Building effective clinical teams in healthcare

"A strong reason why I enjoy coming to work": Clinician acceptability of a palliative and supportive care intervention (PACT) for older adults with acute myeloid leukemia and their care partners

INTRODUCTION

Studies about clinician acceptability of integrative palliative care interventions in the inpatient and outpatient cancer settings are limited. In this study, we examined clinician acceptability of a NIH-funded interdisciplinary PAlliative and Supportive Care inTervention (PACT) for older adults with acute myeloid leukemia (AML) and their care partners that transcends both inpatient and outpatient settings.

MATERIALS AND METHODS

Data was collected using semi-structured interviews with clinicians who were directly involved in PACT. The domains of the Theoretical Framework of Acceptability were used to guide the qualitative analysis.

RESULTS

The clinicians consisted of occupational therapists (37%), physical therapists (25%), registered nurses (25%), and a clinical rehabilitation manager (13%). Five themes were identified in the thematic analysis: (1) Emotions and affect towards the intervention, (2) Intervention coherence and self-efficacy, (3) Barriers, burden, and opportunity costs of delivering the intervention, (4) Usefulness and effectiveness of the intervention, and (5) Recommendations to improve intervention delivery.

DISCUSSION

All clinicians found the PACT intervention highly acceptable and expressed the positive impact of the intervention on job fulfillment and satisfaction. Our findings provide evidence to inform the delivery and implementation of future large scale integrative palliative care intervention trials.

Human resource management at the intensive care unit: A pragmatic review and future research agenda for building a learning health system

Recently, the importance of efficient and effective health care has been recognized, especially during the acute phase of the Coronavirus Disease-2019 (COVID-19) pandemic. Intensive care units (ICUs) have faced an immense workload, with massive numbers of patients being treated in a very short period of time. In general, ICUs are required to deliver high-quality care at all times during the year. At the same time, high-quality organizational goals may not be aligned with the interests, motivation, and development of individual staff members (eg, nurses, and doctors). For management of the ICU, it is important to balance the organizational goals and development of the staff members ("their human capital"), usually referred to as human resource management. Although many studies have considered this area, no holistic view of the topic has been presented. Such a holistic view may help leadership and/or other stakeholders at the ICU to design a better learning health system. This pragmatic review aims to provide a conceptual model for the management of ICUs. Future research may also use this conceptual model for studying important factors for designing and understanding human resources in an ICU.

Followership in interprofessional healthcare teams: a state-of-the-art narrative review

OBJECTIVE

A state-of-the-art (SotA) literature review-a type of narrative review- was conducted to answer: What historical developments led to current conceptualisations of followership in interprofessional healthcare teams (IHTs)?

DESIGN

Working from a constructivist orientation, SotA literature reviews generate a chronological overview of how knowledge evolved and presents this summary in three parts: (1) this is where we are now, (2) this is how we got here and (3) this is where we should go next. Using the SotA six-stage methodology, a total of 48 articles focused on followership in IHTs were used in this study.

RESULTS

Articles about followership within IHTs first appeared in 1993. Until 2011, followership was framed as leader-centric; leaders used their position to influence followers to uphold their dictums. This perspective was challenged when scholars outside of healthcare emphasised the importance of team members for achieving goals, rejecting a myopic focus on physicians as leaders. Today, followership is an important focus of IHT research but two contradictory views are present: (1) followers are described as active team members in IHTs where shared leadership models prevail and (2) conceptually and practically, old ways of thinking about followership (ie, followers are passive team members) still occur. This incongruity has generated a variable set of qualities associated with good followership.

CONCLUSIONS

Leadership and followership are closely linked concepts. For leaders and followers in today's IHTs to flourish, the focus must be on followers being active members of the team instead of passive members. Since theories are increasingly encouraging distributed leadership, shared leadership and/or situational leadership, then we must understand the followership work that all team members need to harness. We need to be cognizant of team dynamics that work within different contexts and use leadership and followership conceptualisations that are congruent with those contexts.

Multi-level learning in public healthcare medical teams: the role of the social environment

PURPOSE

This study explores how individual, dyad and team levels of learning interact in public healthcare medical teams.

DESIGN/METHODOLOGY/APPROACH

A single interpretive case study is carried out in the public Health Service Executive (HSE) in Ireland, involving three rounds of semi-structured interviews with non-consultant hospital doctors (NCHDs), supported by relevant professional documentation and researcher log entries.

FINDINGS

An experience hierarchy, interpersonal relationships and social dynamics form the backdrop to learning interactions within public healthcare medical teams. Individual and team learning primarily occur in informal settings where interpreting and developing understanding takes place either in dyads, small groups or with the whole team. NCHD learning may vary depending on how effectively they build interpersonal relationships, take advantage of informal learning opportunities and manage the social dynamics within their team. Willingness and confidence to share insights and asking questions are triggers for individual and team learning.

RESEARCH LIMITATIONS/IMPLICATIONS

As a single case study focused on the HSE NCHD individual and team learning experience, this research study represents a relatively small exploration of individual and team learning interplay in the public healthcare medical team environment. The development of learning theory in this domain presents an intriguing avenue of further research, including observation of interactions within a team.

