Healthcare Team Members

As indicated in Chapter 1, teamwork competencies are the combinations of values, knowledge, and skills that team members need in order to work effectively in teams. In the last few years, health professional groups in the United States and Canada have developed lists of competencies for interprofessional or collaborative healthcare practice. These competencies pertain equally to nurses, physicians, administrators, psychologists, social workers, and others working as members of a healthcare team. The previous chapter, Chapter 6, delineated characteristics of effective teams. In this chapter we discuss the competencies required of individual team members to achieve effective teamwork. In later chapters, we cover additional competencies specific to team leaders (Chapter 8), team sponsors (Chapter 12), and senior leaders of organizations in which teams function (Chapter 18).

TEAMWORK COMPETENCY FRAMEWORKS

A variety of groups and researchers have concentrated on the development of competencies for interprofessional healthcare practice in the past 2 decades, meaning that consensus-based competency frameworks for interprofessional practice are relatively current. In 2011, 6 professional associations in the United States—American Association of Colleges of Nursing, Association of American Medical Colleges, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Dental Education Association, and Association of Schools of Public Health—issued a joint statement of core competencies for interprofessional collaborative practice (Interprofessional Education Collaborative Expert Panel [IECEP], 2011). Interprofessional competencies are defined by that expert panel as “integrated enactment of knowledge, skills, and values/attitudes that define working together across the professions, with other health care workers, and with patients, along with families and communities, as appropriate to improve health outcomes in specific care contexts” (IECEP, 2011, p. 2). The panel’s framework separates 38 competencies into 4 domains: values/ethics (10 competencies), roles/responsibilities (9 competencies), communication (8 competencies), and teamwork (11 competencies).

The study of interprofessional collaboration has a more extensive history in the United Kingdom, Europe, and Canada than in the United States. Those countries have a longer and deeper experience base with collaborative care, probably due to their stronger public systems and the lower levels of fragmentation in their systems of healthcare financing and delivery. A Canadian group, the Canadian Interprofessional Health Collaborative (CIHC), issued a National Interprofessional Competency Framework in 2010, after 2 years of work that included a review of literature and existing competency frameworks (CIHC, 2010). The Canadian Collaborative defined competency as “a complex ‘know act’ that encompasses the ongoing development of an integrated set of knowledge, skills, attitudes, and judgments enabling one to effectively perform the activities required in a given occupation or function to the standards expected in knowing how to be in various and complex environments and situations.” The competencies are customized around interprofessional collaboration, which is defined as “a partnership between a team of health providers and a client in a participatory, collaborative, and coordinated approach to shared decision making around health and social issues” (CIHC, 2010, p. 24). Six competency domains or clusters are identified in the Canadian framework, with a total of 39 competencies: team functioning (7 competencies), role clarification (7 competencies), interprofessional conflict resolution (8 competencies), collaborative leadership (8 competencies), patient/client/ family/community-centered care (4 competencies), and interprofessional communication (5 competencies).

The US and Canadian frameworks are quite alike. Both the US and Canadian groups define competencies in a highly abstract way, with the US group using the phrase “integrated enactment” and the Canadian group using the phrase “complex ‘know act.’” This abstraction reflects both the breadth of the term “competency” and the fact that it is difficult to specify exactly what constitutes proficient workplace behavior.

The 2 definitions refer to integrated sets of knowledge, skills, and “values/attitudes” (US) or “attitudes and judgments” (Canadian). This is consistent with the delineation by teamwork scholars of competencies as consisting of knowledge, skills, and attitudes (Cannon-Bowers et al, 1995, pp. 336-337). Our definition of competencies as integrated sets of knowledge, values, and skills draws on this consensus and avoids the higher level abstraction of “enactment” or “know acts.” We prefer the term “values” to “attitudes” because it is more foundational, in the sense that underlying values drive attitudes.

In terms of classifying types of interprofessional teamwork competencies, the most notable difference between the US and Canadian framework is that the Canadian framework separates leadership competencies (as do we, in a separate chapter, Chapter 8) and patient-centered competencies. In general, the 2 frameworks are remarkably similar in both scope and in specific competencies, which lends some support to the conclusion that there is general agreement about generic competencies. We draw on both the US and Canadian frameworks to ensure that our list is comprehensive.

We organize competencies into 4 categories: patient focus, team orientation, collaboration, and team management. The categories are the same as those employed in Chapter 6 to explain characteristics of effective teams, minus the category team structure. Team structure is beyond the purview of individual members (except the leader, whose competencies are addressed in Chapter 8). Our intent is to parallel the characteristics of effective teams with the specific expectations of individual members to produce those characteristics, so there is some overlap in the topics covered in this chapter and the previous chapter.

As noted above, competencies are combinations of 3 components—values, knowledge, and skills. Next, we define those 3 terms in more detail. Depending on the wording and content of specific competencies, different competencies emphasize each of the 3 components to different extents.

Some competencies clearly emphasize the values component, because values are fundamental to effective performance on teams. For example, “respect the other members of the team” is a competency worded so that it emphasizes understanding and acceptance of the value “respect.” Values are broad preferences concerning useful, worthy, and important courses of action or outcomes. Values also may reflect preferences regarding what is considered “excellent” in important arenas of one’s life, such as work and family relationships. As such, values reflect a person’s sense of right and wrong, as well as what “ought” to be. Values are deeply held and difficult to change. They often are rooted in family, spiritual, and cultural socialization, established over several years, particularly the younger years. Socialization into a new arena of life, whether it be adopting a new religion, marrying into a new set of relatives, moving to a new part of the world, or entering a new profession, has the potential to alter previously held values and to create new ones. The period of socialization into a new health profession provides opportunities to develop new values around teamwork with other professions.

