Decision-making in teams: issues arising from two UK evaluations

Interagency and interprofessional working has often been operationalised through the development of integrated, multiprofessional teams in the UK. However, there is considerable ambivalence reported about the success of such teams. This paper reports on two evaluations of different types of inter-agency/intra-agency, interdisciplinary/unidisciplinary teams. One study used a soft systems methodology to evaluate a health and social care team for people with enduring mental health needs and the other used a pluralistic framework to examine integrated nursing teams in primary care. In both studies, the team-working arrangements influenced the decisions made by the team members such that client care became increasingly responsive and proactive. These changes were made possible by two processes. First, information transaction was augmented and was instrumental in supporting effective client-related decision-making. Second, there was enhanced support for decision-making, especially in respect of problem solving. However, the increased autonomy of the team members had the potential to marginalise those outside the team from decision-making. It is suggested that working within a team can impact on the decisions made by team members, which exceeds a collection of individual decisions. The strengths of complex multiprofessional teams for service users may be realised if the processes of decision-making are respected.     

Expert supervisors' views of clinical supervision: a study of factors promoting and inhibiting the achievements of multiprofessional team supervision

BACKGROUND: Only a few studies are available of team supervision and its challenges to supervisors. A multiprofessional team supervision project was accomplished in 1995-1998 in one university hospital in Finland. Eighty-two practitioners from five wards participated in the project and 10 experienced supervisors implemented their team supervision. AIM: The aim of this qualitative study is to describe the experiences of five supervisor pairs (n=10) of multiprofessional team supervision. METHODS: Data were collected by semi-structured interviews from the supervisor pairs. The interviewing style was open and followed that of a guided conversation between supervisors and researcher. Interview data were analysed using thematic content analysis. FINDINGS: The factors that influenced team supervision were as follows: advanced knowledge of supervision and confidence in supervisors, commitment and motivation, interaction and collaborative relationships and the arrangements of team supervision. The positive effects of team supervision as identified by the supervisors were as follows: influence on interaction and human relationships in the work community, supervisees' strengthened professional identity and the development of multiprofessional practice. CONCLUSIONS: Several factors can promote or inhibit the achievements of team supervision. Regardless of all the difficulties related to team supervision, its effects on a work community are positive. For the supervisors, team supervision is a demanding and challenging but also a rewarding process.     

Discursive patterns in multiprofessional healthcare teams

AIM: The aim of this paper is to report a study exploring how members of multiprofessional healthcare teams talk about their team. Specifically, the team members' talk was analysed to explore the discursive patterns that emerged and their functions. BACKGROUND: Over recent decades there has been an increasing demand in Western countries to change care organizations and to coordinate resources and professional competencies to meet the needs of patients/service users better. Because society promotes this kind of work, it may be valuable to explore the self-presentations of a multiprofessional healthcare team. METHODS: A discourse analysis was carried out on existing empirical data from focus group interviews with a member-identified category sample comprising 32 healthcare professionals in six authentic multiprofessional teams in south-east Sweden. The analysis focused on the participants' discursive constructions of multiprofessional teamwork, on the way they talked about their group, and, in particular, on their use of the pronouns we, they and I. FINDINGS: The constructions of 'we' by multiprofessional healthcare teams showed discursive patterns that are here referred to as knowledge synergy and trusting support, which included factors such as cross-learning and personal chemistry. The pronoun we was also used as a flexible resource to manage expertise, power and leadership within the teams, and it might also function to ease the pressure for consensus. CONCLUSION: These discursive patterns provided powerful rhetorical resources for team members, both to affirm their choice of membership and to claim superiority in relations with the surrounding community (the others) by linking to a societal discourse that promotes collaboration.     

