The Effectiveness of Health Care Teams in the National Health Service

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The Effectiveness of Health Care Teams

in the National Health Service

Report

Carol S. Borrill, Jean Carletta,

Angela J. Carter, Jeremy F. Dawson, Simon Garrod,

Anne Rees, Ann Richards,

David Shapiro

and Michael A. West

Aston Centre for Health Service Organization Research, Aston Business School, University of Aston

Human Communications Research Centre, Universities of Glasgow and Edinburgh

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Acknowledgements

________________________________________________________

Liaison Officers: Liz Meerabeau

Sue Longsdate John Wilkinson

Advisory Group Members: Debbie Mellors

NHS Executive Sarah Connors NHS Executive Jim Ford NHS Executive Bonnie Sibbald NHS Executive Eileen Robertson NHS Executive Sheila Roberts Department of Health Terry Breugha University of Leicester Anne Netton University of Kent Thelma Sackman NHS Executive Research Team:

Dr Carol Borrill January 1997 - December 1999 Aston Business School

Aston University Birmingham

Sam Bedlingham June 1997 - December 1999 City University

London

Jean Carletta January 1997 - December 1999 Human Communication

Research Centre Edinburgh

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Christine Carmichael June 1997 - February 1998 Institute of Work Psychology

Sheffield University Sheffield

Angela Carter January 1998 - December 1999 Institute of Work Psychology

Jeremy Dawson July 1999 - December 1999 Aston Business School

Simon Garrod January 1997 - December 1999 Human Communications Research Centre

Glasgow University Glasgow

Heidi Frazer-Krauss January 1997 - June 1997 Medical School

Glasgow University Glasgow

Anne Rees January 1997 - June 1997 Psychological Therapies Research Centre

Leeds University Leeds

Anne Richards January 1997 - December 1999 Psychological Therapies Research Centre

Carein Todd April 1997 - May 1998 Institute of Work Psychology

David Shapiro April 1997 - May 1998 Psychological Therapies Research Centre

Michael West January 1997 - December 1999 Aston Business School

David Woods January 1998 - June 1999 Institute of Work Psychology

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______________________________________________

S

ummary

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A primary prescription that policy makers and practitioners have offered for meeting the challenges facing the National Health Service is the development of multidisciplinary team working. The importance of team working in health care has been emphasised in numerous reports and policy documents on the National Health Service. One particularly emphasised the importance of team working if health and social care for people are to be of the highest quality and efficiency:

"The best and most cost-effective outcomes for patients and clients are achieved when professionals work together, learn together, engage in clinical audit of outcomes together, and generate innovation to ensure progress in practice and service."

Over the last thirty years this has proved very difficult to achieve in practice because of the barriers between professional groupings such as doctors and nurses. Other factors such as gender issues also influence team working. For example, G.P.s are predominantly men while the rest of the primary care service population is predominantly women; community mental health psychiatrists are predominantly men, whereas the rest of the population of community mental health teams is predominantly women, and in hospital settings the ranks of consultants continue to be largely made up of men. Other factors which impede the creation of effective multidisciplinary teams include multiple lines of management, perceived status differentials between different professional groups, and lack of organisational systems and structures for supporting and managing teams.

The Health Care Team Effectiveness Project was commissioned by the Department of Health. The overall aim of the research described here was to determine whether and how multidisciplinary team working contributes to quality, efficiency and innovation in health care in the NHS.

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The objectives of the research were to establish:

• which team member characteristics such as age, gender, occupational group, experience, qualifications, and team size, influence how well the teams work together;

• how team working processes, such as participation, reflexivity, communication, decision-making and leadership contribute to the effectiveness of teams, particularly the quality of health care and the development of innovative practice;

The research programme was carried out over a three year period by a team of researchers based at the universities of Aston, Edinburgh, Glasgow, Leeds and Sheffield. During the course of the study information on team working was gathered from some 400 health care teams. This involved consulting over 7,000 NHS personnel and a large number of NHS clients. Five national workshops were held with key representatives from primary health care and community health care. A wide range of research methods was used, including questionnaire surveys, telephone interviews, in-depth interviews, observation, focus groups and video and audio tape recordings of meetings

The research was carried out in two stages: quantitative data collection from 100 primary health care teams (PHCTs), 113 community health care teams (CMHTs) and 193 secondary health care teams (SHCTs), and in-depth work with a sub-sample of teams.

Key findings

Effectiveness

Quality of teamworking is powerfully related to effectiveness of health care teams: Ø The clearer the team's objectives

Ø The higher the level of participation in the team Ø The higher the level of commitment to quality Ø The higher the level of support of innovation

…. the more effective are health care teams across virtually all domains of functioning

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Innovation

Quality of teamworking is powerfully related to innovation of health care teams:

• The clearer the team's objectives

• The higher the level of participation in the team

• The higher the level of commitment to quality

• The higher the level of support of innovation

….. the more innovative are health care teams across virtually all domains of functioning

Mental Health

Those working in teams have much better mental health than those working in looser groups or working individually. The benefits appear to be due to:

• Greater role clarity

• Better peer support

Those working in teams are also buffered from the negative effects of organizational climate and conflict.

The better the functioning of team with respect to…

• Clarity of objectives

• Levels of participation

• Commitment to quality

• Support for innovation

… the better the mental health of team members across all domains of health care. Organisational performance

There is a significant and negative relationship between the percentage of staff working in teams and the mortality in these hospitals, taking account of both local health needs and hospital size. Where more employees work in teams the death rate is significantly lower (calculated on the basis of the Sunday Times Mortality

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Index, Dr Foster; deaths within 30 days of emergency surgery and deaths after admission for hip fracture)1.

Retention and turnover

Within health care, those working in well functioning teams are more likely to stay working in their settings than those working in poorly functioning teams.

Leadership

In Community Mental Health and Primary Health Care, where there is no clear leader/co-ordinator or where there is conflict over leadership team objectives are unclear, and there are….

Ø Low levels of participation

Ø Low commitment to quality

Ø Low support for innovation

Ø Poor team member mental health

Ø Low levels of effectiveness and innovation

Communication

Communication, integration and regular meetings in PHC and CMC health care teams are associated with higher levels of effectiveness and innovation, yet the quality of meetings (particularly in Primary Health Care) is often poor.

Professional diversity

Diversity of professional groups in Primary Health Care is clearly linked to levels of team innovation. In newly formed Community Mental Health Teams, this relationship does not appear. The same findings emerged from research carried out with 85 breast cancer care teams2.

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This finding is based on research recently completed by the research team at the Aston Centre for Health Services Organisation Research (further details available from West or Borrill).

