What do doctors mean when they talk about teamwork? Possible implications for interprofessional care

ABSTRACT

The concept of teamwork has been associated with improved patient safety, more effective care and a better work environment. However, the academic literature on teamwork is pluralistic, and there are reports on discrepancies between theory and practice. Furthermore, healthcare professionals’ direct conceptualizations of teamwork are sometimes missing in the research. In this study, we examine doctors’ conceptualizations of teamwork. We also investigate what doctors think is important in order to achieve good teamwork, and how the empirical findings relate to theory. Finally, we discuss the methodological implications for future studies. The research design was explorative. The main data consisted of semi-structured interviews with twenty clinically active doctors, analyzed with conventional content analysis. Additional data sources included field observations and interviews with management staff. There was large variation in the doctors’ conceptualizations of teamwork. The only characteristic they shared in common was that team members should have specific roles. This could have consequences for practice, because the rationale behind different behaviors depends on how teamwork is conceptualized. Several of the teamwork-enabling factors identified concerned non-technical skills. Future studies should put more emphasis on the practitioners’ perspective in the research design, to create a more grounded foundation for both research and practice.

KEYWORDS:

• Teamwork
• Interprofessional care
• doctors
• conceptualization of teamwork
• non-technical skills

Introduction

In healthcare, teamwork as an organizational form and a way to describe work has gained considerable interest in recent years. Previous research indicates that teamwork is associated with improved patient safety, more effective care and a better work environment (Kalisch, Lee, & Rochman, 2010; Lemieux-Charles & McGuire, 2006; Manser, 2009; Welp & Manser, 2016). We know that the language used in the team relates to the quality of teamwork, and that team members’ philosophies or interpretations of teamwork may affect performance (Freeman, 2000; Sheehan, Robertson, & Ormond, 2007). However, we know little about what healthcare professionals actually mean when they talk about teamwork. In a study conducted by Lyubovnikova, West, Dawson, and Carter (2015) of the English National Health Service, as many as 92% of the healthcare organizations reported that they organized their work in teams, but when classified according to Lyubovnikova et al.’s more precise definition of team membership only 37% worked in teams. Thus, many organizations that perceive their work as teamwork might not actually be working in teams when scrutinized through an academic lens. Another possible obstacle is the vast research literature on healthcare teams, which contains many different definitions of teamwork and inconsistent use of the term “team” (Bleakley, 2013; Xyrichis & Ream, 2008). Thus, if a different definition of teamwork were to be applied, it is likely that the result would be different compared to Lyubovnikova et al.’s (2015). To better describe different types of interprofessional practices, Reeves, Xyrichis, and Zwarenstein (2018) argue that the teamwork terminology needs to be further differentiated. They suggest that besides teamwork, the terms collaboration, coordination and networking could be used. Together, this leads to difficulties when discussing teams as an organizational form. Given the plurality of the use of the concept of teamwork in scientific discourse, we suspect that its use among practitioners could be just as confused. For this reason, it is surprising that so little research explores how healthcare team members actually understand the concept of teamwork.

The conceptions that different team members have about their team, its ways of working and its priorities, impact team performance (Makary et al., 2006; Mills, Neily, & Dunn, 2008). In practice, problems often occur when staff members from a variety of professions have different interpretations of the purpose of the team’s work or apply different perspectives. This results in different rationalities and priorities (Hall, 2005; Kvarnström, 2008; Rydenfält, Johansson, Larsson, Åkerman, & Odenrick, 2012). Insufficient knowledge of the other professions can also negatively affect team communication and collaboration (Ebert, Hoffman, Levett-Jones, & Gilligan, 2014). These findings show that at times, there is a lack of shared or intersubjective understanding among different team members. Such an understanding about the work at hand, though, is considered to be a “key foundation for effective interprofessional care” (Billett, 2014, p. 210). People’s understanding of teamwork affects how they interpret situations, and in turn their actions in those situations. Thus, flawed intersubjective understandings of teamwork between different healthcare professionals in the same organization can result in differences in their expectations of the actions of other team members. In this sense, the team members’ understanding of the concept of teamwork can have implications for the practical organizing of work (Weick, 1995). Doctors’ conceptions of teamwork are especially important as they often have a leading role in the interprofessional teams they are part of, not only from a medical perspective but from an organizational one too (Edmondson, 2003; Henrickson Parker, Flin, McKinley, & Yule, 2014; Rydenfält, Johansson, Odenrick, Åkerman, & Larsson, 2015).