Several teamwork competencies require a strong knowledge base. Knowledge includes the key technical and contextual information, theories, and concepts needed to be competent. For example, we emphasize the need for professionals to have knowledge of the potential contributions of other professions to the team. Managing conflict, discussed below as a competency, benefits from knowledge of the options for constructively addressing conflict. Of the 3 components of competencies, knowledge is the easiest to obtain. Knowledge can be gained by reading, studying, and learning. Knowledge about teamwork can be conveyed to health professionals in their education and continuing education.

Many competencies are phrased such that they emphasize the third component of competencies, skills. Skills are the specific behavioral practices needed to be proficient in the workplace. For example, “communicate effectively” is phrased as a skill, although in the context of interprofessional teamwork, those who exhibit effective communication likely benefit from underlying knowledge and values, such as knowledge of effective communication practices and adherence to the value of respect for teammates. Skills are difficult to learn through reading and studying; developing skill requires practice in realistic settings. The applied learning of skills is a significant component of the training of all health professionals, including administrators. Teamwork skills can be learned by practicing them in “safe” settings such as classrooms and simulation laboratories and fieldwork projects, followed by practice in “real” settings under the guidance of mentors and preceptors. In practice, values, knowledge, and skills are all inputs that are synthesized or integrated into workplace behaviors.

TEAMWORK COMPETENCIES

Focus on the Patient

Three competencies in support of a patient focus are required of team members. Table 7–1 lists the 3 competencies, which begin with having respect for the interests of patients and family members. Respect is a value that has important behavioral implications that are detailed in the 2 other patient focus competencies. The importance of respect in all effective relationships has a deep foundation in human history (DeLellis, 2000). Respect is a way of regarding another person, specifically, attending to the person because one deems the person to be important, usually because of some special worth or excellence but also simply because the other person is a person. As argued in Chapter 4, patient interests are central to team-based clinical care, and they are central to the mission of healthcare delivery organizations and the management teams in those organizations. Unless team members are enrolled in respecting the role of patients and family members on the team, the members will vitiate or sabotage the underlying, shared purpose of healthcare teamwork.

Respect is manifest in behavior and thoughts. Behavioral indicators of respect include listening to others, using appropriate language and forms of address, and seeking advice from others (DeLellis and Sauer, 2004). In demonstrating respect for patients, we particularly emphasize 2 individual member behaviors: soliciting and acting on patient and family input, and performing roles in a culturally sensitive manner.

Team members who respect patients listen to and incorporate patients’ goals in receiving care (Competency 2 in Table 7–1). Patients are “experts in their own lived experiences and are critical in shaping realistic plans of care” (CIHC, 2010, p. 13). For clinical teams providing care for defined episodes, a full team meeting with the patient and family, early in the care planning process, is often useful when such a meeting is feasible (Mitchell et al, 2012, p. 7). Respectful listening to the patient and family, rather than conveying of information from the professionals to the patient, is the main purpose of the meeting. For patients with chronic disease, if they wish to manage their own care, support for self-management is implied by respect for the patents’ goals. For management teams, inclusion of patients in teams is important as well. Team members who meet privately with the patient can share their learning with the team, if the patient is not an active member. To solicit input from patients and families, health professionals often must communicate technical information to them. It is important that team members do so in an understandable, jargon-free way. This behavior is discussed further below in the context of a competency for effective communication.

Effective involvement of patients in healthcare teams also requires sensitivity to cultural differences (Competency 3 in Table 7–1). The Canadian competency framework identifies a separate skill in cultural sensitivity (practitioners “perform their own roles in a culturally respectful way” [CIHC, 2010, p. II]), and the US competency framework urges team members to “Embrace the cultural diversity and individual differences that characterize patients, populations, and the health care team” (IECEP, 2011, p. 19). Cultural sensitivity is a key to effective communication when patients or clients are from different cultures than other care team members. In particular, cultural sensitivity includes collaborating to overcome linguistic and literacy challenges (Expert Panel on Cultural Competence Education for Students in Medicine and Public Health, 2012, p. 8). Patients and families with limited English proficiency are a significant component of the population served by many clinical practices and healthcare delivery organizations.

We also note the need to involve patients and families in the evaluation of team outcomes as explicitly noted in the statement of Competency 3 in Table 7–1, and individual team members can assist in making that happen. This issue is discussed in Chapter 13 on evaluating teams and team members.

Cultural diversity is but one dimension of human diversity. Differences between the social status, economic position, sexual orientation, and other characteristics of patients and families all challenge healthcare professionals to treat patients and families with equity—to treat them the same regardless of their life condition other than their health concerns. As explained earlier in Chapter 6, equity in the delivery of services is a desired outcome of all clinical teams. Equity requires sensitivity to the wide range of potential differences between patients and team members.

“Generation of trust in patients and families” was noted as a characteristic of effective healthcare teams in Chapter 6. Patient and family trust will result from individual members demonstrating the 3 patient focus competencies of respect, involvement in service design, implementation and evaluation, and cultural sensitivity.

Team Orientation

In Chapter 6, the example of Red Family Medicine, an 11-member primary care team, was used to illustrate orientation to working in a team. Individual members contributed to team goals as well as their own. Five competencies, delineated in Table 7–2, are required for individuals to demonstrate a team orientation. First, individual team members should actively participate in setting the foundations for successful teamwork—agreement on basic values, goals, and processes. In particular, team members need to share feelings about ethical principles, such as patient confidentiality and transparency. The US Interprofessional Education Collaborative competency framework specifies the following competency: “Develop consensus on the ethical principles to guide all aspects of patient care and team work” (IECEP, 2011, p. 25).

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