Governments over the past four-decades have heralded multiprofessional working in health and social care as desirable in order to improve the quality of care to patients. Foreman and Nyatanga (1999) discuss the political and professional developments that have been put forward to encourage the development of what they call ‘ co-operative care delivery practice’. They provide a list of legislation and reports covering the period 1962 – 1997 that they claim should have fostered interdisciplinary co-operation.
During this period (1988) Griffiths coined the phrase the “seamless service” and it appears in the NHS and Community Care Act of 1990. This was intended to enable the different agencies to work better together and to deliver care based on the needs of the patient. Patients should be able to move between hospital and primary care efficiently without problems arising with the communication of information between different professional groups delivering the service. As with many government documents this was more of a vision than an evidence-based achievable goal. But what research evidence is there for the benefits of teamworking?
Work done by Guzzo (1996) suggests that only in the past 15 years has the importance of teams to public and private organisations been realised and acted upon. Although there has been effective teamworking for many centuries. The Egyptians would have required teams to work well together in order to have built the pyramids and military teams have been operating as successful units over probably a greater number of years.
Convergent evidence for the benefits of teamworking comes from work by Macy and Izumi (1993) and Applebaum and Batt (1994) in West and Slater (1996). Macy and Izumi analysed 131 organisational change studies in order to determine their effectiveness. The interventions with the greatest effects on financially related measures of organisational performance were found to be team related interventions. They also reduced staff turnover and absenteeism more than other interventions. This showed that team related activities can have positive effects on organisations. Applebaum and Batt reviewed a dozen surveys of organisational practices and 185 case studies and found evidence of improved organisational effectiveness. On a cautionary note West and Slater, who looked at effectiveness of primary care teams, state that when determining effectiveness, teams can be seen as effective or not depending upon the criteria used to determine effectiveness.
So there is some research evidence to suggest that there are benefits to multiprofessional teamworking but what are the features that would lead to teams being successful and can these be transferred to teams in different contexts?
Guzzo and Shea (1992) developed some research-based recommendations for developing effective teamwork.
1. Individuals need to believe that they are a vital part of the team. If they feel there contribution is not valued they are less likely to perform effectively or put in much effort to achieving the team goals. Roles should be developed to make individuals feel indispensable and essential.
2. Roles should be meaningful and intrinsically rewarding. This will make individuals feel more committed and creative if the tasks they are doing are engaging and challenging.
3. Teams should have intrinsically interesting tasks to perform this makes them committed, motivated and co-operative.
4. Individuals contributions need to be identifiable and subject to evaluation. People need to feel that their work is being seen by others.
5. Above all the team goals need to be clear and have built in performance feedback. There is consistent research evidence that suggests that when people are set clear goals their performance is better than with ill-defined goals.
These are general team rules but are they applicable to the range of situations that are found in the multidimensional teams in health and social care. West and Slater (1996) question whether these are applicable to Primary care teams. The first three conditions they believe are met but they feel it is rare for individual contributions to a team to be measured and for feedback to be given on performance. Most noticeably they assert that primary health teams do not have clear, specific objectives and goals (West and Poulton 1995). If this is the case then the notion that a “seamless service” can be accomplished with better teamworking in health and social care would appear to be an unattainable goal. If the teams do not have clear targets they will not be able to function effectively.
Taking a more specific view of the successful features of teams in interdisciplinary working contexts Mandy (1996) suggests five characteristics for successful teams. Goal directedness: There should be a clear, central purpose and recognisable idea which serves as a focus for the work which transcends disciplinary boundaries. This may be difficult as members of healthcare teams often have different interpretations of the care required depending upon their professional perspective.
Disciplinary articulation: The role of each member of the team should be clear and areas of commonality transparent. Role development is the expansion of the traditional duties and responsibilities of a professional into roles undertaken by others. For example a nurse practioner, with suitable education and training, may undertake some of the duties of a doctor. With the increase in role development that is likely to occur as a result of the NHS plan (D.o.H. 2000) there is an even greater imperative for professions to communicate their role within the multidisciplinary team. Failure to do this may affect the ability of professions to be able to work efficiently together, as they might not know what the other does or may be able to do for the patient. This could lead to a duplication or omission of services.
Communication: It is necessary for professions to understand the different ways in which disciplines understand, gain and use knowledge otherwise they will not understand how the same phenomena are interpreted differently by others. For example some disciplines use a medical model to inform their body of knowledge. This knowledge is passed on using language particular to this model and uses a hypothetico- deductive approach to knowledge acquisition. There is often a disease process or reductionist focus to care. Others use a social model which again has its own language and uses a more sociological approach to knowledge. There is often a holistic approach to care.
Flexibility: This refers to the valuing of different perspectives, accepting changes in authority and status and a willingness to take on challenges. With the increasing pace of change in the health and social services this is likely to become an imperative.
Conflict management: This can include the understanding of the difference between accountability and responsibility for the team members as well as knowing what is expected of them.
These are the conditions that can promote effective and successful teamworking in health and social care teams. If implemented the quality of the service patients receive should be extremely high. The reality of the service provided for many patients suggests that there are many problems and difficulties in trying to achieve these conditions for effective teamworking. Several of these barriers to effective teamworking will now be discussed and some examples of poor teamworking described.