The purpose of this explorative study is to examine doctors’ conceptualizations of teamwork. We also investigate what doctors think is important in order to achieve good teamwork and how the empirical findings relate to teamwork theory. We then discuss the methodological implications of our results for future studies. The sources of our empirical data are two advanced hospital departments that apply different organizational principles when it comes to teamwork: one intensive care unit (ICU) and one emergency department (ED). In both settings, the nature of the tasks at hand require an interprofessional approach to work.

Background

How professionals conceptualize teamwork has been studied in other fields. In industry, for example, the conceptualization of teamwork varies across different cultural settings (Gibson & Zellmer-Bruhn, 2001). Different conceptualizations can give rise to different levels of psychological safety in the team (Gibson & Zellmer-Bruhn, 2001), an organizational trait associated with open communication and patient safety in healthcare (Edmondson, 1999, 2003). Studies in the healthcare context address how attitudes to teamwork develop among medical students (Willis, Jones, McArdle, & O´Neill, 2003) and how different professions perceive teamwork, operationalized according to the TeamSTEPPS framework (Weaver, Hernandez, & Olson, 2017). How Team Mental Models (TMM) affect team performance has also been investigated (Burtscher, Kolbe, Wacker, & Manser, 2011). However, TMM differs from the concept of teamwork itself. TMM can be defined as “team members’ shared and organized understanding of relevant knowledge – i.e. aspects of their common work” (Burtscher & Manser, 2012, p. 1345). Thus, TMM focuses on characteristics of the task. Instead, the study presented in this paper focuses on what teamwork means to the participants, that is, their conceptualizations of teamwork, independent of predefined taxonomies. Thus, we take an explorative vantage point intended to capture the insiders’ view of doctors involved in teamwork, rather than a descriptive one.

Leadership is identified as an important factor for teamwork (Ezziane et al., 2012; Lakhani, Benzies, & Hayden, 2012; Manser, 2009; Rydenfält, Odenrick, & Larsson, 2017). Leadership can be seen as a type of management of meaning (Smircich & Morgan, 1982), and as a “process of influencing others to understand and agree about what needs to be done and how to do it…” (Yukl, 2006, p. 8). Team leadership can be distributed, with different team members contributing to the leadership depending on the situation (Rydenfält et al., 2015). However, as doctors often are the designated team leaders, their framing or conceptualization of teamwork is particularly important. This means that doctors who are team leaders, through their framing of a given situation, influence the interpretations of that situation made by themselves and the other team members. This does not mean that all team members understand the situation in the same way, but rather that the leader influences how the others make sense of the situation (Smircich & Morgan, 1982).

As our purpose is to investigate doctors’ conceptualizations of teamwork and of how it can be improved, the following sections provide a brief overview of the defining characteristics of teams and teamwork in the literature, and summarize some of the aspects associated with effective teamwork in the healthcare literature.

Definitions of team and teamwork

Many of the existing definitions of teamwork that are used in the healthcare context today include characteristics that are also considered to define teams. Prominent defining characteristics of both teams and teamwork from the literature include: interdependent tasks (Baker, Day, & Salas, 2006; Cohen & Bailey, 1997; Lyubovnikova et al., 2015; Reeves, Lewin, Espin, & Zwarenstein, 2010), shared responsibility (Cohen & Bailey, 1997; Reeves et al., 2010), a group (Baker et al., 2006; Manser, 2009; Wheelan, 2005; Xyrichis & Ream, 2008), shared goals or objectives (Baker et al., 2006; Lyubovnikova et al., 2015; Manser, 2009; Reeves et al., 2010; Wheelan, 2005; Xyrichis & Ream, 2008) and specific roles (Baker et al., 2006; Manser, 2009; Reeves et al., 2010; Xyrichis & Ream, 2008).

In this study, we use a definition of teamwork that is very inclusive and less normative. We do this in order to capture more of all those situations in which the term “teamwork” actually is used to describe the organization of work. In this research, a team is defined as “a group of people who are set to work together on a task” (Rydenfält et al., 2017; p. 349), and teamwork is defined as what this group does in relation to the task. In this sense, a team implies organizational aspects, while teamwork implies action. It also means that for something to be teamwork, there has to be a corresponding team.