PRACTICAL IMPLICATIONS

The findings have practical relevance to those who are interested in the effectiveness of post-graduate/ NCHD learning in the public healthcare system. Interpersonal relationships and social norms play strong roles in how interaction and learning occurs in a team. These findings highlight the challenge of ensuring consistent quality across individual NCHDs or across hospital sites when training is heavily influenced by the approach of senior colleagues/ consultants to their more junior colleagues and the degree to which they take an active interest in NCHD learning.

ORIGINALITY/VALUE

The proposed learning framework is a key theoretical contribution, which draws upon the multi-levels of learning and provides greater insight into how individual, dyad and team learning interact in public healthcare medical teams when managing patient care. The findings have practical relevance in how to facilitate effective teamwork and learning interactions and for those who are interested in the consistency and quality of the training experience for NCHDs.

Physicians' perceptions of followership in resuscitation in Japan and the USA: a qualitative study

OBJECTIVES

While leadership is accepted as a crucial aspect of a successful resuscitation team, the role of followership has not been sufficiently explored. This study aims to explore physicians' perceptions of common favourable followership in resuscitation teams in two different countries.

DESIGN

A qualitative study with interviews and a reflexive thematic analysis.

SETTING

The authors individually interviewed critical care and emergency physicians whose clinical experience exceeded 6 years in Japan and the USA.

PARTICIPANTS

A total of 18 physicians participated in a face-to-face, semistructured and in-depth interviews.

RESULTS

Five themes and nine subthemes related to followership in resuscitation were identified. Under technical skills, two themes (being knowledgeable and skilled) and three subthemes (understanding guidelines/algorithms, clinical course and being competent with procedural skills), were generated. Under non-technical skills, three themes (assuming roles, team communication and flattening hierarchy) and six subthemes (taking roles spontaneously, calm tone of voice, sharing information, closed-loop communication, respectful attitude and speaking up), were generated. Each generated theme involved commonly perceived favourable attributes of followership in resuscitation teams by experienced critical care and emergency physicians in both countries.

CONCLUSIONS

This study clarified physicians' perception of common favourable followership attributes in resuscitation teams, both in Japan and in the USA. The results of this study shed light on followership-focused resuscitation education, where followership skills are generally underestimated.

Changing me to we: Developing teambuilding in radiation therapy

BACKGROUND

There has been a causal link identified within the literature between poor team function and errors, patient outcomes, staff satisfaction and performance. Lacking is supporting evidence on teambuilding and its impact on overall team performance and team dynamics. Within radiation therapy, there is difficulty in understanding the inner workings of team dynamics due to the unique complex nature of teams and with very little evidence on the impact of team building specific to radiation therapy. The focus of this research is to form a better understanding of the effects of teambuilding before and after a teambuilding education session.The knowledge gained can help in future trainings to promote and facilitate teambuilding to develop team dynamics and lead a change in culture.

METHODS

Team building sessions were booked and scheduled for 148 radiation therapists. Pre and post session evaluations were distributed to all participants and collected at the end of each team building session. Descriptive statistics were used to analyze Likert scale responses. Open-ended question responses were coded and analyzed for emerging themes using thematic analysis.

RESULTS

110 of 148 radiation therapists attended one of the scheduled team building sessions. Pre-session evaluations indicated radiation therapists have a good understanding of factors that affect teamwork (88% agree); are aware of the multi-generational impact (78% agree); have the skill set to build a respectful team (86% agree); and are comfortable dealing with conflict (67% agree). Post-session evaluations indicated that participants had gained increased knowledge on teamwork (66.3% agree; 30.7% strongly agree); are more aware of the generational impact within teams (59% agree); new strategiesdeveloped to help improve team dynamics and the ability to use the lessons learnt immediately (67% and 71% respectively agree). Open ended comments indicated an interest in additional teambuilding sessions and further education on conflict resolution.

CONCLUSION

Results showed an increased awareness of the factors that impact team dynamics amongst radiation therapists and an interest in receiving further education in teambuilding. Findings will be utilized to better inform debate in future development of teambuilding educational sessions to improve overall team dynamics in radiation therapy.

The leadership and followership challenges of doctors in training during the COVID-19 pandemic

Research carried out in 2016 by the authors investigated the challenges that doctors in training experience around leadership and followership in the NHS. The study explored contemporary healthcare leadership culture and the role of followership from the perspective of early career doctors. It found that the leadership and followership challenges for these doctors in training were associated with issues of social and professional identity, communication, the medical hierarchy, and relationships with senior colleagues (support and trust). These challenges were exacerbated by the busy and turbulent clinical environment in which they worked. To cope with various clinical situations and forms of leadership, doctors in training engage in a range of different followership behaviours and strategies. The study raised implications for medical education and training and suggested that followership should be included as part of formal training in communication and team working skills. The importance of both leadership and followership in the delivery of safe and effective patient care has been brought sharply into focus by the COVID-19 pandemic. This article revisits these challenges in light of the pandemic and its impact on the experiences of doctors in training.

