Team working Megan Joffe (PhD)

Team working

Megan Joffe (PhD)

Edgecumbe Health Practice Lead

Clinical and Occupational PsychologistKaren WadmanLead Adviser, National Clinical Assessment Service 2015

Working in a team requires individuals to contribute equal effort, manage their emotions and respect group normsTeams go through stages in their development  and these stages recycle when a team member joins or leaves

Interpersonal relationships affect team workingGood team work requires both individual reflection and team reflexivity

Learning points

Ponder the following...How do you know you are a good surgeon?

How do you know you are clever, charming and productive?How do you know you are a valued team member?

What have you actively contributed to your team functioning or its dysfunction?

Self-assessment of communication and teamwork skills by surgeons & anaesthetists is disturbingly discordant with the opinions of their associated nursing and perfusion staff (Wauben et al, 2011)

Surgeons rated the teamwork of other surgeons as high/very high 85% of the time – the nurses rated teamwork with surgeons as high/very high 48% of the time (Mackery et al, 2006)

During simulations strong correlation found between expert’s assessment and surgeon’s self-assessment of technical skill (Moorthy et al, 2006); surgeons rated themselves higher on their non-technical skills level than did the expert observers (Arora et al, 2011)

Watching videos of conflict scenarios, surgeons, anaesthetists, nurses rated the tensions similarly but rated their own profession as having relatively less responsibility for creating or resolving tensions (Lingaard et al, 2004/5)Behaviours viewed as decisive and necessary to achieve task goals may be viewed as harsh and demeaning by subordinates (Rogers et al, 2011)

How well do surgeons knowthemselves?

A team (12 consultants) working across 3 sites

Two distinct groups with differing deeply entrenched issues with one or two individuals remaining on the periphery

Two of twelve are recently qualified consultants, one of whom was a registrar hereRelationships described as “absolutely terrible”

A climate of fear and mistrustLoss of management control over a long periodCulture of complaint - grievance and counter grievanceClinical Director struggling to get agreement to protocols; different approaches to riskTheatre teams and anaesthetists complain regularly about behaviour of two surgeons and some nurses have refused to work with a particular consultantPatchy attendance at team meetings with one individual refusing to attend because of other commitments

Case study: Part 1

Where is the problem?

What is the problem?If you were in charge what would you do?

In groups of three discuss?

Some theory: team disruption and dysfunction

Clinical impact: Poor patient handover; refusal to cover

Stress

: Sickness, absence & excuse making higher than usualTeam behaviour:

staff playing one clinician off against another; splitting; poor quality meetingsAvoidance: no communication, absent at certain meetings; failure to reach agreement – agree only to disagree; attribute problems to others – failure to take individual responsibilityUndermining: public contradiction/criticism of professional opinion, ideas, leadership Sabotaging: absence from crucial meetings; passive aggressiveWork-arounds and bypassing the “difficult” team member(s)

Early warning signs of lapses

These can be one of or a combination of problems with:

The

tasks and responsibilities e.g. lead roles, training, job design

The team processes e.g. leadership, decision-making, conflict resolution, communication, meeting managementThe relationships e.g. interpersonal dynamics, trust, legacy issuesThe institution e.g. leadership, culture, history, external pressures

Where might team difficulties be situated?

Disruptive behaviour“inappropriate conduct, whether in words or actions, that interferes with, or has the potential to interfere with quality healthcare delivery” (ORCP)

“any behaviour that impairs the medical team’s ability to achieve intended outcomes” (Hickson

& Pickert, 2010)

Passive disrespectA range of uncooperative behaviours not malevolent or rooted in suppressed anger. Whether because of apathy, burnout, situational frustration, or other reasons, passively disrespectful individuals are chronically late to meetings, respond sluggishly to calls, fail to dictate notes on time, and do not work collaboratively or cooperatively with others.

A culture of disrespectful behaviour (i) (Leape, 2012)

Passive aggressive behaviour a pattern of negativistic attitudes and passive resistance to demands for adequate performance(difficulty/inability to confront directly – comply but resist behind the scenes)

Dismissive treatment of patients, juniors, nurses or others colleaguesDemeaning, disrespectful and dismissive treatment of others

Systemic disrespectSystems and process which are inherent in the way the organisation is run which disrespect employees and patients

A culture of disrespectful behaviour (ii) (Leape, 2012)

The undiscussed?

The undiscussable!

The unmentionable!?

What aren’t you talking about?

What is in the shadows?

Inclusion – Exclusion What are the alliances/groups/cabals?Who are black sheep? Why?

Conformity – Diversity How much challenge and difference is tolerated?Intimacy – Distance

Professional and personal boundariesCompetition – RivalryFormal and informal leadership

Power distribution

The team dynamics?

