a qualitative study of the attitudes to teamwork of graduates from a traditional and an integrated...

Advances in Health Sciences Education 8: 139148, 2003. 2003 Kluwer Academic Publishers. Printed in the Netherlands. 139

A Qualitative Study of the Attitudes to Teamworkof Graduates from a Traditional and an IntegratedUndergraduate Medical Course

SARAH WILLIS, ALISON JONES, PATRICIA MCARDLE and PAUL A.ONEILLUniversity of Manchester, Mount Sinai School of Medicine(author for correspondence, 1st floor, Rusholme Health Centre, Walmer Street, Manchester M145NP, UK, E-mail: [email protected])

Abstract. Introduction: In 1994 the University of Manchester medical school introduced anintegrated undergraduate course using problem-based learning throughout. This study exploresdifferences between the new and old (traditional) course graduates attitudes to, and conceptual-ization of, teamwork.Methods: Semi-structured interviews were conducted with 24 graduates of the traditional course(graduating in 1998) and 23 from the new course (1999 graduates), representing approximately 14%of graduates from each cohort. Theories were then developed from concepts emerging from the data.Results: The new course graduates (NCGs) had a broader view of members of a health professionalteam. The NCGs believed that the medical team should provide support and were more comfortableconsulting them when faced with problems.Conclusions: The new curriculum has had some impact on conceptualization and attitude to team-work. However, further development is required if graduates are to see themselves as part of amulti-professional team.

Key words: attitudes, medical education, problem based learning, qualitative research methods,teamwork

Introduction

In 1994 the undergraduate curriculum at the University of Manchester medicalschool changed from a traditional to a more learner centred, integrated course, withstudents using problem-based learning (PBL) throughout the five undergraduateyears.

Several reasons underlie the change to the new course, with many innovationsbeing introduced in response to recommendations made by the General MedicalCouncil of the U.K. (GMC, 1993). Among these recommendations was theproposal that undergraduate medical education should promote the developmentof professional attitudes that would enable effective team-working such as havingan awareness of your limitations and a willingness to seek help. Specific elementsof our new course were designed to develop effective team-working skills in our

140 SARAH WILLIS ET AL.

students. For example, much of the learning done throughout the course is done insmall groups in order to develop good communication, collaborative working andinterpersonal skills. In addition, the PBL cases emphasize the roles various healthprofessionals play in relation to particular clinical scenarios. Furthermore, in theirclinical attachments, students spend a total of 20 weeks in a community settingwith an emphasis on the multi-professional team. Yet despite this general movetowards the promotion of professional attitudes amongst medical undergraduates,some recent research has shown that the competitive nature of medical school canmake collaborating and valuing collective effort difficult (Johnson, 2000).

However, other studies of teamwork have produced different results. Whileone comparison between graduates of a traditional and non-traditional coursefound that the non-traditional graduates rated themselves significantly higher forcollaboration (Hill et al., 1998), another (Mann and Kaufman, 1999), has reportedno significant differences in perceptions of preparation for teamwork. In a studyassessing junior doctors training needs it was found that while they had receivedtraining for teamwork in a general sense e.g., understanding the concept, appre-ciating the needs of other healthcare workers, they lacked training in specificskills such as chairing meetings or using strategies to facilitate teamwork (Hannon,2000).

Given the radical change to our course, we felt it was important to exploreand compare graduates perspectives on their levels of preparedness for teamwork.We considered that if the new course had had an impact on the development ofprofessional attitudes amongst our graduates, they would have different conceptsof, and attitudes towards, teamwork.

Methods

DATA GENERATION

A qualitative method was used to allow exploration of the subjects perceptionsand interpretations of their experiences (Pope and Mays, 1995; Silverman, 1997).Individual semi-structured interviews were conducted to allow respondents to talkfreely about their experiences, but within this we included a prompt for graduatesviews on teamwork. During the course of each interview, the house officers wereasked general questions about their perceptions of their undergraduate course aspreparation for the role of house officer, as well as more specific questions directedat exploring their attitudes to teamwork. The interview began with a prescriptive,set question about the respondents undergraduate course, but then developed toallow both the researcher and the graduate to discuss issues raised in relationto this question. If the respondent did not describe or allude to their role as ahouse officer and other members of staff (such as more senior physicians, nurses,social workers etc) then a prompt to reflect on teamwork was introduced by theresearcher.

