This page sets out what behaviours someone with capability three would show, and the knowledge and skills needed. The capability is: “Able to work as a full and equal member of any multi-professional team, participating actively, sharing responsibilities and blurring professional and role boundaries.” This capability focuses on the characteristics of a single team member, but that person is set in the context of a team and each team will have its own context. Successful teamwork depends upon all team members, and it also depends vitally upon the team being located within a managerial, organisational and financial environment that allows, fosters and develops good teamwork. The best team-worker in the world cannot function if other team members do not also collaborate, and the best team in the world cannot work in a hostile cultural environment.
Context – why multi-disciplinary teams
This brief setting of the context explains why a team is necessary, what a team is, and where a rehabilitation team is located in the complex network of healthcare services. Background reading includes a chapter written on teams in rehabilitation (here), and a document on ‘Advancing Medical Professionalism’ (Royal College of Physicians, available here), in which the third chapter is devoted to “Doctor as team worker” (page 39) The content applies to all professions.
Problems within healthcare are among the most complex problems faced by society. Complexity arises from the many factors that influence every part of and every process within healthcare, and the additional fact that these factors themselves are inter-related. The consequence is that all relationships are non-linear, and outcomes are not very predictable, so that all processes need constant monitoring and feedback control.
This analysis applies both at a macro-level, considering healthcare organisation, and at a micro-level, considering an individual patient. It is also well established that complex problems are best managed by multi-disciplinary teams. A hospital board will have 5-15 high-level executives covering different aspects of the organisation. A team managing a patient will have 5-15 highly qualified professionals, covering different aspects of the patient’s problems.
In rehabilitation, and increasingly in many other areas of healthcare, this group of people working together is termed a multi-disciplinary team. In acute and disease-focus services, the disciplines may be different specialities but with many being doctors. In rehabilitation and other services focused on disability (e.g. learning disability, geriatrics, palliative care), the multi-disciplinary team is usually also multi-professional.
As ‘Advancing Medical Professionalism’ stated, “Although long-recognised as important, team working in healthcare is still underdeveloped.” As it also noted, “Barriers to teamwork include failure to recognise that it depends on learning, failure to build it into the training of health workers, and the structure of healthcare.” The curriculum for training in rehabilitation may be one of very few to have a capability devoted to teamwork, but without high-quality multi-professional teamwork, rehabilitation will fail.
Context – what is a good team
A team is not simply a group of people who happen to work together with a patient (or on any other complex problem). This has been well expressed in ‘Advancing Medical Professionalism’ – “Pseudo-teams, in contrast, do not have shared objectives, do not work interdependently, and do not meet regularly to review performance. Unfortunately, pseudo-teams are common in healthcare.” Unfortunately pseudo-teams are not only common, they are also associated with increased stress, reduced engagement of staff, and dissatisfaction with work.
Originally the word applied to a group of oxen or horses pulling a plough, carriage or cart, and this illustrates one main feature. A team works together towards a set of patient goals. But it is much more than that. The team, as a team, also has its own goals such as improving outcomes of all patients seen, reducing length of hospitalisation, supporting families, training junior staff etc. A team also provides mutual support, one to another, and team members trust and respect each other. They work together over long time-spans with many patients. They have a history, and a culture (not necessarily a good culture).
The features needed for better teamwork are discussed in another page on this site – here. They are also discussed in ‘Advancing Medical Professionalism’ where the barriers to better teamwork are summarised as including “failure to recognise that it depends on learning, failure to build it into the training of health workers, and the structure of healthcare.” Maybe this page and the development of rehabilitation capabilities will encourage overcoming some of these barriers.
The three key factors that ‘Advancing Medical Professionalism’ identifies as important are: “improving are culture, communication, and reflexivity (the ability to reflect on events and learn from them).” It is interesting that reflecting on experience has been highlighted. Reflective practice by individual healthcare professionals is now considered one of the important ways in which practice can be changed and improved. (here) It makes sense that teams will also benefit.
Context – other teams
As is said on another page (here), “No team is an island entire of itself; every team is a piece of the healthcare system.”. Many patients involved with a rehabilitation team will be in contact with other organisations and agencies and, sometimes, involved with other teams within them. Common examples include other secondary care hospital services managing their disease(s), social services providing care and support, employers, a care agency and so on.
This complexity it illustrated in this diagram. (here) The next capability, capability four. is specifically concerned with how a rehabilitation professional manages this complexity.
There is a further complexity within most rehabilitation teams. At the macro-level, there is a large group of people from many different professions, who constitute ‘the rehabilitation team’ or, as an alternative title, ‘the rehabilitation service team‘. It is this service team which discusses matters such as team goals and team policies.
There is also a patient team at the micro-level. This is the group of particular individuals who are involved with a particular patient. This has been explored in more detail in a blog on rehabilitation professions (here). The team involved will be chosen to meet the specific needs of the patient, and will also be influenced by factors such as the availability of individuals, the personalities of the professionals and the patient, and so on. The nature of a patient’s own team is illustrated here.