2

This finding is based on research recently completed by the research team at the Aston Centre for Health Services Organisational Research (further details available from West or Borrill).

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Conclusions

• Systematic and revolutionary organizational change is necessary if the positive results of this research are to be implemented in practice.

• NHS organizations have to developed as team-based, rather than hierarchical.

• Structure, culture, work design, HRM and management have to accommodate and enable rather than impede team-based working.

• NHS employees should be trained in the KSAs for working in teams.

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Chapter 1

Teamwork, Communication and Effectiveness in Health

Care:

A Review

The challenges of organising health care in the modern United Kingdom context are considerable. There are continual improvements in medical technologies, greater levels of knowledge and awareness amongst patient populations and increasing demands for the variety of sources of health care available within the National Health Service. The provision of free health care at the point of delivery to the population has become one of the most important issues in the national political agenda in the early part of the twenty-first century. At the same time the National Health Service has become a massively complex institution characterised by large organisations, repeated restructurings, and subject to a wide range of political and economic pressures. The response of the government has been to promise a huge increase in spending on the NHS; a key question to be answered in relation to this political agenda is how can we organise health care and achieve good, fair and cost effective services for the whole population. This report focuses on determining whether, and if so, how teamworking can help.

In this first chapter we review the research evidence about the potential benefits of teamworking and the factors that influence the effectiveness of teams, focusing particularly upon their use in health care settings. We draw on empirical evidence from research conducted in the United Kingdom, mainland Europe, North America and Australia. The literature on team composition and the processes which influence team performance is briefly reviewed with particular emphasis on communication, decision-making and problem-solving. We then explore the influences of organisational context and leadership, before presenting the theoretical model which guided the research programme described in this report.

First we consider what a ‘team’ means. The activity of a group of people working co-operatively to achieve shared goals is basic to our species (Baumeister & Leary, 1995). The current enthusiasm for teamworking in health care reflects a deeper,

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perhaps unconscious, recognition that this way of working offers the promise of greater progress than can be achieved through individual endeavour. Mohrman, Cohen, and Mohrman (1995) define a team as:

“a group of individuals who work together to produce products or deliver services for which they are mutually accountable. Team members share goals and are mutually held accountable for meeting them, they are interdependent in their accomplishment, and they affect the results through their interactions with one another. Because the team is held collectively accountable, the work of integrating with one another is included among the responsibilities of each member".

Benefits of teamwork

The belief that teamwork is the most effective way of delivering products and services has gained increasing ascendancy within diverse organisational settings (Guzzo & Shea, 1992; West, 1996). As organisations have grown in size and become structurally more complex, the need for teams of people to work together in co-ordinated ways to achieve objectives that contribute to the overall aims of organisations has become increasingly urgent. Mohrman et al. (1995) offer ten reasons for implementing team-based working in organisations:

• Teams are the best way to enact the strategy of organisations, because of the need for consistency between organisational environment, strategy and design (Galbraith, Lawler, & Associates, 1993).

• Teams enable organisations to speedily develop and deliver services cost effectively, while retaining high quality.

• Teams enable organisations to learn (and retain learning) more effectively (Senge, 1990).

• Cross-functional teams promote improved quality of services (Deming, 1986; Juran, 1989).

• Cross-functional teams can undertake effective process re-engineering (Davenport, 1993).

• Time is saved if activities, formerly performed sequentially by individuals, can be performed concurrently by people working in teams (Myer, 1993).

• Innovation is promoted within team-based organisations because of cross-fertilisation of ideas (Senge, 1990; West & Pillinger, 1995).

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• Flat organisations can be monitored, co-ordinated and directed more effectively if the functional unit is the team rather than the individual (Galbraith, 1993, 1994).

• As organisations have grown more complex, so too have their information processing requirements; teams can integrate and link in ways individuals cannot (Lawrence and Lorsch, 1969, Galbraith, 1993, 1994).

This approach to the delivery of services and products is not simply a managerial fad, since there is substantial empirical evidence that the introduction of teamwork can lead to increased effectiveness in the delivery of both quantity and quality of goods or services (Guzzo & Shea, 1992; Weldon & Weingart, 1993).

Macy and lzumi (1993) conducted an analysis of 131 organisational change studies in order to determine their effectiveness. Those interventions with the greatest effects on organisational performance and 'the bottom-line' were team-related interventions. They also reduced turnover and absenteeism more than did other interventions, showing that team oriented practices can have broad positive effects in organisations. Other research by Kahleberg & Moody (1994), who studied over 700 work establishments, found that those in which teamwork was developed were more effective in their performance than those in which teams were not used. Finally, Applebaum and Batt (1994) offer similar evidence. They reviewed the results of a dozen surveys of organisational practices, as well as 185 case studies of innovative management practices. They too found compelling evidence that teams contribute to improved organisational effectiveness, particularly increasing efficiency and quality.

Teamwork in health care

The importance of teamworking in health care has been emphasised in numerous reports and policy documents on the National Health Service (NHS). One (NHSME, 1993) particularly emphasised the importance of teamworking if health and social care for people were to be of the highest quality and efficiency:

"The best and most cost-effective outcomes for patients and clients are achieved when professionals work together, learn together, engage in clinical audit of outcomes together, and generate innovation to ensure progress in practice and service."

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Some limited research has suggested the positive effects of multidisciplinary teamworking in health care. However, there are many difficulties inherent in comparing evaluation studies, which include teams having different objectives and organisation patterns, studies variously controlling for other concurrent changes in local services and the pre-existing variations in services and cultures (Jackson, Gater, Goldberg, Tantam, Loftus & Taylor, 1993).

In terms of the delivery of care, teams have been reported to reduce hospitalisation time and costs, improve service provision, enhance patient satisfaction, staff motivation and team innovation. We review the literature relevant to each of these outcomes below.

Reduced hospitalisation and costs

Sommers and colleagues (2000) compared primary health care teams with physician care across 18 private practices, and concluded that primary health care teams lowered hospitalisation rates and reduced physician visits while maintaining function for elderly patients with chronic illness and functional deficits. Significant cost savings were born from reduced hospitalisation, which more than accounted for the costs of setting up the team and making regular home visits. Jones (1992) also reported that families who received primary health team care had fewer hospitalisations, fewer operations, less physician visits for illness and more physician visits for health supervision than control families. A similar pattern emerged for terminally ill patients, where their increased utilisation of home care services more than offset savings in hospital costs, such that there were average savings of 18% in hospital costs (Hughes, Cummings, Weaver, Manheim, Brown & Conrad, 1992).