GRADUATES FROM UNDERGRADUATE MEDICAL COURSE 141

A teaching hospital and a district general hospital were chosen as the sites of theinterviews. We aimed to interview all the PRHOs at those sites who had graduatedfrom our medical school. These sites were selected on the basis that the hospitalshad participated in the curriculum in Manchester for many years. In addition, itwas reasoned that these hospital environments would probably remain stable forthe period of the evaluation. The two types of hospital were included as thesebroadly reflected the PRHO posts that all graduates enter for their first professionalpost. Permission to carry out the interviews was obtained from the clinical tutors(responsible for the education and supervision of all house officers in a hospital).

At the induction programme for the PRHOs at each hospital, one of the authors(AJ) gave a short overview of the evaluation project and invited participation. Thiswas followed up with a letter to each PRHO explaining the study and seekingwritten consent for participation. All contact with the PRHOs was through researchassociates (AJ or SW), as it was considered that they would be seen as independentof the undergraduate course in Manchester.

The intention was to interview all PRHOs around three months following thestart of their first professional post. The reasoning was that this would allow timefor the PRHO to orientate and settle into their job, but that they would still bestrongly influenced by their experiences as an undergraduate. Each PRHO wascontacted by phone to arrange a time and place to meet.

The interviews took place in the hospital in which the PRHO was working. Aprivate room was used wherever possible and the interviews were scheduled to lastfor up to one hour. With the house officers consent, the interviews were recordedon tape and field notes were taken.

DATA ANALYSIS

The interview transcripts were read by each author independently and a codingframework devised. The data were coded and organised using the QSR NUDIST4 qualitative data analysis software package. NUDIST (Non-numerical Unstruc-tured Data Indexing Searching and Theorizing) is designed to support processesfor coding data via an index system, which enables complex searching to retrievepatterns in the data. These patterns derived from the data were analysed by theauthors and used to further refine the data coding framework. The authors then metand agreed between themselves theories emerging from, but still grounded in, thedata.

As the transcripts were analyzed to seek out emerging themes, negative caseswere sought to ensure concepts were refined appropriately (Taylor and Bogden,1984). The analysis drew on the constant comparative method (Glaser and Strauss,1967), with simultaneous coding and analysis of data to allow development ofconcepts. The authors then looked for similarities and differences between the twocohorts. Only the sections relating to teamwork are reported here, although therewere overlaps with communication skills and other areas.


Table I. Counts of Pre-Registration House Officers descriptions of who is in their team

OCGs NCGS

Who is in the team?The medical or surgical team currently working with only 8 2Medical/surgical team plus nursing staff 1 8The house officer plus nursing staff 0 3The team is multi-disciplinary 2 8

Total no. responses 11 21

Results

Twenty-four traditional course graduates (TCG) and 23 new course graduates(NCG) were interviewed. Those interviewed represent around 14% of each cohortof graduates from the University of Manchester medical school. The results arepresented in relation to three themes: Who is in the team? The team and the house-officer. The role of the course in developing the concept of teamwork.

A table of counts is presented below indicating the relative numbers of TCGsand NCGs who, during the course of their interview, and when prompted, clearlydefined who was in their team. This table also shows counts of the numbersof respondents who described their relationships with other members of staff,particularly nurses, as constituting working as a team.

WHO IS IN THE TEAM?

Traditional Course Graduates (TCGs)In general, unless they were prompted otherwise, the TCGs tended to interpret ourasking them to describe their experiences of working as a team as simply referringto what it was like to work with their medical or surgical firm. When asked to elab-orate on specific members of the team involved in an incident, a typical responsewas:

I think that its. . . . my SHO and registrar have always worked very much asa team . . . we tend to have a business round together in the morning.

