Unit 5 Casestudy ldrsh2

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References Fletcher, M. (2008). Multi-disciplinary team working: building and using the team. Practice Nurse, 35(12), 42–47.

Section: advanced practice -- module 08.7, part 1

Multi-disciplinary team working: building and using the team Multi-disciplinary team working: building and using the team. Practice Nurse 2008; 35( 12): 42-7 Date received: 6 April 2008 Date accepted for publication: 16 May 2008

Primary care is becoming increasingly complex. Recent health and social care reform has focussed on improving the efficiency of the NHS, making services more accessible and reducing inequalities.( n1) It is the Government's wish to shift services closer to people's homes, and it sees prevention and the improved management of long-term conditions as a key priority.( n2, n3) Primary care is seen as the enabler of these reforms, both as a provider and increasingly as a commissioner of services.

These changes and the resulting expansion of services now provided in primary care has made it necessary to call on the skills, knowledge and experience of a wide range of clinical and non-clinical staff. The plurality of providers from the public and independent sectors now working within primary care makes team working an increasingly complex task, as does the blurring of the boundaries of the traditional roles of individuals and organisations. The shift from hierarchies to flatter, collaborative, multi-skilled working means that team working skills are becoming a necessity for everyone working in contemporary health and social care organisations, both within primary and secondary care and across the boundaries.

'Collaborative teamwork will be a predominant feature of the modern health services'? Given the increasing demands and expectations placed on primary care, it is essential that effective teamwork becomes a reality and is not simply rhetoric.

TEAMWORK IN PRIMARY CARE Teamwork in primary care is not a new concept. The Dawson Report of 1920 suggested that teamwork was the most productive way of working in primary care.( n5) Even before the NHS was formed, the vision was for family doctors to work in teams. There have been successive policy, legislative and financial incentives to encourage team working over the years (Table 1).

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Despite permissive legislation and the vision to promote teamwork, there has been a continuous struggle to integrate primary healthcare teams (PCHTs) into fully functional units. This is partly because of barriers between professional groups, but also the result of a lack of real commitment from some individuals and disciplines. Over the years, a lack of co-operation has led to the well documented ineffectiveness of teamwork in primary care, particularly between community nurses, midwives, and GPs and their staff.( n6-n8) Some of this failure has been blamed on management structures, which have been perceived as hierarchical and therefore responsible for impeding the efficient integration of services. With the amalgamation of community services and GP practices within primary care organisations, the potential for team working has improved considerably.

There has also been an assumption that the attachment of staff to GP practices, or 'co-location', is synonymous with teamwork. This has too casual an inference for the special relationship on which inter- and intra-professional teamwork needs to be based.

WHY IS TEAMWORK IMPORTANT? There are many benefits to teamwork.( n9) Effective teams:

• enable improvement opportunities, which cross boundaries

• create more responsive services for patients, with better utilisation of resources and more cost-effective service provision

• improve problem-solving by using a greater diversity of staff

• promote better service redesign

• enable more satisfying roles and improve morale.

There is a belief that collective input always benefits outcome. It needs to be stated that teamwork is not a panacea for sub-optimal healthcare delivery. Although a group of people working together to achieve a common goal or function can bring huge benefits, there are also times when it makes more sense to work individually, rather than to try to artificially 'weld' individuals together in a 'quasi-team'.( n10) For example, simple task-orientated issues are probably best dealt with by an individual. More complex tasks, which deal with uncertainty, such as strategic planning, benefit from many views. Rarely can an individual effectively tackle such a task in isolation. The team leader will need to decide when a teamwork approach affords greater benefits than an individual approach.

WHAT IS TEAMWORK? A simple definition of a team is: 'A small group of people who relate to each other to contribute to a common goal'. ( n11) A more encompassing definition, which is used by the Modernisation Agency and the Health Care Team Effectiveness project team, is: 'A group of individuals who work together to produce products or deliver services for which they are mutually accountable. Team members share goals and are mutually held accountable for meeting them; they are interdependent in their accomplishment, and they affect the results through their interactions with one another. Because the team is held collectively accountable, the work of integrating with one another is included among the responsibilities of each member.'( n12)

Teamwork, whether in a formal team (eg a permanent team formed to carry out a regular function, such as a community mental health team) or an informal team (eg those brought together to work on a specific task or project) requires individuals to adapt to working in different ways.

