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Team-Based Practice

Team-Based Practice

Teams are important because they are made up of people who have more or less flexible ways of keying into care complexities. Care is complex, because as it unfolds in the here-and-now care acts as the ‘collection point’ for a number of ‘runaway’ phenomena: Patients present with increasing numbers of diseases or multimorbidities (1); patients over the age of 60 tend to have at least 3 diseases (2); looking after these patients with rising levels of multimorbidity, clinicians have to oversee and manage rising numbers of treatments, drugs, technologies, specialties and tests (3), and so forth. While streaming, bundling and pathwaying clinical work provide important resources for simplifying care, people and their commitment and creativity are still needed to address the (rising number of) occasions where care practices stretch beyond the conventional envelope of accepted practices and routines.

Part of this picture too is that clinical decision-making is increasingly complicated by the fact that science now creates rather than limits uncertainty (4). A recent study found that 40% of trials examined had their findings overturned (5). These knowledge uncertainties are compounded by uncertainties about relationships due to people churn in health care: staff and patients are subject to increasing mobility and migration. This in turn means that team memberships are unstable (6). Services are also more and more frequently being redesigned and restructured, and bureaucratic and regulatory pressures in the form of reporting, monitoring, policy updates, accreditation and the like, are intensifying (7). Thanks to technological advances, some of these problems are alleviated, but technologies also exacerbate ethical tensions in healthcare (8). Resources are also shrinking. Collectively, these factors converge upon the in situ practices of doctors, nurses, allied health staff and managers, and upon the care received by patients in the here and now.

What does all this means for how we work and learn as teams on a day-to-day basis? In the general literature, everyday care complexity is rarely allowed to come to the fore except when clinicians publish their diaries (9, 10), or when inquiries delve into the details of a healthcare scandal (11, 12). Healthcare research privileges specialised and ‘distanced’ ways of converting care realities into formal data produced from medical record analyses (13), statistical process control analyses (14), to name but two (15).

That said, ethnography and real-time observations of the unfolding of care have become more common in recent healthcare improvement research. These observations are beginning to reveal the intricacies of how clinicians collaborate in complex environments, and inform how we think about team practice. Prominent concepts in this emerging domain are collective competence (16) and distributed intelligence (17). These concepts enable us to begin to talk about simple team dimensions such as task continuity and role complementarity, but also about more sophisticated team dimensions that involve reflexive adaptation, distributed leadership, normative flexibility and emotional intelligence. It is these six dimensions of teamwork that are woven throughout the interprofessional learning programme at King’s.

1. Hughes L, McMurdo M, Guthrie B. Guidelines for people not for diseases: The challenges of applying UK clinical guidelines to people with multimorbidity. Age & Ageing. 2013;42(1):62-9.
2. Yu A, Flott K, Chainani N, Fontana G, Darzi A. Patient Safety 2030. London, UK: : NIHR Imperial Patient Safety Translational Research Centre; 2016.
3. Brown N, Webster A. New medical technologies and society: Reordering life. Cambridge: Polity Press; 2004.
4. Arbesman S. The half-life of facts: Why everything we know has an expiration date. New York: Penguin; 2012.
5. Prasad V, Vandross A, Toomey C, Cheung M, Rho J, Quinn S, et al. A decade of reversal: an analysis of 146 contradicted medical practices. Mayo Clin Proc. 2013;357(2013):790-8.
6. West M, Lyubovnikova J. Real Teams or Pseudo Teams? The Changing Landscape Needs a Better Map. Industrial and Organizational Psychology. 2012;5(2012):25-55.
7. Greenhalgh T. Why do we always end up here? Evidence- based medicine’s conceptual cul-de-sacs and some off-road alternative routes. Journal of Primary Health Care. 2012;4(2):92-7.
8. Agledahl KM, Førde R, Wifstad A. Choice is not the issue. The misrepresentation of healthcare in bioethical discourse. Journal of Medical Ethics. 2011;37(2011):212-5.
9. Kay A. This is Going to Hurt: Secret Diaries of a Junior Doctor. London: Macmillan; 2017.
10. Watson C. The language of kindness: A nurse’s story. London: Penguin Books; 2019.
11. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013.
12. Kennedy I. The Bristol Royal Infirmary Inquiry. London: Department of Health; 2001.
13. Classen D, Resar RK, Griffin F, Federico F, Frankel T, Kimmel N, et al. 'Global Trigger Tool' shows that adverse events may be ten times greater than previously measured. Health Affairs. 2011;4(2011):581-9.
14. Carey RG, Lloyd RC. Measuring quality improvement in health care: A guide to statistical process control applications. Milwaukee Wisc.: American Society for Quality Press; 2001.
15. Shekelle PG, Wachter RM, Pronovost PJ, Schoelles K, McDonald KM, Dy SM, et al. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. (Prepared by the Southern California-RAND Evidence-based Practice Center under Contract No. 290-2007-10062-I.) (AHRQ Publication No. 13-E001-EF. ). Rockville, MD: Agency for Healthcare Research and Quality; 2013.
16. Boreham NC, Shea CE, Mackway-Jones K. Clinical risk and collective competence in the hospital emergency department in the UK. Social Science & Medicine. 2000;51(2000):83-91.
17. Iedema R, Mesman J, Carroll K. Visualising health care improvement: Innovation from within. Oxford UK: Radcliffe; 2013.

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