Forming

Storming

Norming

Performing

Stages of team development (Tuckman)

The five dysfunctions of a team

Lencioni

(2002)

Status and ego

Low standardsAmbiguity

Artificial harmony

Invulnerability

Poor or absent leadership

Worn down and worn outDisengaged and disconnected

No strategic plan or directionTurbulent team history (“grievance and grudge”)

Dominant personalitiesFactions, cliques and silosPower struggles and competitionTurbulent organisational contextExternal scrutiny (e.g. media; investigations)

Top ten derailers in clinical teams

Some theory: individual behaviour

Consultant interventional cardiologist Dr Star,

works in a department with three other consultants

It is known that he and his colleague, Dr Senior, do not get on A colleague, Dr Rock, who started at the same time as Dr Star is the clinical lead and has started to rearrange clinic times and procedures

Dr Star has reacted badly to this sending abusive emails but not attending team discussions There have been patient complaints about rudeness and poor communication ahead of cardiac catheterisation; and staff complaints about rude and irritable discussions about services and service changes in front of patients. Dr Rock has tried to discuss the difficulties with Dr Star who does not accept there is a problem. Dr Rock has now raised this with the MD after a cluster of complaints.

Case example – Dr Star

What is the risk to:Patients?

Self?Team?Organisation?

Dangerous

Demoralised/DistressedDestructiveDysfunctional

DisruptiveA spectrum of difficulty in a team

“I will return the document over the next few days and let you know if I have anything else to offer. I know you believe me to be hasty in such things, but I am able to process a lot of new information quickly and make firm decisions, after all. That does not make me a rash person, but I concede that you have concerns re may ability to cope with external pressures at work. I operate well under pressure, although I dislike interruptions and think of the operating room as a sanctuary, much like churches and cathedrals once were for victims of persecutions in long past.”

For good team work members must

contribute adequate effort by working towards group goals with intensity and persistence

perform “emotional labour” by regulating expressions of feelings to facilitate comfortable and positive interpersonal interactions within the group

perform “contextually” by respecting and adhering to interpersonal and social normsWithholder of effort: dodges responsibilities (“social loafing”) leading to unfairness and inequityNegative individual: frequently expresses negative feelings (pessimism, irritation, insecurity, anxiety); blocks progress and upsets others

Interpersonal deviant: violates norms of behaviour (acts rudely; humiliates others)

Team stars

Rock Star: hard-working; self-promoting, opportunistic

Soap Star: attention seeking, moody, unpredictableRising Star: enthusiastic, driven, ambitiousFalling Star: senior, independent, resistant to change

(All tend to consume a disproportionate share of management time)

Adapted from “Rock Stars in Academic Medicine”, Lucey, Sedmak & Notestine (2010)

Known to others

Unknown to others

Known to me

Unknown to me

Luft

, Joseph (1969). "Of Human Interaction," Palo Alto, CA: National Press

Johari Window: Dr Star

37 year old male surgeon qualified abroad; in UK 4 years; LOS:3 years as locum consultant; doesn’t talk to 3 colleagues; trainees complained about undermining; asked repeatedly to join private practice consortium.

Mid divorce; children with mother abroad; elderly & sickly parents abroad; sleepless nights; feels bullied by colleagues; few friends; feels colleagues want him out and that he hasn’t been given a chance to prove himself.

Peers concerned about attitude to risk; doesn’t listen to

feedback – seems offended and

reacts by shouting or isolating himself;

rebuffs offers of help; the team is

worried about his moodiness and seeming isolation.

The future/potential?

Change?

Stay or leave?

Accept support?

Performance manage?

Professional support?

Executive support and intention?

Is the team “projecting” its difficulties onto one individual?This helps them disown their own part in the group problem

If the focus moves to another person, this signifies something more systemicThe presenting problem must be tackled at several levels

Who is the troublemaker?

The Drama Triangle

Persecutor

Rescuer

Victim

Denial

we usually have a favourite position

hard to be in 2 positions at once

the one least like you will get to you and often trigger the triangle

boundary limits

PersonalityCareer success associated with:Conscientious

General mental abilityEmotional stability (neuroticism) neuroticism negatively correlated with success

can be problematic later in lifeCan drive (negative or neurotic) perfectionismOpenness

Correlated with willingness to reflect Consider alternatives

References Borrill et al. (2000) Health Care Team Effectiveness Project, UK

Flin, R (2010) Rudeness at work. BMJ, 2010;340:c2480.Hogan and Hogan (1997

).Lencioni (2002) The Five Dysfunctions of a Team Lucey, Sedmak & Notestine (2010) Rock Stars in Academic Medicine”, Academic Medicine Aug;85(8):1269-75.Mazzocco et al. (2009) Surgical team behaviours and patient outcomes. Am J Surg 197, 678-695.

Neily J, Mills PD, Young-Xu Y, et al. (2010) Association between implementation of a medical team training program and surgical mortality. JAMA ,2010;304(15):1693-1700 .Rock, D (2008) SCARF: A brain-based model for collaborating with and influencing others. NeuroLeadership Journal, 1, 78–87.Rosenstein A, O’Daniel M (2008) Managing disruptive physician behavior: Impact on staff relationships and patient care. Neurology 2008;70;1564-1570.Schippers,M, West M, Dawson J. Team Reflexivity and Innovation: The Moderating Role of Team Context Journal of Management, 2014Wahr JA et al (2013) Patient safety in the cardiac operating room: human factors and team work. American Heart Association Scientific StatementWest, M http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.427.1253&rep=rep1&type=pdfhttp://homepages.inf.ed.ac.uk/jeanc/DOH-glossy-brochure.pdf