MEDI11004 Professional Practice Study Guide

2. Teamwork & Interprofessional Collaborative

Care
Synopsis
Collaboration is a recent focus in health care. It is now well recognized that practitioners cannot work in
isolation and that collaboration and teamwork lead to better health outcomes for patients. This chapter of your
study guide will consider the team work process and how health practitioners can improve and enhance their
practice, to deliver optimal care for patients, through the use of team work.

Learning outcomes
Upon successful completion of this week’s study, you should be able to:
1. Define a team and teamwork
2. Describe team characteristics and roles
3. Identify team ground rules
4. Describe the stages of team formation
5. Identify issues related to dysfunctional teams
6. Describe the key components of interprofessional care provision
7. Describe the benefits of interprofessional collaborative care
8. Discuss factors for effectively participating in an interprofessional health care team.
9. Describe the role of interprofessional collaboration (IPC) in difficult or unexpected ethical problems and/or
dilemmas.
10. Identify methods to improve and support IPC including Interprofessional Collaborative education (IPE)

Key terms
 Team work
 Stages of team development
 Team roles
 Team ground rules
 Dysfunctional teams
 Team conflict & conflict resolution
 Social loafers
 Interprofessional collaboration.
 Interprofessional collaborative care (IPC)
 Interprofessional Education (IPE)

Teamwork
‘A team is not a bunch of people with job titles, but a congregation of individuals, each of whom
has a role which is understood by other members. Members of a team seek out certain roles and
they perform most effectively in the ones that are most natural to them.’
Dr. R. M. Belbin

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The Importance of Teamwork

One of my good friends is a regional health manager who has worked all over Australia. He recruits health care
professionals to staff multiple facilities and engages with students on clinical placement within these facilities.
Students often ask him about the possibility of employment on qualification. His first, and instinctive reply, is:
are you good with people?

He’s not really interested in their GPA, or their technical expertise, or in their creative ideas, or their ability to
manage a patient list on time or a department on budget, but in their people skills. “People skills” are sometimes
referred to as “soft skills”, as if to differentiate them from the hard skills of science, knowledge of diagnostic
pathways and treatments, procedures and processes. Pulko and Parikh write:

Over the past 10 years there has been an increase in emphasis on 'soft' skills in HE (higher education)
programs. Reflecting both the demands of potential employers and professional bodies, as well as the
creativity of course designers, modules such as first year 'study skills' and final year 'professional skills'
have become more and more common. The greatest focus has been placed on fundamental topics such as
presentation skills, effective report writing, teamwork, and time/project management. (Pulko & Parikh
2003: 243).

In Australian universities, all undergraduate programs aim to deliver a set of “graduate attributes” or generic
skills. The ability to work as part of a team is invariably one of these skills.
Learning to be a functioning, effective and contributing member of a team means that you will graduate with
enhanced personal and professional skills. These attributes contribute to a higher demand for your services,
better remuneration, and greater kudos for your alma mater in the inevitable league tables generated from the
various forms of monitoring graduate outcomes.

Team Characteristics
In evaluating communication and teamwork, The Melbourne Law School (2013) developed a list of
characteristics common to effective teams. These include:
 Membership: 2 or more individuals work towards a common goal (ideal number is 3-5)
 Common goal: members have negotiated shared aims and goals
 Social organisation: group develops or negotiates functional norms, roles and relationships
 Interdependence between members: members succeed only if all succeed
 Productive involvement: all members contribute equally to the workload; resources and skills are
identified early on and used effectively. Decisions are made by consensus.
 Effective communication and interaction: face-to-face and other modes of communication help to
monitor group processes and dynamics, drive creativity and enable productive work practices.
 Mutual interest: members focus on the interests of the group as a whole, and avoid personalising
problems or differences of opinion.
 Collective consciousness: members perceive themselves belonging to the group even when the
group is not together.
 Mutual trust: members listen to each other, respect contributions, help each other to clarify ideas,
and show interest in each other.
 Cohesion: group processes function smoothly without the need for intervention, members are able
to contribute equally to produce something greater than the individual parts, individual
contributions are brought together seamlessly and within nominated deadlines, and members feel
that they have learnt something from the process and from the group members.
(Adapted from Maughan & Webb, Lawyering Skills and the Legal Process; and Hay Dungey & Bochner Making the
Grade: A Guide to Successful Communication and Study)