Every team needs a coach: Training for interprofessional clinical placements

Despite growing awareness of the benefits of interprofessional education and interprofessional collaboration (IPC), understanding how teams successfully transition to IPC is limited. Student exposure to interprofessional teams fosters the learners’ integration and application of classroom-based interprofessional theory to practice. A further benefit might be reinforcing the value of IPC to members of the mentoring team and strengthening their IPC. The research question for this study was: Does training in IPC and clinical team facilitation and mentorship of pre-licensure learners during interprofessional clinical placements improve the mentoring teams’ collaborative working relationships compared to control teams? Statistical analyses included repeated time analysis multivariate analysis of variance (MANOVA). Teams on four clinical units participated in the project. Impact on intervention teams pre- versus post-interprofessional clinical placement was modest with only the Cost of Team score of the Attitudes Towards Healthcare Team Scale improving relative to controls (p = 0.059) although reflective evaluations by intervention team members noted many perceived benefits of interprofessional clinical placements. The significantly higher group scores for control teams (geriatric and palliative care) on three of four subscales of the Assessment of Interprofessional Team Collaboration Scale underscore our need to better understand the unique features within geriatric and palliative care settings that foster superior IPC and to recognise that the transition to IPC likely requires a more diverse intervention than the interprofessional clinical placement experience implemented in this study. More recently, it is encouraging to see the development of innovative tools that use an evidence-based, multi-dimensional approach to support teams in their transition to IPC.     

Team type,team maturity and team effectiveness in specialist palliative home care: an exploratory questionnaire study

ABSTRACT

To meet complex needs in persons and families within specialist palliative care, care team members are expected to work together in performing a comprehensive assessment of patient needs. Team type (how integrated team members work) and team maturity (group development) have been identified as components in team effectiveness and productivity. The aim of the study reported in this paper was to identify team types in specialist palliative care in Sweden, and to explore associations between team type, team maturity and team effectiveness in home care teams. A national web-based survey of team types, based on Thylefors questionnaire, and a survey of healthcare professionals using the Group Development Questionnaire (GDQ-SE3) to assess team developmental phase, effectiveness and productivity were used in an exploratory cross-sectional design. The participants were: Specialist palliative care teams in Sweden registered in the Palliative Care Directory (n = 77), and members of 11 specialist palliative home care teams. Teams comprised physicians, registered nurses, social workers, physiotherapists and/or occupational therapists, full-or part-time. Our national web survey results showed that the 77 investigated teams had existed from 7 to 21 years, were foremost of medium size and functioned as inter- or transprofessional teams. Results from the 61 HCPs, representing 11 teams, indicated that more mature teams tended to work in an integrated manner, rather than in parallel. The effectiveness ratio varied from 52% to 86% in teams. Recommendations arising from our findings include the need for clarification of team goals and professional roles together with prioritizing the development of desirable psychosocial traits and team processes in clinical settings.     

Modern team work and rehabilitation of handicapped patients

Since the early 90s, team work has become enormously important as a new model of labour organisation. Team work is the centre-piece of far-reaching restructuring and rationalization processes in companies. New team work concepts generate both risks and opportunities for workers with disabilities. The implementation of teams has been accompanied by a reduction of traditional employment areas in which people with disabilities have often been employed in stand-alone workplaces. Within teams, disabled workers may face discrimination and exclusion if other team members have to be afraid of wage cuts due to performance restrictions. The risk of exclusion has to be counteracted by adaptation and redesign of the working conditions, by selective training, mechanisms to manage social processes and conflicts in teams, as well as by rehabilitation.     

Review article: Use of the Team Emergency Assessment Measure in the rating of emergency teams' non-technical skills: A mapping review

The present study aims to explore the utility of the Team Emergency Assessment Measure (TEAM) in relation to the enhancement of emergency team non-technical skills based on research conducted over the last decade. In this mapping review, a citation mining process identified 22 primary studies for inclusion, published between 2012 and 2022. It provides outcome data on emergency teams' non-technical skills following team training and/or real-life patient emergencies. Emergency team studies related to resuscitation teams (adult, paediatric, newborn and obstetric cases) and medical emergency team (MET) management of patient deterioration. Team performance ratings varied, ranging from approximately 90% for experienced clinical teams down to 38% for students. Statistically significant improvements in performance were notable following training and/or repeated practice. Validity evidence, across 11 studies that provided change data described positive learning outcomes and moderate intervention effects. However, according to Kirkpatrick's model of educational evaluation the studies were limited to professional development phases of learning and immediate post-training assessments rather than care quality improvement. The review highlights a lack of studies evidencing quality improvement or clinical impact such as change of patient care practice or health service performance. There is a need to conduct well-designed studies that explore both technical and non-technical skills of resuscitation teams and METs. Currently, non-technical skills training and repeated performance evaluations using the TEAM contribute immensely to the proficiency of emergency teams.     