What it takes for teamwork to be effective

Increased efficiency or productivity is a common motive behind the introduction of teamwork. Several studies and reviews have investigated factors associated with effective teamwork. According to Manser (2009), quality of collaboration, shared mental models, coordination, communication and leadership are aspects of teamwork that are important for patient safety. Mickan and Rodger (2000) highlight that effective teamwork is associated with a process characterized by effective coordination, communication, decision-making, conflict management, and performance feedback. They also state that good social relationships between team members as well as group cohesion are important ingredients of teamwork. On the organizational level, Mickan and Rodger (2000) point out that a clear purpose, an appropriate culture, a specified task, and clear and distinct roles as well as leadership are important teamwork characteristics. Rydenfält et al. (2017) show that an organization characterized by team stability, occasions for communication in the team, and a participative and adaptive approach to leadership can achieve many of the traits associated with an effective teamwork process. Weller, Boyd, and Cumin (2014) report on the need for shared mental models, trust, mutual respect and closed loop communication. Trust is a crucial aspect of psychological safety, which according to Edmondson (2003) is an important factor for learning and for safety in operating room teams. Psychological safety in a team setting is defined as “a shared belief that the team is safe for interpersonal risk taking” (Edmondson, 1999, p. 354).

Methods

Research design

The overall research design applied in this explorative study was qualitative. It applies an emic or insider perspective because it focuses on the participants’ own understandings and conceptualizations rather than on testing or applying an a priori defined theory (Morey & Luthans, 1984). The main data source was semi-structured interviews (Kvale & Brinkmann, 2009) with clinically active doctors at two different departments located in two different Swedish hospitals: an emergency department (ED) and an intensive care unit (ICU). Additional data sources included field observations and interviews with staff in management positions at the two departments, as well as data from a series of focused group discussions at the ICU. The main data were analyzed thematically using conventional content analysis as described by Hsieh and Shannon (2005). In practice, this means that the analysis is conducted bottom-up with categories and themes being defined during the coding. The field observations and management interviews provided knowledge about the organizations as well as the doctors’ actual work situations and how their work was conducted in practice. In this sense, this additional data played the role of background data with the primary purpose being to provide sufficient knowledge about the context studied to be able to analyze the main data successfully.

Participants

The main data consisted of 20 semi-structured interviews with clinically active doctors, 8 from the ED and 12 from the ICU. All ICU participants were specialists. The ED participants consisted of residents and specialists. In addition, we conducted 8 interviews with staff in management positions, 3 from the ED and 5 from the ICU. Thus, in total, the data set consisted of 28 interviews. The participants in the observations and focused group discussions were recruited from the interviewed doctors (see Table 1 for a data set outline). The ICU had worked with organizational development for many years, with improved teamwork as one of the main objectives (Erlingsdottir, Ersson, Borell, & Rydenfält, 2018). The ICU had fixed staff, while the ED had a minority of fixed staff and a large number of doctors from other departments (e.g., surgery or orthopedics) that also had to work shifts at the ED. This meant that the doctors assigned to the ED worked there to varying degrees, some several times a week and others once a month.

Table 1. The outline of the data set and how different types of data were used.

Type of data source	Main data	Additional data
Interviews	20 clinically active doctors	8 management staff
Observations (Shadowing)	-	12 sessions with clinically active doctors
Focused group discussions	-	6 sessions with clinically active doctors

Data collection

The interviews were conducted in 2013 and the first half of 2014. The interviews with the 20 doctors that constituted the main data lasted between 25 and 62 min (mean = 43 min). The interviews were designed around the following topics: teams and teamwork, teams or no teams, teams and the professions, teams and the patient, and teams vs. the work environment. In addition to these 20 interviews with clinically active doctors, 8 interviews were conducted with staff in management positions at the two departments. All interviews were audio recorded and transcribed.

The field observations were carried out in the form of shadowing (Czarniawska, 2007). This means that a researcher followed or shadowed a study participant during an entire work shift or part of one. The field observations took place in 2014 and the first half of 2015. In total, 12 shadowing sessions were conducted, 5 at the ED and 7 at the ICU. The focused group discussions at the ICU, in total 6 sessions, took place during the last half of 2014 and the first half of 2015. The outline of our complete data set can be found in Table 1 below.

Data analysis

QSR Nvivo 10© was used to analyze the main data. The overall approach was bottom-up, which means that codes and themes were created during the coding (i.e., no a priori coding scheme was used). The analysis comprised five steps, with iterative elements in between, allowing the emergent coding to be revised throughout the process:

1. All 20 interviews were read by the first author.

2. Then the ED interviews (8 interviews with doctors) were initially open coded (Charmaz, 2014; Emerson, Fretz, & Shaw, 2011) by the first author. This resulted in a number of broad themes derived from the data, often consisting of rather large meaning units.