New Course Graduates (NCGs)The NCGs referred to a more extensive network as a team. Many referred to theimportance of establishing and maintaining a good relationship with nursing staff:


One of the things that is drummed into you at medical school is to be nice tothe nurses and then theyll be nice to you back . . . . The other medical staffas well; the phlebotomists tend to get a bit annoyed with us because theresnormally quite a lot of blood taking that needs doing . . . . You have to workwith a team and with other members of staff, the same as in any job I wouldimagine.

THE TEAM AND THE HOUSE-OFFICER

Traditional Course Graduates (TCGs)In many instances TCGs did not use or define when prompted the term team-work, but their concept of working as a team emerged when they were discussingissues about working with other people, work relations, patient care, support fromother staff and asking for advice or information from other staff.

One of the most common elements in the TCGs views of how they related toother staff, particularly nurses, was when they needed their help, especially if theyfelt their knowledge was inadequate. Their descriptions suggest that, as PRHOs,they were not afraid to ask nursing staff for assistance and that they found themto be a useful source of information. The most frequently reported need for advicewas on prescribing medication.

. . . there are a lot of antibiotics and routine post-operative things that every-body gets and initially the nurses just used to tell me this is what you do. Itsaves you from having to look it up in the BNF or whatever, its a much quickerprocess . . . it saves a lot of time because, you know, theyve been working foryears and they could just tell you in five seconds.

Although TCGs did not conceptualise this gathering of information from varioussources as constituting teamwork, they valued the cooperation and support fromstaff and saw it as important for achieving their role.

Lack of support from others members of the medical team was frequently raisedas a negative aspect of the job, with many PRHOs reporting the difficulties of beingleft on their own on the ward when there were decisions that needed to be made.Most often, this problem was described in terms of neglect by more senior membersof the house officers firm:

I was on another ward for the first two months where it was so disorganisedand the senior doctors were no help at all, they just werent interested in us,so we were totally out on a limb. You know, this is your first job and yourejust not getting support from other people.

Knowing that help and support were available was crucial for TCGs, but this wasnot conceptualised as an issue relating to teamwork and they did not discuss theduty of care team members owe to each other.


While there was variation in the TCGs awareness of the role of nurses in termsof patient care, many commented that nurses had unrealistic expectations of therole of PRHOs:

. . . for example, the nurses have done something for many, many years andyouve only just started working, but if they cant manage something theyexpect you to be able to do it, but youve hardly done it twice.

This learning to negotiate with others, in terms of their expectations of the juniordoctors role, was problematic for some:

Ive had criticisms from my senior house officer and my reg saying that Ishould stamp my authority more down because I am the doctor . . . . It doesntmatter if the nurse has been there forty years, Im the doctor, Im more seniorto the nurse, and I find that bloody hard.

The value of effective teamwork in terms of better patient care did not emergeconsistently from an analysis of the transcripts. One TCG did see the value ofmulti-disciplinary meetings so that staff could work together to make sure thepatient was ready to go home. Others noted that multi-disciplinary meetings werea focus for interaction and discussion about patients.

The actual experience of working as a member of a medical team weredescribed as varying according to the culture of the internal medical or surgicalteam they are working with, and in particular to the attitudes of the consultanttowards others. One TCG commented that internal medicine teams incorporated amore multi-disciplinary approach.

It was not only the local practices of a team that TCGs felt had an effect onthe ways individuals worked together; two referred to working within a NationalHealth Service as constraining the ways people work:

I dont think its a question of whether I learnt it (teamwork). I mean Impretty good at working in a team. I just dont think the NHS is that up toworking teamwork / community and I think thats one of the big flaws, thatpeople dont work together as a team. That the duties are divided into this ismy duty, this is your duty, and then theres stuff in between, a grey area.