In another study in the U.S., Eggert and colleagues (1991) concluded that a team focussed case management system generated similar benefits for elderly, chronically ill patients. The team approach reduced total health care expenditures by 13.6%, when compared to an individualised case management system. The team combined earlier discharge, more timely nursing home placement and better-organised home support and care, to reduce patient hospitalisation by 26%. Similarly, the cost increases in ambulatory and nursing home care were offset by fewer and shorter stay hospital admissions and reduced home care utilisation. For patients with dementia in this study, the team model of case management reduced overall costs even further, by 41% (Zimmer, Eggert & Chiverton, 1990). At the end of the 27-month study, there were more team than control patients living at home and fewer in nursing homes. An

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audit of the case managers' records highlighted more intense management activity in the team group, where patients were referred more frequently for medical evaluation, respite and day care. Team case managers had smaller caseloads, made more home visits and had more case conferences. Teams were more familiar with local community resources and were reported as being more responsive to patient crises. The team approach was reported to offer greater intensity of case management, which resulted in more efficient care provision in hospitals and home health services.

Improved service provision

Primary care teams appear to produce better detection, treatment, follow-up and outcome in hypertension (Adorian, Silverberg, Tomer & Wamosher, 1990). Specifically, nurses in England reported that working together in primary health care teams reduced duplication, streamlined patient care and enabled specialist skills to be used more cost-effectively (Ross, Rink & Furne, 2000).

Jansson, Isacsson and Lindholm (1992) analysed the records of general practitioners and district carers over 6 years in Sweden. Care teams (GP, district nurse, assistant nurse) were introduced into one region but were absent in another comparative region. The care teams reported a large rise in the overall number of patient contacts and in the proportion of the population who accessed the district nurse. Concurrently, there was a reduction in emergency visits, which they attributed to better accessibility and continuity of care in the teams.

Jackson and colleagues (1993) reported a similar pattern twelve months after the introduction of a community mental health team in England. They reported a threefold increase in the rate of inception to care, a doubling in the prevalence of treated psychiatric disorder and a reduction in demand on the hospital’s outpatient services. It was suggested that the team was making specialist care more available to patients with severe mental illness who would not have previously received care from mental health services. The team also provided care in a timelier manner that was accessible and continuous.

Enhanced patient satisfaction

Hughes and colleagues (1992) compared the provision of hospital-based team home care and customary care for 171 terminally ill patients in a large U.S. Department of Veterans Affairs hospital. They noted increased access to home care services and improved patient and carer satisfaction with hospital-based team home care. Both

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patients and caregivers of the team expressed significantly higher levels of satisfaction with continuous and comprehensive care at one month, and they continued to express higher levels of satisfaction at six months. The team program maintained patients at home for significantly more days than the control group, who were kept in hospital in general wards for longer. Patients of the team received almost twice as many home visits as the control group and visited the clinic significantly fewer times.

Increased satisfaction by patients who had access to a primary health care team was reported to include a higher mean number of social activities, fewer symptoms and slightly improved overall health. These differences were noted in comparison to patients who only had access to a physician (Sommers et. al., 2000).

Staff motivation

Primary care teamworking has been reported to improve staff motivation (Wood, Farrow, & Elliott, 1994). In a study in Spain, Peiro, Gouzalez-Roma & Romos (1992) showed relationships between work team processes, role clarity, job satisfaction and leader behaviours. Effectiveness of teamwork was also related to job satisfaction and mental health of team members. Sommers and colleagues (2000) suggested that lower rates of hospitalisation for patients of primary health care teams were more likely to be found in teams where individual members were most satisfied with their working relationships.

Innovation

Teamwork is reputed to promote innovation in organisations including those in the health care sector. In order to promote organisational innovation, policy makers and practitioners are increasingly asking for clarification of the factors that determine innovation in teams. Many input and process variables have been demonstrated to predict innovation in teams.

In relation to inputs, there is some evidence that heterogeneity of team composition is related to team innovation (Hoffman & Maier, 1961; McGrath, 1984; Jackson, 1996). West and Anderson (1996) carried out a longitudinal study of the functioning of top management teams in 27 hospitals and examined relationships between team and organisational factors and team innovation. Their results suggested that team processes best predicted the overall level of team innovation, while the proportion of innovative team members predicted the rated radicalness of innovations introduced.

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Specifically, West and Wallace (1991) found that team collaboration, commitment to the team and tolerance of diversity were positively related to team innovativeness.

By what means are these various benefits of teamworking in health care realised? Partly at least through their composition and through effective team processes such as communication, decision-making and problem-solving. We therefore briefly review research in these areas before turning to consider the influence of the organisations within which teams function.

Team composition and Processes

There is considerable agreement that heterogeneity of skills in teams performing complex tasks is good for effectiveness (e.g., Campion et. al., 1994; Guzzo & Dickson, 1996; Jackson, 1996; Millikan & Martins, 1996; Maznevski 1994). Heterogeneity of skills and knowledge automatically implies that each team member will bring a different knowledge perspective to the problem, a necessary ingredient for creative solutions (Sternberg & Lubart, 1990; West, 1997).

However, teams that are diverse in task-related attributes are often diverse in individual attributes. Variation in individual characteristics can trigger stereotypes and prejudice (Jackson, 1996) which, via interteam conflict (Tajfel, 1978; Tajfel & Turner, 1979; Hogg & Abrams, 1988), can affect team processes and outcomes. As an example, Alexander, Lichtenstein and D’Aunno (1996) found that individuals in multidisciplinary treatment teams in U.S. Department of Veterans Affairs hospitals, who were members of larger and more heterogeneous teams, reported poor team functioning. Physicians and social workers assessed team functioning more positively than did nurses. The greater the diversity of individual characteristics of team tenure, age and occupation within teams, the more negatively did team members assessed team functioning.

Gender

Gender is an important influence on communication within teams. Not only are men consistently more assertive in public situations and confrontations (Kimble, Marsh & Kiska, 1984; Mathison & Tucker, 1982), but also communication expectations differ for men and women. Sex-role stereotypes prescribe passive, submissive and expressive communication for women while men are expected to be active, controlling and less expressive communicators (LaFrance & Mayo, 1978). Punishment for violation of expectations (Jussim, 1986; Jussim, Coleman & Lerch,

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1987; Jackson, Sullivan & Lodge, 1993) may influence both the perceptions of women in teams and their willingness to participate in team communication. Such considerations are vitally important in health care teams where women dominate in number, but men predominate in the highest status positions (in the present research, GPs and psychiatrists, for example).

