Towards more effective clinical teamworking

Difficulties faced by the NHS and the teams of professionals working within it are widely recognised and, most days, some related article appears in the daily newspapers. Why then, where it perhaps matters the most, are sound team leadership and effective team working so little in evidence? In our experience, working with NHS teams struggling with a lack of resources and in pressured decision-making situations, the existence of destructive hierarchies, bullying in the workplace and poor communication seems to be prevalent.

Destructive hierarchies and bullying does seem too often to be the case in key medical teams. Overcoming such problems is particularly difficult and challenging for clinical teams. These are very powerful issues for the teams to face and they have to work incredibly hard to deal with them so that clinical excellence can come to the fore.

Why strive for clinical excellence in this environment? Why not carry on with the outdated ways of working, keeping the hierarchies intact and preserving the principles of keeping people in the dark and only communicating in extreme situations? After all, what does the nursing team need to know about important clinical judgements?

The simple answer to this is that the outdated methods do not work. The following points should be considered:

• Clinical excellence does not rely on one person’s judgement but on the performance of a whole team.

• Tight budgets become even tighter if costly mistakes are made through ignorance and poor communication.

• Patients are far more aware of their conditions and treatment options than ever before and have high expectations of their treatment.

• Everyone in the healthcare team has a legal responsibility and unfortunately litigation is becoming as much a feature of UK medical culture as it is in the USA.

WHAT DOES WORK?

What are the characteristics, principles and skills of high performance teams and how do clinical teams achieve what is necessary?

Possibly more importantly, how do those teams maintain this level once they have achieved it?

Team development expert Mike Woodcock has identified 11 building blocks that reflect effective teams and these hold just as true for medical teams as well as business teams. There should be balanced team roles – and the right balance of skills, abilities and team aspirations.

This flies in the face of medical hierarchies in which job role and function dictate the contribution to the team. Effective teams require different talents and skills and abilities regardless of job title. Truly effective teams are able to use different abilities, personalities and approaches to suit differing situations, but they can only do this if the mix of team membership is right. Every member of an effective team has a unique contribution to make.

GOALS

There must be clear agreement about, and understanding of, goals and objectives. People are only likely to be committed to goals and objectives if they can identify with them and feel ownership of them. It is especially important that the aspiration and goals and objectives necessary to become a centre of excellence are shared by everyone and not merely be an aspiration of the clinical lead.

Openness and confrontation issues need to be addressed. All team members should be able to express themselves openly and honestly without fear of ridicule or retaliation.

This is probably one of the most difficult objectives for healthcare teams to achieve. Assertive behaviour is rarely used as a behaviour option and it is more usual for team members to swing from submissive to aggressive behaviours – both behaviour types are highly damaging to the goal of clinical excellence.

Mistakes should be faced openly and used as vehicle for learning, and difficult situations need to be confronted rather than avoided without fear of blame or other repercussions.

Personal relationships within the team should be characterised by support and trust, with individuals helping each other whenever possible, whatever role they have. Trust is a belief that words will be translated into action and that others will take your interests into account. Support and trust are essential ingredients for team working if all team members are to feel valued and retain the high levels of self-esteem and confidence that make the difference to overall performance and patient perceptions.

Helpful competition and conflict of ideas can be used constructively. Unhelpful competition and conflict need to be eliminated. Everyone must put the team’s objectives before their own. A certain amount of positive conflict is helpful as it prevents teams from becoming complacent, and often produces new ideas. Team members should take pride in the success of their team.

All procedures must be clear and agreed to. This includes clinical procedures as well as more general administrative ones. Meetings should be productive and stimulating with all team members participating and feeling ownership of the actions which result from the decisions made. New ideas can abound and their use enables the team to stay ahead. There is a need to define at what level decisions are taken, how information is collected, how decisions are implemented/communicated, and how decisions are reviewed.

APPROPRIATE LEADERSHIP

Appropriate, motivational, leadership is essential – a team must feel it is being led in an appropriate way. The team should follow a plan/do/review process, with a strong emphasis on review. The team should regularly review performance and relate that performance to where it is going, why it needs to go there, and how it is getting there. If necessary, the team should alter its practices and behaviour in the light of that review.

All team members should have clear objectives and regular performance reviews. Individual development, either for career progression or advancement within a job role, is seen as positive, supportive and enriching. Personal development should be seen as highly important, but career progression is not necessarily the route all individuals wish to take. However, the encouragement of personal development is vital to the “health” of the team, keeping it “fresh” and proactive. Communication must be effective up, down and across the organisation. External help should be welcomed and used where appropriate. Often in clinical areas, teams keep to themselves for fear of exposing themselves to criticism, envy or unnecessary ego or power struggles. To create a successful team, effective communication methods are necessary for both team members and leaders. Even though some people understand that their communication skills need improving, many are not certain how to improve them. Working within a team can be rewarding, but at times it can be difficult and downright frustrating. If there are poor communicators within the team, individuals may feel left in the dark, confused or misunderstood.

Following are tips on how to avoid some common team mistakes, and how to be a better team member or leader. Individuals should:

• Communicate. If an individual has a problem with someone in a group, he or she should talk to that person.

• Avoid blaming others. People in a group lose respect for you if you constantly blame others for not meeting deadlines.

• Support ideas from other members of the group. If a team member suggests something, always consider it – even if it does not immediately appear sound.

• Avoid bragging. It is one thing to rejoice in your successes with the group, but do not act like a superstar.

• Listen actively. Effective communication is two-way and listening is a key skill. Look at the person who is speaking to you, nod, ask probing questions and acknowledge what is said by paraphrasing points that have been made.