New Course Graduates (NCGs)A noticeable difference between the two sets of graduates was that NCGs recog-nized the need to consult other members of the team when decisions had to bemade:

I knew to call in for senior help when appropriate . . . Im sure if I couldnthave contacted anyone else, because my registrar, although he wasnt therehe was at the other end of the phone, so if he hadnt have been around I wouldhave called the consultant because I would have needed to.

Whilst another commented:


. . . its as equally important, teamwork and being able to communicate effec-tively with members of your team . . . . knowing when you cant handle thingsas well is quite important. Being able to ask for help as well . . . . I find itvery easy to discuss with my registrar what my problems are . . . shes veryconstructive about things and so is the consultant as well, so it does dependon teams.

Reflecting on the meaning of teamwork one said,

Well, the nurses come to you when they need something doing and you cometo the nurses when you need something doing. Is that really teamwork . . .? Itseems to me that its more about not stepping on anyones toes and just sortof getting on with people, but is that really teamwork?

Support from colleagues emerged as playing an important role in working as ateam:

It really helps if youre on a really good team, like we go out for meals andstuff, the whole crew, and its alright, but if youre not on a good team youbasically have to rely on your other colleagues for support.

The need for a multi-professional approach when dealing with rehabilitation issuesfor patients was also raised, but even then the NCG differentiated between theirteam and the other professionals:

You have to talk to physios quite a lot and ask for home as well, getting themready for home, you have to talk to OTs [Occupational Therapists] and socialworkers. But they tend to take care of all that side . . . . I tell them briefly whatI want or what the team has decided . . .

THE ROLE OF THE COURSE IN DEVELOPING THE CONCEPT OF TEAMWORK

Traditional Course Graduates (TCGs)Some TCGs said that they were unaware of the roles of non-medical staff until theystarted their PRHO post:

Its more difficult to get into the role of nursing staff when youre a studentbecause a lot of the time you can feel a spare part . . . . Whereas when yourea doctor youve got a need for you to be there, as a student there is no need.

It was suggested that spending time as part of a team while still a student wouldbe useful to familiarise students with the experience of ward work. The perceptionwas that they had not been taught enough about teamwork in the undergraduatemedical course, or had experience of working alongside the nurses. There had beenlittle exposure to the work of other health professionals as a student.


New Course Graduates (NCGs)Some NCGs drew on the small group work in their undergraduate course as usefultraining for working in a team. One illustrative comment was:

. . . we did a lot all the way through of working in different groups andworking with different people, and I think that sort of helps you. Once youstart you just have to get on with people.

Similarly, another reflected:

Youve just got to learn to adapt to different people really. I dont know, thecourse sort of put you in with different people and I thought that was reallygood . . . . In PBL . . . you [meet] different personalities and different walks oflife, and I thought that was really good . . . You should be put in with peoplethat you dont know, because thats what happens when you come here, youdont know them and you have to work with them.

The course was also praised for allowing students to learn the value of a multi-professional approach to patient care:

I think the bits of the course emphasising the sort of MDT approach, themulti-disciplinary approach to the patients, perhaps thats helped reallybecause the old school attitudes of us against them arent instilled in us atall and I think thats useful . . . . If you dont interact properly then things getvery difficult, both for you and for the nurses and for patients . . . I think itsright that theres a lot of emphasis on it.

Discussion

In this study, we have used a qualitative, goal free, approach to outcome evaluation(Worthen et al., 1997). In contrast, systematic reviews of outcome evaluation suchas those produced by Albanese and Mitchell (1993) and Vernon and Blake (1993)have commonly focused on achievement in examinations against set criteria. Suchevaluations have been limited in their ability to shed light on a range of theoutcomes from a medical undergraduate program that exist beyond a prescribed setof criteria. In order to explore perceptions and experiences of house officers thatmay fall outside of a prescribed set of criteria, in this research we encouraged ourrespondents to bring their own evaluative criteria. For this reason we used semi-structured interviews which invited the graduates to reflect on their attitudes to,roles in, and interactions with, others while caring for their patients. We asked thegraduates to describe these interactions, to describe what they thought teamworkinvolved, and then describe who was involved in teamwork in their own terms.