In support, Alexander, Lichtenstein and D’Aunno (1996) reported that the greater the gender diversity, the more positive were team members’ assessment of how cohesively and harmoniously teams operated. Their research suggested that mixed gender teams included different orientations to work, namely a female focus on workplace processes and relationships and a male focus on tasks and outcomes.

Team roles

It is important that teams have the appropriate mix of clearly defined team roles. Jansson, Isacsson and Lindholm (1992) analysed the records of general practitioners and district carers over a six-year period across 2 districts in Sweden following the introduction of care teams into one region. They found that through the independent roles of nurses and doctors were retained in the primary health care teams, all team members interacted with the population in various situations, including home visits and complemented each other across different competencies.

Team affective tone

Another important, but more controversial approach to understanding work team processes and effectiveness, is offered by research on team affective tone. George (1990) suggests that if members of a team experience similar kinds of affective states at work (either negative or positive), then affect is meaningful not only in terms of their individual experiences, but also at a team level. A number of studies have demonstrated a significant relationship between team affective tone and behaviour such as absenteeism (George, 1989, 1990, 1995). George proposes that teams that are interested, strong, excited, enthusiastic, proud, alert, inspired, determined, attentive and active, enable cognitive flexibility, creativity and effectiveness (George, 1996). However, she argues that team affective tone may not exist for all teams, so it cannot be assumed a priori that it is a relevant construct for every team. George (1996) sees team affective tone and team mental models as having a reciprocal influence. So in a team with a negative affective tone, members would have different cognitive processes from those in a team with a positive affective tone, which then may influence team effectiveness.

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There is some evidence that team mental models play an important role in team decision-making (Klimoski & Mohammed, 1994), impacting on aspects of team decision-making such as problem definition, speed and flexibility, alternative evaluation and implementation (Walsh & Fahey, 1986: Walsh, Henderson & Deighton, 1988). A team that has a high negative affective tone may tend to be more rigid when making decisions. The nature and outcomes of team decision-making are therefore likely to be affected by the interaction between team affective tone and team mental models.

Communication

The study of communication in teams has a long history in social psychology, but recent reviews by Guzzo & Dickenson (1996) and Guzzo and Shea (1992) reveal the paucity of thorough industrial and organisational research in this area. Blakar (1985) proposes five pre-conditions for effective communication in teams. Team members must have shared social reality within which the exchange of messages can take place, including a shared language base and perception. Team members must be able to “decentre”, to take the perspective of others into account in relation to both their affective and cognitive position (Redmond 1989, 1992). Team members must be motivated to communicate. There must be “negotiated and endorsed contracts of behaviour” (i.e. agreement among team members about how interactions take place). Finally, the team must attribute communication difficulties appropriately, so if one of the other preconditions is not being met, the team is able to correctly identify the problem and develop a solution.

Several research studies in England have highlighted interprofessional communication problems within primary health care teams. West and Field (1995) and Field and West (1995) interviewed 96 members of primary health care teams and described factors that impacted upon teamworking and communication in health care. Structured time for decision-making, team cohesiveness and team-building all influenced communication within teams. They highlighted the failure of health care teams to set aside time for regular meetings to define objectives, clarify roles, apportion tasks, encourage participation and handle change. Other reasons for poor communication included differences in status, power, educational background, assertiveness of members of the team, and the assumption that the doctors would be the leaders (see also West & Pillinger, 1995; West & Slater, 1996).

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Communication difficulties between different professional groups have been highlighted particularly. Bond, et. al., (1985) surveyed 161 pairs of General Practitioners (GPs) and health visitors, and 148 pairs of GPs and district nurses who had patients in common. They reported low levels of communication and collaboration between GPs and community nursing staff and suggested that GPs had a very poor understanding of the health visitor's role. Similarly, McClure (1984) describes low levels of communication in a survey of 48 health visitors and 45 district nurses attached to general practices. Community nurses reported that communication with practice staff was usually only about specific immediate patient issues rather than team objectives, strategies, processes and performance review. Health visitors were noted to be similarly unenthusiastic about progress in teamwork. Ross, Rink and Furne (2000) found that health visitors perceived teams as less effective. They suggested that health visitors were comparatively more defensive about the benefits of changing role boundaries and considered themselves less able to contribute to the teams as currently constituted. Cant and Killoran (1993) reached similar conclusions, based on their research study with 928 practice nurses, 682 health visitors and 679 district nurses. They argued that joint professional training and the instigation of regular team meetings were necessary to promote good communication.

Cott (1997) used a social network analysis of 93 health care workers across 3 multidisciplinary long-term care teams to explore communication processes within teams. She concluded that higher status multi-professional members communicated most openly and worked fairly autonomously across loosely structured tasks, with low levels of authority. In contrast, hierarchical nursing sub-teams did not report high levels of information sharing.

West and Slater (1996) reported that much of the potential benefit of teamwork was not being realised, with less than one in four health care teams building effective communication and teamworking practices (see also West & Poulton, 1997). In a similar vein, the Audit Commission report in 1992 drew attention to a major gap between the rhetoric and reality:

"Separate lines of control, different payment systems leading to suspicion over motives, diverse objectives, professional barriers and perceived inequalities in status, all play a part in limiting the potential of multi-professional, multi-agency teamwork. . . for those working under such

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circumstances efficient teamwork remains elusive" (Audit Commission, 1992).

A number of researchers in different countries have highlighted the impact of communication problems on patients across different types of teams. Nievaard (1987) interviewed 112 nurses and 298 patients across 6 medical and surgical wards of 2 general hospitals in the Netherlands. The study demonstrated the phenomenon of problem shifting, where communication problems within the team were transferred onto patients. It was reported that for hospital teams with a good communication climate, nurses perceived patients as more attractive and interesting and less dependent. However, if nurses viewed relationships with doctors, managers and nurses in the team as problematic, their images of patients tended to be more negative (unattractive, non-cooperative, dependent) and they did not want to increase their contacts with patients.

Yeatts and Seward (2000) reported similar findings when they compared 3 self-managed work teams in a medium size U.S. rural nursing home. They concluded that enhanced communication between team members positively affected the service to residents. Observations of a high performing team’s meetings showed that team members had a high level of respect for each other, listened to each other, and were not afraid to disagree when they held different views. Team members sought and valued approval from each other, and they assisted each other to complete tasks.

Several studies have demonstrated how individual perceptions about teamwork and roles can influence communication in teams. Dreachslin, Hunt & Sprainer (2000) developed a grounded theory of the role that race plays in the self-perceived communication effectiveness of nursing care teams in the U.S. They concluded that racially diverse team members evaluated team communication according to different perspectives and alternative realities.

