Unidisciplinary and multidisciplinary health teams

Simpson’s anaesthesia project team (Case Study 7.1) was very successful. It was a traditional medical team; it was unidisciplinary.

A unidisciplinary team usually forms or ‘coheres’ rapidly and with less struggle over power and leadership because its members are professionally homogeneous. Everyone, despite differences in age, experience and personality, fits into the same professional culture, understands the professional argot and salutes the professional values.

Multidisciplinary or interdisciplinary teams usually take longer to form, and the period of cohesion building may be troublesome because of value differences between various professional groups. One-half of the 113 respondents in a rehabilitation study admitted to team discord because members encroached on their professional territory (Strasser et al 1994). However, teams that survive their stage of formation can develop strong and complementary work patterns, necessary to deal with complex health-related problems.

The emergence of multidisciplinary and interdisciplinary health teams

World War II created problems for health services in how to rehabilitate a large number of injured and disabled people. John Bonica, father of modern pain management, turned to teamwork for quality pain assessment and treatment in Seattle in the years 1944–46. Bonica (1990) had to face the fact that he could not manage complex pain problems by himself. First he asked colleagues in neurology, neurosurgery, orthopaedics, psychiatry and other disciplines to assess clinic patients with pain in a traditional medical manner; that is, in serial consultations. Bonica would receive the usual consultant’s report (a telephone call or a letter, or via a comment on the patient’s chart). He then attempted to read the findings, decide on a diagnosis and devise an appropriate treatment plan. He discovered that this was slow, inefficient and, in the long term, probably not a feasible way to proceed. So Bonica began to work in a new way altogether. He held frequent (two or three per week) face-to-face meetings with all the specialists who had seen the patient. They discussed the case until they reached a consensus on the diagnosis and therapy. As far as is known this is the first time that the multidisciplinary/interdisciplinary approach to pain was practised. Bonica (1990, p 197) wrote:

Sixty years on, many health care settings are ‘intense and unpredictable,’ requiring members to speak up about using new equipment or interacting with one another and leaders who will coach inside the team and defend the team externally (Edmondson 2003).

Teams as a vehicle for improving the delivery of health care services

Some services should, no doubt, continue to be offered by individual agents, but managers will appreciate that many ambulatory care services for the care of people with complex chronic conditions are still being delivered by individual or serial specialists in what we may now term ‘a pre-1945 modality’. As a result, the care that patients receive is fragmented, time-wasting and frequently stressful as patients wait for one appointment after another and the subsequent integration of these various opinions and diagnostic results by their primary practitioner. It is little wonder that there is growing public concern over the use of health resources and the outmoded manner in which some services are organised.

Types of teams in health services

Both formal and informal groups are to be found in the health industry. A formal group is one that is constituted by an organisation for a specific purpose. On the other hand, an informal work group is one that has no legitimate organisational standing, for example a journal club or jogging group. These groups exist to meet the social, personal or professional needs of the individuals involved (Fried et al 1999). Informal groups are not addressed in this chapter, but health service managers should be aware of their existence because of their potential to influence employee opinion, morale and behaviour, both positively and negatively. For more information about informal health work groups, see Rakich et al (1992).

Sundstrom et al (2000) described six types of teams differentiated mainly according to the work they do and their outputs, work cycles and membership; viz, production, service, project, action, advisory and management teams.

Teams and the professionally stratified health system

No team functions in isolation. All work teams function within a larger organisational system, and the policies, structures and culture of the organisational environment govern the team. Indeed, teams often function at the interface between the organisation and the external environment and, under these conditions, team members may be particularly vulnerable to influence by external forces that may thereafter compete for team resources with organisational imperatives (Choi 2002). The extent to which the work of the team is valued, for example, influences member participation and contribution. A challenge for many new health service managers and team leaders is understanding the unwritten ‘pecking orders’ that exist within the highly professionalised health industry and how these status differentials affect the behaviour of team members and, ultimately, team performance. Professional and organisational social rankings are referred to in the literature as ‘stratification’, which Bullough (1988) describes as the ‘hierarchical ranking of people according to their wealth, power or social class’ (p 289). To this must be added power associated with expertise. Integrating the work of high-powered specialists poses particular challenges (Mintzberg et al 2002).

Recent attempts to ‘flatten the management hierarchy’ in health organisations have sought, among other things, to reduce stratification caused by organisational structure. There can scarcely be any part of human society so stratified as a modern hospital. Other contenders might be the prison, the school or the military base, but the hospital takes some beating. One reason is that the hospital reflects public opinion as to who is at the top of the health profession pecking order and who is at the bottom (Bullough 1988). Another reason is the way power in the hospital is exercised by dominant groups to express and maintain socially perceived strata. Nevertheless, teams grow and flourish in this seemingly alien culture.

To John or Jane Citizen, the hospital offers a seamless and usually effective response to the crisis of trauma, elective surgery or childbirth. Emergency room teams, surgical teams, nursing teams, labour ward teams and rehabilitation teams march onto centre stage, perform their skilled services and depart. However, each of these teams works through an organisational hierarchy. So, in addition to the knowledge and skills required to respond to the client group, each health professional has learned an intricate set of responses to enable him/her to negotiate the rocks and shoals of professional status. Doctors and nurses have played the strata game with vigour. In the United States, for example, a tripartite structure for nursing, embracing registered nurses, practical nurses and nursing aides, was put in place during the 1950s (Lambertson 1953) and rapidly became legislated into a more permanent arrangement (Bullough & Bullough 1978). It is of interest to note that Lambertson (1953) called the new stratified organisation of the nursing profession in the United States ‘team nursing’. This seems an unlikely conjunction of hierarchy and teamwork. Can teams function productively in a hierarchical, socially stratified environment? Paradoxically, in the health industry, the answer is yes — teams can and do function with every appearance of efficiency in the exceedingly stratified social environment of the modern hospital. In this environment, some professional groups have developed norms of communication, sometimes referred to as a ‘game’ to assist them to work effectively together. For example, Stein (1967) was the first to note the extraordinary way that nurses — avoiding any appearance of ‘managing up’ — would give information to physicians, correct their errors, and offer them advice on dosage or other treatment issues. The ‘game’ was rendered necessary because in a stratified society those of lower status do not tell those of higher status how to do their business.

