putting teamwork in context

Putting teamwork in context

Noel Boaden & Joanna Leaviss

Summary1 Multidisciplinary teamwork is becoming

more important in both the delivery of health care and

in the organization and management of that delivery.

The ®rst of these has been accepted but traditional

professional education has done little to address the

challenge it presents to professionals. Recent reforms in

the British NHS have made the challenge more urgent.

Professionals must work together but in increasingly

¯exible and innovatory ways. They are also required to

play more formal roles in NHS management and

policy. Where teamwork has been addressed in

professional education it has concentrated on the inter-

personal dynamics of working teams. This remains

important but to respond effectively to the new chal-

lenges curricula and educational practice will have to be

clearer about the variety of teams involved and the

importance of the context within which teams work.

One view is offered as to how that context might be

understood in order to map team diversity. Two models

are offered to help develop multidisciplinary team

learning. One of these deals with key aspects of the

organizational setting and the other with factors that

affect team processes. It is argued that both should help

to facilitate multidisciplinary curriculum development

but also suggest learning needs to be met within

unidisciplinary professional education. Concentration

on team dynamics alone will not deliver the teamwork

required in the new NHS.

Keywords Curriculum; delivery of health care,

*organization, trends; education, medical; Great

Britain; health care team, *organization, trends;

National Health Service, British.

Medical Education 2000;34:921±927

3A characteristic feature of much health care provision is

the wide range of people who contribute in various ways

to the diagnosis, treatment and continuing care of

patients. The role of the doctor and the nurse has long

been recognized, but the list of those involved often

now extends to include a range of other professional or

semi-professional staff, support staff of various kinds

and, increasingly, the lay carers who play a vital role in

many cases. This has led to acceptance of `teamwork' as

being fundamental to health care. The term `teamwork'

used in this singular way, however, hides the diversity of

staff involved in different `teams' and the variety of

teams needed to deliver care in large national health

care systems. The British National Health Service

(NHS) will form the basis of the discussion that follows

but the lessons apply to any developed system.

Membership of the group involved with any one

patient varies with their illness and their treatment. The

typical hospital group may work together as a `team',

sharing the care of a patient in the clinic or ward setting,

often dealing with an acute condition treated over a

short period. In community or primary care settings,

the group involved may be more widespread,

geographically and organizationally, often working

sequentially with patients in their own homes dealing

with longer term, chronic conditions. These latter cases

change the concept of `team' in signi®cant ways,

particularly given the wider range of professionals

involved in such cases.

A proper concentration on either kind of `care team'

should not disguise the fact that the organization of such

care involves large acute hospitals or community trusts

and smaller (now becoming larger), but equally com-

plex, primary care organizations. All of these involve

appropriate management arrangements and the need

for a basis from which to establish formal accountability

for care, both of which introduce elaborate teamwork

often including professionals alongside managers in

multidisciplinary teams. Such teams have no direct

involvement with patients, but do create the framework

within which service-delivery teams have to work. In

that sense, they are just as important for the delivery of

Department of Health Care Education, University of Liverpool,

Liverpool, UK

Correspondence: Professor Noel Boaden, Department of Health Care

Education, University of Liverpool, 2nd Floor, Thornley Building,

Brownlow Street, Liverpool L69 3BX, UK

Policy issues

Ó Blackwell Science Ltd MEDICAL EDUCATION 2000;34:921±927 921

ef®cient and effective care as the direct care teams.

Concern with teamwork needs to embrace the whole

spectrum of teams if it is to engage with development

in the NHS and if professional education and training

are to serve the realities of modern professional practice.

This is not a new concern. It has been recognized for

a long time, but a recurrent criticism in the past has

been the failure of teams to function adequately.1 In

terms of service delivery, the tradition of medical team

leadership has not always produced harmonious or

cost-effective working.

In the worst cases,

particularly in the

community, services

have often been poorly

integrated creating

gaps in service provi-

sion or duplication of

services. This was

caused in part by the

structural problem of

people working for

different organizations

and by the idea of

cross-referral among

team members being

seen as an adequate

model of `teamwork'.

Referrers often knew

little of the skills of

those they referred to,

or of the constraints

under which they worked. Employing organizations in

any case had their own priorities that might cut across

the demands of referrals, especially where staff also had

their own direct caseloads. Even where such factors

were not present, in hospitals and sometimes in general

practice, there were often failures of communication

and mutual understanding among the members of

groups, even where they were formally constituted as

teams. The background of team members, their varied

organizational constraints and the inadequacy of team

dynamics created a recipe for team failure.

