Background
Methods
Setting and participants
Study design and data collection
Data analysis
1. Team members act autonomously guided by internalized basic rules | |
Each team member can act in an autonomous way, guided by basic internalized rules. These rules can be expressed as instincts, constructs | |
2. Team members’ interactions are non-linear | |
Each team member can act autonomously but the actions have an effect on other team members (and vice versa). This is called the interdependence of the team members. These interactions encompass an exchange of information. An important aspect of the interactions is their non-linearity: small inputs may have large effects and vice versa. | |
3. The team has a history and is sensitive to initial conditions | |
The non-linear effects observed in a team result from the modifying influence of initial conditions on the interactions between components. As a result of evolution in the system, the ‘initial conditions’ for future interactions will be different. As such, a team has a history and a memory, which means that changed conditions are ‘remembered’ by the system. | |
4. Interactions between team members can produce unpredictable behaviour | |
As the interactions can cause non-linear effects, it is impossible to always predict the behaviour resulting from the interactions. Secondly, since the internalized rules are not necessarily equal for all components, the influencing factors for a cause-effect mechanism are not always clear. | |
5. Interactions between team members can generate new behaviour | |
A team can display behaviours that cannot be understood by the characteristics of the individual team members. | |
6. A team is an open system and interacts with its environment | |
Teams are connected with their environment in different ways. Some of the internalized rules come from the environment; if these rules change, the team changes. As such, the emergent behaviours of teams can be seen as adaptations to the environmental conditions, also called ‘self-organisation’. This self-organisation is informed by feedback loops by which the environment feeds the outcomes of the team’s actions back into the system. Next, depending on the scale we use, the environment may be part of the team or act as environment. As such, the borders of a team are not fixed but can open or close as a response to interactions with the environment. Finally, the environment consists of teams as well and they all influence each other. A team and its environment co-evolve during this interaction. | |
7. Attractors shape the team functioning | |
The actions and interactions of team members are influenced by a set of basic rules as described earlier. Rules push a team member towards a certain action. As a mirror image, attractors attract team members towards a certain action. The trajectory of a team (i.e. the usual pattern of behaviour) is for a great deal determined by its attractors. The precise behaviour of a team on a precise moment is still unpredictable but the ‘usual’ behaviour will always incline towards the attractors. |
Reliability, rigour and credibility
Results
Participants
Discipline (N) | Mean age (range) | Gender (male/female) | Working experience (years) | Practice situation (solo/duo/group) |
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General practitioner (18) | 46 (33–65) | 12/6 | 6–38 | 9/4/5 |
PHCT nurse (21) | 46 (34–57) | 3/18 | 0,5–15 | 0/0/21 |
Community nurse (20) | 46 (35–57) | 4/16 | 2–35 | 4/0/16 |
Results aim 1
CAS principle | Number of interviews where fragments have been found according to the CAS principle (GP/PHCT/CN) | Number of excerpts according to the CAS principle (GP/PHCT/CN) | Example of interview fragment coded under the CAS principle |
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1. Team members act autonomously guided by internalized basic rules | 48 (16/14/18) | 190 (40/62/88) | I think I might have a talk to him about this, because, you know, I really don’t like nurses administering drugs without me knowing it. Or give some extra painkillers just like that. (GP) |
2. Team members’ interactions are non-linear | 11 (1/6/4) | 11 (1/6/4) | He broke it off quite abruptly. Erm, the procedure was what she was, yes, euh, I had the impression that he shot the messenger while he was talking about the procedure. If he doesn’t agree with the procedure, then he can question it, but he doesn’t have to shoot the messenger, I think. So erm it ended up us having to ignore the syringe driver. That he was going to see to it himself] (PHCT nurse, after an altercation between a GP and the PHCT nurse on medication dose) |
3. The team has a history and is sensitive to initial conditions | 44 (10/17/17) | 130 (25/45/60) | That’s right, yes yes. Personality, yes, plays a major role in everything. Yes Yes. I see that, if you look at all of our GPs we work with, and those with whom you work occasionally, or those with whom you work very often, then your communication is also very different. (CN) You will be more assertive in the presence of certain general practitioners. How many times have you worked with them? Erm. What are previous experiences with this general practitioner? If you’ve had a very bad experience, then you will also be much more cautious. Then I think: “Well, the previous experience wasn’t good, I have to make sure that this one goes well” (PHCT nurse) |
4. Interactions between team members can produce unpredictable behaviour | 21 (2/11/8) | 38 (2/22/14) | It depends on your openness as a doctor. If you have a closed mentality, then you will receive suggestions that you don’t really need, whether you like it or not. (GP) |
5. Interactions between team members can generate new behaviour | 25 (5/13/7) | 54 (6/31/17) | I go and ask the members of the palliative team. Is there a solution to this problem? And there’s also a development in this and those people are more aware of it. If we try to do it well, each from our own expertise and our own training background, you will reach a higher level together] (GP) |
