TEAMS AND TEAMWORKING

In the health and social services there are many different teams who work together for the benefit of the patient. The reason why teams are necessary in health and social care is, according to Leathard (1994), due to a number of factors. Two of the main ones are that the complexity of health and welfare services has increased in recent years, and that the degree of specialisation of services has also increased. For example in 1953 the structure of DNA was uncovered Roberts (1977). Since then a whole host of new services have become available such as genetic screening and genetic counselling.

Leathard also describes there being a perceived need for rationalisation and an increase in efficiency of services as well as a need to avoid duplication.

These health and social care teams function in different settings, have different funding arrangements and organisational structures and are composed of a range of professional and non-professional staff. Their goal ostensibly is the same - to provide a service for the client/ patient. However as I shall explain in this chapter this is not always achieved.

Before considering how teams work and the factors promoting and hindering team work it is necessary to explore some definitions of teams and team working. The World Health Organisation (1984) defined the health care team as;

“ a group who share a common goal and common objectives, determined by community needs, to the achievement of which each member of the team contributes, in accordance with his or her competence and skill and in co-ordination with the functions

of others.” (WHO 1984:13)

This may appear to be an important and comprehensive definition by a world body. Further scrutiny is required to unpack this definition. The first question that springs to mind is if the community determines the goal and objectives how is this achieved. Is this through the democratic process of voting for the political party with whom the community believes will set appropriate goals for Health and Social care. If so does this mean that the views of the members of the community who voted for the unsuccessful party are not taken into account. Therefore the team can not be working for the benefit of all of the community. Co-ordination is a feature of a team in this definition and may be affected by several factors. The leadership of the team, the individual members of the team sharing and contributing to the common goal being just three examples. However in health and social care there are many individuals involved in the team each trained separately and working in different contexts who might not be able to share the common goal.

Engel (1994) too offers a critique of this definition. He questions the common goal ideal which presupposes that the group of people in the team have agreed the goal and are happy to work towards achieving it. Looking more widely he compares teams in the armed forces and sport to those in health and social care contexts noting that the former

may share the same education and skill but the professionals in the latter have their own body of knowledge, skills and attitudes. This he suggests is a barrier to effective teamworking. He does, however, note some similarities which are team spirit and extensive training.

Miller et al (1999) in their study of multiprofessional teams in a range of contexts such as community mental health and primary care offer a simpler definition

“a group of people working together towards a common goal”.

They too question the goal centredness of the team but also make the point that some people work towards the same goal but do not describe themselves as a team. They go on to expand upon the idea of working together. People who are designated to work in a team may also work independently some of the time but when they do work together this may be in parallel, series or a combination of the two. Another dimension of “working together” is whether the work is based around tasks or decisions and if it is decision-making what weight is given to the input from different team members. There is clearly a complex, multidimensional nature to teamwork and Miller et al begin to provide some possible explanations in table 1 below.

Team

Designated as a “team” but may work as individuals or together Not designated as a team but may work together

Work together may mean Work independently in sequence Work independently in parallel

Work collaboratively in sequence (i.e. separately but each member feeds back to the next at the end of their input)

Work collaboratively some of the time Work interactively all of the time Collaborative work

Tasks

Decision-making contribution (input of different members may have different weight)

West and Slater (1996) define some characteristics of formal groups or teams in a primary care context. They state that members of teams have collective responsibility for achieving shared aims and objectives and that they must interact with each other to achieve these objectives. They do not however make any reference to who should set the wider goal for the team unlike the “community” role as implied by the WHO definition above. They suggest that primary care teams have well-defined roles some of which are differentiated from one another such as doctors, district nurses, receptionists. These teams should have an organisational identity, they suggest, as a work team with a defined organisational function. West and Slater (1996) also define the size of the team in this context which they say should be less than 20 members. Although they then go on to state that in some practices there can be 40 primary care workers.

There are many other definitions of teams in the literature however as Ovreveit (1996) points out. From his research into team organisation, and work to help practitioners and managers to develop multidisciplinary working in health and social services he believes it would not be possible to define a team comprehensively by using only one descriptive approach. He offers a five point descriptive approach to defining teams.

1. Degree of integration

2. Extent of collective responsibility for team resource allocation

3. Membership

4. client pathway and decision-making 5. Management structures

Ovretveit concludes with some reasons why we need to define different types of teams and types of interprofessional working. These being to help new practitioners to understand how a team works; to compare different ideas about what teams to create; to be able to improve teams and to facilitate different types of research into teams.

Having defined and discussed team working in health and social care it would seem prudent to now explore some of the benefits that can be accrued from successful team working and some of the features of team work that promote success. However prior to doing this some explanation of the range of terms used for when teams work together in a health and social care context is required.

As can be seen already in this chapter the terms interprofessional, multiprofessional and multidisciplinary have been used by different authors for ostensibly the same thing, teamworking. A wide variety of terminology has been used throughout the literature to define situations where groups of professionals work or are educated together in the context of health and social care. Before proceeding with this chapter it is necessary to shed some light on what Leathard (1994) calls a “terminological quagmire”. Leathard listed fifty-four terms she had come across to define when professionals learn and work jointly. She classified them into concept-based, process-based and agency-based. These included such terms as inter-, multi- or trans- disciplinary/professional, joint training, shared learning and collaborative care planning. It is clear that at this time individuals were using a range of terms indiscriminately and that although they may have an understanding of what the term meant in their context there was no agreed national or international definition. She summarised her discussions by saying:

"What everyone is really talking about is simply learning together to work together" p 6

One of the aims of Leathard’s publication was to help clarify and define the ambiguous terminology in this developing area of education and work. Rawson (1994) offered a grammatical analysis of the range of terms and provided some clarity by recognising that there are three sets of concepts. These he describes as

1. The problematic associations that cover the examples of the prefixes inter, multi, and trans.

2. The grouping for example the terms professional, occupational, disciplinary, sectoral and agency.

3. The focus of operations which are work, teamwork, collaboration, co-operation and integration.

He states that although different permutations from the list have been used each variation has different connotations. The term ‘inter’ he suggests denotes relationships between and among professionals and implies some notion of reciprocal operations. The term for the grouping he admits is problematic and does not suggest a definitive answer. He concludes that occupational and professional may be the best options. However one disadvantage of the term professional is that much of the team working that goes on in

the health service requires significant contributions from non-professionals such as administrators, voluntary workers and hospital porters.

Work, with regard to the focus of operation, he regards as his favoured term as it provides the most encompassing definition. In the end he suggests:

“Interprofessional work is arguably the phrasing with the greatest utility.” p40

This terminology for ‘working together’ has not been widely adopted and other terms are still found throughout the literature and practice. Therefore for the purposes of this thesis the terms put forward by the authors of the literature reviewed will be used in the absence of an agreed definition. The term multiprofessional working will be used by the author of this thesis when referring to practical situations when health and social care professionals work together. This has been influenced by the terminology in the literature for ‘learning together’. The terminology regarding ‘learning together’ will be discussed in the next chapter.