Professional Documents
Culture Documents
INVITED ESSAY
Alicia Priest
Freelance Medical Writer
ABSTRACT
Issues affecting health workplaces range from serious concerns that could affect the
immediate physical safety of workers to those that would improve productivity and
efficiency, or make an organization a preferred employer. Employers and workers
might consider effective teamwork an asset, but for patients it is a prerequisite.
This paper reviews the evidence for effective teamwork, primarily that gathered
by a research team funded by the Canadian Health Services Research Foundation
(CHSRF). We also review the expert opinion provided by a group of 25 researchers
and decision makers convened by CHSRF in late 2005 at a forum for discussion
about issues related to effective teamwork. Included in the retreat were representa-
tives from professional organizations and occupations as well as areas such as legal
liability.
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Effective Teamwork in Canadian Healthcare: Research and Reality
Taken together, the research and expert opinion provide a comprehensive over-
view of the benefits of effective teamwork and the conditions needed for its imple-
mentation. In addition, we review policy and management perspectives on the most
significant challenges to the implementation of effective teamwork in the Canadian
context, and potential opportunities to overcome these obstacles.
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al. 2006). With a draft report in hand, the In healthcare, teamwork is the ongo-
CHSRF also brought together a number of ing process of interaction between team
policy and management decision makers, members as they work together to provide
clinicians and researchers for two days of care to patients. The researchers found
frank and open discussion about priorities that while teamwork and collaboration are
and concerns, with the goal of developing often used as synonyms in casual discus-
recommendations that tackle the issue of sion, they are not synonymous. Critically,
how to implement effective teamwork at the researchers identified inter-professional
the different levels of Canada’s healthcare collaboration as both a process affecting
systems. teamwork (and, in turn, patient care and
This paper references some of the key health provider satisfaction) and an outcome
evidence gathered by the researchers funded in and of itself. In fact, collaboration can
by the CHSRF, as well as other key research. take place whether or not health profession-
It is not a summary of their synthesis work als consider themselves to be part of a team.
(which is available in complete form on the The researchers cite the example of primary
CHSRF website) but, rather, a perspec- healthcare, where professionals including
tive on the report, as well as other relevant a family physician, a physiotherapist and
research. Similarly, the discussions with a dentist may all provide care to the same
managers and policy makers referenced patient, yet in most cases do not see them-
in this paper are not verbatim transcrip- selves as a functioning team. On the other
tions but, rather, a presentation of what the hand, effective teamwork rarely happens
CHSRF sees as some of the most pertinent where there is no collaboration (Oandasan
discussions regarding the challenge at hand: et al. 2006).
the evidence-informed implementation of Teamwork requires an explicit deci-
effective teamwork in healthy workplaces sion by the team members to co-operate in
across Canada. meeting the shared objective. This requires
that team members sacrifice their autonomy,
Teams, Work and Teamwork allowing their activity to be coordinated
The CHSRF-funded researchers found by the team, either through decisions by
that, in the literature, the concept of a team the team leader or through shared decision
is indeed broad – it is something that exists making. As a result, the responsibilities of
any time two or more people are working professionals working as a team include not
together with a shared purpose. According only activities they deliver because of their
to the literature, the way teams are designed specialized skills or knowledge, but also
depends greatly on the task that needs to be those resulting from their commitment to
performed and when and where it is being monitor the activities performed by their
performed. However, despite the broad defi- teammates, including managing the conflicts
nition of a team, there are some common that may result (Oandasan et al. 2006).
ideas. For instance, when people are working
in a team, they have particular responsibili- When Is Teamwork Effective?