6. A team is an open system and interacts with its environment | 31 (7/12/12) | 70 (16/24/30) | But I think it’s actually because of us that they can be admitted (PHCT), that’s not an obvious a step to take. So often, it’s the hospital that takes the first step. The patients are discharged from the hospital and then we have to take care of the aftercare. They are usually aware of the existence of a palliative service, but I still think we take the first step most of the time (CN) And there are those who know it very well, of course. We also have several GPs who have followed the course (on palliative care), who are also well-informed. Sometimes, when I enter the place they approach me and say, ‘Have a look, I’ve done that calculation in such or such a way, what do you think. In consultation, that’s great, isn’t it? But there are different types of general practitioners. Yes, there is still a lot of work to be done] (PHCT) |
7. Attractors shape the team functioning | 52 (14/18/20) | 180 (26/50/104) | In the case of older doctors, it is usually the case that we try to give them the impression that the decision is theirs, but in most cases, we have talked them into it. How can we give them the sense that they made the decision while arriving at a point where it becomes doable for our patient? (CN) |
Results aim 2
1. Team members act autonomously, guided by internalized basic rules
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Participants in our study clearly stated that their mission in healthcare was to focus on the patient and the quality of care. ‘We are here for the patient’ is the most important basic rule for the three professional groups in our study, making it the driving force for team collaboration by sharing complementary expertise. The focus on patient care, along with the willingness to act in the best interests of the patient makes team members acknowledge each other’s expertise and allow them to express their opinions on patient problems within their area of expertise or seek advice with other team members in cases of indecision without interference of professional hierarchy. In cases of team members not sharing their expertise or acting on their own, other team members will restore communication without damaging interprofessional relationships.
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The awareness of GPs carrying final responsibility is a second basic rule within the context of the healthcare team in our study. As such, nurses cannot initiate or adapt medication or other therapies without seeking the GP’s consent. The PHCT nurse confirms the GP’s central position by taking the time necessary to deliberate with them the treatment options before meeting the patients and their families.
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A third basic rule in the context of our study is that tasks and responsibilities need to be clear for everybody. Having said that, every team member is responsible for their own tasks and duties, although these are not always clearly defined and agreed upon. For instance, monitoring the effect of changes in medication dose on patient’s pain level can be done by all professionals involved. Clear agreements are needed in order for therapy adjustments to be followed up efficiently. Even when tasks and roles are being negotiated and agreed upon within a team according to the patient’s care needs, some external rules are not to be violated, for instance certain protocols on complex procedures, like palliative sedation.
2. Team members’ interactions are non-linear
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Escalating communication conflicts were identified as examples of non-linear interactions. One PHCT nurse reported explaining to a GP why they could not assist them in a euthanasia case of a non-terminal patient, because these cases do not belong to the target group of the palliative care team (thereby correctly stating the limits of the team’s official mandate). As a response, the GP reacted in an angry manner and subsequently decided to cease collaboration with the nurse involved.
3. The team has a history and is sensitive to initial conditions
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Previous positive experiences of perceiving the complementarity of each other’s expertise in providing good quality patient care makes professionals trust one another and share tasks and responsibilities more easily. The resulting mutual respect of each other’s knowledge and expertise creates a positive working atmosphere and prevents role conflicts. In case of disagreements on treatment options or differing views on care aims, open and immediate communication is initiated. Positive experiences allow for professionals making a mistake without being blamed by other team members.
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Previous negative experiences, however, like nurses acting autonomously without consulting the GP, or GPs neglecting to inform CNs sufficiently on the patient’s medical status or ignoring expert palliative care advice, result in an atmosphere of distrust and lead to professionals acting on their own without sharing tasks. This results in a fragmented care delivery, often confusing both professionals and patients about general care aims. In case of disagreements or differing views, there is insufficient communication and professionals act according to their own views on care without consultation or support for their views from other professionals. As such, a history of poor collaboration makes team members judge each other in a harsher way.
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Knowing each other either through previous collaboration or on a personal level facilitates communication and establishes a basic sense of trust in each other’s competences. You get to know the other’s strengths and weaknesses, which results in tailored communication and collaboration.
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The communication history also has a major impact. A tradition of systematic and frequent communication facilitates the initiation of a deliberation in case of problems. Previous communication problems, like a GP being repeatedly unavailable for consultation or unwilling to negotiate treatment, cause nurses to find support with other team members, thus excluding the GP from the interaction.