The results of the frequency counts clearly show that the TCGs had a biastowards the medical/surgical firm when conceptualising who they work with andwho constitute members of the same team. On the other hand, we have collected


evidence of a broader view among NCGs. In general, the NCGs were able to bettercontextualise their work and role as a house officer as involving working with arange of healthcare professsionals, and in particular nursing staff. In addition, therole of the team was described differently, with NCGs being clear that their teamhad a duty of care in supporting them when they needed help. The NCGs alsobelieved that their undergraduate course had played a role in their development ofattitudes towards teams and other professions.

As Boaden and Leaviss (2000) note, the organisational context of teamworkhas to be considered as well as the process. This is reflected in some of ourgraduates comments about the NHS and its cultural construction of particular,valued attitudes to certain ways of working. This means that even though the NCGsmay be better prepared for teamwork at the end of medical school, they will beexpected to fit in with the culture of a workplace which may not specifically, orovertly, value collaborative teamworking once they begin professional life. Thisrepresents a limitation to our study, since we asked the respondents to reflect ontheir undergraduate course and how it had prepared them for life as a junior doctor,rather than asking them to describe how the hospital they were working at valued(or undermined) working as a team in order to maximise patient care.

The emphasis in the new course on attitude development also seemed to haveproduced graduates who were aware of their own limitations and who were ableto act professionally alongside other members of their team. However, it was diffi-cult to attribute more general attitudinal effects to the change in curriculum. Itwill be interesting to see if the differences and similarities observed for conceptsof teamwork are evident in our analysis of the transcripts for domains such ascommunication skills or awareness of psycho-social aspects of medical care.

Conclusion

In conclusion, our research found evidence that the change in curriculum has had aneffect on outcomes, but there is a need for further more focussed research to explorein detail the complexity of the concept of teamwork. In particular, more researchis necessary to study the effect of the hospital setting on graduates perceptions ofteamwork.

Acknowledgements

The project is funded by the NHS, North West Region. We would like to thank thegraduates who took part in the survey.

ReferencesAlbanese, M. & Mitchell, S. (1993). Problem-based learning: A review of the literature on its

outcomes and implementation issues. Academic Medicine 68(1): 5281.Boaden, N. & Leaviss, J. (2000). Putting teamwork in context. Medical Education 34: 921927.


General Medical Council (1993). Tomorrows Doctors: Recommendations on UndergraduateMedical Education. London: General Medical Council.

Glaser, B.G. & Strauss, A.L. (1967). The Discovery of Grounded Theory: Strategies for QualitativeResearch. New York: Aldine de Gruyter.

Hannon, F.B. (2000). A national medical education needs assessment of interns and the developmentof an intern education and training programme. Medical Education 34: 275284.

Hill, J., Rolfe, I.E., et al. (1998). Do junior doctors feel they are prepared for hospital practice? Astudy of graduates from traditional and non-traditional medical schools. Medical Education 32:1924.

Johnson, C.E. (2000). The transformative process of residency education. Academic Medicine 75(6):666669.

Mann, K.V. & Kaufman, D.M. (1999). Evaluation of innovative curricula. Academic Medicine 74:S4S6.

Pope, C. & Mays, N. (1995). Reaching the parts other methods cannot reach: An introduction toqualitative methods in health and health services research. British Medical Journal 311: 4245.

Silverman, D. (ed.) (1997). Qualitative Research. Theory, Method and Practice. London: Sage.Taylor, S.J. & Bogden, R. (1984). Introduction to Qualitative Research Methods: The Search for

Meaning, 2nd ed. New York: John Wiley.Vernon, T.A. & Blake R.L. (1993). Does problem-based learning work? A meta-analyses of

evaluative research. Academic Medicine 68(7): 550563.Worthen, B.R., Sanders, J.R. & Fitzpatrick, J.L. (1997). Programme Evaluation: Approaches and

Practical Guidelines, 2nd ed. New York: Longman.

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