http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2015; 29(1): 55–61 ! 2015 Informa UK Ltd. DOI: 10.3109/13561820.2014.940038

ORIGINAL ARTICLE

Enhancing patient-engaged teamwork in healthcare: an observational case study Lynn M. Casimiro1, Pippa Hall2, Craig Kuziemsky3, Maureen O’Connor4 and Lara Varpio2 1

Department of Academic Affairs, Montfort Hospital, Ottawa, ON, Canada, 2Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada, Telfer School of Management, University of Ottawa, Ottawa, ON, Canada, and 4Accreditation Canada, Ottawa, ON, Canada

3

Abstract

Keywords

The purpose of this study was to describe how teamwork that effectively engaged patients and families, manifested itself in an acute rural care setting in order to inform the development of teamwork skills. One hundred and forty participants were included in the study representing providers, patients, family, hospital and clinical support personnel, education specialists and students. Using a modified grounded theory approach, and informed by activity theory, observational field notes and interview transcripts were analyzed. Through the analysis of 343 events of providers interacting with, or exchanging information about, patients, three patterns of teamwork emerged that facilitated patient-engaged care: uniprofessional, multiprofessional and interprofessional. The data indicated that providers navigated between these patterns, as well as others, throughout their workday. Providers should be skilled in applying the construct of situation awareness in order to adopt a pattern of teamwork that best facilitates patientengaged care. Interventions that can enhance teamwork should focus on: valuing the perspectives of others; developing relational competence and resilience; employing reflective learning and shared decision-making skills; and incorporating principles of change theory for both individuals and systems.

Case study, interprofessional care, patient-centered practice, team-based practice, team effectiveness, teamwork

Introduction Working more effectively and efficiently with co-workers and stakeholders is becoming a part of healthcare providers’ required competencies (Canadian Interprofessional Health Collaborative, 2010). There is evidence to support implementing collaborative teamwork, especially in the areas of patient safety and complex patient care, in order to achieve better quality of care with the best use of available resources (Barr, Koppel, Reeves, Hammick, & Freeth, 2005; Canadian Health Services Research Foundation, 2006; Canadian Patient Safety Institute, 2008; Gilbert, 2005; IOM, 2001). Collaborative teamwork allows healthcare professionals to address the multiple physical, psychological, social/ cultural and spiritual needs of patients with complex and chronic health issues (Hall, Bouvette, Heillman-Stille, & Weaver, 2012). However, some issues linked to professionalization, such as professional fragmentation, traditions of individualism, hierarchical authority and diffuse accountability create a daunting challenge to teamwork in healthcare (Bunniss & Kelly, 2013; Reeves, Lewin, Espin, & Zwarenstein, 2010; Varpio, Hall, Lingard, & Schryer, 2008). In addition, while care providers may be expected to work collaboratively, existing team-based research does not consistently address the involvement of the patient as a contributing team member (Casimiro et al., 2011;

Correspondence: Dr. Pippa Hall, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada. E-mail: [email protected]

History Received 12 June 2013 Revised 28 April 2014 Accepted 26 June 2014 Published online 22 July 2014

Martin & Finn, 2011). Clearly, an integration of team collaboration with patient-engaged care is needed. Based on Herbert’s (2005) definition, this study considers patient-engaged care to be a practice orientation which seeks the best possible participation of the patient, and when appropriate the family, through exchanges which enhance patient- and family-centered goals and values. This perspective in supported in the literature on person-centered care (e.g. Kitson, Marshall, Bassett, & Zeit, 2012; Lamb et al., 2013; Wynia, Von Kohorn, & Mitchell, 2012) and shared decision-making (Tinsel et al., 2012; van de Bovenkamp, Trappenburg, & Grit, 2009). Research has identified certain situational factors that influence the way teams work together to facilitate patient-engage care. These include the type of care setting, care needs of individual patients as well as the number and professions of the care providers involved (e.g. Bleakley, Allard, & Hobbs, 2013; Brady & Goldenhar, 2014; Chiappe, Rorie, Morgan, & Vu, 2014; Lemieux-Charles & McGuire, 2006). The term ‘‘situation awareness’’ has been applied to explain a person’s conscious attention to these factors, and has been identified as a driver of healthcare team dynamics (Brady et al., 2013; Mackintosh, Berridge, & Freeth, 2009; Wauben et al., 2011). According to Bleakley et al. (2013, p. 33), ‘‘situation awareness grasps what is happening in time and space with regard to one’s own unfolding work in relation to that of colleagues’’. Research on effective teamwork often fails to take into account how team members facilitate patient-engaged care or explore how the complexities of situational factors influence this approach to care (Lingard et al., 2012). Research is thus needed to examine how healthcare

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providers navigate the complexities of these situational factors to facilitate patient-engaged care. This study was undertaken to better understand the types of teamwork that demonstrate patient-engaged care while taking into account the complexities of the situational factors in a community hospital setting. This work was also seen as a first step in identifying areas of patient-engaged teamwork that merit more targeted research studies.