CREATING A TEAM

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The common goal of a sporting team is to win. The best way to create a functional team is to develop a work programme with a common goal, aims and objectives that are clearly understood by all the team members. Teams that are thrown together without this often fail. This is why co-location of staff alone will not build an effective team.

In healthcare, there may be several team objectives. Initially however, it is important to identify a common goal; something the team is passionate about and believes it can influence. This could be, for example, a service improvement; such as developing a new care pathway or a workforce redesign, looking at the competencies and skills required to deliver a new service. A useful tool to use for this task is process mapping, which can identify the steps involved in a patient journey. This draws on the day to day experiences of each team member and enables them to contribute, both as individuals and as part of the team.( n13)

LEADERSHIP All teams need leadership (Box 1). Even teams that appear to be self-managing will have a team leader, whether or not he or she is formally designated as such. One of the biggest mistakes is to believe that inter-professional conflicts, rivalries and protectionism can be avoided by not determining a team leader role.( n11) The Modernisation Agency found that teams involved in service improvement that did not have a designated team leader were stressful for individual members of the team and were less successful.( n14) In today's NHS, with its increasing interdependency between managers and clinicians, consideration of a shared leadership role might be of considerable benefit.

Nurturing and developing a successful team is a lengthy process, requiring comprehensive skills from the team leader. All teams are unique and dynamic and will present challenges to even the most experienced leader. The team leader's role should change as the team develops.

The Tannenbaum and Schmidt leadership continuum (Figure 1) is a simple model, which shows the relationship between the team's level of freedom as it becomes more mature. In time, a team should require less direction from the team leader and become increasingly self-sufficient. This does not mean the team leader role is superfluous, but a good team leader should recognise that these changes are inevitable and their style should evolve over time to accommodate them.

The basic premise of Adair's leadership model (Figure 2) is that a team leader has to balance three competing needs: those of the individual, the team and the task.( n16) The model emphasises the importance of distinguishing the differences between these needs because there will rarely be a perfect fit between the three elements. Team leaders, however, should be able to identify when they are widely out of line, to minimise disruption to the team, and attempt to manage the differences.

If teamwork was easy, we would see many functional teams within the NHS. The Healthcare Commission's annual survey of NHS staff( n17) reported that nine out of 10 respondents stated they worked within a team. However, when analysing this data the researchers assessed four out of 10 teams as dysfunctional.( n18) In the public sector this is not surprising because many teams are brought together from disparate backgrounds and cultures and have differing agendas.

DEVELOPING THE TEAM There are a number of teamwork and team building theories and tools available to help with the task of developing and sustaining a functional team. Although many are descriptive rather than prescriptive, they are useful for diagnosing problems within a team.

Teams take time to become functional, and unfortunately some fail to do so. Theories on how date back to the early 20th century and the work of psychologist LeBon. Since then there have been many theories and models. One of

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the most well known was developed by Tuckman in 1965.( n19) This model has been widely adopted in both team and organisational development.

Essentially the theory is that all teams or groups go through several stages on their way to becoming functional and able to deliver results. There are four stages:

• forming

• storming

• norming

• performing (Table 2).

Latterly a fifth stage, adjourning, has been added. This occurs when the team is disbanded.( n20)

Some stages, such as storming, can be unpleasant. They can be painful to members of the team who are uncomfortable with confrontation, and they require excellent leadership skills. It is worth noting that if a member leaves or joins, the team may revert back to a previous stage. It is also important to share the expected stages of development with new and existing teams. This understanding enables the team members to recognise when they are entrenched, and can help them to identify possible issues. If the team arrests at a particular stage of development, it can become less productive and may fail to mature (See 'Risks' in Table 2). Teams tend to mature more rapidly when:

• the task is important

• the individuals are highly committed

• individual and team objectives are aligned.

TEAM ROLES Individuals, by nature of their background, experience and personality, have preferred roles within a team. However, there is strong evidence that teams require a balance of the various roles. Getting this mix right is the key to success.

In the 1960s and 1970s, Meredith Belbin used business games to identify roles; they then conducted research showing that teams with a good balance of team roles performed better than teams with a poor balance, even when the latter had brighter and more capable team members. Belbin subsequently developed a classification system for assisting teams to develop their effectiveness.( n21) He suggests that successful team members need to adopt eight main team roles (see Table 3).