Exploring Local Initiatives to Improve the Work Environment: A Qualitative Survey in Swedish Home Care Practice

Home care for the elderly constitutes a large and growing part of the social welfare system. Though, home care work is associated with a number of work environment-related challenges, including an increased risk for injuries, musculoskeletal disorders, high levels of sick leave and staff turnover, as well as stress and high workload, research is sparse. The present study explores local initiatives to improve the work environment initiated by the home care organizations themselves, and asks whether or not these initiatives affected gender equality. A qualitative web survey was sent to Swedish home care organizations, with open questions about change initiatives intended to have a positive effect on the work environment. There is an impressive amount of local work environment-related change initiatives going on. 80 categories of change initiatives were identified in answers from 178 units. However, these change initiatives were seldom evaluated or made accessible to stakeholders outside the organization. Main themes were concerned with work organization, digitalization, and planning, which largely follows trends in society (ie, digitalization, teamwork), rather than the actual needs identified by research (eg, musculoskeletal disorders). Despite apparent gender-related challenges, little of the work was associated with gender equality. The results indicates that there is a huge learning potential as the identified initiatives can serve as inspiration for others. However, to fully take advantage of these type of initiatives, more systematic evaluations are required.

Understanding team dynamics to promote team building in a radiotherapy department

Background:

Teamwork is a central framework in healthcare delivery. Team dynamics can impact the team as a whole and has been identified within the literature as a contributory factor to quality and safety, patient satisfaction, staff satisfaction and overall performance. Within radiation therapy (RT), teamwork is essential in the delivery of high-quality care, yet team building and team development is under-reported.

Aim:

The focus of this research is to form a better understanding of what plays an impact on teams in a large urban RT cancer centre and how to better engage staff to work together, improve team dynamics and promote team building.

Materials and Methods:

An electronic search of the literature was conducted to better inform debate and aid in the development of team-building sessions in a busy radiotherapy department. Abstracts were screened and relevant articles selected if they met the search criteria that included relevancy related to team building, contributory factors on team dynamics, team-based learning, team performance and implication of civility.

Results:

A total of 45 articles were included in the final analysis. The majority were from the disciplines of medicine (45%), business (22%) and nursing (18%). Only 3 of the 45 articles (7%) focused on the profession of RT. Most articles discussed more than 1 theme with team dynamics and team building being the most common themes discussed in 16 articles each (36%). Other common themes included teamwork (31%), respect and civility (20%), leadership and hierarchy (11%), medical errors (11%) and team training (11%). Only 3 of the 45 articles (7%) focused on RT.

Conclusion:

There is a lack of longitudinal evidence to support the impact of team building sessions to improve team dynamics and promote a positive, cohesive team environment. Specifically within RT, the impact team building has on team dynamics has been under investigation.

Highlights:

High-quality patient care can be linked to team collaboration and cohesiveness. Changing the culture within a team and engaging in civility and respect in everyday practice has the potential to improve team dynamics, patient safety, staff and patient satisfaction.

Inter-professional teamwork and its association with patient safety in German hospitals-A cross sectional study

Background

Inter-professional teamwork is a prominent factor in quality of care and may lead to improved patient safety. Although team members’ points of view are highly relevant when trying to improve inpatient procedures, there is a lack of systematic assessment of their perceptions. Therefore, study aims were to explore inter-professional teamwork, safety-related behavior, and patient safety in German hospitals from team members’ point of view. Furthermore, we wanted to examine the association between inter-professional teamwork and safety-related behavior as well as the association between inter-professional teamwork and patient safety.

Methods

We used cross-sectional pre-intervention data of a multicenter longitudinal study (German KOMPAS project). We gathered descriptive statistics for sample characteristics and to describe the current state of inter-professional teamwork, safety-related behavior, and patient safety. We used one-way variance analyses to assess differences between groups, and linear regression analyses to examine the association between inter-professional teamwork and the outcomes safety-related behavior, and patient safety.

Results

326 inpatient care team members participated in the study. Participants perceived a moderate to high level of inter-professional teamwork, and a moderate level of patient safety. Moreover, they reached rather high values in safety-related behavior. Professional group, work experience, and period of employment had an impact on the perceptions of inter-professional teamwork, and patient safety. Higher inter-professional teamwork was associated with better patient safety. We did not find an association between inter-professional teamwork and safety-related behavior.

Conclusions

Based on the association between inter-professional teamwork and patient safety, we recommend the implementation of team interventions. Because professional group, period of employment, and work experience had an impact on the perceptions of inter-professional teamwork and patient safety, we suggest future qualitative research to explore reasons for caregivers’ critical evaluation. Moreover, we recommend longitudinal studies to reveal causal relationships, and subsequently to determine areas of improvement for a safer health care.

Safety Culture at Primary Healthcare Level: A Cross-Sectional Study Among Employees with a Leadership Role

Introduction

An effective leadership is critical to the development of a safety culture within an organization. With this study, the authors wanted to assess the self-perceived level of safety culture among the employees with a leadership function in the Ljubljana Community Health Centre.

Methods

This was a cross-sectional study in the largest community health centre in Slovenia. We sent an invitation to all employees with a leadership role (N=211). The Slovenian version of the SAQ - Short Form as a measurement of a safety culture was used. The data on demographic characteristics (gender, age, role, work experience, working hours, and location of work) were also collected. An electronic survey was used.

Results

The final sample consisted of 154 (69.7%) participants, out of which 136 (88.3%) were women. The mean age and standard deviation of the sample was 46.2±10.5 years. The average scores for the safety culture domains on a scale from 1 to 5 were 4.1±0.6 for Teamwork Climate, Safety Climate, and Working Conditions and Satisfaction, 3.7±0.5 for Perception of Management, 3.6±0.4 for Communication, and 3.5±0.6 for Stress Recognition.

Conclusion

The safety culture among leaders in primary healthcare organizations in Slovenia is perceived as positive. There is also a strong organizational culture. Certain improvements are needed, especially in the field of communication and stress recognition with regards to safety culture.