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Stages in Team Development

The stages that a group moves through as it develops and undertakes the tasks required are shown in the table
below in sequential order. Although the initial stages of group formation generally involve a fair amount of
socialising, it is essential to guide the team as quickly as possible through this stage so that performance of the
task takes place (Wielandt & Wolfe, 2013). This is achieved through refocusing the group discussions by
negotiation and coming to a shared understanding of the direction for each meeting and long-term goals (Royal
Collage of Nursing & Clinical Teams Programme, 2007). Group members are also more likely to adhere to
these goals if they believe that the process leading to them was fair (Wielandt & Wolfe, 2013).

Stage Tasks Group Structure Potential Problems

Identify task and methods to
accomplish.
Establish rules for behaviours
FORMING and how to handle group
conflict.
Decide what information is
needed.
Question the value and
feasibility of the task.
STORMING
Choose sides within group and
draw divisional lines.
Establish and maintain realistic
group parameters for
behaviour and performance.
NORMING Establish plans and work
standards.
Develop communication of
views.
Understanding of members
strengths and weaknesses.
PERFORMING
Constructive and effective work
on the task.
Public celebration/ closure
MOURNING ceremony to mark the formal
end of the team.
(Worcester Polytechnic Institute (2002) Groups: Forming, Storming, Norming, and Performing, Accessed: 28 June 2004
http://www.cs.wpi.edu/~dcb/courses/CS3041/Group-info2.html.)
Considerable anxiety, testing to Impatience of some members
discover the nature of the with abstract discussions.
situation, what help can be No clear focus on task as
expected from the facilitator, and evidenced by irrelevant
what behaviours will be discussions or complaining
appropriate or inappropriate. about organisational problems.
Conflict emerges among sub- Argument among members
groups; the authority/ even if there is agreement on
competence of individuals is issues.
challenged. Opinions polarise. Tension, jealousy, lack of unity.
Individuals react against efforts of Establishment of unobtainable
the others to control them. goals.
The group begins to harmonise; it
experiences group cohesion or
unity for the first time. Norms
Conflict avoidance in an
emerge as those in conflict are
attempt to promote harmony.
reconciled and resistance is
overcome. Mutual support
develops.
The group structures itself or
accepts a structure which fits
most appropriately its common
task. Roles are seen in terms
functional to the task and
flexibility between them develops.
The group must accept that the
Sense of loss and anxiety at
project is complete and disband
having to break-up.
gracefully.

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Team Ground Rules

Consider the following questions and you will identify the need for team ground rules in the form of a team
charter. A team charter is best drawn up during your first group meeting:

o How will we make decisions?

o Must all team members be present to make a team decision?

o How will we structure the meetings (frequency, agenda, roles, interruptions, closure)?

o How will we communicate with each other so that information doesn’t fall through the cracks?

o How will we stay on top of team issues, such as task completion and performance
management?

o How will we resolve team conflicts?

(Slobodnik, D. and Slobodnik, A. (1996) The 'team killers', HRFocus, June, 22-23.)

Developing a team charter which establishes ground rules is best undertaken during the initial team meetings – as a
team negotiate responses to the categories below. A team charter is an important part of the forming stage of the
groups processes
1. Communication
a. Method
b. Frequency of checking
c. Response time/ acknowledgement required
2. Meetings
a. Potential times / places for meetings
b. Responsibility for setting agenda
c. Responsibility for taking minutes
d. Procedure if can’t attend (apologies)
3. Roles & responsibilities
a. Method of selecting leader
b. Leader responsibilities
c. Team member responsibilities
4. Task Timeframes – deadlines
a. Task allocation
b. Negotiation of timelines
c. Procedure if can’t make deadline (ask for extension/ help)
d. Procedure for repeat offender (support / seek advice of course coordinator / exclusion of social
loafer)
5. Means of resolving conflict
a. Emergency team meeting
b. Procedure for seeking help with unresolved conflict (support / seek advice of course
coordinator)
c. Procedure for repeat offender (support / seek advice of course coordinator / exclusion)