Although most people tend to have strong preferences for certain roles and weaker preferences for others, it is possible to have more than one preference and to be able to adapt to develop some of the roles. Belbin's theory is that a team needs a full mixture of roles to be successful across all tasks. A limitation of this approach is that teams are frequently developed from a group of people who have been appointed to undertake a role because of their skills, experience or qualifications and not because of their Belbin preferences. However, it is a useful tool that can be helpful in allocating particular team roles to individuals. It can also be used to identify individuals who might work well together to complete a task, and to identify potential for conflict and underachievement.

TEAM MEMBER PERSONALITIES

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Different personalities within a team are inevitable and necessary, but can also cause conflict and interfere with the performance of the team. Personality profiling tools can accurately identify such differences. One of the most commonly used tools is the Myers-Briggs Type Indicator.

MYERS-BRIGGS TYPE INDICATOR The Myers-Briggs Type Indicator (MBTI) was developed by Isabel Briggs-Myers and her mother Katherine Cook- Briggs and is based on the work of the psychologist Carl Jung. It helps us to understand why different people excel at certain tasks and why they sometimes find it hard to understand other team members' behaviour. Essentially 16 different personality preferences are identified via a self-administered, validated questionnaire. MBTI questionnaires are licensed and have to be administered under that licence.

After completing the questionnaire, an individual is given a four-letter categorisation denoting their personal type (see Box 2). Each type has a distinctly different personality. Individuals will tend to polarise between the two preferences to varying degrees. For some people the degree is so small that it barely influences behaviour. However, in others it is so dominant that it defines their approach to life. If people with different profiles work together on tasks it can bring richness to their work, but also some frustrations.

MBTI helps individuals to understand their own behaviour. However, and perhaps more importantly, when used in the context of team working, it helps individuals understand how others behave and to value the diversity.

CONCLUSION Team development and training in team working are not always seen as a priority in the health service. Training and educational strategies for team working among healthcare professionals in primary care are lacking in the UK and the US.( n22) This is likely to emerge as a rate-limiting step in providing high performance primary care. This article has highlighted some of the commonly used tools that can help teams develop. However, taking time out as a team with a skilled facilitator is probably the most beneficial intervention that can be made.

LEARNING OBJECTIVES After working through this article you will be able to:

• Discuss the importance of teamwork in healthcare

• Describe the role of the team leader in team development

• Identify the stages of development of a team, from initiation to maturity

• Discuss the effect of personality traits and team roles on team development

BOX 1. THE KEY ROLES OF THE TEAM LEADER • Takes responsibility and is accountable for the team

• Sells the vision of the team internally and externally

• Enthuses and motivates the team Embeds the culture of the team

• Is open and honest

• Promotes integration and understands principles of team development

• Understand why conflict could happen and aims to minimise it

BOX 2. MYERS-BRIGGS RANGE OF PREFERENCES

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• Extrovert (E) to Introvert (I)

• Sensing (S) to Intuitive (N)

• Thinking (T) to Feeling (F)

• Judging (J) to Perceiving (P)

KEY POINTS • Teamwork in healthcare can create more responsive and efficient services for patients, and more satisfying roles and improved morale for healthcare professionals

• Team leaders are essential for the nurturing and development of a team and to balance the competing needs of the individual, the team and the task

• Multidisciplinary teams are dynamic organisations that go through several stages of development from initiation to maturity: forming; storming; norming; performing

• Team members, by nature of their background, experience and personality, have preferred roles within a team. A balance of various roles within a team is key to success

ACTIVITY • List the number of teams you are currently working in and assess their levels of functionality, based on process and outcomes

• What is the role of the team leader?

• Identify someone you consider to be a good team leader and list the key skills or abilities that they demonstrate

• Where did they sit on the Tannenbaum and Schmidt leadership continuum, and was this appropriate for the stage of development of the team you were in?

• What stage of development is your current team at according to Tuckman? How do you justify this analysis of your team? What are the behaviours being portrayed?

• Research on the internet how you would conduct an MBTI test on your current team. Put together a business case for justifying the cost of undertaking a team analysis

SELF-ASSESSMENT 1 When was the concept of team working in healthcare first suggested?