When team members develop belief systems that are consistent with their perspective and incongruent with other vantage points, differences in perspective can result in alternative realities. Alternative realities encourage participants to attribute causality differently which in turn fuels team conflict and miscommunication by diminishing the team’s ability to reach a common understanding of both the source of the conflict and the optimal path to its resolution through effective communication (p. 1408).

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Black participants were more likely to suggest that race exacerbated team conflict and miscommunication, whereas white participants attributed problems to role and status in the team. Further, different emphases and responsibility for communication were acknowledged amongst the diversity of races, ethnicities, ages and genders. Social isolation, selective perception and stereotypes also served to reinforce these differences and deepen communication problems. Fewer occasions for social interaction reduced opportunities to develop shared beliefs and a common social reality across racial groups. The researchers therefore suggested that team members be encouraged to understand different perspectives and appreciate alternative realities, in order to lessen social isolation and reduce selective perceptions and stereotyping behaviours.

Freeman, Miller and Ross (2000) also developed a grounded theory about collaborative practice at the levels of the organisation, group and individual. They conducted case studies of 6 teams working in a variety of specialist healthcare services (diabetes, medical ward, primary healthcare, neuro-rehabilitation unit, child development assessment, community mental health) and concluded that the meanings different professionals ascribed to teamwork shaped how they communicated and what they communicated about. When there was a lack of congruence about aspects of teamwork, communication could potentially be compromised. Individual perceptions determined the level of role understanding considered necessary, and the value assigned to others’ contributions. Differences in the understanding and valuing of team roles and levels of team learning exacerbated underlying resentments, undermined professional esteem and created conflict. Individual perceptions also influenced communication regarding tasks and about sharing professional knowledge and ideas.

Decision making

Effective decision-making processes are central to team performance. Several studies have reported the positive benefits of participative decision making in health care teams. Yeatts and Seward (2000) compared 3 self-managed work teams in a medium size U.S. rural nursing home. Team members of highly performing teams reported that their ability to participate in work related decisions greatly increased their job satisfaction and desire to come to work. These team members adopted a consensus model of decision making, in which they clarified the problem, considered alternatives, weighed the strengths and weaknesses of each alternative, and

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selected the best option. Following their participation in making decisions, team members reported an enhanced self-image and self-confidence, and they described more positive interactions amongst themselves and with residents.

In contrast, Cott (1997) suggested that team members may not be equally empowered to participate in decision making. Using a social network analysis of 93 health care workers across 3 multidisciplinary long-term care teams, she reported that the highest status nurses and the core multidisciplinary professionals participated most in decision making and problem solving activities. In comparison, the lower status nursing sub-team primarily planned and assisted each other with their more mechanistic tasks.

Problem solving

Team problem solving improves when members examine their definitions of a situation to ensure they are solving the "right" problem (see for example, Bottger & Yetton, 1987; Hirokawa, 1990; Landsberger, 1955; Maier, 1970; Schwenk, 1988). In contrast, teams that detect problems too slowly or misdiagnose them often are ineffective. Attributing problems to the wrong causes, or not communicating about potential consequences, often undermine team effectiveness, especially when team members fail to reflect on the possibility of error (Schwenk, 1984; Staw & Ross, 1989).

Teams that engage in more extensive scanning and discussion of their environments perform better than those which do not identify problems (Ancona & Caldwell, 1988; Main, 1989; Billings, Milburn & Schaalman, 1980). Tjosvold (1985; 1990) linked the open exploration of opposing opinions within teams with effectiveness. Maier and colleagues also suggested that cognitive stimulation produced novel ideas, and that team effectiveness could be improved if teams were encouraged to be "problem minded" rather than "solution minded" (Maier & Solem, 1962; see also Maier, 1950, 1970). Effectiveness was improved when teams questioned current approaches or considered other aspects of problems (Maier, 1952). Similarly, Hackman & Morris (1975) found that additional process discussions facilitated the quality of team performance. The judged creativity of team decisions was related to the number of comments made about performance strategy. When teams produced alternative solutions to a problem, or separated and recombined problem solving strategies, enhanced productivity was reported (Maier, 1970).

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Teams that have to make complex decisions report that planning enhances their performance (Hackman, Brousseau & Weiss, 1976; Smith, Locke & Barry, 1990). However, when the environment becomes more uncertain, problem identification is more difficult (Hedburg, Nystrom & Starbuck, 1976; Kiesler & Sproull, 1982). Ineffective teams tend to deny, distort or hide problems (Stein, 1996). In some teams, the identification of problems is discouraged as problems are regarded as threats to morale, or a source of conflict (Janis, 1982; Miceli & Near, 1985; Smircich, 1983).

Thus far we have reviewed the benefits (and potential difficulties) of teamworking in health care organisations - but the fact that teamworking takes place within organisations is often ignored in the zeal to promote team effectiveness. Accordingly, we now turn to address what is currently known about the influence of their organisations upon teams.

Organisational context

Recent research suggests the broader context within which teams work has an influence on their performance. Indeed the major change in emphasis in research on teams in the last 15 years has been the shift from discussion of intrateam processes to the impact of organisational context on teams. The organisation within which a health care team functions can influence team effectiveness in a variety of powerful ways. Researchers, such as Hackman (1990) and Tannenbaum, Beard and Salas (1992) have suggested that the following are among the contextual factors that influence team effectiveness:

• Team and organisational rewards

• Team objectives and performance feedback

• Training and technical assistance

• Physical work conditions

• Organisational climate

• Inter-team relationships

• Contracts and management structures

• Team size

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Team and organisational rewards

It has long been known in the social sciences that rewards are important for improving performance. Reward systems, such as public recognition, preferred work assignments and money enhance motivation and performance, particularly when the rewards are contingent upon task achievement (Hackman, 1990; Sundstrom et al., 1990; Vroom, 1964). However, team performance is most effective when rewards are administered to the team as a whole and not to individuals, and when they provide incentives for collaboration and communication rather than individualised work (Hackman, 1990). This reinforces individuals working together as a team. Gladstein (1984) found that in sales teams, pay and recognition affected the leader’s behaviour and the way the team structured itself. Yet, NHS management directly undermines teamwork in primary health care when they provide bonus systems to GPs as independent contractors, despite the whole team contributing to the final outcome.

Clear team objectives and performance feedback

In healthcare environments, team members need information about local health needs and services, and national policies and guidelines, in order to set objectives and target their activities appropriately. Further, feedback on team performance is important for setting realistic goals and fostering high team commitment (Lathom, Erez & Locke, 1988). Job satisfaction requires accurate feedback from both the task and other team members (Drory & Shamir, 1988). However, team feedback can be difficult to provide to teams with either long cycles of work or one-off projects (Sundstrom et. al., 1990).