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Examples of team ground rules are given below:

Example 1
 Open, honest, focused discussion
 Supportive of each other’s involvement
 Challenging but constructive
 Mutual respect
 Well prepared for meetings
 All contribute – discussion and workload
 Work to a timetable
Example 2
 People should feel free/ assertive enough to state when rules are being infringed
 More consultation about decisions – more information about decisions made
 Everyone should have a voice and be heard
 People to be encouraged to be innovative (the risk takers)
 Risks are for the common good of the group – not just individuals
 Be open to change – be prepared to try different ways of doing things
 That there be mutual respect for all team members
 Dignity of all people is maintained
 Don’t be backward in asking/ coming forward if you need help
 Each person to be committed to communicating with each other
 Be positive and give praise to others
Example 3
Team members will:
 do their fair share of work
 check to ensure that everyone understands what is to be done
 Encourage planning
 Listen willingly and carefully to others, even if viewpoints differ
 Help the team organise work
 Involve others by asking questions
 Treat all team members as equals
 Continue to look for different ways to solve a problem
 Openly voice opinions and share ideas
Example 4
 Punctuality
 Respect others – let them speak
 Prepare for meetings
 Agenda for meeting + opportunity to expand it
 Keeping flexibility to agenda
 Achieve resolutions
 Purpose for meetings
 Structure meeting times to meet schedules of all
 Keeping to agenda
 Meet for good of the team
 Suspend judgement
 Allow time for reflection
 Be creative

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Dysfunctional Teams

A dysfunctional team is a group in which the members do not work effectively together towards a common goal
(Foundation Coalition 2001).

The Melbourne Law School (2013) identified common reasons why a team might fail to perform:

 Disorganisation, lack of direction or leadership

 Unclear or conflicting goals and expectations

 Fragmentation of time and competing commitments

 Lack of motivation or dedication

 Conflict

Two major causes of dysfunctional teams are social loafing, and unresolved conflict.
Social loafing, “the tendency for individuals to reduce their own personal input when performing as part of
group” (North, Linley & Hargreaves 2000: 389), can be but one cause of conflict within a team. Research shows
that having the right number of people is a key element for a cohesive team. Too many people can be
unconstructive and bring on social loafing (group members work less hard on tasks as they think another
member will do it for them). (Levine and Hogg, 2009). Students find it difficult to report social loafing.
The literature suggests that there can be two forms of conflict within a team: task conflicts and relational
conflicts. While for a number of years it was thought that task conflict in teams could be productive, and that
relational conflicts were destructive in relation to team performance, more recent research suggest that both are
destructive of team performance (De Dreu & Weingart 2003).

Methods to Overcome Team Conflict or ‘getting teams unstuck’

If there are dysfunctional patterns in your group, confirm that these are problem behaviours and not acceptable
norms. When a conflict arises between two or more parties it should not be allowed to escalate out of control.
Conflicts usually arise when team members disagree on how to approach a problem and they become unwilling
to back down on their respective ideas. If you disagree with another member’s idea or approach:

 Do not stay silent. This can lead to holding grudges.

 Say that you disagree (in a logical and respectful manner)
 Suggest an improvement or debate. To achieve the best team outcome all ideas must be heard.
 Never be critical of the person; debate the idea.
Agree on which tools to use in changing behaviours. For example, using humorous props such as a devil’s
trident for playing devil’s advocate or a plastic fish for naming “dead fish under the table” (taboo topics) to
allow free expression in meetings.

If stuck in circular decision making then use one of the following to keep members on track:

o polling: go around table and ask each member for opinion, preference or input;

o multi-voting: make list of options/ solutions and give each member 10 point to divide among
their top three solutions;

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o straw voting: ask for non-binding vote to break deadlock or gauge team’s current stance on an
issue;

o form subgroups: ask a subgroup to come to next meeting with recommended solution if a
problem is weighing the group down.