Interprofessional teamwork in decentralized child welfare in The Netherlands: A comparison between the cities of Amsterdam and Utrecht

The recent transformation of child welfare in the Netherlands has improved opportunities for interprofessional working. We compared two models of teamworking within newly established interprofessional teams in the cities of Amsterdam and Utrecht, conducting a secondary analysis of semi-structured interviews collected through three broader research projects. Respondents include seventeen interprofessional team members (six from Utrecht, eleven from Amsterdam), representing a variety of teams across city, as well as two policymakers from Utrecht and one from Amsterdam. Team members were approached using convenience sampling, policymakers were purposively recruited. In different rounds of open and focused coding, we found that differences in team organization between the two cities have led to differences in the quality of interprofessional teamworking. Teamworking is best developed in Utrecht partly because team members are recruited and employed by a single organization. This has enabled a more careful process of selection and team composition than in Amsterdam, where a delegation approach entailed fragmentation as well as the risk of divided loyalty between team and mother organization. In addition, while the development of interprofessional teamwork in Utrecht is served by certain structures, teams in Amsterdam have suffered from an imbalance between freedom and structure, causing insecurity amongst staff and reduced chances of interprofessional integration. Despite the apparent success of the Utrecht model of interprofessional teamworking, interprofessional collaboration across team boundaries might suffer from the fact that teams in Utrecht, unlike in Amsterdam, do not comprise representatives of relevant partner organizations.     

Evaluating clinical supervision in community homes and teams serving adults with learning disabilities

Evaluating clinical supervision in community homes and teams serving adults with learning disabilities This paper provides a discussion of some of the professional and policy outcomes associated with implementing clinical supervision within a community service for adults with learning disabilities. It is based upon a small qualitative study whose aim was to examine how clinical supervision was operating, its strengths, its weaknesses and where improvements might be made. The study followed the introduction of clinical supervision 9 months earlier for nurses and carers employed in three community homes and one community multiprofessional team. The method consisted of direct observation of individual and group supervision and staff completing critical incident questionnaires, followed by semi-structured, audio-taped interviews with seven registered nurses and four community team members, including a social worker, psychologist and physiotherapist. Outcomes were expressed in two ways: in terms of the benefits of clinical supervision or of its ambivalence. The range of matters brought for discussion, or resolution, in supervision reflected some of the difficulties or dilemmas staff faced working in this area, for example promoting empowerment and assisting clients to make choices, and dealing with clients' challenging and inappropriate behaviours. As for the role of supervisor there was some evidence of nurses expressing apprehension or unpreparedness, also a perceived general concern over the relatively low status of clinical supervision, thought to be due to absence of visible management approval or failure to articulate properly the objective of supervision. A limitation of the study was its small subject sample although considerable data were gathered in each of the units through relatively long-term contact.     

Better team management-better team care?

Team building should not be a 'bolt-on' extra, it should be a well planned, integrated part of developing teams and assisting their leaders. When asked to facilitate team building by a group of NHS managers we developed a framework which enabled individual members of staff to become more effective in the way they communicated with each other, their teams and in turn within the organization. Facing the challenge posed by complex organizational changes, staff were able to use 3 training days to increase and develop their awareness of the principles of teamwork, better team management, and how a process of leadership and team building could help yield better patient care.     

Reflection in an intermediate care team

Objectives

Reflection has been cited as an effective method of providing evidence of professional development, learning and continued competence. Reflection in teams is thought to develop trust within the team and greater understanding of other team members’ roles and responsibilities. The aim of this qualitative study was to describe the experiences and perceptions of reflection by members of an intermediate care team.

Design

Phenomenological design, consisting of individual semi-structured audiotaped interviews. The interviews were transcribed and read to gain understanding. Themes were identified and grouped into categories.

Participants

Ten members of a multidisciplinary intermediate care team were interviewed.

Findings

Team reflection had not been developed formally in the intermediate care team, although many of the prerequisites for team reflection were present. Team members primarily used dialogical reflection in clinical practice as a problem-solving tool. Written reflection was limited, with its use being dependent on the skills, level of training and postqualification support of the participants.

Conclusion

A formal structure and managerial support is necessary to facilitate team reflection. Additional postgraduate support is required to enable team members to utilise written reflection effectively. Further research to investigate reflection in health and social care teams is warranted.     

Can staff attitudes to team working in stroke care be improved?