Training and technical assistance

Hackman (1990) argued that training and technical assistance is required for teams to function successfully. Knowledge and training about team functioning is needed to supplement team members’ own technical and medical skills and knowledge (Poulton & West, 1993; Poulton & West, 1994a, 1994b; Poulton & West, 1997). Limited empirical evidence suggests training is correlated with both self-reported effectiveness (Gladstein, 1984) and managers’ judgements of effectiveness (Campion et. al., 1993) in teams.

Physical Work Conditions

Physical conditions are another situational constraint that affect the relationship between performance dimensions and team effectiveness. For example, a health

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care team whose members are dispersed across sites, will find decision making more difficult and ineffective than a team whose members share the same physical location.

Organisational Climate

The climate of the organisation - how it is perceived and experienced by those who work within it - will also influence the effectiveness of teams (Allen, 1996). Where the climate is one characterised by high control, low autonomy for employees, lack of concern for employee welfare and limited commitment to training, it is unlikely teamworking will thrive (Markiewicz & West, 1997).

The extra commitment and effort demanded in team-based organisations requires organisational commitment to the skill development, well-being and support of employees (Mohrman, Cohen & Mohrman, 1995). Competition and intrigue can further undermine team based working in health care, since teamwork depends on shared objectives, participative safety, constructive controversy and support (West, 1990; West & Anderson, 1996). Ross, Rink and Furne (2000) reported that team members’ willingness to work in teams was limited by the lack of a common set of values about the benefits of teamwork. They recommended the need for clear objectives, leadership, commitment and wide organisational ownership as precursors for working in teams.

Professional subcultures also influence team effectiveness. Kinnunen (1990) used an anthropological approach to distinguish different subcultures between medical, nursing and management staff in a large primary health care organisation in Finland. These three professional groups described different relationships to formal power structures, which influenced their group behaviour, leadership style, administrative orientation, decision-making preferences and patient interactions. In general, doctors and managers shared basic assumptions about work that were paternalistic, proactive, dominant and emphasised loyalty to authorities. In contrast, nurses stressed participation, delegation, traditions and symbiotic harmony in work relations.

Inter-team relationships

In a comprehensive study of team-based organisations involving both questionnaire and case study methods, Mohrman et. al. (1995) demonstrated that inter-team competition is a major threat for team-based working. Teams that compete may develop greater commitment to the team’s success than the organisation’s success.

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Thus the health care team may focus on increasing the financial benefits to their team at the expense of the wider National Health Service. Teams competing against, rather than supporting each other may withhold vital information or fail to offer valuable support in the process of trying to achieve team goals, without reference to the wider goals of the organisation. Thus, health care teams may fail to pass on information about former patients to other teams, focusing their efforts on their own team’s immediate demands.

Ross, Rink and Furne (2000) reported a lack of focus on patient care in their evaluation of primary care nursing teams in England. Nurses perceived that current organisational change promoting teamwork was concerned with structure, professional and organisational issues rather than with patient care. Some nurses were concerned that moves towards integrated nursing were primarily motivated to cut costs.

Contracts and Management Structures

Other relevant aspects of the organisational environment in health include the independent contractor status of GPs and different management structures. There are very few organisations where one or more senior team members work as independent contractors and the rest of the team work within a variety of organisations. Even the most sophisticated management practices, in environments such as the oil and gas industry, are struggling with notions of how to operate joint venture systems - whereas health care teams must deal with these issues constantly but without the training and support given to teams in these other sectors.

Team size

The size of the team is also important, since bigger teams experience much greater strains on effective communication. In most other sectors, teams tend to be divided once they reach 12 or 13 members. But primary and secondary health care teams (for example) can be 20, 30, 40 or more members in size. These ‘teams’ would be more correctly termed ‘organisations’. In and of itself, this would not be a problem, if those who run such organisations are adequately trained to manage large operations. They require knowledge of the management of culture, power, conflict, spans of control, strategies, innovation and above all, people. Yet primary health care team leaders are rarely given such training (West, 1994). It is to the topic of leadership that we now turn.

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Leadership

There is considerable research evidence that leaders affect team performance (e.g. Brewer, Wilson & Beck 1994; Komaki, Desselles & Bowman, 1989) and evidence of the relationship between leadership style and team effectiveness. Eden (1990) examined the effects of platoon leaders’ expectations on team performance. His work with the Israeli Defence Forces showed that those platoons which trained under leaders with high expectations, performed better on physical and cognitive tests. Podsakoff and Todor (1985) investigated the relationship between team members’ perceptions of leader reward and punishment behaviours and team cohesiveness, drive and productivity. Results showed that both leader contingent reward and punishment were positively related to team drive and productivity. Leader contingent reward was also related to cohesiveness, while leader noncontingent punishment behaviour was negatively related to team drive. Jacob and Singell (1993) examined the effects of managers on the won-lost record of professional baseball teams over two decades and found that leaders did influence team performance by exercising tactical skills and improving the performance of team members. George and Bettenhausen (1990) studied teams of sales associates reporting to a store manager and found that the favourability of leader’s moods was negatively related to related to employee turnover.

Primary health care team members in England rated their effectiveness more highly when they had strong leadership and high involvement of all team members (Ross, Rink & Furne, 2000). In nursing care teams, Dreachslin, Hunt and Sprainer (2000) concluded that leadership mitigated the influence of race in self-perceived communication effectiveness. Participants’ comments supported the theme that team leaders who encouraged discussion about differences enhanced perceived team effectiveness. They suggested that leaders provided a unifying force through validating the alternative realities and appreciating the different perspectives of team members, thus moderating the potentially negative effects of racial diversity on team processes.

Developing Teams in Organisations

To what extent is it possible to develop team working to ensure higher levels of effectiveness? Tannenbaum, Salas, & Cannon-Bowers (1996) have reviewed research in this area and related results to a comprehensive model of team which

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integrates interventions (Tannenbaum, Beard and Salas, 1992). They describe a number of intervention types include team member selection and teambuilding:

Team member selection

Although organisations tend to use quite sophisticated methods for selecting employees for individual jobs, they rarely use systematic methods for selecting for teams. But systematic selection methods can help identify people with greater skill levels. There is strong evidence that a team composed of skilled and motivated people will be more effective than other teams (Tziner, 1988). Selection interventions could improve team effectiveness by increasing the professional or skill diversity of health care team members, thereby increasing the range of competencies in the team.

