to interdisciplinary communication,
including role ambiguity and hierarchical organizational cultures, increase the
likelihood of failures in care processes, underscoring the need for management
models that integrate communication as a core safety vector (Dietl et al., 2023; Gleeson et al., 2023; Ribeiro et al.,
2021).
1.2. Group Dynamics and Cohesion in Healthcare Teams
The effectiveness of healthcare teams intrinsically depends on the
cohesion among their members. Team cohesion can be defined as the tendency of a
group to unite in the pursuit of common goals, serving as a significant
predictor of job satisfaction and the intention to remain within the
organization (Bragadóttir et al., 2023).
In the specific context of PHC and CCUs in Portugal, cohesion faces
unique challenges. Teamwork within these units necessitates integration and
voluntary cooperation, often predicated on interpersonal affinities during the
initial stages of team formation (Carrapiço et al.,
2025; Marques, 2025).
Factors such as participative leadership, technical-operational
autonomy, and a shared action plan positively influence team morale and
perceived service quality (Carrapiço et al., 2025; Souza & Sá, 2013).
Conversely, a lack of mutual support and defensive communication
fragment the team and exacerbate the risk of burnout (Bragadóttir
et al., 2023).
1.3. Structured Interventions: Briefing and Teambuilding as Management
Tools
To mitigate communication failures and strengthen cohesion, the
literature proposes evidence-based structured interventions, most notably
briefings (or huddles) and teambuilding. The daily briefing, frequently
referred to as a 'safety huddle,' is rooted in High-Reliability Organizations
(HROs). This tool consists of brief, frequent meetings of 5 to 15 minutes
designed to increase situational awareness, facilitate the rapid identification
of risks, and ensure the alignment of care plans (Pimentel
et al., 2021). Studies demonstrate that the systematic implementation of
huddles enhances safety climate, teamwork culture, and operational efficiency,
thereby mitigating delays and adverse events (Pimentel
et al., 2021).
In parallel, teambuilding interventions are essential for managing
relational dynamics and role clarification. Unlike purely social activities,
effective teambuilding in healthcare settings focuses on goal alignment,
conflict resolution, and the enhancement of interpersonal communication skills (Haugstetter et al., 2024; Weller et al., 2024).
The effectiveness of these tools can be explained through the theory
of Shared Mental Models (SMM). This framework suggests that team performance
improves when all members possess a common and accurate understanding of the
tasks, equipment, individual roles, and the current situation (Ashour et al., 2025; Curșeu et al., 2025; Friederich et
al., 2025). Briefings
and teambuilding act as coordination mechanisms that build and update these
mental models, enabling the team to anticipate needs and adapt their actions in
a coordinated manner amidst the complexity of care (Ashour
et al., 2025).
Consequently, these interventions emerge as strategic pillars for
enhancing clinical governance within the specific framework of Portuguese PHC.
2. METHODS
This study is an exploratory pilot
investigation with a quantitative approach, employing a quasi-experimental, pretest-posttest
design (T_0 and T_1) without a control group. The primary
objective was to evaluate the impact of a structured intervention, comprising
daily briefings and teambuilding activities, on interprofessional communication
and team cohesion within a nursing team. The reporting of this study adheres to
the TREND (Transparent Reporting of Evaluations with Nonrandomized Designs)
Statement recommendations.
2.1 Sample
The study population consisted of nurses working at a Community Care
Unit (CCU) in the Central Region of Portugal. A non-probability convenience
sampling technique was adopted. Given the exploratory nature of this pilot
study, the sample size was determined by the number of nurses available in the
unit rather than by a formal statistical power calculation.
From the total staff (N = 9), three professionals were initially
excluded: two who were members of the research team to prevent response bias,
and one who was on long-term medical leave during the intervention period. The
remaining six nurses were considered eligible for participation.
The inclusion criteria were: (a) working at the CCU for at least six
months; (b) performing direct clinical care during the intervention; and (c)
completing both pre-test (T0) and post-test (T1) evaluations. Given the
resulting small sample size (n = 4), the statistical power of subsequent
analyses was inherently limited, a constraint that is considered throughout the
interpretation of the results.
2.2. Intervention
The structured intervention was designed to optimize interprofessional
communication and strengthen nursing team cohesion. It comprised two
complementary components: team-building activities and the implementation of
structured daily briefings, conducted from June to December 2025.