Traditional professional education has done little to

address this. Single discipline courses taught by role

models steeped in more traditional disciplinary ways of

working have created a culture in which professional

differences are maximized and mutual professional

awareness is less likely. Experiential learning is

emphasized but the opportunity for such learning in

effective multidisciplinary settings is rare, simply

because such settings are rare. Where they are

addressed, these issues are often seen as ones that can

be met by the transfer of core professional skills into

wider team settings. This has helped to produce a

concentration on team dynamics and team processes.

It is maintained that team problems can be overcome

by developing qualities among team members which

have been identi®ed as important to effective team-

work, e.g. communication skills, motivation and trust,

or by ensuring that teams are structured to optimize

co-ordination, cohesion and information sharing.

Shared team goals and clarity of team roles may

also impact on per-

formance. These fac-

tors are, of course,

important but such

approaches perhaps

pay insuf®cient atten-

tion to the impact of

professional and orga-

nizational roles on the

performance of team

members. Leadership

is a central role in such

approaches but the

traditional assumption

of medical leadership

has sometimes led to

complications in prac-

tice within teams. Less

account has been

taken of the context in

which teams work and

the extent to which

that affects the operation of teams, relationships

between team members and their behaviour within the

team.

The impact of recent reforms

There has never been a more appropriate time to con-

sider this wider setting. Already, dif®cult concerns

about teamwork are being greatly complicated by

events in the wider context of the health service. The

agenda is moving from a concern with established

teams blending traditional professional roles to deliver

team-care more effectively, to a concern to use team-

work to provide care both more ¯exibly, more equitably

and more cost-effectively. The implications of this for

the professionals within teams and for the organiza-

tional teams charged with managing development are

much more radical than the traditional drive for

teamwork. The issue is given greater urgency by other

changes, in structure and organization, designed to

facilitate the overall NHS agenda. The organizational

Key learning points

· Teamwork is a central feature of modern health care at all

levels of health care organizations.

· Teamwork is essential to service quality but is now

expected to deliver wider changes to deliver equitable

and economic services.

· Professional education has not developed teamwork and

current changes tend to focus on the narrower issues of

service delivery.

· Future education will need to focus on the wider concerns

of teamwork and this will involve consideration of the

range of teams and the contexts in which they work.

· This will be helped if we can develop models which help to

conceptualize teams in relation to their varied place

within health care organizations.

· It will also be helped by a clearer understanding of the

range of team member characteristics which may affect

team performance.

Ó Blackwell Science Ltd MEDICAL EDUCATION 2000;34:921±927

Putting teamwork in context · N Boaden & J Leaviss922

setting in which teams work, for example, in primary

care where the Primary Care Group or Trust is taking

responsibility for the performance of large numbers of

doctors and of associated professional and other staff.

Clinical governance with Chief Executives assuming

formal responsibility for performance, the operation of

the National Institute for Clinical Excellence (NICE)

and the possible intervention of the Commission for

Health Improvement (CHI) are all designed to secure

greater uniformity of practice across the emerging

teams within the new structures.2

In secondary care, hospital stays have shortened,

with a rapid increase in day-case treatment and much

earlier discharge for many conditions, together with

the movement to community care of many long-term

mental health patients. This is changing the work of

both the hospital and the community sectors, with

major implications for the role of different profes-

sionals, and of teams, in both settings. Finally it is clear

that a number of policies are directed at changing

directly the character of professional inputs. This

involves direct intervention in the clinical decisions

of many doctors, around treatments and priorities. It

involves changes in the staff mix involved in many

`teams' and, most importantly, changes in their roles

within teams.3 It also involves much more explicit tar-

geting of objectives for the service, evident in National

Service Frameworks and centrally determined targets,

which have a direct impact on clinical and related

decisions.

Such changes are giving added importance to the

need for teamwork and are adding to the complexity of

the teams in which many professionals participate. This

poses a challenge to professional education that is in

many ways only just beginning to take on board the

educational demands made by more traditional con-

cerns about teamwork. This suggests the need for a

more fundamental look at educational change, but one

that takes into account the more complex model of

teamwork outlined earlier.

Models of teamwork in organization

This approach to teamwork requires a much clearer

conceptualization of the typical settings that charac-

terize the NHS. Figure 1 outlines such a model

that seeks to re¯ect some of the important aspects of

most NHS organizations. Acute hospital trusts and

Figure 1 Organizational characteristics and team structures.

Putting teamwork in context · N Boaden & J Leaviss 923


community trusts are already large and complex

organizations and the advent of Primary Care Groups

(PCGs) and Trusts (PCTs) is moving primary care/

general practice in the same direction. In such organ-

izations, with their extensive and diverse staff, the model

suggests three key levels of organizational concern:

policy, management and direct service delivery. Clearly

the divisions between these levels are not absolute but

the main emphasis of teamwork at the different levels is

relatively clear. An important consideration at each

level, as the model suggests, is the environment within

which different teams operate. The organizational

environment at each level is very different with the

dynamics of decision re¯ecting the immediacy of dif-

ferent kinds of work. More important, perhaps, is the

external environment within which trusts and their

teams operate, with external directions looming large at

policy and management level while patient needs and

demand assert themselves in delivery teams.