Teambuilding

Some teambuilding interventions focus on role clarification, some on interpersonal relationships or conflict resolution issues, while others take more of a general problem-solving approach (Tannenbaum, Salas & Cannon-Bowers, 1996). Team norms, attitudes, climate and power distribution can be affected by teambuilding approaches. Many team processes, including communication, decision-making and mutual role understanding, are often direct targets of team building interventions.

Weldon and Weingart (1993) describe the importance of planning in teams for achieving team goals, and suggest that team members are characteristically slow to respond to changes in their tasks or their environments that make their strategies ineffective or their goals obsolete. They propose five ways of supporting team work. Goals should be set for all dimensions of performance that contribute to the overall effectiveness of the team; feedback should be provided on the team's progress towards its goal; the physical environment of the team should remove barriers to effective interaction (consider the difficulties faced by members of a dispersed health care team); team members should be encouraged to plan carefully how their contributions can be identified and co-ordinated to achieve the team goal; and team members should be helped to manage failure, which can damage the subsequent effectiveness of the team.

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Pritchard, Jones, Roth, Stuebing and Ekeberg (1988) tested some of these ideas by measuring the effects of team feedback, goal setting and incentives on productivity. Five organisational units in the military were studied. One, a maintenance section, repaired a variety of electronic equipment used for aircraft communications. The other four sections together made up a material storage and distribution branch. Productivity baselines were established before each team received new "treatments" (i.e., performance feedback eight months after the study began, goal setting five months later, and incentives a further five months later) to determine the incremental effects of these "treatments". First, the level of performance of the teams was measured over a period of eight months and then information on their performance was given to each unit for five months. The teams next set clear targets in addition to the performance feedback, and their performance was measured for another five months. Feedback was in the form of computer-generated reports, given monthly to the personnel of each unit. Finally, incentives were offered for high performance, in the form of time off from work. Using these approaches, the average increase over baseline productivity was 50% for feedback, 75% for goal setting and 76% for incentives. The results showed a major increase in productivity among the teams, though the unique contribution of each component of the intervention is difficult to estimate accurately. Both goal setting and feedback had powerful effects on performance.

Transition of organisations to teamworking

One of the most exciting developments in the field is the new emphasis upon the development of team-based working in organisations (Mohrman, et. al., 1995; Markiewicz & West, 1996, 2001). This reflects a concern amongst practitioners with how team-based working can be effectively introduced into organisations. Mohrman et. al., studied 25 teams in four companies using a grounded research methodology, involving managers and internal customers. In the second phase of their research they surveyed 178 teams across seven corporations, involving team members, managers and customers. In this way, they developed a five stage design sequence for the transition to a team-based organisation:

1. Identifying work teams and the nature of the task

This involves process analysis to determine essential work activities that have to be conducted and integrated to produce products or services; deliberations analysis which identifies dialogues about issues that have to be repeatedly resolved in order

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to provide shared direction and enable people to complete their tasks; and task interdependence analysis which determines where and to what extent individuals and teams have to rely on each other to complete their tasks.

2. Specifying integration needs

In order to integrate across multiple teams and components of business units, Mohrman et al recommend management teams, representative integrating teams (where an overall co-ordinating team had representatives from each of those teams collectively involved in producing a product or service), individual integrating roles, and improvement teams.

3. Clarifying management structure and roles

This stage involves putting as much self-management responsibility into the teams as possible; involving team members in determining how leadership tasks will be performed and by whom; using lateral mechanisms for cross-team and organisation-wide integration so that teams participate in that integration; and creating management roles which link teams to the organisational strategy and ensure they are responsive to the organisational and wider environmental context.

4. Designing integration processes

The research evidence suggests that team-based organisations should set clear directions in the organisation, (for example by defining, communicating and operationalising a strategy at all levels, aligning goals, assigning rewards in accordance with organisational goals, and planning collectively); managing information distribution and communication; and developing an appropriate decision making strategy (by clarifying decision making authority, and appropriately involving organisational contributors).

5. Developing performance management processes

Finally, the model suggests the need to manage performance - defining, rewarding and reviewing performance and involving internal and external customers, and team members. Mohrman et. al., report that the more people were rewarded for individual performance, the worse team performance was. The more people were rewarded for team performance, the better was the team and the business unit’s performance and the more process improvements the team and the business unit instituted.

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Conclusions and Research Mode

A review of the literature reveals that progress has been made in understanding the factors that influence the ability of people to work effectively together in teams. However, in the health care domain progress is still patchy and only a few studies are constructed on firm theoretical bases. Progress is further inhibited by the added difficulty of operationalising the concept of effectiveness. In the research described in this report we attempted to build our research on a well-accepted theoretical base and to engage a large number of health care teams in the research endeavour. Moreover, we were charged with grasping the nettle of effectiveness in health care and developing robust and sufficiently broad measures of this difficult concept. Finally, the research team, drawn from a wide range of epistemological backgrounds and theoretical orientations, determined to employ diverse, powerful and innovative research methods to answer the question of what factors influence the effectiveness of health care teams. The starting point for the research was a model of the factors influencing team effectiveness and which distinguishes between at least three major domains of effectiveness. Theoretical approaches to understanding teams at work have been dominated by the input-process-output structure, mainly because of its categorical simplicity and utility (see Figure 1 below) (West, Borrill, & Unsworth, 1998). This is the model used to guide the research described in this report.

Figure 1: Input, process, output model of team effectiveness

INPUTS GROUP PROCESSES OUTPUTS

Domain Health Care Environment Organisational context Team task Team composition Leadership Clarity of objectives Participation Task orientation Support for innovation Reflexivity

Decision making Communication/ integration

Effectiveness - self and externally rated

Clinical

outcomes/quality of health care

Innovation - self and externally rated Cost effectiveness Team member mental health

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Inputs

Teams work within a domain such as primary care, secondary care or community mental health. They also work in a health care environment that may be more or less deprived. The team works for and within an organisation; thus it will be affected by the interaction with the surrounding organisational context. A team has a task that potentially impacts upon team processes and effectiveness (the management of immunisation for children under five years; intensive care nursing; or care of the elderly with mental health problems). The team consists of a collection of individuals - who represent the group’s composition – varying in professional background, gender, age, personality etc. Finally, the team exists within a wider society that will affect the teams’ fundamental beliefs and value systems, i.e., the cultural context. Processes

Processes within teams enable them to achieve their goals. A fundamental requirement for effectiveness is that teams have clear objectives to which their members are committed. Other processes include participation in decision-making,

emphases on quality, and support for innovation. Another fundamental process is the extent of coordination and integration of team members’ work (Worchel, Wood, & Simpson, 1992). And of course, leadership and communication are likely to be important to team effectiveness. Another potentially important process variable is

reflexivity or the extent to which team members collectively reflect on the objectives, strategies, processes and environment of the team and make changes appropriately and accordingly.