Teams in highly stratified health services can function because:

professionals are intelligent people;

their primary commitment is to patient improvement;

they understand the layer-cake culture in which they work; and so

they tolerate the frustrations of professional power games so that they can do what they really enjoy doing.

Phillips (2001) concluded that managers can assist socially stratified health teams to work effectively by giving careful consideration to the social structure of each team when selecting members and by ensuring that each team has clearly articulated ground rules and a leader skilled in the facilitation of teamwork.

Team participation as a social exchange contract

Teams are interpersonal influence settings and participation in health teams is voluntary. No-one can oblige professionals to work in a team. Hence, cooperation must prove to be both professionally and personally rewarding or members will withdraw from the group, either physically or psychologically. It follows that the team leader must give attention to team task and team process. Social exchange theory provides useful concepts for exploring why attention to process is important.

Underlying social exchange, a theory that emerged in the 1950s and 1960s, is the notion that people often prefer to cooperate for mutual benefit rather than compete (Thibault & Kelley 1959; Blau 1964). Exchanges between people occur at the most superficial level (e.g. the purchase of a bread roll) to the most profound level (e.g. the contracting of a marriage) and may be momentary or lifelong in their duration. With respect to teams, exchanges among team members include verbal and non-verbal communications, such as information exchange, smiles and frowns. These exchanges are evaluated in terms of their relative rewards or costs (Homans 1974). Rewards might include recognition of expertise and contribution, while punishments might include negative or hostile feedback, rejection, conflict and a sense that time is being wasted. In this respect, social exchange theory provides a conceptual basis for understanding: why a teamworking arrangement is attractive to many workers; why some teams manage exchange between members to maintain rewards above costs and thereby protect the viability of the team; and why some teams fail.

Managers can profit in several ways from thinking about social exchange in relation to teams. First, there is the contract between the organisation and the team. Have both sides of the exchange been spelled out so that it is clear to organisation managers and to the team what is to be gained by each from the team formation? Second, there is the contract between team members. Has the team thoroughly explored with all its members the costs and benefits of belonging to the team? One such cost might be the limitations on individual professional autonomy, while a potential benefit is the satisfaction for individual team members from successful collaborative effort.

Operant conditioning as a framework for analysing team process and performance

Like social exchange, operant conditioning theory maintains that social behaviour is learned and maintained through reward (reinforcement) (Skinner 1953, Watson & Rayner 1920, Kazdin 1989). In teamwork, the implication is that managers (and team members) should attend to the task-related and interpersonal components of teamworking to ensure that balance is maintained and that members are rewarded by their efforts. Occasionally, the perception by team members of rewards gained from their work becomes obscured. When this occurs the manager should line up the usual suspects: viz, the team member is bringing personal troubles to work; the organisation has removed resources, changed the duties and/or performance expectations for members; or interpersonal conflict has arisen in the team and has not been resolved. For example, a well-functioning team may be assigned additional duties by its manager without additional resources. The performance of the team apparently lifts to incorporate the new tasks. Then, unexpectedly, a team member resigns, another goes on extended leave due to ‘work-related stress’, and the manager is called in to deal with a general revolt blamed on ‘overwork’. It is perilously easy for a manager to ‘scapegoat’ team members in order to account for team decay. More likely, for example, changes introduced by the organisation increased patient care or project duties and reduced work satisfaction in the team to the point where, for some members, it seemed better to search for work elsewhere.

A reinforcer, from the operant conditioning approach, is defined in terms of its behavioural effect (Kazdin 1989). Hence, a positive reinforcer is any event that follows a behaviour if subsequently the frequency of the behaviour increases. Several propositions follow: first, it is only possible to decide what will improve future team performance by an examination of past performance. Reinforcers for ‘good’ team behaviour can only be identified after the event. Armchair debate on how to improve team performance is pointless without excellent data on how the team has performed in the immediate past. In particular, information is needed by managers from team members as to events (consequences) that have ‘reinforced’ their efforts and events that have ‘punished’ their efforts (Salkovskis 1996).

A defining characteristic of ‘team-ness’, according to Katzenbach and Smith (1996), is that members accept ‘mutual accountability’ for achievement of group goals. In terms of operant conditioning, this means that a rather unusual shift occurs when an individual joins a health care team: namely, the professional earns reinforcers not only for their individual effort, and not only for the standard of team performance but, significantly, when the client survives/improves/recovers or the change process is successfully implemented. Some of the most stable, effective and longest-serving teams in health are in the most ‘stressful’ places — emergency rooms, intensive care, surgical teams and labour wards. This is hard to understand except in terms of the personal and professional satisfaction that team members gain from care of patients in extremis. More research is needed to examine how health professionals expand the boundary of professional accountability to the patient, to the team, and beyond to the organisation. That said, we predict that increased accountability does not necessarily overload them but, rather, may assist in maintaining team member rewards for their health practice and buffer the team member against frustration and disappointment. Nurses find palliative care, for example, a very stressful work environment (Harris & Turnbull 1990). Nevertheless, teams in palliative care tend to be stable and long-lasting.