BACKGROUND: Teamwork is regarded as the cornerstone of rehabilitation. It is recognized that the skills of a multiprofessional team are required to provide the care and interventions necessary to maximize the patient's potential to recover from his/her stroke. LITERATURE REVIEW: Critical evaluation of team working is lacking in the literature. Indeed, there is no consensus on a precise definition of teamwork or on the best way of implementing it, beyond a general exhortation to members to work to the same therapeutic plan in a cohesive manner. The literature has highlighted many problems in team working, including petty jealousies, ignorance and a perceived loss of autonomy and threat to professional status. AIM: To determine if the use of team co-ordinated approaches to stroke care and rehabilitation would improve staff attitudes to team working. METHOD: A pre-post design was adopted using 'The Team Climate Inventory' to explore attitudes to team working before and after introducing the interventions. Local Research Ethics Committee approval was obtained. RESULTS: Improvements in attitudes towards team working suggest that the introduction of team co-ordinated approaches (integrated care pathways and team notes) did not result in greater team working. LIMITATIONS: The introduction of an integrated care pathway and team notes is based on an assumption that they would enhance team working. CONCLUSIONS: The results suggest that the introduction of team co-ordinated approaches (team notes and care pathways) do not improve attitudes to team working, teams appear to take a long time to establish cohesion and develop shared values.     

Medical dominance in multidisciplinary teamwork: a case study of discharge decision-making in a geriatric assessment unit

AIM: To investigate the degree of medical dominance in multidisciplinary teams in a geriatric assessment unit by focusing on decision-making with regard to patient discharge. BACKGROUND: The persistence of medical dominance in multidisciplinary teamwork has been widely assumed but insufficiently researched, particularly through close observation of team practice. The present study seeks to rectify this by examining the extent of medical dominance in two multidisciplinary teams working in a hospital-based geriatric assessment unit. METHODS: Team practice was analysed by observing and audiotaping five case review meetings in each team and by semi-structured interviews with team members. RESULTS: In terms of level of contribution, the issues raised at meetings, and the team responses to discharge initiation, a lower than expected level of medical dominance was identified. This lower than expected level is related to consultants' views on the nature of rehabilitation, leading to a consensus amongst team members as to the purpose of geriatric assessment, and to a high level of team stability. CONCLUSION: Reducing the level of medical dominance encourages the contributions of all team members and thus enhances patient care. More training in team skills would also be beneficial, including interprofessional training.     

Multiprofessional clinical supervision: challenges for mental health nurses

Recent reform and developments in mental health care provision have increasingly espoused the value of multiprofessional teamwork in order to ensure that clients are offered co-ordinated packages of care that draw on the full range of appropriate services available (DoH 1999a; DoH 2000). Supervision in some form is seen as a key part of all professional practice to provide support to practitioners, enhance ongoing learning, and, to a greater or lesser degree, offer some protection to the public (Brown & Bourne 1996, UKCC 1996). Clinical supervision has gained increasing momentum within the nursing profession, but to a large extent this has been within a uni-professional framework -- nurses supervising other nurses. This paper seeks to explore the ways in which multiprofessional working and clinical supervision interlink, and whether supervision across professional boundaries might be desirable, possible, and/or justifiable. Whilst our own view is that multiprofessional supervision is both possible and desirable, we seek to open up a debate, from our perspective as mental health nurses, about some of the issues related to the concept. Our motivation to explore this topic area emanates from our experiences as supervisors to colleagues within multiprofessional teams, as well as the experiences of those attending supervisor training courses. Following a brief overview of the development of clinical supervision in mental health care and recent policy guidelines, some models of clinical supervision are reviewed in terms of their suitability and applicability for multiprofessional working.     

Psychological safety and emergency department team performance: A mixed-methods study

Objectives

Team culture underpins team performance. Psychological safety – ‘a shared belief held by members of a team that the team is safe for interpersonal risk taking’ – is a critical component of team culture for high-performing teams across contexts. However, psychological safety in ED teams has not been well explored. We aimed to explore this core teamwork concept in the ED.

Methods

This was a sequential mixed-methods study of nursing and medical staff at a large tertiary care ED in Australia from October 2020 to March 2021. First, participants completed the ‘Team Learning and Psychological Safety Survey’ and a narrative questionnaire. These findings informed semi-structured interviews. We determined median psychological safety and compared results across role and length of time working in the department. Qualitative results were analysed using a deductive thematic analysis using a previously generated framework for enablers of psychological safety at the individual, team and organisational levels.