Critical elements for multigenerational teams: a systematic review

Purpose

Therefore, the purpose of this paper is to review the existing literature on multigenerational teams, to evaluate the maturity of the research area, identify key themes, and highlight areas for future research. Generational differences in the workforce are becoming a critical factor, as four generations (Veterans/Traditionalists, Baby Boomers, Generation X and Generation Y/Millennials) currently co-exist, and a fifth generation (Generation Z) stands poised to enter the workforce. To manage these differences effectively, organizations must first understand the various generations and, ultimately, their interaction and engagement with each other. Whereas some literature on the differences between the generations and how they pertain to the organizational work environment exists, currently, it is unclear what is known about how these differences impact the performance of multigenerational teams.

Design/methodology/approach

This paper presents a systematic literature review on teams and generational differences. A total of 7 platforms were included, resulting in 121 articles in the final paper set.

Findings

The review confirmed a low presence of literature related to generational differences and teams, implying the knowledge area is currently immature; however, despite this, there is an upward trajectory in publications and citations over the past few years, and existing publications and citations span a number of countries, suggesting a likelihood of significant growth in the research area in the near future. Further, key themes were identified in the current literature relating to commitment, leadership, team dynamics, conflict and wages and work environment.

Research limitations/implications

Only seven platforms were included in this review, although the seven platforms chosen are believed to provide comprehensive coverage of the field. The search strings used were “generation” and “team,” which was the word combination found to produce the largest number of results in preliminary trials; however, it is possible that using additional word combinations might have yielded some additional papers. Finally, the review was limited to English-language articles (or their translations); although, ultimately, only two articles were eliminated because of lack of an English language version.

Practical implications

The findings can be used by organizations to identify factors of interest in managing multigenerational teams, as well as what is currently known about influencing those factors to achieve more positive team outcomes.

Originality/value

To the best of the authors’ knowledge, this appears to be the first systematic literature review on generational differences in teams. Given the importance of this topic, this review is critical to provide a baseline on what is currently known in the field and existing research and practice gaps.

Dynamics of an orthopaedic team: Insights to improve teamwork through a design thinking approach

BACKGROUND:

Supporting teamwork in healthcare is a way to foster both the quality and safety of care, and better working conditions for all the team members. Although increasing attention is paid to this topic on a general level, there is less knowledge about its unfolding in orthopaedic units and its translation to interventions.

OBJECTIVE:

To identify concrete opportunities for teamwork intervention through a design thinking approach by analysing the teamwork dynamics of an orthopaedic team.

METHODS:

An adaptation of the learning history method, comprising shadowing, observations and interviews involving 26 orthopaedic team members at a top clinical teaching hospital in the Netherlands, was applied. A thematic analysis was conducted to derive themes that describe team dynamics and to subsequently extrapolate opportunities for intervention.

RESULTS:

We identified five themes and translated them into four design opportunities for intervention, namely: a) Improve daily rounds by reducing cognitive overload and promoting confidence; b) Improve collaboration by building empathy; c) Connect the patient with the professional team; and d) Support changes by fostering learning. Suggestions for concrete actions are presented for each opportunity.

CONCLUSIONS:

Opportunities to improve teamwork among healthcare professionals, specifically those in orthopaedics, revolve around the creation of common knowledge, the fostering of mutual understanding, and the design of tools and activities that support these processes.

What do doctors mean when they talk about teamwork? Possible implications for interprofessional care

The concept of teamwork has been associated with improved patient safety, more effective care and a better work environment. However, the academic literature on teamwork is pluralistic, and there are reports on discrepancies between theory and practice. Furthermore, healthcare professionals' direct conceptualizations of teamwork are sometimes missing in the research. In this study, we examine doctors' conceptualizations of teamwork. We also investigate what doctors think is important in order to achieve good teamwork, and how the empirical findings relate to theory. Finally, we discuss the methodological implications for future studies. The research design was explorative. The main data consisted of semi-structured interviews with twenty clinically active doctors, analyzed with conventional content analysis. Additional data sources included field observations and interviews with management staff. There was large variation in the doctors' conceptualizations of teamwork. The only characteristic they shared in common was that team members should have specific roles. This could have consequences for practice, because the rationale behind different behaviors depends on how teamwork is conceptualized. Several of the teamwork-enabling factors identified concerned non-technical skills. Future studies should put more emphasis on the practitioners' perspective in the research design, to create a more grounded foundation for both research and practice.

Team based communication and the healthcare communication space

Purpose

While previous studies have described structural, process and social aspects of the healthcare communication space there is no overall model of it. Such a model is an essential first step to improving the operationalization and management of healthcare communication. The paper aims to discuss these issues.

Design/methodology/approach

This paper used a case study approach to study team-based communication on a palliative care unit. Non-participant observation, interviews and documents were analyzed using qualitative content analysis.

Findings

The analysis developed an overall model of the healthcare communication space that consists of five stages: purpose, practices and workflows, structures, implementation, and the development of common ground to support team-based communication. The authors’ findings emphasized that implicit communication remains a predominant means of communication and workflow issues at the individual level are a frequent cause of unnecessary group communication tasks.

Originality/value

To improve team-based communication we first need to develop protocols that support team communication needs such as loop closing of group communication tasks in order to minimize unnecessary individual communication tasks. We also need to develop common ground at the protocol, document and terminology levels as part of supporting team-based communication.