3. From the initial coding, two themes were selected for further analysis: What teamwork is and What it takes to achieve good teamwork. The analysis consisted of conventional qualitative content analysis (Hsieh & Shannon, 2005). In practice, this meant:

   1. coding the ICU material from the perspective of the two selected themes, followed by

   2. coding to refine the two themes and break them down into more specific categories. Again, the categories were derived from the data. This resulted in two different sets of categories: one for the What teamwork is theme and one for the What it takes to achieve good teamwork theme. Detailed coding annotations were made during this process.

4. The coding was reviewed by the second author, and then the first and the second authors jointly made adjustments.

5. The first author went on to further refine the coding, with the second and third authors reviewing it again. In the end, all authors could agree on the final coding. The deliberate choice was made to let the first author carry out the first steps of the coding on his own. This made it possible for the second and third authors to test the reliability of the coding in the later stages of the process.

Ethical considerations

Before the data collection began, the participants in the interviews, observations, and focused group discussions received information about the study, and were told that they could withdraw from the study at any time, no questions asked. They also signed an informed consent form. The study was approved by the local ethical review board (DNR 2013/888).

Results

It is evident from our field observations that the work conducted by the doctors at both the ED and the ICU at least partly could be considered what Reeves et al. (2018) describe as “teamwork”, i.e. that it is characterized by a shared team identity, clear roles, interdependence and integration. At the ED this is for instance the case in the trauma room. However, in relation to other tasks, when the work is less tightly coupled to the work of the other team members, interprofessional collaboration, as described by Reeves et al. (2018), sometimes can be a better descriptor. Though, it should be acknowledged that the participating doctors themselves refer to the work conducted as teamwork, and it is their conceptualizations of teamwork that is our object of study here.

We first present the results on how the doctors conceptualized teamwork corresponding to the What teamwork is theme, and then their opinions on What it takes to achieve good teamwork.

Theme 1. what teamwork is: the doctors’ conceptualizations of teamwork

As outlined above, not only is the use of the terms team and teamwork blurred, but also the demarcation between them. This also became apparent in the analysis as the participants used the two terms inconsistently. This often resulted in them describing what a team was when asked to describe teamwork. Because of this, no distinction was made between team and teamwork in the analysis.

In total, there were 11 categories in the What teamwork is theme (see Table 2). The 6 prominent ones, expressed by at least 3 participants, are presented below. More categories were found, but they were less grounded in the data and included: identity, a stable group, service to doctors, joint training, and common methods to achieve the team’s common goal.

Table 2. A list of the categories that appeared in the analysis in relation to the themes.

Theme 1. What teamwork is: the doctors’ conceptualizations of teamwork	Theme 2. What it takes to achieve good teamwork: the doctors’ opinions
Specific roles	Good communication skills
Common direction of work	Interprofessional team training
A group of people	A high degree of psychological safety
Psychological safety	Explicit roles
A leader	A high degree of team stability
The whole is larger than the sum of the parts	Explicit leadership
	Shared goal
Less prominent categories	Less prominent categories
Identity	a common understanding
a stable group	social communication
service to doctors	a sense of belonging – group cohesion
joint training	enabling interprofessional interaction
common methods to achieve the team’s common goal	personal chemistry
	leadership traits
	proximity
	common debriefing
	common values
	a common definition of teamwork

Specific roles

By far, the most prominent category was specific roles, defined as, teamwork requires that the team members have different roles. All but one of the participants expressed this conception of teamwork, which implies that there was a consensus among the participating doctors that for something to be teamwork, different roles had to come together and work in a complementary way. This could be expressed explicitly:

Participant

: “What teamwork means is that even if we work together, we still have different roles in this team…” - ICU doctor

However, it was often expressed implicitly as different functions, professions, training or competences that had to come together and work, rather than as roles:

Interviewer

: “What is teamwork? What is required for it to be teamwork?”

Participant

: “Good question. From a healthcare perspective, I see it as being a process in which people with different competences, different professional roles share their knowledge and skills …” – ED doctor

Interviewer

: “What does teamwork mean to you?”

Participant

: “You don’t possess the whole truth yourself. You see different things because you have different educational backgrounds, and because you do different things with the patients.” - ICU doctor

“Knowing your function and what you should do in every encounter with the patient, is what I would say.” – ED doctor

Common direction of work

A common direction of work implies that for something to be teamwork, there must be an intent to do something together. Some doctors stressed that this intent required a shared goal, while others only highlighted the importance that everybody worked for the patient, indicating that the patient and the patient’s needs gave the work a common direction shared by the team members. Almost half of the participants conceptualized this, and it was evenly distributed between the ED and the ICU.