In summary, a team is a good way to manage complex problems. Rehabilitation problems are complex. Rehabilitation has developed multi-professional teams to manage groups of patients with similar problems, but an individual patient will only be involved with a subset of that greater team Moreover, the healthcare system is complex, and other teams and people from outside health will also be involved with the patient. Consequently, the concept of a single multi-professional rehabilitation team managing a patient is a gross simplification, but a useful one.
The attitudes needed to acquire and maintain this capability are:
- empathy, an acceptance of the experience of others
- willingness to share duties, responsibities, and expertise
- flexibility about status and roles
- adaptability to the needs of others and of the team
- self-awareness of impact of behaviours on other team members
To be successful as a team member, one must develop a commitment to the team as an entity, and one must develop personal relationships with the team members. It is not dissimilar to belonging to a family, to a fan club, to a sports team, or any other group of people who have shared interests and goals.
A team will usually have a leader. Considering the rehabilitation service team, this is likely to be a single person who will be leader for months or years. However, for the patient team, there is not necessarily a definite leader and leadership may be diffuse and specific to particular problems. For example a nurse might ‘lead’ on interactions with the family, and an occupational therapist on arranging transfer home.
However there will be formal team meetings of the patient team, for example to formulate the situation, to undertake planning, and in response to particular difficulties that may arise. Under those circumstances, a team leader is needed and it may be any member of the patient team. It is usually agreed by the team on the basis of experience, availability, extent of involvement with the patient and so on.
Therefore there are three different aspects of behaviour: as leader of a patient team within a meeting; as a participant in a patient team meeting or a service team meeting; and generally as a member of the service team and/or the patient team.
As a leader of the patient team, the professional should:
- When acting as chair of a patient team meeting:
- ensures that all people present are heard and listened to;
- treats all comments and contributors with respect;
- ensures that all jargon is explained;
- Curtails input that is unnecessary, repetitive, disrespectful, or otherwise inappropriate.
- When acting as a participant in patient team meeting:
- contributes information, analysis, advice clearly when needed;
- supports the chair in his/her role, giving feedback afterwards if needed.
- At all times:
- participates actively in all team meetings (e.g. education, service management etc);
- educates other team members about his/her own expertise;
- communicates effectively, verbally, in writing and in other ways at all times;
- respects, and learns from expertise of other team members;
- liaises with relevant team members about any activity likely to be relevant to them;
- demonstrates understanding of him/herself and their effect on others;
- supports other team members in achieving patient team goals;
- support service team members through any difficulties;
- negotiates within the team to create consensus and avoid conflict;
- is committed both to patient team goals and service team goals.
Knowledge and skills
It is probably helpful for all team members to have some awareness of the research into team functioning, and how to optimise it. Much of the literature will be outside health research. It would, indeed, be a valuable component of team education to review and discuss literature three or four times a year. The chapter in ‘Advancing Medical Professionalism’ and the other chapter mentioned at the beginning of this page would be a good start.
The knowledge referred to here is rather more mundane, and concerns knowledge about the teams being worked in. It is not possible to work within a team without learning and knowing something about all members to the team. Given the fluid nature of patient teams, it means getting to know something about each professional group involved.
Therefore, in order to achieve the required behaviours, the professional will need to learn and know:
- the roles and expertise of all other professions involved in team;
- how team is managed and funded within the organisation;
- all team policies and procedures relating to patient care;
- when another team member should be asked to assess and/or advise on patient;
- the common measures, assessments, and jargon used by other team professions;
- the approaches and treatments commonly used by other team professions.
The skills needed to work in the team are those needed on a generic basis, to work as a healthcare professional in almost any part of the healthcare system. They are not unique to this capability, but they maybe particularly important for people working within multi-professional rehabilitation teams.
In order to be a valued and useful functioning member of a rehabilitation service and patient team, the professional will be able to:
- communicate effectively with the whole team at all times, both directly and through using notes and other communication channels;
- give feedback to team members positively – clearly but sensitively;
- receive feedback from team members positively – gracefully and thoughtfully;
- be led, and to lead equally well;
- integrate educating and teaching of team members into clinical practice;
- speak up, ask questions, acknowledge errors, and raise issues rather than ignore them;
- reflect on, discuss, observe and question team culture and working practices;
- accept that team members will have differing opinions, and use the differences constructively;
- experiment, and learn from errors and mistakes;
- listen actively to other team members.
This page has discussed the concept of multi-professional teams in rehabilitation, highlighting that matter are actually quite complex, and that there are many teams: service teams, patient teams, teams of teams etc. Nevertheless, the characteristics needed by someone working in this milieu to integrate well into all the teams are similar. They have been set out, and are summarised in a MindMap available here.