To prevent an argument from escalating- never be disrespectful and adopt the following behaviour:

 Speak clearly and calmly- neither aggressive nor submissive

 Be careful with body language – keep anger / irritation concealed

 Remain patient and speak in a calm and friendly tone (this cools everyone down)

 Remain seated – hides body language

 Use ‘I’ and not ‘You’- don’t assign blame

 Be patient and listen carefully for common ground

 Never ever criticise the other team members – only their ideas and do so in a logical and respectful
manner.

(Slobodnik, D. and Slobodnik, A. (1996) The 'team killers', HRFocus, June, 22-23.)

Interprofessional collaborative care provision

The World Health Organization in a recent report entitled Framework for Action on Interprofessional Education
and Collaborative Practice (WHO 2010) maintains that:
‘A collaborative practice-ready health worker is someone who has learned how to work in an interprofessional team and
is competent to do so.’

Collaborative practice happens when multiple health care practitioners from different professional backgrounds
work together to provide care and treatment for patients, families, and communities. This is a complex
interaction, involving mutually negotiated goals including care plans and procedures. The interprofessional team
pools knowledge and expertise to reach joint decisions based on shared professional viewpoints. The goal of
collaborative care is to deliver the highest quality of care for patients through harnessing the unique skills of
individual practitioners and building on the shared competencies of teams to analyze and address any problems
that arise.
The World health Organizations maintains that collaborative practice strengthens health systems and improves
health outcomes. Evidence supports this and research has shown both improved health outcomes for patients,
greater satisfaction for patients and improved patient safety. As an example, an interesting initiative that began
with the World Health Organization and was adapted by the University Health Network in Toronto, Canada, is
the surgical checklist that is used prior to any surgery being initiated. Such basic items on the list include a
requirement for each team member to introduce themselves by name and role prior to the surgery commencing.
It was found that just this small step made practitioners more willing to speak up when they had concerns and to
be listened to by the rest of the team regardless of their position or professional status. Below is an example of a
sample component of the checklist.

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Briefing—Before induction of Anaesthesia

Hand-off from ER, Nursing Unit or ICU

All team members introduce themselves by name and role

Anaesthesia equipment safety check completed—patient information confirmed

Identity (2 identifiers)—consent(s)—site and procedure—site, side, and level marked—clinical

documentation

History and physical, labs, biopsy, x-rays

Review final test results

Confirm essential imaging displayed

Medications

ASA class

Allergies (drugs, latex)

Antibiotic prophylaxis: Double dose? —Glycaemic control—Beta blockers—Anticoagulant

therapy (e.g., Warfarin)?

VTE Prophylaxis—Anticoagulant

Mechanical

Difficult airway/aspiration risk—Confirm equipment/assistance available

Monitoring—Pulse oximetry, ECG, BP, arterial line, CVP

Temperature; urinary catheter draining?

Blood loss—anticipated to be more than 500 ml (adult) or more than 7 ml/kg (child)

Blood products required and available—patient grouped, screened, cross matched - blood fridge
eligible?

The Surgical Checklist has been adopted worldwide and is now a well-researched tool that has been
recommended and published in leading medical journals. The Pilot study conducted by the World Health
Organization between October 2007 and April 2008 involved eight hospitals in eight cities: Toronto, Canada;
Seattle, WA; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara,
Tanzania; and London, England. The results found significant decline in the death and complication rate for
surgical procedures employing the Checklist. (An actual decline from a rate of death of 1.5 per cent before the
Checklist was introduced to 0.8 per cent afterward and a reduction in inpatient complications rates from 11 per
cent before the Checklist, to an astounding seven per cent after its introduction). These impressive results can be
largely attributed to the simple step of ensuring that the right information, about the right patient, was available
to the right health-care practitioner, at the right time and that all health-care practitioners in the operating room
functioned as a true team.
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An article on the pilot study and results can be found in the New England Journal of Medicine at:
http://www.nejm.org/doi/full/10.1056/NEJMsa0810119

Benefits of Interprofessional collaborative care

Interprofessional collaboration has been shown to:

Increase Decrease
workplace practices and productivity total patient complications

patient outcomes tension and conflict among caregivers

staff morale length of hospital stay

patient safety staff turnover

access to health-care for patients and families hospital admissions & wait time

potential for innovative solutions clinical error rates

Responsibility sharing & patient centred care mortality rates

understanding of discipline roles repetitive or duplicate services

use of multiple expertise

rural accessibility

Effective interprofessional health care teams

Interprofessional learning domains or competencies have been developed to assist educational program
development and professional development activities directed towards clinical practitioners. Although these
competencies have been taught in traditional health education programs, the focus with interprofessional
education is the team and effective collaboration aimed at improved patient outcomes. Effective
interprofessional collaboration involves the competencies listed below:
1. Team performance

 being able to be both team leader and team member and knowing the barriers to teamwork,
combined with effective leadership.
2. Clarification of Role and Responsibility

 understanding one’s own roles, responsibilities and expertise, and those of other types of
health workers
3. Effective Interprofessional Communication Skills

 expressing one’s opinions competently to colleagues and listening to team members,

combined with an understanding of conflict management.

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4. Learning and Critical Reflection

 reflecting critically on one’s own relationship within a team and transferring
interprofessional learning to the work setting
5. Patient / Family Centered Care
• working collaboratively in the best interests of the patient
• engaging with patients, their families, carers and communities as partners in care
management
6. Ethical Practice
• understanding the stereotypical views of other health workers held by self and others
• acknowledging that each health workers views are equally valid and important

Interprofessional Team problems

Interprofessional team problems generally revolve around issues associated with aspects of:
• Leadership- different styles, egos
• Different values, beliefs and opinions - Embodies holistic care but does require professional
‘connectivity’ (Robinson, 2005)
• Different codes of conduct and views – different titles - ethics vs conduct, language, dialogue and
negotiation - caring versus curing philosophy
• Role change as professions overlap somewhat, people can feel threatened
• Personal conflict between personal values and demands of professions e.g., termination. End-of-life
issues, ethical issues and differences of opinion

Methods to increase Interprofessional collaborative care (IPC)

The three mechanisms which act to increase IPC are improved interactions between health care professionals,
interprofessional student education and interprofessional support networks:
To Increase interaction between Health Care Professionals
• Use appropriate language when speaking to other health care providers or patient/family
• Understand all health care providers contribute to team or collaborative unit
• Show respect and building trust among team members
• Introduce new team member to the team in a way that is welcoming and gives them the information
they need in order to be a contributing member
• Turn to colleagues for answers
• Support each other when mistakes are made and celebrating together when success is achieved.
• Group reflection and supervision
• Joint education and training
• Managerial support

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(Barrett & Keeping, 2005)

Interprofessional Education
Interprofessional Education occurs when two or more professions learn with, from and about each other
For interprofessional collaborative practice to be realized in the health care environment, health care students
must be exposed throughout their educational program. WHO maintains that:
‘This interprofessional education is essential to the development of a “collaborative practice-ready” health
workforce, one in which staff work together to provide comprehensive services in a wide range of health-care
settings.’

Some of the educational benefits of interprofessional education are to:

 Improve collaborative practice, delivery of service and patient care
 Enable students to understand the knowledge and skill necessary for interprofessional collaboration
 Can be delivered in educational setting
 Be an enjoyable learning experience
 students have real world experience and insight
 staff from a range of professions provide input into program design/development
 students can learn about the work of other practitioners.

Interprofessional Support Networks

Australia has been one of the leaders in the movement for interprofessional collaborative care and education.
The UK and Canada have also been quite active in the promotion, support and implementation of
interprofessional care and education. In Australasian AIPPEN—Interprofessional Practice and Education
network is a very good resource that you should be aware of. The following, taken from the AIPPEN website
describes their role and activities in support of interprofessional practice:
‘AIPPEN is a network of individuals, groups, institutions and organizations committed to researching, delivering,
promoting and supporting interprofessional learning, education and practice. The primary aim of the network is to
promote better health-care outcomes and to enhance interprofessional practice through interprofessional learning in
Australia and New Zealand by developing a network to promote communication and collaboration among
members.
AIPPEN aims to:
• promote the development of a network that can link health professional education and care sectors,
universities, vocational education and training sector, government, practitioners and service users (patients);
• organize a series of seminars and conferences to share information and experiences;
• influence workforce policy and practice change in Australia and New Zealand;
• encourage research, evaluation and collaboration between different teams that can demonstrate the health-care
and economic advantages of interprofessional learning;
• disseminate information on interprofessional learning.’
(WHO 2010) http://www.aippen.net/