The historical picture of incremental change within

largely stable patterns of care delivery has given way to a

much more volatile situation. The volatility partly arises

from the accelerated pace of medical advance but is

mainly driven by external intervention to promote

organizational change, greater equity of treatment and a

re-allocation of functions between organizations and

between staff to achieve goals of ef®ciency and cost

effective treatment. Such pressures mean that NHS

organizations are now awash with new demands over

and above those of maintaining patient care. Demands

are met by the creation of special teams, special projects

and by short-term initiatives to meet perceived crises or

externally determined performance goals. These special

teams work alongside the more established teamwork

patterns in the organization and can give rise to serious

tensions. Teams working in more traditional mode

enjoy a less glamorous role in maintaining existing

services, while the new developments are often given

special funding and are the object of higher pro®le

attention which can bring both positive and negative

results for those involved.

If the pattern of teams is more complicated, so too is

team membership across the different levels. There is

no longer an exclusive division of labour by organiza-

tional level. There are staff at each level whose concern

is exclusively focused within that level, particularly

among the very large number of care delivery staff. At

the same time there are some staff who participate at all

three levels. In the main, this involves professional staff

who continue to engage in direct clinical services but

who also play a part in both managerial and policy

making teams. Clinical Directors in acute trusts are one

such group and general practitioners or nurses on PCG

or PCT Boards are another. There are also profes-

sionals who have moved exclusively into managerial

roles but who often carry their professional identities

into the new role creating potential problems of team-

work with both professional and managerial colleagues.

If this model is accepted, it raises a wide range of

questions for those involved in providing initial edu-

cation and training, both for professional and other staff

and continuing education for all of the groups involved.

This is a timely moment to raise such questions.

Multiprofessional education is taking an important

place in the educational debate, responding in the main

to the debate about care delivery. At the same time,

basic professional education is being changed quite

signi®cantly in nursing and in medicine, though again

the emphasis concentrates on core needs that are uni-

disciplinary in character. The wider analysis being

offered here suggests the need for a more radical

approach in all these areas.

Curriculum reform for team development

In terms of the approach adopted here, there are three

areas where change is necessary:

· in the core curriculum of professional education, to

include some conceptual understanding of the issues

that surround the context of health care discussed

earlier;

· in the core curriculum of professional education, to

widen the concept of some professional skills to

facilitate their transferability into those areas of the

professional role that develop in the mature career;

· in postgraduate professional education and con-

tinuing education for all NHS staff, developing more

sensitivity to the complexity of teamwork processes

and the teamwork context.

The ®rst of these needs is, in principle, being met by

the advent of problem-based and community-based

learning into the undergraduate medical curriculum.

Both of these provide an opportunity within which the

health service context is important. The organization

and management of health care is relevant to most

problems that arise in problem-based learning but it

needs facilitators who can engage that relevance and

students with some awareness of the intellectual

material to which it gives rise. In community-based

learning the relevance of context is self-evident and

perhaps implicit in the development. The under-

standing of the community context, however, requires

some background in areas of study that currently fall

outside those required of students as well as outside the

experience of their teacher/facilitators.4



The second need poses a similar challenge. One of

the core skills that has achieved a very high pro®le in

professional education has been that of communica-

tion. Inevitably, this has focused on the clinician/patient

communication, recognizing the changing perceptions

of patients' rights and the dif®culties that arose when

communication was inadequate. Many of these issues

have been addressed and students are now more

exposed to learning opportunities that help to develop

communication skills. The assumption that such skills,

even in their more developed form, are easily translated

into other professional settings remains problematic

and lies at the core of improving teamwork processes.

Teamwork throws up communication needs, in group

settings with professional peers, with other professions

and with non-professional and lay members that are not

analogous to the clinician/patient relationship. Nor are

the purposes of teamwork always like those of the

relationship with patients. New skills are needed and

new forms of communication are involved, all of which

need training and practise if they are to develop.

These two needs are important but the concern of

this paper lies mainly with the third need, concerned

with postgraduate and continuing education for team-

work. Development of the model considered earlier

provides a basis from which educators and trainers can

develop their approach to the provision of opportunities

for staff involved in health care. Two aspects of team-

work are involved. The two matrices shown in Fig-

ures 2 and 3 illustrate the varied dimensions that might

underpin learning development in both areas.