Results

The survey was completed by 72/410 participants and 19 interviews were conducted. The median psychological safety score was 37/49 (IQR 13). Psychological safety was not experienced universally, with nurses and new staff experiencing lower levels. Individual, team and organisational factors impacted psychological safety. The primary force shaping psychological safety was familiarity with colleagues and leaders.

Conclusion

Familiarity of team members and leaders was critical to the development of psychological safety within the ED. Fostering familiarity should be a focus for frontline leadership each shift and a priority in broader departmental decisions for those seeking to enhance the psychological safety of their teams.     

Healthcare Team Vitality Instrument (HTVI): developing a tool assessing healthcare team functioning

Title.  Healthcare Team Vitality Instrument (HTVI): developing a tool assessing healthcare team functioning.
Aim.  This paper is a report of a study conducted to refine, shorten and validate the Healthcare Team Vitality Instrument.
Background.  The Healthcare Team Vitality Instrument was developed to assess team vitality of nurses as well as other licensed and unlicensed personnel working as part of healthcare teams in inpatient hospital units. This instrument was necessary for two reasons. First, other commonly used instruments assess characteristics of Registered Nurses or perceptions about and characteristics of the organizations in which they work, but not these factors in combination with critical factors of interdisciplinary team functioning and collaboration. Second, a short tool for repeated, regular measurement of team vitality was needed to track the impact of changes to improve work environments.
Method.  Revisions to the Healthcare Team Vitality Instrument occurred in two phases. Phase 1 entailed collecting preliminary data and conducting cognitive interviews to refine the initial items. During Phase 2, the factor structure of the Healthcare Team Vitality Instrument was identified and a brief form developed and validated. Data were collected in 2006 and 2007.
Findings.  Exploratory factor analyses suggested a four-factor solution with the following dimensions: (1) support structures, (2) engagement and empowerment, (3) patient care transitions and (4) team communication.
Conclusion.  The Healthcare Team Vitality Instrument can contribute both to better management practices and advancing knowledge to promote retention of nurses, and to some extent other healthcare professionals, as well as efforts to transform the acute healthcare work environment.     

Achieving teamwork in stroke units: The contribution of opportunistic dialogue

Collaborative interdisciplinary working is central to contemporary health policy. The specialized and co-ordinated multidisciplinary care provided in stroke units is considered to contribute to improved patient outcomes in such units. However, how stroke unit teams co-ordinate their work is not clearly understood. This paper reports on a grounded theory study which explains how health professionals in two stroke units in northern England achieved teamwork. Data were generated through 220 hours of participant observation and 34 semi-structured interviews. Interviews were undertaken during and following participant observations. A basic social process common to teamworking in both units was identified; this was termed “opportunistic dialogue”. The division of labour in respect of rehabilitation activities was negotiated through this interactional process. Co-location of most team members led to repeated engagement in sharing patient information and in exploring different perspectives. Opportunistic dialoguing contributed to mutual learning and explained the shift in thinking and team culture as team members moved from concern with discrete disciplinary actions to dialogue and negotiations focused on meeting patients' needs. The findings indicate that routinely incorporating periods of joint working in which team members articulate the reasoning for their decisions and interventions, contributes to achieving interdisciplinary teamworking in rehabilitation settings.     

The effects of clinical supervision on the quality of care: examining the results of team supervision

AIM(S) OF THE STUDY: This study is part of a larger research project (1995-1998) aiming at quality improvement by means of clinical supervision (CS). The purpose of the study is to ascertain the conceptions of five ward teams having CS of its effects on the quality of care. BACKGROUND: The quality of nursing care has been debated since at least the 1980s. An extensive literature and research reports describe a variety of interventions and methods to improve the quality of care. One of the interventions is CS. However, the amount of empirical research exploring the effects of CS especially on the quality of care is limited. METHOD: Data were collected using group interviews and analysed using the method of phenomenography. FINDINGS: The following categories describing the conceptions related to CS and to the quality of care emerged: knowledge, change and 'I and we as providers of quality'. Conceptions of the effects varied between and within the teams and sometimes contradicted each other. The importance of knowledge was underlined on three of the five wards. The patient's point of view emerged only on one ward. CONCLUSIONS: It can be concluded that CS has effects on the quality of care and it can be considered a quality improving intervention in nursing practice. However, the knowledge of the different conceptions produced in this study also gives proof that team supervision is a challenge for supervisors.