The need for a common direction could be expressed like this:

Participant

: “It means that different occupational categories work together for the patient.” – ED doctor

The need for a shared goal could be expressed like this:

Participant

: “Teamwork is work in a group where you have a shared goal or a shared task to solve.” – ICU doctor

A group of people

A group of people implies that for something to be teamwork, more than one person has to be involved. One fourth of the participants distributed over both the ED and the ICU conceptualized this. But it is likely that many more participants did not explicitly express this because they took it for granted, since the terms group and team were sometimes used interchangeably.

This category could be expressed implicitly:

Participant

: “For me in the emergency room, teamwork means that you cannot function here on your own.” – ED doctor

Or explicitly:

Interviewer

: “What does teamwork mean to you?

Participant

: “A group that works towards the same goal. And that everyone has functions on the team, which are not necessarily the same, but that together, they aim for the same goal.” – ICU doctor

In this quote, the participant conceptualizes teamwork as something that requires: 1) a group, 2) a common direction of work (the same goal), and 3) team members that have different functions or roles.

Psychological safety

Psychological safety did not come up as an in vivo term required for teamwork, but it was indirectly coded through concepts strongly associated with it, such as “trust” and “an open climate”. Again, one fourth of the participants, distributed between the ED and the ICU, made this conceptualization.

Participant

: “There simply should be a climate that allows you to ask dumb things.”

Interviewer

: “Or else?”

Participant

: “It ends up that you don’t dare to say anything, and then there will be no team to speak of; you must have an open climate.” – ICU doctor

A leader

Some of the participants highlighted that for something to be teamwork, there had to be a specified leader. One participant expressed it like this:

Interviewer

: “What does teamwork mean to you?”

Participant

: “I think it really means that you utilize one another’s competences. First of all, someone needs to lead the work, of course, but good teamwork also means that everyone’s competences are utilized optimally. ” – ICU doctor

Others made it clear that this leader in fact should be the doctor.

The whole is larger than the sum of the parts

A couple of participants also indicated that for them, teamwork was something more than the sum of the work or functions provided by the individual members. They stated that in some cases it does not matter how good the individuals are; without a team nothing works. This category also indicates that the different team members indeed have interdependent tasks. One participant expressed it like this:

Interviewer

: ”What does teamwork mean to you?”

Participant

: “It is necessary with teamwork you could say. That the team consists of parts that make the whole stronger.” – ICU doctor

Theme 2. what it takes to achieve good teamwork: the doctors’ opinions

Compared to their conceptualizations of what teamwork is, the doctors’ views on what it takes to achieve good teamwork were more diverse. In total, the theme consisted of 17 categories (see Table 2). The 7 most prominent categories, expressed by at least 4 of the participants in this study, are presented below. The other 10 categories were: a common understanding, social communication, a sense of belonging – group cohesion, enabling interprofessional interaction, personal chemistry, leadership traits, proximity, common debriefing, common values, and a common definition of teamwork.

Good communication skills

About two thirds of the participants mentioned explicitly or implicitly the need for good communication skills to achieve good teamwork.

Participant

: “If the others don’t know what the doctor has in mind, everything comes to a halt. But if there is someone down there who is good at communicating and cooperating with the others, work runs smoothly.” – ED doctor

Participant

: “Then I think that if you have good communication and everything flows, it is quicker to make decisions and take action. That’s the way it has to be.” – ED doctor

Interviewer

: “What do you need to get a well-functioning team? What do you think?”

Participant

: “I think that you need to make sure that the communication is better so that everyone understands what our goal is. Because if I think that they know, and they think that they know – it might not be so. And then we don’t understand why we do what we do.” – ED doctor

The ED participants stated that for teamwork to be good, everybody needed to understand how to communicate. It was also noted that it was very important for the doctor to communicate his/her intentions for the patient. Not knowing what the doctor has planned will bring the procedure to a halt, as the doctor in the first quote stated.

At the ICU, the participants expressed the need for communication as a need for good feedback. They also stated that communication should be explicit and that it should be open, by which they meant explaining one’s own ideas and listening to other’s ideas. The latter indicates that there can be nuances in the participants’ views on communication needs, from an unreflective focus on the need for clarity in the communication to an ability to listen and maintain an open dialogue.

Interviewer

: “What do you personally think is needed to get a well-functioning team? What are the demands?”