2 Why do some PCHTs fail to develop into fully functional units? 3 What do team members need to have in common if they are to become a functional team? 4 What three competing needs must a team leader balance, according to Adair? 5 According to Tuckman, what are the four stages of team development? 6 What is the role of the team leader in the second of the above stages? 7 List the factors that enable a team to mature rapidly 8 List four of the possible benefits of effective team working in healthcare 9 What, according to Belbin, are the profiles of the 'shaper' and 'plant' in a team? 10 What is the potential benefit of using the Myers-Briggs Type Indicator (MBTI)? 11 What do the initials ENTP denote in terms of MBTI personality types? Answers

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1 In the 1920 Dawson Report. 2 Barriers between professional groups and a possible lack of commitment from some individuals and some disciplines. 3 A common goal, aims and objectives, which need to be clearly understood by all the team members. They should feel able to influence this goal and should also feel passionate about it. 4 The competing needs are those of the individual, the team and the task. 5 Forming, storming, norming and performing. 6 Storming -- requires a strong, but facilitative style. The leader should also confront any conflicts and address them. 7 Teams tend to mature more rapidly when: the task is important; the individuals are highly committed; individual and team objectives are aligned. 8 Four of the following: improvement opportunities that cross boundaries; more responsive services for patients; better utilisation of resources, which are more cost-effective; service provision; improved problem-solving through using a greater diversity of staff; better service redesign; more satisfying roles and improved morale. 9 A 'shaper' shapes the team effort; tends to be dynamic, outgoing and challenging; finds ways around obstacles, but may be prone to impatience. The 'plant' is a source of original ideas; creative, imaginative and unorthodox; may not be good at managing ordinary people. 10 MBTI is useful in raising awareness and increasing understanding of one's own behaviour. More importantly, when used in the context of team working, it helps individuals understand how others behave and to value the diversity. 11 E = extrovert; N = intuitive; T = thinking; P = perceiving.

RESOURCES • www.institute.nhs.uk

For information on process mapping

• www.healthmanagementonline.co.uk/toolkit

For information on leadership in your team

TABLE 1. HISTORY OF TEAMWORK IN PRIMARY CARE 1911 National Insurance Act establishes the principle of a family doctor and a registered population

1920 Dawson Report envisaged family doctors working in teams

1948 Birth of the NHS. GPs negotiate independent contractor status

1963 Healthcare workers encouraged to work in teams

1966 Family Doctor Charter: 70% reimbursement for practice staff and opportunity for premises development

1968 Health Authority staff (treatment room nurses, district nurses and health visitors) can work in surgeries

1980s 70% of GPs in partnership, 25% work in health centres; 70% have attached staff, few have practice nurses

1990 The GP contract - encourages an increase in

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the number of practice nurses by reimbursing GPs for chronic disease management clinics

1997 PMS contracts - Personal Medical Services encourage new forms of teams and services in primary care

2004 GMS contracts - shift from GP contract to a team, practice-based contract TABLE 2. TUCKMAN'S STAGES OF TEAM BUILDING(19) Legend for Chart:

A - Stage B - Behaviour C - Leader role

Immature team

Forming

• Individuals start to get to know each other • Start to agree on goals and tackle the tasks • Individuals usually on 'best behaviour' - polite • Team members behave independently. not as a team

Directive and clear

Storming

• Different ideas compete for precedence • Individuals begin to open up and revert to true styles • Team members confront other ideas • General disagreement • Relationships are made or broken

• Needs strong but facilitative style • Should confront and address any conflicts

Risks: Team can get stuck here; try to convince others their ideas are right; some members will focus on minutiae; team evades the real issues; conflicts over leadership

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Norming

• Moves towards more harmonious working • Agree ways of working - rules of behaviour • Begin to trust each other and accept contributions • Want to limit agenda and get on with tasks

• Less directive • Encouraging collegiate working

Risks: Team can become complacent and lose 'edge'

Performing

• Era of high performance: mature and capable • Collaborative decision-making • Dissent expected and encouraged • High levels of respect, trust and group loyalty • Self-regulating

Light touch

Mature team TABLE 3. BELBIN'S TEAM ROLES(21) Shaper Shapes the team effort. Tends to be dynamic, outgoing, challenging, finds ways round obstacles. May be prone to impatience