ties that relate to their own specific skills The CHSRF-funded team pulled together
and knowledge. One individual is always the a strong evidence base for the character-
leader, and this is agreed upon by the team istics of effective teams, and the evidence
or those who created it. tells us that these teams adapt and respond
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Effective Teamwork in Canadian Healthcare: Research and Reality
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resource management (CRM), a team train- Direction process in 2004, a clear separation
ing model from the aviation field, has many appeared between the workforce and work-
important lessons to offer healthcare profes- place aspects of the issue, and concerns about
sionals, a point also noted by the CHSRF- teamwork were pervasive and prominent
funded team (Baker et al. 2006; Oandasan within both themes. Within the workforce
et al. 2006). So far, a few jurisdictions have aspect were concerns about the best ways
developed customized healthcare CRM to facilitate inter-professional teamwork
programs for teams in operating rooms, and approaches, as well as the regulation
obstetrics, intensive care and emergency of scope of practice and entry to practice.
care. However, the delivery of medical team Within the workplace aspect was an inter-
training across the healthcare community is est in the role of occupational hierarchies,
“generally haphazard” (Baker 2005b). organizational structures and management
practices and approaches and their effects on
Is Effective Teamwork a Priority in workplace productivity, stress, absenteeism
Canada? and so on (Dault et al. 2004).
Broadly speaking, health human resources In other words, for Canadian decision
have been a preoccupation for managers makers, effective teamwork is a means to
and policy makers in Canada’s healthcare achieve improved quality and productiv-
systems. Back in 2001, those who were ity for patients. For decision makers, it is a
consulted as part of the first Listening for way to achieve a better balanced and more
Direction national priority-setting exercise productive workforce but also one that is
on health services and policy issues said able to better serve the needs of patients.
clearly that health human resources would Teamwork is seen as a way to improve qual-
be the number one priority in the next two ity of care for the patient, not only through
to five years (Gagnon et al. 2001). improved efficiency but also through a
With the exception of clinical organi- happier and healthier workforce. Since the
zations, which in 2001 were concerned 2004 process, the Health Council of Canada
about how new healthcare teams should has identified improving teamwork as a crit-
be composed in order to meet the chang- ical component to both accelerating system
ing needs of patients, decision makers were change (Health Council of Canada 2005a)
preoccupied not with healthy workplaces and improving human resource manage-
or effective teamwork but with the supply ment (Health Council of Canada 2005b).
of health human resources. In particu-
lar, federal and provincial policy makers Challenges and Opportunities for
wanted to find mechanisms to help them to Management and Policy
avoid cycles of surplus and shortage, while It is difficult to imagine who could oppose
managers wanted to know about forecasting implementing effective teamwork as a way
models that might help them plan for these to improve healthcare. Even casual observ-
cycles and employ retention and recruitment ers would likely equate the healthcare sector
strategies. In 2001, teamwork came across with teams and teamwork, and cite the
as a major concern, primarily in clinical history of nursing as an example. However,
organizations. in healthcare delivery, teams rarely exist that
However, when the CHSRF and incorporate different professions and occu-
its partners repeated the Listening for pations, as well as patients and families.
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Effective Teamwork in Canadian Healthcare: Research and Reality
The greatest obstacle to change is argu- lenges, the CHSRF convened a group of
ably the hierarchical culture of healthcare. 25 researchers and decision makers in late
Entrenched attitudes about scopes of prac- 2005 to provide a forum for discussion about
tice, professional “turf ” and historical power issues related to effective teamwork. Included
structures can sabotage the essence of what in the retreat were representatives from
teamwork is. Providers need to address their professional organizations and occupations as
personal power issues, adopt common goals, well as areas such as legal liability. The idea
break down hierarchies and then educate was to bring together experts from various
patients about how each team member perspectives with the goal of working toward
contributes to their care. tackling the issue and developing recommen-
Formidable barriers that arise out of this dations of how to implement teamwork at
culture include the self-regulation of profes- the differing levels of the healthcare system.
sions, current malpractice and liability laws While a consensus was not expected, the aim
and funding and remuneration models. All was to secure a foundation based on current
these discourage and deter the establishment knowledge and evidence that would serve as
of teams. For instance, current malpractice a basis for evolving discussions and decisions
legislation places responsibility solely on in the future.