Participant

: “Straight-forward leadership and good feedback about it. I think like this, anyone can be a leader, really, just so that it is clear that, ‘Now we are going to do it like this, and I’ll do it like that.’ And that the others in the group help out and say, ‘O.K., good. I’ll be responsible for fixing this,’ or ‘O.K., you want us to do it like that? Have you seen that it could look like this too? Can you consider that we do it this way instead, based on that?’ That is what I mean by clear feedback.” – ICU doctor

Interviewer

: “O.K. What do you think is needed to get a well-functioning team?”

Participant

: “Clearly defined roles are needed. Leadership is needed, along with the ability to follow; clear communication; competence, skills and specialist knowledge too. Openness, respect for one another. Yes.” – ICU doctor

Interviewer

: “What do you think is needed to get a well-functioning team?”

Participant

: “I think I mentioned it in a previous [question], open communication and that everyone contributes as much as they can. Open communication can be a very broad concept. That you can both listen and explain your ideas. Just so the dialog works.” – ICU doctor

Interprofessional team training

At both the ED and ICU, interprofessional team training was perceived as something that could improve teamwork. At the ED it was considered a pity that team training was not always interprofessional. Instead, the professions often trained in isolation, simulating the other professions’ roles in the team.

Participant

: “In the emergency department, there may be emergency care exercises involving all occupational groups. As it is now, for example, the doctors practice CPR as a group by themselves where one doctor takes on the role of a nurse and another that of an assistant nurse. That seems odd.” – ED doctor

The participants at the ICU highlighted the need for training, but also that the real work situation was a valuable source of training and teamwork experience.

Interviewer

: “What do you think is needed to get a well-functioning team?”

Participant

: “A clearly articulated organization about who does what. And that we have a goal. And that we can train for it.” – ICU doctor

Interviewer

: “How do you maintain a well-functioning team?”

Participant

: “It’s really a matter of training. Training as much as possible. Now we are lucky that we are able to train really a lot in reality.” – ICU doctor

A high degree of psychological safety

Just like when the doctors conceptualized teamwork, they did not explicitly refer to psychological safety as a factor that facilitated teamwork, but a number of organizational traits associated with it came up in the interviews. These traits were expressed, for example, as openness, respect for each another, trust, and being open minded. Compared to the other categories in the What it takes to achieve good teamwork theme, psychological safety stood out in the sense that we only identified it in the ICU.

Participant

: “There should be an open climate… . I think that a good team should consist of professionals with many different competences that can result in a synergizing effect. I think that it should have, as I already said, an open and friendly climate, so that you feel secure in the group. I think that these keywords we have, with sensitivity, are important; that you are tuned into the other team members. Well-functioning; there shouldn’t be any element of fear in this group because that would stifle good teamwork.” – ICU doctor

Participant

: “And there has to be a tolerant atmosphere for open and honest discussion; you must be allowed to say something wrong or make a mistake. Simply put, there should be a climate that allows a person to ask dumb questions.” – ICU doctor

Explicit roles

As shown, the participants agreed that for something to be teamwork, it required that the team members had different roles in the team. However, they also attributed explicit and clear roles as a means of achieving more effective teamwork.

Interviewer

: “So then, you mean that the team is important?”

Participant

: “Then it is extra important that you have a structure so that everyone knows exactly what is to be done.” – ICU doctor

This could be expressed implicitly as in the quote above as “a structure”, or explicitly:

Interviewer

: “What do you think is needed to achieve a well-functioning team?”

Participant

: “Communication, communication, communication. A clear understanding of what teamwork means, that is to say, that they see it the same way I do. And a clear division of roles.” – ICU doctor

The second quote also highlights the main topic of this study in the form of a perceived need for a shared and clear understanding of what teamwork means in the team.

A high degree of team stability

As with psychological safety, team stability did not appear as an in vivo term in the material but was expressed implicitly as something that was desirable to achieve good teamwork. For instance, the doctors emphasized that the team structure was affected negatively when new team members were added. They also emphasized that it was important to know the other team members and that such knowledge was compromised when new team members arrived.

Participant

: “Yes, because the existing teams vary a bit from day to day as to who is part of the team just then. But if new people show up, then the team structure becomes a little disjointed with someone who is not really used to the job; a new nurse or a new assistant nurse. All the time a learning situation, and then the teamwork is not optimal.” – ED doctor

Participant

: “It works best when you know the people, when you trust those people, when you have good personal chemistry and have plenty of time to do your job. When you have chaotic days and new people show up that you don’t know very well, or that you are in conflict with, it doesn’t work well.” – ICU doctor

Other doctors indicated that social relations could have a positive effect on teamwork and that team stability (i.e., working with the same people over time) affects social relationships positively. One participant described it like this:

Participant

: ”If you know each other better, it is also possible to have a more direct communication. Which is important in emergency situations…” – ED doctor

Explicit leadership

Some participants regarded an explicit leadership as beneficial for the teamwork. This was expressed explicitly as clear leadership or more subtly as:

Participant

: “… knowing who the team leader is; knowing who is in charge.” – ED doctor

Shared goal

The participants at the ICU stressed the importance of a shared goal in order to facilitate teamwork.

