-Victor Sigalov, MD, Senior Staff Research Associate, UCLA School of Medicine and Co-Investigator on the UCLA Macy grant
-LuAnn Wilkerson, EdD, Sr. Associate Dean for Medical Education, Professor of Medicine, UCLA School of Medicine and Co-PI on the UCLA Macy grant
For the past two years supported by a grant from the Macy Foundation, we have been working with faculty members from medicine and nursing at UCLA to create a set of tools for assessing interprofessional competencies based on the Core Competencies for Interprofessional Collaborative Practice.
Our initial work focused on developing tools for assessing the knowledge, attitudes, and behaviors of individuals. Over the past six months, we have turned our focus to the assessment of teamwork in the workplace. As we have moved into the workplace to pilot test several direct observation tools, it has become increasingly clear that none of the groups we observed working together constituted a team.
What is teamwork?
Much of what is known about teamwork is drawn from professions outside of health care. Understanding of teamwork principles and universal components—collaboration, interdependence, coordination of roles, communication, shared identity, integrated decision making, and common goals—has evolved over years from studies in the military, sports, engineering, business, and the airline industry.
In health care, teamwork talk is all the rage. Several years ago, all surgeons, nurses, and other operating room personnel at UCLA were required to participate in cockpit management training.
But, “exporting” successful teamwork or team building experience to health care is a tricky business that does not guarantee the same success (or success at all) we’ve seen in other professional environments. Different environmental contexts define, often in a distinctive way, the conditions of team existence, the space and time of team operation, the consequences of team success and failure, and, overall, the team culture. Indeed, building a successful team in any particular field requires careful consideration of both the universal and the unique contextual characteristics of teams and teamwork.
Building Teams in the Healthcare Workplace
The environmental context of a cross-disciplinary healthcare team is extremely complex and multi-demanding. Through our work, we’ve identified several contextual limitations:
- First, the members of a healthcare team are not forced to cooperate to “win” against an external threat except when it is the time pressure in an emergency situation. Nor do healthcare teams have to compete with one another in the pursuit of a personally valued commodity as do sports teams. Thus, the urgency that creates true interdependence among team members is often missing for healthcare teams.
- Second, healthcare team membership is unstable and ever shifting. The health workplace is characterized by endless interruptions, shifting responsibilities, limits on work hours, immediate patient needs, competing time demands, and educational goals that often necessitate fast and frequent changes in the team structure. In our recent observations of ICU teams, the team composition shifted from moment to moment, even during discussion and care of a single patient.
- Third, the healthcare teamwork environment requires that communication, collaboration, and shared-decision making be established not only between designated team members, but also between the team members and a patient – conventionally known as a “subject of care” and, generally, someone who is not familiar with the language and the content of care, as well as with the “rules” of teamwork. Sports fans and airplane passengers are appreciated and pay for the work of the team, but do not directly contribute to achieving the team goal as patients do in healthcare.
- Fourth, unlike in the airline industry, the lives at risk should a healthcare team fail almost always includes only one—the patient, not other team members “in the cockpit”!
Our Proposal: Adding the Patient to the Team
In the absence of a threat to the team survival, external competition, or a tangible reward, a patient as a team member might serve as the strongest motivating factor for turning a group of healthcare providers into a team.
To pilot test a tablet-based observation tool in interprofessional teamwork settings, we have spent time on a geriatrics service, with multiple ward teams, in various ICU settings, and in outpatient clinics. In the many observations that we have done, we have not seen patients engaged as members of the team.
Engaging the patient as a team member means more than practicing patient-centered care—it requires that everyone in the team, including the patient, becomes well-informed on the issues at hand and capable of making and negotiating health care and prevention decisions.
A patient who becomes intimately involved in the improvement of his or her own health, safety, and wellbeing by establishing communication with every team member makes the shared goal visible and necessary to turn a group into a functional team. More importantly, it can instill the emotional commitment that stimulates interdependence against a common threat now experienced by every member of the group—losing one of the team members.