2.2.1. Team-Building Activities
Team-building activities were conducted during the intervention period
and consisted of three in-person sessions, each lasting approximately 30
minutes. These sessions were informed by the TeamSTEPPS (Team Strategies and
Tools to Enhance Performance and Patient Safety) framework, widely used in
healthcare to promote effective communication, shared leadership, situation
monitoring, and mutual support. The activities were structured around three
core domains:
Team Cohesion Dynamics: Interactive exercises aimed at strengthening
mutual trust, professional empathy, and team psychological safety.
Role Clarification: Guided discussions based on clinical scenarios and
collective reflection on the distribution of responsibilities and the nurse’s
role in care coordination.
Assertive Communication Training: Exploration of communication
strategies that support the expression of clinical opinions, constructive
management of divergences, and the sharing of scientific knowledge. The
sessions were facilitated by the researchers during regular team meetings and
served as catalysts for the subsequent implementation of daily briefings. The
facilitator held training in human resources management and clinical
simulation, through which facilitation competencies were developed. Sessions
were supported by structured guides outlining the planned activities,
complemented on occasion by projected slides.
2.2.2. Implementation of Daily Briefings
The second component involved introducing a structured communication
procedure through daily briefings at the start of each shift. The briefings
followed these principles:
·
Frequency and
Duration: Conducted daily at shift onset, with an average duration of
approximately 10 minutes.
·
Structured
Content: Information was shared regarding critical patient data, daily care
planning, and logistical coordination. Communication followed the SBAR
(Situation, Background, Assessment, Recommendation) framework, widely
recommended to standardize and improve clarity in clinical communication.
·
Shared
Leadership: Briefing leadership rotated among team members, allowing each nurse
to present updates regarding their respective patients and assume an active
role in care coordination. This model aimed to promote professional agency,
strengthen shared decision-making, and encourage active participation in care
management.
2.2.3. Intervention Fidelity and Adherence Monitoring
To ensure intervention fidelity, a systematic record of briefing
implementation was maintained throughout the study period. Adherence was
evaluated through a documentary audit, calculating the percentage of eligible
working days in which the briefing was performed. This indicator served as a
measure of organizational adherence to the intervention and provided contextual
support for interpreting the results of the interprofessional communication
competency assessment. In addition, professionals' satisfaction with the daily
briefing procedure was assessed; as this outcome concerns a distinct dimension
of the intervention and falls outside the scope of the present analysis, it is
not reported in this manuscript.
2.3. Data collection instruments
To assess the study
variables, several instruments were utilized. First, a sociodemographic and
professional characterization questionnaire was developed specifically for this
study to collect data on age, gender, years of professional practice, and length
of service at the CCUs. Furthermore, the Interprofessional Communication in
Health Scale (ICHS), validated by Brás et al. (2023),
was employed to assess professionals' perceptions of communication in
healthcare contexts. This Likert-type scale focuses on key domains such as
clarity, feedback, and collaboration. Additionally, an investigator-developed
adherence monitoring grid (audit) was used to measure the implementation rate
of the new briefing procedure by recording the percentage of days the intervention
was successfully performed relative to the total working days.
2.4. Statistical analysis
Data were analyzed using the Statistical Package for the Social
Sciences (SPSS), version 26.0. Descriptive statistics, including absolute and
relative frequencies, means, standard deviations, and ranges, were employed to
characterize the sample and analyze audit adherence rates.
To explore the impact of the intervention, ICHS scores were compared
between baseline (T0) and post-intervention (T1). Given the exploratory pilot
design and small sample size (n = 4), data distribution was assessed
using the Shapiro–Wilk test. Although no statistically significant deviations
from normality were detected (p > 0.05 for all variables), results
were interpreted with caution due to the limited power of normality testing in
very small samples.
Paired-sample t-tests were conducted to examine within-subject
differences between T0 and T1. Considering the pilot nature of the study,
findings were interpreted as preliminary trends rather than confirmatory
evidence. Accordingly, the primary purpose of the statistical analysis was to
explore potential trends and estimate effect sizes, rather than to demonstrate
the effectiveness of the intervention. To complement p-values and
provide an estimate of practical relevance, effect sizes were calculated using
Cohen’s d.
Statistical significance was set at p < 0.05, and 95%
confidence intervals were reported where applicable.
2.5. Ethical Considerations
The study was conducted in strict compliance with the ethical
principles of the Declaration of Helsinki. The research protocol was approved
by the Health Ethics Committee of the Local Health Unit of Viseu Dão-Lafões
(ULSVDL) (Opinion No. 24/06/06/2025).
All participants were fully informed regarding the study objectives,
the voluntary nature of their participation, and their right to withdraw at any
stage without penalty. Data collection was preceded by the signing of Informed
Consent. To ensure anonymity and confidentiality, questionnaires were coded to
prevent the individual identification of professionals, and data were analyzed
in aggregate form.