Driving for successful change processes in healthcare by putting staff at the wheel

Purpose

The purpose of this paper is to describe five salient factors that emerge in two successful change processes in healthcare. Organizational changes in healthcare are often characterized by problems and solutions that have been formulated by higher levels of management. This top-down management approach has not been well received by the professional community. As a result, improvement processes are frequently abandoned, resulting in disrupted and dysfunctional organizations. This paper presents two successful change processes where managerial leadership was used to coach the change processes by distributing mandates and resources. After being managerially initiated, both processes were driven by local agency, decisions, planning and engagement.

Design/methodology/approach

The data in the paper derive from two qualitative case studies. Data were collected through in-depth interviews, observations and document studies. The cases are presented as process descriptions covering the different phases of the change processes. The focus in the studies is on the roles and interactions of the actors involved, the type of leadership and the distribution of agency.

Findings

Five factors emerged as paramount to the successful change processes in the two cases: local ownership of problems; a coached process where management initiates the change process and the problem recognition, and then lets the staff define the problems, formulate solutions and drive necessary changes; distributed leadership directed at enabling and supporting the staff’s intentions and long-term self-leadership; mutually formulated norms and values that serve as a unifying force for the staff; and generous time allocation and planning, which allows the process to take time, and creates room for reevaluation. The authors also noted that in both cases, reorganization into multi-professional teams lent stability and endurance to the completed changes.

Originality/value

The research shows how management can initiate and support successful change processes that are staff driven and characterized by local agency, decisions, planning and engagement. Empirical descriptions of successful change processes are rare, which is why the description of such processes in this research increases the value of the paper.

Analyzing How Discursive Practices Affect Physicians' Decision-Making Processes: A Phenomenological-Based Qualitative Study in Critical Care Contexts

An intensive care unit (ICU) is a demanding environment, defined by significant complexity, in which physicians must make decisions in situations characterized by high levels of uncertainty. This study used a phenomenological approach to investigate the decision-making (DM) processes among ICU physicians’ team with the aim of understanding what happens when ICU physicians must reach a decision about the infectious status of a patient. The focus was put on the identification of how the discursive practices influence physicians’ DM processes and on how different ICU environments make different discursive profiles emerge, particularly when a key issue is at the center of the physicians’ discussion. A naturalistic approach used in this study is particularly suitable for investigating health care practices because it can best illuminate the essential meaning of the “lived experiences” of the participants. The findings revealed a common framework of elements that provide insight into DM processes in ICUs and how these are affected by discursive practices.

Trauma team discord and the role of briefing

BACKGROUND

Briefing of the trauma team before patient arrival is unstructured in many centers. We surveyed trauma teams regarding agreement on patient care priorities and evaluated the impact of a structured, physician-led briefing on concordance during simulated resuscitations.

METHODS

Trauma nurses at our Level II center were surveyed, and they participated in four resuscitation scenarios, randomized to "briefed" or "nonbriefed." For nonbriefed scenarios, nurses independently reviewed triage sheets with written information. Briefed scenarios had a structured 4-minute physician-led briefing reviewing triage sheets identical to nonbriefed scenarios. Teams included three to four nurses (subjects) and two to four confederates (physicians, respiratory therapists). Each team served as their own control group. Confederates were blinded to nurses' briefed or nonbriefed status. Immediately before, and at the midpoint of each scenario, nurses estimated patients' morbidity and mortality and ranked the top 3 of 16 designated immediate care priorities. Briefed and nonbriefed groups' responses were compared for (1) agreement using intraclass correlation coefficient, (2) concordance with physicians' responses using the Fisher exact test, (3) teamwork via T-NOTECHS ratings by nurses and physicians using t-test, and (4) time to complete clinical tasks using t test.

RESULTS

Thirty-eight nurses participated. Ninety-seven percent "agreed/strongly agreed" briefing is important, but only 46% agreed briefing was done well. Comparing briefed versus nonbriefed scenarios, nurses' estimation of morbidity and mortality in the briefed scenarios showed significantly greater agreement with each other and with physicians' answers (p < 0.01). Rank lists also better agreed with each other (intraclass correlation coefficient, 0.64 vs 0.59) and with physicians' answers in the briefed scenarios. T-NOTECHS Leadership ratings were significantly higher in the briefed scenarios (3.70 vs 3.39; p < 0.01). Time to completion of key clinical tasks was significantly faster for one of the briefed scenarios.

CONCLUSIONS

Discordant perceptions of patient care goals was frequently observed. Structured physician-led briefing seemed to improve interprofessional team concordance, leadership, and task completion in simulated trauma resuscitations.

Organizing for teamwork in healthcare: an alternative to team training?

Purpose

The purpose of this paper is to explore how organizational design could support teamwork and to identify organizational design principles that promote successful teamwork.

Design/methodology/approach

Since traditional team training sessions take resources away from production, the alternative approach pursued here explores the promotion of teamwork by means of organizational design. A wide and pragmatic definition of teamwork is applied: a team is considered to be a group of people that are set to work together on a task, and teamwork is then what they do in relation to their task. The input – process – output model of teamwork provides structure to the investigation.

Findings

Six teamwork enablers from the healthcare team literature – cohesion, collaboration, communication, conflict resolution, coordination, and leadership – are discussed, and the organizational design measures required to implement them are identified. Three organizational principles are argued to facilitate the teamwork enablers: team stability, occasions for communication, and a participative and adaptive approach to leadership.

