Although health and social care teams share several of the above characteristics, they also have attributes that are specific to their role in the delivery of care. For example, the main goal of care teams is that members work together in a collaborative and cooperative manner to deliver care to patients or clients (Henneman et al 1995, Williams & Laungani 1999). Also, as noted above, a care team can be made up from a number of people from the same professions, or it can be made up from people in different professions such as nurses, doctors, physiotherapists and social workers. This diversity of care teams led Meerabeau & Page (1999, p 31) to note that:

Working as a member of a care team can involve a number of activities, from ‘hands on’ work with patients to handovers and case conferences where professionals review, discuss and plan patient care. This type of work can also be undertaken on a ‘real-time’ basis, as, for example, when you and other colleagues are delivering nursing care together. In addition, teamwork can be undertaken on a time-delayed basis (e.g. delivering care following a decision taken in a multidisciplinary case conference).

Increasingly patients/clients are becoming involved in team meetings where decisions are taken about their care. As the Nursing and Midwifery Council state in the ‘NMC Code of professional conduct’ patients and clients are equal partners in their care and therefore have the right to be involved in the health care team’s decisions.

To develop a comprehensive understanding of teams and teamwork, a number of authors have outlined the different types of care team that can exist. For example, Bruce (1980) devised a model of teamwork that contained three types of teams:

Katzenback & Smith (1993) developed a model that contained five different types of team:

Such models are helpful to think about when you are working in a team, as they can help to pinpoint what type of team you are in. They might also be used to help individuals who are in poorly performing teams work towards achieving a more collaborative approach to their work.

An interest in the emotional dimension of teams has led some authors to compare team relations to those of family members (Woodhouse & Pengelly 1991). For example, it has been noted that interpersonal rivalry that can develop between team members has a similarity to sibling (brother or sister) tensions that emerge when one family member is competing to gain advantage over another for the attention of a parent (or a team leader).

Firth-Cozens (1998, p 4) draws on this idea when she notes that such emotions can have a problematic affect on teams and the way they work together:

Similarly, interprofessional teams (consisting of two or more different care professions) have also been compared to different tribes (Beattie 1995, Pirrie 1999). It is argued that professions, like tribes, are protective of their individual identities, cultures and beliefs. Consequently, interaction between tribes (or professions) can be strained and, on occasions, can lead to friction. The challenges related to working in an interprofessional team are discussed in more depth later in the chapter.

It is important to recognize that teams develop and change over time. Tuckman & Jensen (1977) devised a model of group development to help understand the different stages groups and teams pass through as they work together. They identified five different stages:

Although Tuckman & Jensen considered that most groups would progress directly from stage 1 to stage 5, they did acknowledge that in problematic situations, for example in groups who experience a high degree of membership change, some of the stages would be repeated. Recent research into the nature of teamwork has revealed that Tuckman & Jensen’s model can usefully track the different stages of team development (Farrell et al 2001, Janicik & Bartel 2003).

Øvertveit (1997) argues that teams need to spend time undertaking preparatory work to achieve clarity around team roles, responsibilities and goals. Such preparation can provide a team with opportunities to agree how to coordinate their collaborative work in an efficient and mutually satisfying manner.

An important outcome of this preparation work is that teams develop a ‘team policy’, which explicitly records the collective aims, roles and responsibilities of the team. It also helps to ensure that a team has a formal document that provides members with ‘defining details of how they operate’ (Øvertveit 1997, p 272). øvertveit saw that each team policy should contain a number of key elements:

For øvertveit, on-going discussion between team members is required to ensure that their team policy is regularly updated and amended if, for example, a new member joins and there is a need to modify a previously agreed policy. Research has revealed that where team members spend time undertaking this form of preparatory work, they can be more effective in their collaborative work (Larson & LaFasto 1989, Meerabeau & Page 1999).

Team leaders play a central role in ensuring that teams work together in an effective manner. Cook (2003, p 84), for example, provides a helpful definition of a care team leader as:

Based on his research into the nature of leaders in care teams, Cook identifies a number of personal attributes required for such leaders. These include the ability to motivate staff, take effective decisions, encourage innovation and release the talents of the team members.

As well as requiring a variety of personal attributes, Adair (1983) found that an effective leader needs to attend to three central functions in relation to their team:

It has also been argued that an individual’s style of leadership can have a significant impact on how a team works together. Bass (1997), for example, identified two main types of leadership style: ‘transactional’ and ‘transformational’. For Bass, a transactional leader adopts an authoritative approach to their work with team members. They also tend to work in isolation from the team and will take decisions without including other team members. In contrast, a transformational leader adopts a democratic approach to their work. In doing so, they work flexibly with the members of their team and they promote creative problem-solving among members.