• Be involved. Share suggestions, ideas, solutions and proposals with other team members. Take the time to help your fellow team members, no matter what the request.

Team leaders should:

• Coach, not demonstrate. A leader under time pressure can be tempted to be directive rather than to provide supportive coaching. Urgent medical needs must come first, obviously, but, wherever possible, the leader should take a coaching approach.

• Provide constructive feedback, communicating the good and the bad. It is always hard to hear criticism, but if you highlight the good things too it makes taking the bad a little easier. The leader should invite suggestions about how the team can improve.

• Know when to back off. A leader might assign a project – that is of particular interest to him or her – to another member of the team. Initially, the leader should provide some guidance and communicate that it is an open door policy for additional questions that may come up along the way. Then, importantly, the leader should back off.

• Try to be positive. Enthusiasm is contagious. If the leader is excited about a group project, it is likely others in the group will be excited too. Team members look to the leader for direction. If the leader notices that the group’s motivation and output levels have slumped, it is a “wake-up call”.

• Value ideas from the group. The leader should avoid phrases such as “Yeah, but…” and “We’ve already tried that”. If a suggested idea was attempted in the past but failed, consider that it may not have been executed properly or that it simply was not the best time for the idea to be implemented. Consider each and every idea that group members generate and encourage them to communicate their insights on a regular basis.

STAGES OF TEAM DEVELOPMENT

All teams have to pass through several stages of development as they move towards excellence.

Each stage has certain signs or characteristics that can be identified. A simple model based on four essential stages of development is useful in helping teams understand where they are and what they need to do to make progress. Clinical teams that we work with often find themselves oscillating between stages depending on the current situation facing the team and the changes that are continually taking place.

LEARNING AND DEVELOPMENT

Clinical teams aspiring to clinical excellence will benefit from learning and development, and need external help to provide them with the skills and guide them through the challenges.

Recent research has shown that health professionals receive little in the way of skills development and would willingly partake in development initiatives if these were available to them. Unfortunately, the reality is that the NHS provides little in the way of funding in this area. We have found that NHS teams can look to the help and support of pharmaceutical companies for educational sponsorship. It is through this route that teams have been able to obtain the knowledge and support they need to make the necessary changes, often in their own time, to achieve the goal of clinical effectiveness.

TOWARDS HIGH PERFORMANCE

Moving to a high level of team performance is not for the faint-hearted but it is the only successful and rewarding way of working in today’s challenging environment. Teams expressing an interest in taking this journey often need external help and we have found that teams respond well to this, seeing real success and satisfaction very early on, then building on excellent foundations to achieve their long-term goals.

Stages of team development

Stage 1: Underdeveloped This is the most common stage in which healthcare teams are found.

Characteristics of stage one:

• People are brought together to complete a job.

• People conform to the established line.

• Constructive ideas are not welcomed.

• People are disheartened.

• Leadership is not challenged.

• Little care is shown for others or their views.

• There is more talking than active listening.

• Personal weaknesses are covered up.

• The team cannot confront issues.

• Mistakes are used to convict rather than as opportunities to learn.

• There is no shared belief and understanding.

• The leader often has a different view to others.

• Outside threats are treated defensively.

• People confine themselves to their own defined jobs and the boss takes most of the decisions.

The greatest leap forward is when a team leaves stage one and moves to stage two because it has taken the decision to do something serious to improve matters.

Stage 2: Experimental

Characteristics of stage two:

• Problems are faced more openly.

•Wider options are considered before decisions are taken.

• Underlying values and beliefs are debated.

• More risky topics are opened up.

• The way in which the team is managed is discussed.

• Personal issues are raised.

• Feelings begin to be considered.

• Personal conflicts begin to be faced.

• People say things they have previously kept to themselves for years.

The team at this stage inevitably becomes more inward looking as it is almost obsessed with its own problems and new horizons. The team often rejects other groups and individuals. More concern is shown for the views and feelings of colleagues with a consequential increase in real listening.

Meetings become characterised by more listening and thinking, and less talking. Teams can sometimes feel uncomfortable at this stage but are also excited by the dynamics created.

Stage 3: Consolidating

Having moved through stage two, the team will have confidence, an open approach, and the trust to examine its operating methods.

At stage three, generally the team agrees to adopt a more systematic approach which leads to a clearer and more methodical way of working.

The rules and procedures of stage one are reintroduced as agreed operating rules of the team which everyone has had a part to play in developing.

Characteristics of stage three:

• The level of commitment is much higher.

• The purpose of the task or activity is clarified.

• Objectives are agreed.

• The required information is collected.

• All options open to the team are considered.

• Detailed planning takes place.

• Outcomes are reviewed and used as a basis for future improvements.

Stage 4: Mature

The openness, concern and improved relationships achieved by stage two, and the systematic approach introduced in stage three can now be used to complete the task of building a really mature team.

Characteristics of stage four:

• Flexibility becomes the keynote.

• Different procedures are adopted to meet different needs.

• People are not concerned with defending positions.

• Leadership is decided by the situation not protocol.

• Everyone’s energies are utilised for the team because individual commitment to the success of the team exists.

• There is pride in the team and its achievements.

• Individual initiative and achievement is recognised.

• People are happier and more effective.

• Needs and aspirations are met.

• Development becomes an increasing priority because the team realises that success depends on continued development.

• Trust, openness, honesty, cooperation and confrontation, and a continual review of results becomes a way of life.

• Above all, the team is a happy and rewarding place in which to be.