Research limitations/implications

The findings could be used as a foundation for intervention studies to improve team performance or as a framework for evaluation of existing organizations.

Practical implications

By implementing these organizational principles, it is possible to achieve many of the organizational traits associated with good teamwork. Thus, thoughtful organization for teamwork can be used as an alternative or complement to the traditional team training approach.

Originality/value

With regards to the vast literature on team training, this paper offers an alternative perspective on how to improve team performance in healthcare.

Conceptions of patients and their roles in healthcare: Insights from everyday practice and service improvement

PURPOSE

The purpose of this paper is two-fold. First, it sets the context for the special issue by considering conceptions of patients and their roles in service delivery and improvement. Second, it introduces the contributions to the special issue, and identifies thematic resonance.

DESIGN/METHODOLOGY/APPROACH

The paper utilises a literature synthesis and thematic analysis of the special issue submissions. These emanated from the Ninth International Organisational Behaviour in Healthcare Conference, hosted by Copenhagen Business School on behalf of the Learned Society for Studies in Organizing Healthcare.

FINDINGS

The articles evidence a range of perspectives on patients' roles in healthcare. These range from their being subject to, a mobilising focus for, and active participants in service delivery and improvement. Building upon the potential patient roles identified, this editorial develops five "ideal type" patient positions in healthcare delivery and improvement. These recognise that patients' engagement with health care services is influenced both by personal characteristics and circumstances, which affect patients' openness to engaging with health services, as well as the opportunities afforded to patients to engage, by organisations and their employees.

ORIGINALITY/VALUE

The paper explores the relationally embedded nature of patient involvement in healthcare, inherent in the interdependence between patient and providers' roles. The typology aims to prompt discussion regarding the conceptualisation patients' roles in healthcare organisations, and the individual, employee, organisational and contextual factors that may help and hinder their involvement in service delivery and improvement. The authors close by noting four areas meriting further research attention, and potentially useful theoretical lenses.

Distributed leadership, team working and service improvement in healthcare

PURPOSE

The purpose of this paper is to analyse the introduction of distributed leadership and team working in a therapy department in a healthcare organisation and to explore the factors that enabled the introduction to be successful.

DESIGN/METHODOLOGY/APPROACH

This paper used a case study methodology. Qualitative and quantitative information was gathered from one physiotherapy department over a period of 24 months.

FINDINGS

Distributed leadership and team working were central to a number of system changes that were initiated by the department, which led to improvements in patient waiting times for therapy. The paper identifies six factors that appear to have influenced the successful introduction of distributed learning and team working in this case.

RESEARCH LIMITATIONS/IMPLICATIONS

This is a single case study. It would be interesting to explore whether these factors are found in other cases where distributed leadership is introduced in healthcare organisations.

PRACTICAL IMPLICATIONS

The paper provides an example of successful introduction of distributed leadership, which has had a positive impact on services to patients. Other therapy teams may consider how the approach may be adopted or adapted to their own circumstances.

ORIGINALITY/VALUE

Although distributed leadership is thought to be important in healthcare, particularly when organisational change is needed, there are very few studies of the practicalities of how it can be introduced.

Integrating cognitive rehabilitation: A preliminary program description and theoretical review of an interdisciplinary cognitive rehabilitation program

BACKGROUND

Interdisciplinary cognitive rehabilitation is emerging as the expected standard of care for individuals with mild to moderate degrees of cognitive impairment for a variety of etiologies. There is a growing body of evidence in cognitive rehabilitation literature supporting the involvement of multiple disciplines, with the use of cognitive support technologies (CSTs), in delivering cognitive therapy to individuals who require cognitive rehabilitative therapies. This article provides an overview of the guiding theories related to traditional approaches of cognitive rehabilitation and the positive impact of current theoretical models of an interdisciplinary approach in clinical service delivery of this rehabilitation.

OBJECTIVE

A theoretical model of the Integrative Cognitive Rehabilitation Program (ICRP) will be described in detail along with the practical substrates of delivering specific interventions to individuals and caregivers who are living with mild to moderate cognitive impairment. The ultimate goal of this article is to provide a clinically useful resource for direct service providers. It will serve to further clinical knowledge and understanding of the evolution from traditional silo based treatment paradigms to the current implementation of multiple perspectives and disciplines in the pursuit of patient centered care.

METHODS

The article will discuss the theories that contributed to the development of the interdisciplinary team and the ICRP model, implemented with individuals with mild to moderate cognitive deficits, regardless of etiology. The development and implementation of specific assessment and intervention strategies in this cognitive rehabilitation program will also be discussed.

RESULTS

The assessment and intervention strategies utilized as part of ICRP are applicable to multiple clinical settings in which individuals with cognitive impairment are served.

CONCLUSIONS

This article has specific implications for rehabilitation which include: (a) An Interdisciplinary Approach is an effective method for cognitive rehabilitation; and (b) Recent theories offer beneficial evaluation and intervention techniques for cognitive rehabilitation.

Knowledge integration, teamwork and performance in health care

Purpose

– Knowledge integration is the process of building shared mental models. The integration of the diverse knowledge of the health professions in shared mental models is a precondition for effective teamwork and team performance. As it is known that different groups of health care professionals often tend to work in isolation, the authors compared the perceptions of knowledge integration. It can be expected that based on this isolation, knowledge integration is assessed differently. The purpose of this paper is to test these differences in the perception of knowledge integration between the professional groups and to identify to what extent knowledge integration predicts perceptions of teamwork and team performance and to determine if teamwork has a mediating effect.