A prerequisite for teamwork to function is that everyone is working toward the same goal, that you are all doing it for the same reason.” – ICU doctor

However, it should be noted that there was relatively little emphasis on making leadership more explicit and shared goal compared to communication skills, interprofessional team training and psychological safety.

Discussion

One explanation for the focus on roles as a necessary condition for teamwork is that healthcare as a field has a long tradition of different roles in the form of different professions (Abbott, 1988; Freidson, 1970). Doctors and nurses from different specialties have traditionally been associated with different roles. When talking about a healthcare organization in terms of teams, and the work conducted by those teams as teamwork, it is possible that the concept of roles has come with the package. Furthermore, the two departments studied, the emergency department and the intensive care unit, may be especially prone to cultivating the role aspects of teamwork, since specific and clear roles become extra important in settings where time is a critical factor. The importance of clear roles has been acknowledged in relation to standardized routines in acute medicine, such as advanced trauma life support (Flin & Maran, 2004), and role understanding is considered to be an important competence for collaborative practice (Suter et al., 2009).

The focus on roles also stands out in the sense that other characteristics of teams and teamwork that are highlighted in several of the prominent definitions in the literature, such as the need for interdependent tasks (Baker et al., 2006; Cohen & Bailey, 1997; Lyubovnikova et al., 2015; Reeves et al., 2010), receives relatively little attention from the doctors. The only category that addresses the interdependence of tasks is the whole being larger than the sum of the parts. The participants express this as “nothing works without teamwork”, which implies that due to the interdependence of the team members’ tasks, they cannot get the work done by themselves. However, this category has rather weak support. Another example that indicates potential differences between the doctors’ understanding of the concept of teamwork and the definitions of the concept in the literature is the category a common direction of work, which implies that teamwork requires a shared goal or focus. This is a very frequent theme in established definitions (Baker et al., 2006; Lyubovnikova et al., 2015; Manser, 2009; Reeves et al., 2010; Wheelan, 2005; Xyrichis & Ream, 2008), but the study participants do not accentuate it to the same degree.

We conclude that doctors conceptualize teamwork somewhat differently from the ways in which it is described in the literature. This is in line with the results of Alexanian et al. (Alexanian, Kitto, Rak, & Reeves, 2015) who state that the team concept was used rhetorically rather than as a reference to traits traditionally associated with teamwork in the literature. The different participants’ conceptualizations include many of the aspects defined as essential in the literature, but there is no apparent agreement among them as to which are the most essential, other than specific roles. This is important, as doctors’ conceptualizations of teamwork affect their expectations when involved in it. For instance, a doctor who emphasizes the specific role and leader aspects of teamwork will approach it differently than a doctor who emphasizes psychological safety and the need for a common direction of work. In the former case, the focus is on functions, and critical questions could be: Do we have the right functions/roles present? Who is going be the leader? In the latter case, the focus is on process, and critical questions could be: Does every team member feel safe to contribute? Does the team’s common work process really proceed towards the team’s common goal? Does the team’s work process keep members updated and in agreement on what their common direction or goal actually should be? When focusing on functions, skills or competences emerge as important factors to improve. When focusing on processes, it is rather a matter of developing the interaction in the team through doing, which stresses relational aspects.

The most commonly emphasized factors to achieve good teamwork stated by doctors from both departments were good communication skills and interprofessional team training. Both are concerned with what is referred to as non-technical skills (Flin, O’Connor, & Crichton, 2008). Several of the other factors perceived as enablers of teamwork were to varying degrees concerned with traits on the group or organizational level. A high degree of team stability is a matter of how the work is formally organized, and as such it is a management issue; a high degree of psychological safety is concerned with trust between team members; and a shared goal is a matter of intersubjective understanding in the team (Billett, 2014). To make roles and leadership explicit is a matter of leadership and of how the organization communicates its expectations on its employees. It is also a matter of non-technical skills, as it implies that individuals should learn roles and have specific expectations about the roles of others. Among the participants, this indicates that there is a large focus on factors associated with non-technical skills that enable teamwork. Thus, in line with the above discussion regarding how different understandings of teamwork can result in different logics regarding how teamwork can be improved, it appears that the highly emphasized role aspect in the doctors’ understanding of teamwork can have affected their understanding of what it takes to achieve good teamwork.