For West (1996), a team that can spend time together reflecting upon their collaborative work can develop a ‘reflexive’ (e.g. integrated and well coordinated) way of working together. As West (1996, p 13) stated:

West identified that the development of a reflexive team approach can help ensure that members are able to adapt and respond effectively to any changes they encounter. This is an important quality to have for teams working in the NHS, as change is an ongoing factor that needs to be managed by students and staff.

A key aspect to achieving a reflexive approach is the creation of an environment where members value one another’s contributions, feel safe to share their ideas openly and trust one another to acknowledge their shortfalls and mistakes. While West noted that the development of a reflexive approach to teamwork will take team members both time and effort, the benefit gained from this input is worthwhile.

Research into effects of incorporating shared reflection time has revealed that this activity can help produce a more effective team effort. For example, in her study of a care team, Opie (1997, p 275) found that when team members engage in shared reflection they are more likely to ‘fuse together’ their different knowledge bases and perspectives and achieve a more integrated way of working together.

As well as attention to the roles and processes that occur within a team, one also needs to be aware that effective teamwork requires support from outside (external) sources. In particular, it is vital that teams have the support of senior management (Onyett 2003). Such support ensures that the team has the resources (i.e. time and money) to work together in focusing on the needs of patients/clients. The failure to obtain support of senior management can result in a team that cannot action its decisions on delivering care.

Another form of external support that teams can access is information technology. Reeves & Freeth (2003) argue that the use of information technologies is beginning to offer health and social care teams an additional means of supporting their collaborative work. They note that, whereas traditional forms of teamwork depend on members sharing the same physical space (i.e. a ward or a team room) to collaborate, the demands of managing patient caseloads in different locations often restrict time for this type of collaboration. The use of information technologies can help overcome such problems. They can provide an ‘electronic bridge’ (Reeves & Freeth 2003, p 81) to support teamwork, especially when there is little time for interaction or a need to rapidly access remote forms of information. Examples of technologies that can be used for this purpose include e-mail, e-conferencing and e-databases (e.g. electronic patient notes).

Professions such as medicine and more recently nursing have undergone a process called ‘professionalization’. For Friedson (1970), this process is undertaken in order to secure ownership of areas of knowledge and expertise. In obtaining this ownership, Friedson argued that professions secure a right to practise in an independent fashion, which in turn leads to financial reward and status enhancement. To protect the gains obtained from professionalization, Friedson claimed that professions guard the areas of knowledge and expertise they have claimed as their own primarily through the regulation of entry and the maintenance of professional standards. Tension and friction can therefore arise if a member of one profession perceives that a member from another is infringing their area of expertise.

A useful illustration of the difficulties that can arise in relation to professionalization is provided by Connolly (1995) in her evaluation of an interprofessional placement for nursing, social work, occupational therapy, nutrition and recreational therapy students. Connolly found that some students occasionally felt their professional boundaries were encroached when working together on the placement. These perceived professional boundary infringements were reported to cause friction, as students attempted to protect their own boundaries. In many senses, the discussion of teams as tribes mentioned above links into the issues of professionalization and the protection of professional boundaries.

Another difficulty that is encountered in multidisciplinary teams is the inequalities in terms of power and status that exist between the health and social care professions (Turner 1995). As doctors have the legal responsibility for the care of most patients/clients, they tend to have more influence (power) than nurses, therapists and social workers in the multidisciplinary team. As a consequence of this influence, they occupy a higher social status than their professional colleagues. As discussed above, given the need for equality within teams, such differences can cause interprofessional friction and tension, as a number of studies have revealed (e.g. Skjørshammer 2001, Walby et al 1994). However, as the section on teamwork in action indicates (see below), team members can often work together successfully despite such differences.

Finding sufficient amounts of time to come together to meet as a team can be difficult given the heavy workloads professionals need to manage. For example, research by Annandale et al (1999) indicated that teamwork between nursing and medical staff based in an accident and emergency unit was restricted because of the heavy workloads each profession had to deal with. Similarly, Atwal (2002) found that nurses and other multidisciplinary team members such as occupational therapists and physiotherapists regularly encountered difficulties in attending discharge meetings due to heavy workloads.

Such time pressures led Engeström et al (1999) to question whether the traditional ideas of teamwork (discussed above) fit the realities of working in a care team. These authors argued that in most care settings, especially in acute care settings, many interprofessional relationships are short-lived and continually shifting between individuals. Teamworking could therefore be seen more as a process of ‘knotworking’, in which individuals tie, untie and re-tie separate threads of activity during their brief interactions.