Figure 2 relates to the signi®cance of team context

and provides a guide to educators in classifying the

teams they are dealing with and a basis for considering

some of the learning needs that are relevant for such

teams. Four dimensions are suggested: member

accountability, team location, team function and team

orientation. Figure 2 suggests a three-fold classi®cation

on each dimension and readers may enjoy trying

to classify their own team experience into the matrix.

A clinical audit team, for example, will be largely con-

cerned with delivery, may be de-centralised or outreach

in location, is likely to be considering adaptation and to

be professional in its patterns of accountability. Clinical

governance, on the other hand, is rather different.

There may be clinical governance arrangements at all

levels of a large trust, but the central team is likely to be

mixed in its perceived accountability, policy oriented or

perhaps managerial in its function and developmental

in its orientation. Immediately the challenge of team-

work in such a setting becomes apparent, and the scope

for problems as the focus moves down the levels of the

organization and nearer to what are wholly professional

teams involved in implementation.

Figure 3 presents a similar approach to model key

dimensions that affect team processes. As in the case of

context, one dimension relates to the geography of

teams in relation to the parent organization. It is argued

that team functioning will be closely related to whether

the team ®nds itself at the core of the organization,

operating in a decentralized mode or enjoying the

`freedom' that comes from detachment in an outreach

position. Of course, the latter may not follow if the

organization is concerned with team control and sets up

a rigorous framework of supervision to counteract the

implications of outreach. The other three dimensions

Figure 2 Dimensions of work teams ± team context.



relate to: team membership, disciplinary character and

the client group involved. Different points on each

dimension are exempli®ed to illustrate the different

features likely to be found in healthcare teams.

Some examples may help. It has already been implied

in the discussion of context that detachment may

loosen some of the constraints within which teams

function. This is equally true of team processes as

environmental factors assume different relevance and as

working relationships are removed from organizational

oversight in a direct sense. The client base of different

teams is also relevant as it affects both the degree of

client (and perhaps carer) involvement with teams and,

of course, the acute/chronic divide changes the pattern

and nature of professional inputs very signi®cantly. All

of these factors may ®nd an echo in the dynamics of

team activity and the distribution of in¯uence within

the team.

More obviously relevant are the varied patterns of

staff involvement that are found. Many teams couple

the two core professions of medicine and nursing and

there are examples in the literature describing the

impact that this has on team performance. The effect

on team dynamics of adding two or three more disci-

plines, no longer perhaps happy with being seen simply

as `associated with medicine', is obvious. This is even

more likely where the modern NHS is extending team

membership to embrace lay participants and the

general public in some cases. It is also likely to have a

bearing when the team is one of those in the senior

management or policy arena and involves managers and

professional members working together. But profession

is not the only variable at work here. There is ample

evidence of division within the different professions and

this is brought into sharper relief by changes in the

pathways of care and the models of care in different

sectors. In particular, this is an issue within teams that

straddle organizational boundaries such as when

general practitioners and consultants come together in

developing the primary/secondary interface. It is also

apparent within nursing where the different nursing

`disciplines' often have dif®culty in reconciling their

differences that are often emphasized in seeking

professional status for emerging specialties.

Conclusions

It seems clear from the models discussed earlier and

from the discussion of common examples found in

practice that teamwork is more complex than the edu-

cational approaches commonly adopted allow. The

seamless nature of health care delivery, and the neces-

sary links between NHS policy and the ultimate service

delivery, require that that complexity be understood.

They also require that many participants, at all levels of

the NHS, develop teamwork skills both within their

core area of expertise but also in handling the many

boundaries at which their work is affected by other

parts of the service. It is argued that this needs a more

fundamental examination of the dynamics of teams and

Figure 3 Dimensions of work teams ± process.



teamwork and developments in education that re¯ect

that examination.

Many useful initiatives are currently underway in

attempts to meet the challenges of multidisciplinary

working in the NHS. These tend to focus on the

professions involved and so omit key members of the

many teams involved. They also tend to focus on team

processes rather than on team context. A new emphasis

on context will require a new approach in basic, post-

graduate and continuing education. If that can be

introduced along the lines suggested earlier then it is

possible that the developing skills of today's graduate

professionals will prove more ¯exible and more trans-

ferable when they come to meet the challenges of a

highly volatile NHS in the future.

References

1 West MA, Poulton BC. A failure of function: teamwork in

primary health care. Journal of Interprofessional Care

1997;11:205±16.4

2 Secretary of State for Health. A First Class Service: Quality in

the New NHS. London: Stationery Of®ce, 1998.

3 Department of Health. A Health Service of All the Talents:

Developing the NHS Workforce. London: Department of

Health, 2000.

4 Boaden N, Bligh J. Community-Based Medical Education.

London: Arnold, 1999.

Received 19 June 2000; accepted for publication 24 June 20005



putting teamwork in context

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