Interprofessional collaboration is a key focus of current educators and leaders in health care practice. They
recognize that health professionals need to break down the traditional silos and work together to provide the best

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possible care for patients. This undoubtedly will be a strong focus in your educational programs. The challenge
is for you to help transform the entrenched ways of thinking and doing things that you will likely encounter in
clinical practice. Interprofessional collaboration is moving forward and is being adopted by many health care
leaders. However, it is still early and much change is needed to really transform the health care environment and
the practitioners who work within it.

References
Belbin R.M. (1981) Management teams: why they succeed or fail, Heinemann, London.
Belbin R.M. (1993) Team roles at work, Butterworth-Heinemann, Oxford.
De Dreu, C. K. W. and Weingart, L. R. (2003) Task Versus Relationship Conflict, Team Performance,
and Team Member Satisfaction: A Meta-Analysis, Journal of Applied Psychology. 88 (4), 741-749.
Foundation Coalition (2004), Facilitating dysfunctional teams, Accessed: 23 April 2004,
http://www.foundationcoalition.org/home/keycomponents/teams/dysfunctional.html.
B Haynes, M.D., MPH, Thomas G Weiser, M.D., et al. for the Safe Surgery Saves Lives Study Group 2009, ‘A
Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population’, N Engl J Med; vol. 360,
pp. 491–499 January 29.
Jessup, R 2007, ‘Interdisciplinary versus multidisciplinary care teams: Do we understand the difference?’,
Australian Health Review, vol. 31, no. 3, pp. 330–331.

Maughan & Webb, Lawyering Skills and the Legal Process; and Hay Dungey & Bochner Making the
Grade: A Guide to Successful Communication and Study
North, A., Linley, P., & Hargreaves D. (2000) Social loafing in a classroom task, Educational
Psychology 20 (4), 389-392.
Pulko, S. H. and Parikh, S. (2003) Teaching 'soft' skills to engineers International Journal of Electrical
Engineering Education 40(4) 243-255.
Slobodnik, D. and Slobodnik, A. (1996) The 'team killers', HRFocus, June, 22-23.
Stone, N 2007, ‘Coming in from the interprofessional cold in Australia’, Australian Health Review,
vol. 31, no. 3, pp. 332–340.
The Surgical Safety Checklist: A Must for Hospitals Performing Surgery Information and Privacy
Commissioner of Ontario April 2009.

Worcester Polytechnic Institute (2002) Groups: Forming, Storming, Norming, and Performing,
Accessed: 28 June 2004 http://www.cs.wpi.edu/~dcb/courses/CS3041/Group-info2.html.

Internet resources
BMJ.com—Reducing errors in medicine

http://bmj.bmjjournals.com/cgi/content/full/319/7203/136

VA’s Culture of Safety—Errors in Medicine

http://www.va.gov/oaa/orientation/safety_disclosure.asp

Indiana University School of Medicine, October 18, 2004

Errors in Medicine: The Patient’s Perspective
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http://medicine.indiana.edu/news_releases/viewRelease.php4?art=212&print=true

http://www.ipc.on.ca/images/Resources/surgicalsafety.pdf

Revision Questions
1. Define a team.
2. List four advantages of team work.
3. List four characteristics common to effective teams.
4. Identify one Belbin team role and describe the typical features, strength & weakness of this
role.
5. Identify the five stages of team development.
6. List four key elements of a team charter.
7. Describe social loafing and the concept of team role conflicts.
8. List four ways to resolve team conflict.
9. Define interprofessional collaborative practice.
10. Describe the goals of interprofessional collaborative care.
11. List four benefits of interprofessional collaborative care.
12. Describe four factors which contribute to the effective working of collaborative health care
teams.
13. List four factors which can cause interprofessional team conflict.
14. Describe two methods used to increase interprofessional collaborative care throughout the
health care professions.
15. Define emotional intelligence.
16. Describe servant leadership.

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