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When a GP is reluctant to share the care for, and the information about, their patient at the start of the collaboration with the PHCT nurses (e.g. when family members ask for the PHCT nurses’ involvement or when hospital services initiate the collaboration when the GP does not feel the need), the interprofessional interaction is less spontaneous throughout the period of collaboration and the PHCT nurses hesitate to make therapy suggestions or discuss care goals. When, however, the GP welcomes the PHCT nurses, or invites them to collaborate, and provides them with insider information about their patient, the PHCT nurses will be more inclined to share all their insights and define shared aims and goals for patient care.
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A team of professionals trusting each other based upon previous collaborations and showing a willingness to collaborate from the start can, therefore, launch a kick-off meeting to define care goals and aims before the start of the collaboration. This ultimately leads to more open and constructive communication throughout the collaboration.
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The composition of the team at the start of the collaboration influences team members’ interactions and the way the team functions. Community nurses having displayed knowledge and expertise on palliative care in previous collaborations receive the GP’s trust and are invited by them to discuss treatment options. Similarly, GPs (e.g. younger doctors who received palliative care training as part of their undergraduate studies) who have proved knowledgeable before, encourage more open communication and straightforward deliberation with CNs than GPs without expertise. The same open interaction is facilitated by GPs addressing CNs as peers from the start while GPs stressing professional hierarchy at the beginning of the collaboration hinder open communication.
4. Interactions between team members can produce unpredictable behaviour
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Crossing task boundaries or tightening them can be the unexpected result of communication on task and role agreements. A GP telling the PHCT nurses that the former will be in charge of medication decisions often receives unsolicited therapy advice from the PHCT nurses who judge the GP’s intentions incorrect, based upon their own expert knowledge. Similarly, PHCT nurses questioning the GP’s decision in a professional way, with good care in mind, can be told not to interfere and not to engage in future therapy discussions.
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Professionals sometimes ignore their own knowledge and expertise and act in suboptimal ways without apparent reason. PHCT nurses often accept that GPs ignore their advice, without confronting the GP. They prefer to provide suboptimal care to the patient (according to the GP’s decision) and to closely monitor the patient and report on suboptimal results, eventually leading to therapy adjustment as was their first choice. The reason to act in this manner is not to damage the collaborative relationship with the GP, which might harm future collaborations for future patients. Similarly, CNs often tend to accept GP’s choices that are in contrast with their own views, without commenting upon it. Their reason is that they are dependent on the GP (for prescriptions, for example) for their daily work.
5. Interactions between team members can generate new behaviour
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During interaction and collaboration, professionals learn from each other. This workplace learning, the acquisition of new skills as an individual or as a team, can lead to a new way of functioning and is major emergent behaviour resulting from the collaboration. Receiving advice from experts in the team makes team members less dependent in the future and the interaction (advice-seeking behaviour) sometimes diminishes or changes its character. Complex procedures (e.g. palliative sedation or paracentesis) can be executed by a team, even when none of them have ever done it, but combining competences and trust in one another makes the team accomplish the task.
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New communication strategies is a second type of emergent team behaviour. Teams with only ad hoc and one-to-one communication may organize whole-team meetings in case of conflicts or as a form of debriefing in the case of complicated collaboration.
6. A team is an open system and interacts with its environment
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External factors influence the collaboration. When the GP is less available (e.g. due to workload in general practice in winter time), the PHCT nurse takes over the coordinating role from the GP. As such, the external conditions (e.g. flu epidemic in wintertime causing the GP’s reduced availability) pare down the interaction between GP and PHCT nurses and lead to a reshuffling of tasks and responsibilities in the team. The organisation of out-of-hours service (usual care not available during weekend) triggers initiatives within the team, like GPs sharing their private phone numbers with PHCT nurses, leading to a different way of interacting and communicating. Similarly, anticipating potential problems during the weekend, palliative care teams prepare sets of emergency medication and standing orders.
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The educational system influences the collaboration. While better education in palliative care for GPs facilitates discussions with PHCT nurses – indeed, the lack of interprofessional training during undergraduate medical training inhibits effective teamwork - learning to use protocols and guidelines results in less flexibility for the team to decide on how to deliver care. Published guidelines, however, are useful for PHCT nurses to prepare a discussion with GPs.
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Organizing and financing the healthcare system. Extra fees for care delivery to palliative patients was mentioned by CNs and GPs as stimuli or compensations for the time-consuming interactions and collaboration. Since community nurses are dependent on GPs for their work (they need prescriptions to be allowed to provide care), they are careful when commenting upon GP’s decisions or actions.
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Mass media and ideas of the general public can influence the team dynamic in complex cases like euthanasia (more requests) or medication use (e.g. morphine is lethal), resulting in discussions and more intense team deliberation.