Design/methodology/approach

– The study is a multi-center cross-sectional study with a descriptive-explorative design. Data were collected by means of a staff questionnaire for all health care professionals working in the rehabilitation clinics.

Findings

– The results showed that there are significant differences in knowledge integration within interprofessional health care teams. Furthermore, it could be shown that knowledge integration is significantly related to patient-centered teamwork as well as to team performance. Mediation analysis revealed partial mediation of the effect of knowledge integration on team performance through teamwork.

Practical/implications

– In practice, the results of the study provide a valuable starting point for team development interventions.

Originality/value

– This is the first study that explored knowledge integration in medical rehabilitation teams and its relation to patient-centered teamwork and team performance.

Interprofessional team management in pediatric critical care: some challenges and possible solutions

BACKGROUND

Aiming for and ensuring effective patient safety is a major priority in the management and culture of every health care organization. The pediatric intensive care unit (PICU) has become a workplace with a high diversity of multidisciplinary physicians and professionals. Therefore, delivery of high-quality care with optimal patient safety in a PICU is dependent on effective interprofessional team management. Nevertheless, ineffective interprofessional teamwork remains ubiquitous.

METHODS

We based our review on the framework for interprofessional teamwork recently published in association with the UK Centre for Advancement of Interprofessional Education. Articles were selected to achieve better understanding and to include and translate new ideas and concepts.

FINDINGS

The barrier between autonomous nurses and doctors in the PICU within their silos of specialization, the failure of shared mental models, a culture of disrespect, and the lack of empowering parents as team members preclude interprofessional team management and patient safety. A mindset of individual responsibility and accountability embedded in a network of equivalent partners, including the patient and their family members, is required to achieve optimal interprofessional care. Second, working competently as an interprofessional team is a learning process. Working declared as a learning process, psychological safety, and speaking up are pivotal factors to learning in daily practice. Finally, changes in small steps at the level of the microlevel unit are the bases to improve interprofessional team management and patient safety. Once small things with potential impact can be changed in one's own unit, engagement of health care professionals occurs and projects become accepted.

CONCLUSION

Bottom-up patient safety initiatives encouraging participation of every single care provider by learning effective interprofessional team management within daily practice may be an effective way of fostering patient safety.

Role confusion and self-assessment in interprofessional trauma teams

BACKGROUND

Trauma care requires coordinating an interprofessional team, with formative feedback on teamwork skills. We hypothesized nurses and surgeons have different perceptions regarding roles during resuscitation; that nurses' teamwork self-assessment differs from experts', and that video debriefing might improve accuracy of self-assessment.

METHODS

Trauma nurses and surgeons were surveyed regarding resuscitation responsibilities. Subsequently, nurses joined interprofessional teams in simulated trauma resuscitations. After each resuscitation, nurses and teamwork experts independently scored teamwork (T-NOTECHS). After video debriefing, nurses repeated T-NOTECHS self-assessment.

RESULTS

Nurses and surgeons assumed significantly more responsibility by their own profession for 71% of resuscitation tasks. Nurses' overall T-NOTECHS ratings were slightly higher than experts'. This was evident in all T-NOTECHS subdomains except "leadership," but despite statistical significance the difference was small and clinically irrelevant. Video debriefing did not improve the accuracy of self-assessment.

CONCLUSIONS

Nurses and physicians demonstrated discordant perceptions of responsibilities. Nurses' self-assessment of teamwork was statistically, but not clinically significantly, higher than experts' in all domains except physician leadership.

Fiery Spirits in the context of institutional entrepreneurship in Swedish healthcare

PURPOSE

Clinical governance and leadership concepts can lead to more or less successful implementations of new clinical practice. The purpose of this paper is to examine how Fiery Spirits, as institutional entrepreneurs can, working in a team, implement sustained change in hospital clinical practice.

DESIGN/METHODOLOGY/APPROACH

This paper describes two case studies, conducted at two Swedish hospitals over a period of two years, in which changes in clinical practice were implemented. In both cases, key-actors, termed Fiery Spirits, played critical roles in these changes. The authors use a qualitative approach and take an intra-organizational perspective with semi-structured in-depth interviews and document analysis.

FINDINGS

The new clinical practices were successfully implemented with a considerable influence of the Fiery Spirits who played a pivotal role in the change efforts. The Fiery Spirits persuasively, based on their structural and normative legitimacy and the adoption of learning processes, advocated, and supported change.

PRACTICAL IMPLICATIONS

Fiery Spirits, given flexibility and opportunity, can be powerful forces for change outside the trajectory of management-inspired and management-directed change. Team members, when inspired and encouraged by Fiery Spirits, are less resistant to change and more willing to test new clinical practices.

ORIGINALITY/VALUE

The paper complements literature on how the Fiery Spirit concept aligns with concepts of clinical governance and leadership and how change can be achieved. Additionally, the findings show the effects of legitimacy and learning processes on change in clinical practice.

Leading and working in teams

This article considers the role of the clinical leader as a team member and leader and explores how an understanding of the purpose and functions of teams can help doctors work more effectively in the various teams with which they are involved.