Comparing the two departments, we find interesting differences on what the participants expressed as important for achieving good teamwork. Specifically, the ICU doctors put more emphasis on factors at the group level in the form of psychological safety and shared goals. Due to the ICUs previous history of organizational development and its deliberate efforts to implement and improve teamwork (Erlingsdottir, et al., 2018), the staff at the ICU may have become more conscious of teamwork. Another explanation can be that the ICU de facto already had more of the factors concerned with the formal organization in place, such as team stability. It is reasonable to assume that it is when you first have a somewhat stable group that it makes sense to develop relations, resulting in psychological safety and shared goals.

So far, research on what teamwork is in healthcare has predominately applied what is sometimes called an etic perspective in the sense that it is built on categories imported from the outside or created by researchers (Morey & Luthans, 1984). These categories correspond to what Schutz (1967) refers to as “constructs of the second degree”, while the doctors’ actual conceptualizations of teamwork are “constructs of the first degree”. That is, constructs based on “the common-sense thinking of men, living their daily life within their social world” (Schutz, 1967, p. 59). According to Schutz, these constructs or thought objects make up our relevance structure and thus motivate and determine our behavior. As researchers, we do not have direct access to the constructs of the first degree held by the people inhabiting our field of study (in this case, interprofessional healthcare). Thus, when researchers create or discover theory (Glaser & Strauss, 1967), it consists of constructs that can only be influenced or based on the constructs of the first degree held by the objects of study (Schutz, 1967).

Given the above, we suggest that future research on what teamwork is in healthcare puts more emphasis on an emic perspective (Morey & Luthans, 1984). We argue that a more emic approach would result in:

1. a better mapping between the healthcare practitioners’ constructs of the first degree of teamwork and the academic concept of teamwork,

2. models of teamwork with more predictive power when it comes to anticipating the behavior of healthcare teams, and

3. a foundation for a more fruitful debate about definitions of teamwork and how teamwork can be used in practice.

In this study, we use an explorative methodology to investigate how doctors conceptualize teamwork. An inherent limitation is that we only can capture what the doctors can articulate and what comes to mind in the interview situation. Whatever tacit assumptions they have or what they perceive as common ground, is impossible to know (Polanyi, 1983). Consequently, one should be careful to generalize explicit conclusions about the actual distribution of the understanding of the concept of teamwork apart from that there is a variation. However, we argue that: 1) the fact that there is a variation, and 2) the width of that variation, is enough to render the results interesting from an explorative point of view.

We have chosen to focus this study on the doctors’ conceptualizations of teamwork. In an interprofessional team setting it would, of course, make sense to study all the professions’ conceptualizations in the team. In this particular case, we chose not to because: 1) these kinds of explorative studies of doctors are quite rare, and 2) doctors often have leading positions in interprofessional teams, and thus are in a position that enables them to influence the conceptualizations of the other team members. The latter implies that the doctors’ conceptualizations of teamwork deserve extra attention.

Concluding comments

There was large variation in the doctors’ conceptualizations of teamwork. The only characteristic that appeared to be common for the doctors was that the team members should have specific roles. This could have consequences for their ways of working, because the rationale behind different behaviors depends on how the doctors conceptualize teamwork.

We also conclude that the two departments studied differ concerning the doctors’ perceptions of how teamwork can be improved. This indicates that organizational structure and efforts to improve teamwork matter. It is possible that the high degree of role focus in the doctors’ conceptualizations of teamwork also affected what they perceived as important in order to improve teamwork, as the identified enabling factors predominantly concerned non-technical skills.

Lately, theoretical terminology associated with teamwork has received some well-deserved attention (Dow et al., 2017; Reeves et al., 2018). However, further education and research is needed when it comes to the practitioners’ use of the concept of teamwork. Thus, more studies are required in order to make further claims about exactly how members of interprofessional healthcare teams conceptualize teamwork and its consequences for practice. Future studies should place more emphasis on an emic perspective in the research design. Such an effort would create a more grounded foundation for research and practice.

Disclosure Statement

There are no conflicts of interest.

Additional information

Funding

This research was funded by AFA Insurance through the project, “Is Teamwork the Key to a Better Work Environment for Doctors in Healthcare?” (DNR 130083).