Plant Source of original ideas, creative, imaginative and unorthodox. Not always good at managing ordinary people

Resource Externally focussed. Often extrovert, investigator enthusiastic and communicative. Explores opportunities and develops contacts. Can lose interest

Co-ordinator Clarifies and promotes decision-making. Mature, confident and trusting. Excellent chair. Not the most creative of the team

Implementer Operationalises ideas. Lists practical actions. Disciplined, reliable, conservative and efficient. Can appear to be a little inflexible and unwilling to adjust

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Team worker The cement of the team. Sociable, perceptive and accommodating. Listens and averts friction. Sometimes not sufficiently decisive in a crunch situation

Completer-finisher Follows through. Painstaking, conscientious and anxious. Searches out errors. Delivers on time. May be inclined to worry unduly and reluctant to delegate

Monitor-evaluator Sober, strategic and discerning. Objective and sees all options. Judges accurately. Sometimes appears to lack drive and ability to inspire others DIAGRAM: FIGURE 1. TANNENBAUM AND SCHMIDT LEADERSHIP CONTINUUM( n15)

DIAGRAM: FIGURE 2. THE ADAIR LEADERSHIP MODEL

REFERENCES (n1.) DH. Our Health, Our Care, Our Say. London: DH, 2006.

(n2.) DH. Supporting People with Long Term Conditions: an NHS and social care model to support local innovation and integration. London: DH, 2005.

(n3.) DH. The National Service Framework for Long Term Conditions. London: DH, 2005.

(n4.) McKenna H, Bradley M, Keeney S. Primary Care and Community Nursing: a study exploring key issues for future developments. Jordanstown: University of Ulster, 2001.

(n5.) DH. Consultative Council on Medical and Allied Services. The Dawson Report: the report of the future provision on medical and allied services. London: HMSO, 1920.

(n6.) Poulton B, West M. The determinants of effectiveness in primary care teams. J Prof Care 1999; 13(1): 7-18.

(n7.) Leese B, Mahon A. Management and relationships in total purchasing pilots. Relevance to primary care groups. J Man Med 1999; 13(23): 154-63.

(n8.) Wiles R, Robison J. Teamwork in primary care: the views and experiences of nurses, midwives and health visitors. J Adv Nurs 1994; 20: 324-30.

(n9.) Borrill C, West M, Dawson J. Team working and Effectiveness in Health Care. Birmingham: Aston University, 2002. http://research.abs.aston.ac.uk/achsor/achsor.html

(n10.) Leigh A, Maynard M. Leading Your Team: how to involve and inspire teams. London: Nicholas Brealey Publishing, 1997.

(n11.) Ovretveit J. Co-ordinating Community Care. Milton Keynes: Oxford University Press, 1994.

(n12.) Mohrman S, Cohen S, Mohrman A. Designing Team Based Organisations. San Francisco: Jossey-Bass, 1995.

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(n13.) NHS Modernisation Agency. Summary Report No 1: from scepticism to support - what are the influencing factors? Leicester: The Modernisation Agency, 2000.

(n14.) NHS Modernisation Agency. Teamwork for Improvement. Planning spread and sustainability (research into practice). Leicester: The Modernisation Agency, 2004.

(n15.) Tannebaum R, Schmidt W. How to Choose a Leadership Pattern. Harvard Business Review 1973; May/June.

(n16.) Adair J. Action-centred Leadership. New York: McGraw-Hill, 1973.

(n17.) Healthcare Commission. National Survey of NHS Staff. Healthcare Commission, 2006. www.healthcarecommission.org.uk

(n18.) Onyett S. On a network with attitude. Health Serv J 2008 (suppl); 21 February: 2.

(n19.) Tuckman B. Developmental sequence in small groups. Psychol Bull 1965; 63: 384-99.

(n20.) Tuckman B, Jensen M. Stages of small group development revisited. Group Organisational Studies 1977; 2: 419-27.

(n21.) Belbin M. Management Teams. New York: John Wiley & Sons, 1981.

(n22.) Dodoo M, Roland M, Green L. UK lessons for US primary care. Annals of Fam Med 2005; 3: 561-2.

~~~~~~~~ By Monica Fletcher

Monica Fletcher, MSc, chief executive, Education for Health, Warwick

Copyright of Practice Nurse is the property of Medical Education Solutions Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

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