Outputs

Six principle outputs can be distinguished: overall effectiveness, clinical outcomes,

team

member mental health, innovation, team member turnover, and cost effectiveness. In the research programme described in this report we explore the relationships between inputs and processes; inputs and outputs; and processes and outputs in 390 UK NHS teams, during the course of which we consulted with over 7,000 NHS personnel and with a large number of NHS clients.

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Using this model, we determined to explore the extent to which team working was associated with better quality health care for patients and to identify the factors associated with effective teamwork.

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Chapter 2

Primary Health Care Team

Research Methods and Sample Details

The research with Primary Health Care Teams had two stages. The first was a questionnaire survey, and related data collection methods, involving large numbers of teams conducted in order to gather data on team inputs, processes and outcomes. The second stage involved intensive examination of a sub-set of teams to explore in more depth targeted team processes and outputs.

Quantitative Methods

An overview of the methods used is given in Figure 2.1.

Figure 2.1: Details of the three samples and research methods

Sample size Survey data Additional

questionnaires/ Telephone interviews External ratings 100 teams 1156 respondents Team composition Team functioning Team effectiveness Team innovation Member stress Team composition Team meetings Team management Decision making Team effectiveness Team innovation The Sample

The research design required data to be gathered from 100 Primary Health Care teams (PHCTs) varying across a number of dimensions, including size (number of team members, number of GPs, list size); Jarman index; location (urban, rural, inner city), and geographical location. Databases of GP practices were accessed from 19 Health Authorities and 300 teams were randomly selected.

Letters explaining the objectives of the research and inviting teams to participate in the research, together with an information sheet were sent to the senior GP partner,

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senior health visitor and practice manager/senior receptionist in each practice. A reply slip was included, which also solicited additional information about the team (fund holding status, frequency and type of meetings, Jarman index, number of GPs, list size etc.)3

The initial letter was followed up with a telephone call to the practice manager/senior receptionist at all 300 practices. If teams had already indicated a willingness to participate, practical arrangements for questionnaire distribution were made. Researchers requested the name of a contact person in the team to enable continued effective liaison. The contact person was telephoned at a later date to determine whether the team was willing to take part in the research. Teams that did not return a reply slip were also telephoned and provided with additional information.

Further follow-up telephone calls were made until the team made a decision about participation in the research (some PHCTs were contacted six or seven times before a decision was made). When teams agreed to collaborate in the research, questionnaires were sent to the contact person for distribution to team members.

After three months the response rate from 10 teams was below 30% and 23 had not returned any questionnaires. These teams were dropped from the sample and replaced with 7 teams based in an inner city area, and 7 from a rural location, resulting in a final sample of 100 teams. The total response rate was 55.8%. Response rates for teams ranged from 21.4% to 100%, with a mean of 57.6%.

Data Collection Methods

Data on team functioning and effectiveness were collected using three methods: self report questionnaires completed by individual team members; self report and telephone interview surveys with the team contacts; and external ratings from primary health care representatives and health authority staff.

1156 respondents from 100 PHCTs completed questionnaires on their perceptions of team functioning and team effectiveness. Of these, 85% were female; 15% were GPs; 14.2 % practice nurses; 23% trust nurses (health visitors, district nurses,

3

Copies of interview schedules, questionnaires and all data collection instruments are available from the first author of this report.

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midwives); 33.5% administrative staff, 7.3% managers and 4.3% professions allied to medicine (PAMs).

Team contacts from 77 PHCTs provided information on team context, team composition and team processes in a self-report questionnaire survey, and 100 provided information via a telephone interview. This enabled a reliability check on the data for 77 of the teams.

Questionnaires completed by individual team members

This questionnaire was in four sections (a copy of the primary health care questionnaire is included in Appendix I).

Section 1: Team working

This contained seven measures of team working. Four of these were drawn from the Team Climate Inventory (Anderson & West, 1994,1998) that is based on a well-developed theoretical model of team functioning (West, 1990). The four measures assess levels of:

• team participation

• clarity of and commitment to team objectives

• emphasis on quality

• support for innovation.

Three other measures were included:

• reflexivity – the extent to which team members reflect upon their team objectives, strategies and processes and make changes accordingly (West, 1996; Swift & West, 1998).

• team innovation – the extent to which the team has introduced innovations in objectives, work strategies, processes and relationships

Respondents were also asked to write descriptions of the major changes or innovations introduced by the team in their work in the previous 12 months.

Section 2: Effectiveness

This included 21 measures of primary health care team effectiveness adapted from Poulton and West (1999). There are three underlying dimensions:

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• team working

• patient orientation

• organisational efficiency

Section 3: Team member stress

This included a measure of psychological stress, the GHQ-12 (Goldberg, 1972; Goldberg & Williams, 1991). The GHQ-12 is widely used as a screening tool for detecting minor psychiatric disorder in the general population, and in occupational mental health research. It covers feelings of strain, depression, inability to cope, anxiety based on insomnia, lack of confidence and other psychological problems. Within a Department of Health-funded study of the mental health of the NHS workforce, the GHQ-12 showed good validity against a psychiatric interview (Hardy, Shapiro, Haynes, & Rick, 1999).

Section 4: Biographical information

This section included questions on biographical and team characteristics (e.g. age, gender, ethnic origin, job title, employer, team composition, team leader).

Additional Practice Information – Survey

This was completed by the contact person in the PHCT (usually the practice manager). It included questions on: team context (relationships with external agencies such as health authorities and trusts); type of primary health care practice (fundholding, non-fundholding, dispensing) quality of premises; team composition number in each occupational group, grade, hours worked, time working in the team); staff development; and team processes (communication and decision making in meetings).

Additional Practice Information - Telephone Interview Schedule

The contact person in the team (usually the practice manager) responded to the telephone interviews. The focus of the questions was on decision-making and communication in the team: specifically who was involved in making operational, strategic and clinical decisions in the team, how these decisions were communicated in the team and what mechanisms were in place within the team to promote communication (memo systems, message books, informal meetings, email). Information was also gathered on the services and clinics provided by the team.

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External ratings – team effectiveness and innovation

Health Authorities employ staff to provide support to primary health care teams, a role involving working closely with a wide range of teams. Contact was made with staff in this role at each of the Health Authorities where the teams in the sample were located. They were asked to provide ratings of effectiveness and innovation for all of the teams from their area that were participating in the research. External ratings of effectiveness were obtained for 84 te

The Effectiveness of Health Care Teams in the National Health Service