7. Attractors shape the team functioning
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The quality of patient care delivery is the main attractor to initiate a collaboration and to shape the collaboration. In order to reach high-quality and comprehensive patient care, professionals combine their complementary knowledge and skills. Acknowledging and respecting each other’s competences often results in deliberation and shared decision-making on treatment plans as peers: professional hierarchy in these cases can be overcome by focusing on expertise instead of on professional background. Some GPs who present themselves as being hierarchically superior in daily practice are willing to make a shift in this behaviour and accept PHCT nurses’ advice in case of complex patient problems. In cases where the attractor of patient care is less present and team members experience rivalry between professions with regard to expertise, collaboration is hindered. Communication as a specific kind of interaction is also influenced by this attractor. Scheduled weekly team meetings are complemented by ad hoc phone calls or supplementary team meetings in case of complex patient problems or when team members do not share the same views on care and care aims.
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Interprofessional relationships are a second attractor as they are highly valued between team members. Professionals cover up for each other in case of little mistakes or miscommunication, thereby strengthening the professional relationships. GPs and PHCT nurses sometimes meet before jointly visiting the patient to agree on treatment plans. This is to avoid bedside discussions that might harm the trust of the patient in one or the other and hinder future interprofessional collaboration. In case of conflicting views on treatment options, PHCT nurses often avoid confronting discussions with GPs, and with a view not to endanger the relationship, they prefer to take up the nurses’ role and report on their observations of symptoms in great detail so as to guide GPs to treatment adaptations. Community nurses state doing the same, except when the problem in hand is clearly within the nurses’ expertise e.g. wound care. In those cases, they have no problems contradicting the GP.
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Personal and professional wellbeing is a third attractor, shaping the interaction between team members. Professionals mention seeking support with others for a debriefing after an emotional experience (e.g. death of a patient) or after a conflict with the patient or their family. After a collaboration episode (i.e. after the death of a patient), there is often a palliative care team debriefing to evaluate the care delivery. Some GPs regret not being invited to these, because they sometimes feel the need for a concluding talk. Knowing or feeling that they are doing the right thing, and thus avoiding moral distress, brings PHCT nurses to adhere to protocols for complex situations like palliative sedation. They use the protocol in their communication with the GPs to plan task execution. Most professionals prefer not to carry responsibility on their own but to share the burden and seek support or availability of others, even during out-of-hours service. A distinct aspect of professional wellbeing is the CNs’ dependency on GP’s prescriptions, resulting in CNs being careful in addressing GPs and being reluctant to contradict them. This might lead to less professional satisfaction in case of CNs feeling pressurized to perform actions they do not agree with.
Results aim 3
Facilitating factors for information exchange and sharing of expertise (CAS principle) | Hindering factors for information exchange and sharing of expertise (CAS principle) |
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Sharing the same mission of delivering quality care – the willingness to act in the patient’s best interests stimulates discussions and shared-decision making (1) | |
Professional hierarchy – PHCT nurse spends time deliberating treatment options with GP (1) Creating horizontal collaborative relationships from the start facilitates open interaction (3) | Professional hierarchy – nurses acting autonomously without deliberation results in atmosphere of distrust (3) Doctors stressing hierarchy structure might hinder open communication (3). Nurses being dependent on doctors for their daily work and therefore hesitate to comment upon doctor’s decisions even when they disagree (4) |
Unresolved communication conflicts (2) | |
Previous positive experiences resulting in mutual respect of each other’s knowledge and expertise (3) | Previous negative experiences – GPs insufficiently informing CNs on patient’s medical status or ignoring expert palliative care advice results in atmosphere of distrust (3) |
Knowing each other’s strengths and weaknesses results in tailored communication (3) Doctor’s education in palliative care facilitates discussions with PHCT experts (6) Using practice guidelines helps nurses prepare a discussion with doctors (6) | Lack of interprofessional training inhibits effective teamwork (6) |
Acknowledging and respecting each other’s competences results in deliberation and shared decision-making as peers (7). Valuing interprofessional relationships trigger anticipatory interprofessional communication in complex cases to avoid bedside discussions (7) | Nurses sometimes avoid confronting doctors with their differing views not to harm relationships. This results in missed learning opportunities (7) |
Tradition of systematic and frequent communication facilitates the initiation of a deliberation in case of problems (3) | Communication problems in the past like being unavailable for others or unwilling to negotiate treatment excludes professionals from future interaction (3) |
Unwillingness to collaborate or not feeling the need to collaborate at the start (3) | |
Sharing information prompts the recipients of information to share information as well (3) | |
A kick-off meeting at the start of the collaboration leads to better communication throughout the collaboration (3) | |
Extra fee compensates for time-consuming interactions (6). Mass media and general public ideas trigger more frequent and intense team discussions on complex cases (6) | Unavailability due to workload, time restraints diminish interaction (6) |
Striving for personal and professional wellbeing triggers interprofessional debriefing after emotional experiences or conflicts with patients (7) Nurses’ hesitation to take up responsibility on their own makes them seek support and deliberate with others, even during out-of-hours service (7) |