3. RESULTS
The nursing staff of the unit under study
consists of nine professionals (N = 9). Three professionals were excluded from
eligibility: two who performed research functions in the current study and one
who was on long-term medical leave during the intervention period.
Of the six eligible nurses, two declined to
participate in the research phase and did not complete the baseline
questionnaire, although they remained involved in the clinical activities of
the unit. Consequently, the final sample included four nurses (n = 4),
corresponding to a participation rate of 66.7% among eligible professionals and
44.4% relative to the total nursing staff (Figure 1).
The participants constitute a homogeneous and
highly qualified group, consisting exclusively of females (100%). The mean age
is 43.6 years (SD = 6.84), with extensive professional experience (M
= 18.8 years; SD = 10.28). It is noteworthy that the entire sample
(100%) holds the title of Specialist Nurse, although none reported prior
structured training in interprofessional communication skills (Table 1).
During the intervention period, briefings were
conducted on 119 of the 135 eligible working days, corresponding to an
adherence rate of 88.1%. Regarding intervention fidelity, the three planned
team-building sessions were completed as scheduled (100% execution). These
indicators demonstrate high consistency in the implementation of all
intervention components designed to support improvements in interprofessional
communication and team coordination.
Data distribution was assessed using the Shapiro-Wilk
test, which is recommended for small sample sizes. No statistically significant
deviations from normality were detected for the ICHS global score at T0 (p
= 0.691) or T1 (p = 0.902), nor for its individual dimensions (p
> 0.05).
While acknowledging the limited power of
normality testing in very small samples, these results, combined with the
exploratory pilot nature of the study, supported the use of parametric
statistics. Consequently, paired-sample t-tests were employed to
identify preliminary trends in communication scores.
A positive trend was observed in the total
ICHS score, with a moderate-to-large effect size (Cohen's d = 0.73) (Table 2).
Given the exploratory nature of this pilot study and the small sample size,
these results are interpreted as indicative of potential improvements in the
team's communicational competencies rather than definitive evidence of
effectiveness.
Note: ICHS: Interprofessional
Communication in Health Scale (24-item validated version); SD: Standard
Deviation; t: Student's paired t-test statistic; df: degrees of
freedom (n-1); p: statistical significance level; Cohen's d
classification: 0.20 - small, 0.50 - Medium, 0.80 - Large.
The 'Leadership' dimension demonstrated the
largest relative increase (d = 0.70). As illustrated in the Radar Chart (Figure
2), this domain showed the most substantial relative change in the competency
profile following the intervention.
Figure 2 – Radar chart of the evolution of ICHS dimensions between baseline (T0)
and post-intervention (T1).
The 'Teamwork' domain remained stable at high
levels, reflecting a previously strong baseline cohesion that was maintained
throughout the intervention period (Figure 3).
Figure 3 – Comparison of mean scores for the global ICHS and its dimensions at
Pre (T0) vs Post-intervention (T1)
A positive, though modest, trend was also
noted in the 'Conflict Management' dimension (Table 2).
It should be noted that the ICHS has been
previously validated, demonstrating robust psychometric properties and ensuring
the theoretical relevance of its items across all three dimensions. Therefore,
observed changes are interpreted with respect to a reliable and theoretically
sound measurement framework.
4.
DISCUSSION
The analysis of this exploratory pilot study—centered on a structured
intervention of teambuilding and briefings within a CCU provides preliminary
insights into potential improvements in interprofessional communication. While
the small sample size (n=4) inherently limits statistical significance (p
> 0.05) and generalizability, the observed effect size (Cohen’s d =
0.73) indicates a moderate-to-large change, suggesting practical relevance
in the team’s communicational dynamics. These findings support the feasibility
of structured communication tools in specialized primary care settings (Dietl
et al., 2023).
Preliminary Trends in Leadership Agency
The most pronounced trend was observed in the “Leadership” dimension,
which increased from 3.46 to 3.75 (d = 0.70). Within the ICHS framework,
this dimension reflects professional agency rather than hierarchical
management. Items indicating improved self-perception in “sharing knowledge”
and “presenting scientific data” suggest that the intervention may have
contributed to an enhanced sense of professional agency. By providing a
formalized space for clinical coordination, the briefings may have supported
nurses in exercising a more active technical role, potentially mitigating
passive professional stances often found in traditionally verticalized
healthcare environments (Kanno et al., 2023).
Conflict Management and Assertiveness
A subtle increase in Conflict Management (3.50 to 3.56) may indicate a
trend toward greater individual assertiveness. As highlighted by Alhur et al.