individuals. Regulations that support team- One major focus of the discussions was
work, on the other hand, would refocus this to identify why previous or existing efforts
“culture of blame” to a culture of patient to implement collaborative practice in
safety and risk management. Much work healthcare organizations had succeeded or
needs to be done to clarify the account- failed to meet expectations. In particular, the
ability for non-physician team members experts around the table were asked the ques-
in performing shared tasks. As for remu- tion, “Based on our knowledge and experi-
neration models, traditional fee-for-service ence, what factors have underpinned success
payment systems for physicians impede in implementing collaborative practice?”
movement toward collaborative care. What The key factors underpinning success
is more, no financial incentives exist that identified by the experts at the retreat were
tie funding to collaboration and teamwork as follows:
efforts, unlike initiatives in other countries
such as England (Oandasan et al. 2006). • Leadership, and having champions who
In addition, significant and persisting can drive change management processes
supply issues continue to preoccupy both • Clarity regarding roles on the part of all
health workers and system managers and team members
policy makers, and confound dedicated • Trust, respect, value, and being valued
efforts to implement effective teamwork. within the teamwork setting
The current shortage of some health profes- • Cultural readiness within the workplace,
sionals creates a pressure-cooker workplace or significant efforts to try to create a
environment where few people have the culture of acceptance
time, energy or will to experiment with new
models of healthcare delivery. Conversely, the factors that would
To get a better picture of not only the signal likely failure in implementing collab-
challenges to implementing effective team- orative practice for the experts included the
work but also ways to overcome the chal- following:
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• A lack of time to bring people together mended accreditation systems that outline
to reflect and to change clear requirements for inter-professional
• Insufficient inter-professional education, collaboration within organizations. In
including continuing education, and the addition, they felt that dedicated funding
persistence of professional silos for inter-professional collaboration would
• Systems of payment that do not reward support a transition to, and ongoing review
collaboration of, collaborative practice. Also, more could
• Few links between collaborative practice be done in the area of intra-organizational
and individual goals knowledge transfer to help organizations
• The absence of efforts to capture share what they know about the results of
evidence for success and communicate research, demonstration site activities and
this to key stakeholders, including the learning projects.
public In the immediate future, the participants
saw opportunities for organizational change
The participants at the retreat identified in the areas of information and education.
particular challenges and opportunities for On the information front, common meas-
furthering the implementation of effective ures of performance to monitor, evaluate or
teamwork in the areas of management and measure collaborative practice need to be
policy. developed. In addition, systems need to be
implemented that capture, share, and link
Management Challenges and patient data, in order to facilitate collabora-
Opportunities tive practice. While they were sympathetic
At the level of health system management, to concerns about privacy and confidential-
the participants at the CHSRF retreat ity, the participants saw expanded access
felt the most serious challenges to inter- to patient information through electronic
professional collaboration include a lack health records as a major facilitator of
of designated responsibility for ensuring collaborative practice.
collaboration takes place. History and tradi- In education, it is vital to bring educa-
tion can serve as barriers as people often tors together to determine core competen-
want to perpetuate the status quo, either to cies and curricula, while building on the
stay within their comfort zones or to protect existing initiatives such as the IECPCP, and
vested interests. Ineffective communication to support learning initiatives throughout
can also be a critical barrier, unless multiple the country where lessons learned vis-à-vis
strategies are put in place to ensure effective collaborative practice could be shared – this
communication within and between profes- could include ways to institute mentorship
sions, as well as vertically within the institu- and other ways of learning by example. In
tion. Finally, while project-based funding addition, structures and a culture to value
for collaboration can stimulate change at the collaborative practice through organizational
project level, it does nothing at a systemic learning mechanisms should be adopted,
level, often making it difficult, or impos- particularly through continuing education.
sible, for change to become permanent and Finally, leadership training opportunities
sustained. that include a collaborative practice compo-
To overcome the challenges at the nent should be promoted within and across
organizational level, the experts recom- organizations.
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