Team-working is now recognised as the most appropriate means for delivering healthcare and, with some effort, every team can increase its level of effectiveness by improving its team-working processes, writes Dr. Claire Armstrong.
“The way a team plays as a whole determines its success. You may have the greatest bunch of individual stars in the world, but if they don’t play together, the club won’t be worth a dime.”
Babe Ruth (1895-1948)
Never more than now, has examining and improving team-working processes been more important in healthcare in Ireland. This is for a number of reasons, foremost amongst which is the proliferation of team-based working in all areas of healthcare and the current moratorium on recruitment, including replacement for those on maternity or sick leave. When working within such constraints, one cannot readily increase or change the staff working in any given team, so one route open to team leaders/managers to increase team effectiveness is to improve the team-working processes within the team.
Team-working is now recognised as the most appropriate means for delivering healthcare. However, as is often the case in many facets of life, people are given a task to complete without the necessary tools to do so. Specifically, in the Irish health services, many teams have been created by putting a group of people together and telling them that they are now a team. Unfortunately, simply putting a group of people together and hoping for the best, generally does not result in an effective team. In my experience, the missing link is usually training to work as a team. The content of most team-working training courses, though not explicitly stated, usually concentrates on creating and maintaining useful team-processes, such as participation and reflexivity, and decreasing the less useful ones, such as interpersonal conflict and poor communication.
In a team, where there is a high level of trust and psychological safety, one could expect that adverse incidents would be used as a learning experience by the entire team rather than being seen as a reason to criticise the individual team member
One of the main/original instigators for examining the importance of team processes for effective team working came from a basics systems model called the input-process-output (IPO) model. Generally, the person credited with its use in healthcare is the Lebanese public health pioneer, Avedis Donabedian, who died in 2000. In his classic 1966 paper1, he discussed the use of the IPO model for evaluating healthcare in general. However it is equally applicable to examining team effectiveness and indeed has spawned much research in the area of teams. Specifically, this model recognises the critical role of processes in terms of achieving outcomes; in this case the role of team working processes in achieving team effectiveness.
It is also important to recognise that hand-in-hand with innovation come mistakes and failures
There is an almost endless list of team working processes that influence team effectiveness. However, from my experience in carrying out research into team functioning in primary care teams, community-based mental health teams and breast cancer teams in Ireland and the UK, this list can be distilled to six important processes.
- Clarity of team objectives: In order for teams to operate successfully, there must be clarity and a shared understanding and agreement about what the team is trying to achieve between all of the members of the team. This may seem simple to ensure but, in fact, it isn’t. Even though teams can have mission statements, vision statements and even statutory duties, when team members are asked individually, to describe the purpose of the team, widely differing responses emerge. Of course, agreement about what the team is trying to achieve is necessary, but not sufficient; there must also be a shared understanding and agreement about how the team will achieve its objective, and the role of each team member in achieving it.
- Team participation: There are a number of components that influence the level and quality of participation within teams, including trust and psychological safety, frequency and quality of communication, in particular in relation to team meetings. Firstly, trust and psychological safety are highly inter-related in so far as they both refer to a sense of personal and professional safety within the team, such as feeling comfortable discussing patients whose care has not gone well or with whom mistakes have been made, without the fear of excessive criticism. Instead in a team, where there is a high level of trust and psychological safety, one could expect that adverse incidents would be used as a learning experience by the entire team rather than being seen as a reason to criticise the individual team member.
- Reflexivity: This is a crucial factor in effective team performance and in particular in improving team performance. Essentially it refers to formal reflection on the team’s performance and/or methods of working. There could be protected time for this, where monthly or bi-monthly ‘business’ meetings (as distinct from clinical meetings) are scheduled, during which team performance is explicitly discussed. Alternatively, it might occur more organically at coffee breaks or when a group of team members simply find themselves together. Undoubtedly, protected time specifically reserved for reflection on performance works best, but some reflexivity in whatever form, is better than no reflexivity at all.
- Support for new ideas/innovation: Generally speaking, innovation and the generation of new ideas occur most readily in teams where there is at least some reflexivity. That said, in order for teams to be a fertile ground for innovation, more explicit effort needs to be directed toward encouraging such behaviour. It is also important to recognise that hand-in-hand with innovation come mistakes and failures. In order to achieve significant improvements in the way the team works, or how patients are referred or treated, there has to be a process of trial and error. If there is a high level of trust and psychological safety within the team, this allows learning and hence improvement, to occur.
- Team conflict: There are two main types of conflict that arise within teams, namely task-related conflict and interpersonal conflict. Task-related conflict relates to the sharing and airing of diverse views on how the team does its work. Interpersonal conflict is conflict between individuals within the team, which is more personal in nature. In the context of team-working, task-related conflict is considered to be a good thing, once kept at a reasonable level, as it encourages innovation and improvement in how the team carries out its task, On the other hand, interpersonal conflict is always to be discouraged as it tends to result in reduced trust and participation in the team.
- Task and relationship oriented leadership: High quality leadership of teams is vital to their successful performance. There can be a single appointed leader but there need not be. Many teams operate successfully on the basis of a rotating leadership. What is very important, however, is that whoever the team leader is at any given time, he/she is able to focus on two very separate issues at once, namely showing concern and urgency about completing the team’s task to a high standard, and equally importantly, but often overlooked, demonstrating genuine concern for the welfare of the team members and understanding their concerns and needs.
In the context of team-working, task-related conflict is considered to be a good thing, once kept at a reasonable level, as it encourages innovation and improvement
What I have provided in this article is a brief snapshot of the team-working processes that have shone through as most important from my work with healthcare teams over the last number of years. Many teams do not have high quality team processes and hence are not as effective as they could be. However, the heartening message in all of this is that, with some effort, every team can increase its level of effectiveness by improving its team-working processes. Whilst having increased resources (human and financial) may also help, given that in the main, this will not happen in the current economic climate, the ability to improve team effectiveness still exists. Given the increasing role of teams in healthcare provision and the continuing roll-out of primary care teams across the country, now is the time to consider the team-processes in which your team engages and how they could be improved.
Dr Claire Armstrong, Graduate Entry Medical School & Department of Occupational Therapy, Faculty of Education and Health Sciences, University of Limerick.
- Donabedian, A. (1966), Evaluating the quality of medical care, Millbank Memorial Quarterly, 44, Supplement, pp. 166-206