(2024), deficits in dialogue are often precursors to errors. In this context,
the introduction of a communication protocol appears to have established a safe
space for more transparent exchange of perspectives. Although modest, these
trends suggest that standardization can support collaborative decision-making
and reduce hierarchical silencing.
Teamwork Stability: The Ceiling Effect
Teamwork scores remained stable at high levels (M = 3.95),
reflecting strong pre-existing social capital. This lack of quantitative
variation is consistent with a ceiling effect, commonly observed in experienced
teams where baseline cohesion is already high (Aaberg
et al., 2025). In this case, the intervention appears to have functioned
as a mechanism to sustain and validate existing cooperative relationships
rather than produce further quantitative growth.
Potential Sources of Bias
Several methodological factors warrant consideration when interpreting
these preliminary trends. The observed changes may partly reflect a Hawthorne
effect, whereby participants' awareness of being observed and involved in a
structured study could have influenced their behavior and self-reported perceptions
independently of the specific content of the intervention. Similarly, as data
collection relied on a self-report instrument, responses may have been subject
to social desirability bias, particularly given the non-anonymous, small-team
context in which the study was conducted. Although the two nurses involved in
the research team were excluded from the participant sample to minimize direct
response bias, they remained integrated members of the clinical unit throughout
the intervention period; their presence during team-building sessions and daily
briefings may nonetheless have influenced group dynamics and participants'
responses in ways not fully captured by the study design. These factors should
be considered when interpreting the observed trends, which are presented as
plausible interpretations rather than demonstrated effects of the intervention.
Methodological Transparency and Feasibility
Finally, the study demonstrates methodological transparency. The
exclusion of investigators and respect for participant self-determination
ensure compliance with ethical standards, including the Declaration of
Helsinki. Despite the small sample and attrition, the observed trends and
effect sizes support the feasibility and potential replicability of this
intervention model, providing a foundation for future studies with larger
cohorts to confirm the effectiveness of structured communication in CCUs.
CONCLUSION
This exploratory pilot study suggests that the implementation of a
structured intervention, based on teambuilding activities and daily briefings,
may represent a feasible strategy for promoting interprofessional communication
in a CCU. The findings indicate that formalizing clinical coordination spaces
was associated with positive trends in the perception of communicational
competencies, potentially contributing to professional empowerment and to
reducing hierarchical silencing in favor of a safer, more collaborative
practice.
The analysis revealed a moderate-to-large effect size (Cohen's d =
0.73), with a particular emphasis on the "Leadership" dimension. This
trend in the self-perception of professional agency and clinical protagonism
may reflect the potential role of structured communication tools in supporting
the autonomous management of care by specialist nurses. Concurrently, the
stability observed in "Teamwork" highlighted solid pre-existing
social capital and cohesion, suggesting that the intervention may also have
functioned as a mechanism for sustaining existing cooperative relationships in
highly experienced teams.
These preliminary trends must be interpreted with caution, considering
the methodological limitations inherent to this study design. The primary
limitation lies in the small sample size (n=4), which restricted the
statistical power to detect significance at the p-value level and precludes the
generalization of findings to the general nursing population or other
organizational contexts. Additionally, the exploratory nature and the absence
of a control group preclude causal inference regarding the intervention's
effectiveness.
Other factors, such as self-selection bias (motivated by voluntary
participation), reliance on self-report instruments (subject to social
desirability bias), a potential Hawthorne effect, and the continued presence of
two research-team members within the clinical unit during the intervention, may
have influenced subjective perceptions and should be considered when
interpreting these findings.
In summary, this study fulfills its exploratory purpose by offering
preliminary methodological insights. These findings should be regarded as
hypothesis-generating rather than confirmatory, and further, larger multicenter
studies employing more robust methodological designs, including a control
group, are needed to examine the effectiveness of this intervention model in
primary care.
ACKNOWLEDGEMENTS
To Margarida Albuquerque Almeida Santos, PhD,
for her selfless collaboration and insightful contributions to the quality and
accuracy of this work.
AUTHORS'
CONTRIBUTION
Conceptualization, J.C.; data
curation, J.C.; formal analysis, J.C., A.C.S. and C.V.; investigation, J.C. and
A.C.S.; methodology, J.C.; project administration, J.C.; resources, J.C.;
software, J.C.; supervision, J.C.; validation, J.C., A.C.S. and C.V.; visualization,
J.C., A.C.S. and C.V.; writing – original draft, J.C., A.C.S. and C.V.; writing
– review & editing, J.C., A.C.S. and C.V.
CONFLICT
OF INTEREST
The authors declares no conflict of interest.
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