Timeliness in breast cancer care as an indicator of quality

The current study sought to define best practice for timeliness for a breast cancer program at each diagnostic step. The study was a retrospective review of patients newly diagnosed with invasive breast cancer who were enrolled in the breast cancer database from 2009-2011. A convenience sampling methodology was used for patient selection, and descriptive statistics for various time intervals were calculated for identified data points from abnormal imaging to surgery. No evidence-based practice standards exist for access to breast cancer care. Practice guidelines that include benchmarks for quality measures and an established process to measure patient outcomes would promote high-quality care. An understanding of how practice sites function also would help healthcare providers identify and develop resources to improve patient outcomes. In the current study, the advanced practice nurse (APN) in the practice setting was identified as a key point person in facilitating patients' timely access to healthcare services. The physician and APN practice model was instrumental in influencing the process. The results of the current study provided clinical data to identify benchmarks that a breast oncology practice can use to monitor timeliness as a quality indicator.

Preparedness for practice: a systematic cross-specialty evaluation of the alignment between postgraduate medical education and independent practice

BACKGROUND

Postgraduate medical education training programs strive to prepare their trainees optimally for independent practice. Several studies have shown, however, that new consultants feel inadequately prepared for practice, and that this increases the risk of stress and burnout.

AIM

To analyze across specialties for which tasks and themes new consultants feel inadequately prepared. And, to identify themes that need improved attention in postgraduate medical education programs or after registration.

METHODS

330 New consultants from all hospital specialities with accredited training programs who completed their training in the north-eastern educational region of The Netherlands between 2004 and 2010 received a questionnaire which was based on a previously validated generic task inventory.

RESULTS

143 respondents (43%) returned the questionnaire. They felt excellently prepared for 40 tasks, well prepared for 25 tasks, marginally sufficiently prepared for 18 tasks and insufficiently prepared for 8 tasks. Preparedness scores were lowest for tasks concerning management administration and leadership, research, end-of-life care, and patient safety-related communication. Surgical specialists felt better prepared for practice than medical specialists, which could not be explained by differences in general self-efficacy.

CONCLUSION

Although new consultants felt well prepared for medical tasks, the scores of more generic tasks indicate that the alignment between the different phases of the medical education continuum and independent practice needs improvement.

Pairing as an instructional strategy to promote soft skills amongst clinical dental students

Training dentists today is challenging as they are expected to provide a wide range of dental care. In the provision of good dental care, soft skills are equally important as clinical skills. Therefore in dental education the development of soft skills are of prime concern. This study sought to identify the development of soft skills when dental students are paired in their clinical training. In this perception study, four open-ended items were used to elicit students' feedback on the appropriateness of using clinical pairing as an instructional strategy to promote soft skills. The most frequently cited soft skills were teamwork (70%) and communication (25%) skills. However, both negative and positive behaviours were reported. As for critical thinking and problem solving skills, more positive behaviours were reported for abilities such as to explain, analyze, find ideas and alternative solutions, and make decisions. Leadership among peers was not evident as leading without legitimate authority could be a hindrance to its development. If clinical pairing is to be used as an effective instructional strategy to promote soft skills amongst students, clear guidelines need to be developed to prepare students to work in a dental team and the use of appropriate assessment tools can facilitate the development of these soft skills.

Determinants for the effectiveness of implementing an occupational therapy intervention in routine dementia care

BACKGROUND

A multifaceted implementation (MFI) strategy was used to implement an evidence-based occupational therapy program for people with dementia (COTiD program). This strategy was successful in increasing the number of referrals, but not in improving occupational therapists' (OTs) adherence. Therefore, a process evaluation was conducted to identify factors that influenced the effectiveness of the MFI strategy.

METHODS

A mixed-method approach of qualitative and quantitative research was used to evaluate the implementation process. The MFI strategy as planned and as executed were reported and evaluated based on the framework of Hulscher et al. (2003; 2006). Data on OTs attitudes and expected barriers were collected at baseline from 94 OTs using a 19-item questionnaire. Data on the experiences were collected after finishing the implementation using focus groups with OTs and telephone interviews with physicians and managers. For quantitative data, frequencies and correlations were calculated and qualitative data were analyzed using inductive content analysis.

RESULTS

The implementation strategy as executed had a stronger focus than planned on increasing OTs promotional skills due to an initial lack of referrals. This resulted in less attention for increasing OTs' skills in using the COTiD program as initially intended. At baseline, OTs had a positive attitude toward the program, however, 75% did not feel experienced enough and only 14.3% felt competent in using the program. Focus groups and interviews revealed various determinants that influenced implementation. Most managers were positive about the program. However, the degree of operational support of managers for OTs regarding the implementation was not always adequate. Managers stated that a well-defined place for occupational therapy within the dementia care network was lacking although this was perceived necessary for successful implementation. Several physicians perceived psychosocial interventions not to be in their area of expertise or not their responsibility. All professionals perceived inter-professional collaboration to be a facilitator for effective implementation, and general practitioners were perceived as key partners in this collaboration. However, collaboration was not always optimal. OTs indicated that increasing the referral rate was most effective when promoting OT via other disciplines within a physician's network.

CONCLUSION

Our data suggests that a first step in successful implementation should be to make sure that individual and organizational barriers are resolved. In addition, implementation should be network-based and encourage inter-professional collaboration. Initial promotion of COTiD should focus on physicians that have a positive attitude toward non-pharmacological interventions.