Methods An instrumental case study design (Stake, 2008) was chosen in order to explore the wider issue of complexity impacting on healthcare teamwork and it was anchored in the premises of activity theory (Engestro¨m, 2001), which provides a rich approach to understanding the complexities of collaboration in the clinical context from a socio-cultural perspective (Bleakley, 2013; Greig, Entwistle, & Beech, 2012). The following questions guided the study: What are the types and characteristics of healthcare teams that facilitate patient-engaged care in the community hospital setting? What role do situational factors play in shaping teamwork practices? Setting This study was conducted over the course of one year in a rural teaching hospital, located in Ontario, Canada, with approximately 300 employees. Four in-patient units (medical-surgical acute care, day surgery, obstetrics and continuing complex care) and one outpatient unit (diabetic education program) in the hospital participated in the study. In all of these units, the administrators purported that patient care was delivered by different providers working in teams. All healthcare providers in these units were informed of the study through published invitations in the hospital’s internal newsletter, and were personally invited to participate in the study by the research assistant.

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Table I. Number of participants by service.

Type of service Medical-surgical acute care Continuing complex care Day surgery and obstetrics Education program General support to all services Total

Number of participants Interviews Observations 62 21 20 5 32 140

15 1 – – – 16

59 20 20 5 32 136

patients and families, purposeful sampling was used to ensure a wide representation of the different types of health care providers and students. All interviews consisted of the same probing categories of questions in content with the language adapted to the patient, provider or student situation. Five interview schedules were used: patients, family members, healthcare providers, students with some profession-specific questions for nursing, medicine and other health professions. The interviews were audio recorded, transcribed verbatim and rendered anonymous during the transcription process. One hundred and forty participants were included in the study. One hundred and thirty-six participants consented to the observations and a total of 127 h of mostly day-time, non-participant field observations were conducted. Sixteen participants were included in the semi-structured interviews. Most participants were from the medical-surgical acute care unit (n ¼ 62), followed by continuing complex care (n ¼ 21), day surgery and obstetrics (n ¼ 20) and an education program (n ¼ 5). Thirty-two of the participants were in general support to all services (Table I). The participants represented providers, patients, family, hospital support personnel, clinical support personnel, education specialists and students (Table II).

Data collection A convenience sample was employed to recruit individuals who consented to participate in the study. Individuals working in the study unit on the day and time of an observation session were eligible to actively participate. The research assistant was experienced and qualified in ethnographic data collection methods and conducted field observations using overt nonparticipant methodology where ‘‘participants understand that the observer is there for research purposes: the observer is present during organizational activities and has a role clearly distinct from that of organizational members’’ (Mills, Durepos, Wiebe, Liu, & Maitlis, 2010, p. 610). Observations were conducted during day and some night shifts. Observations as well as quotes from conversations were documented in writing and later transcribed. Only events or portion of events in which individuals had agreed to participate in the study were documented. Detailed field notes were made and any observations needing clarification were verified with participants immediately following the observed event. Ten hours of initial observation data was reviewed by the research team to establish consistent reporting. This initial data were not included in the study. Study participants were also verbally invited by the research assistant to participate in a semi-structured interview to explore their experiences of working with teams including their communication strategy preferences, the inclusion of patients and family in the decision-making process and their views on collaboration. The questions were thus designed to delve deeper into the issues that were being observed. In addition to approaching participating

Data analysis Using the principles of grounded theory (Dey, 2007), a research team representing different disciplines (medicine, rehabilitation sciences, social sciences and health informatics) undertook data analysis. Through an interpretive analysis approach (Delamont, 2007), the team identified events in the observational data where providers were interacting with or exchanging about patients and discussed the characteristics of those interactions. An event was only considered for analysis if it involved a patient or family member. The events were then sorted into one of the three following categories: (1) Operational exchanges that did not involve direct patient or family interactions or discussions about care delivery; (2) Events where there were exchanges between one care provider and a patient or family member; (3) Events where there were exchanges between more than one care provider and a patient or family member or exchanges between care providers about a patient’s or family member’s care delivery. Operational exchanges did not offer the possibility to observe patient-engaged care and were not analysed further. Events where there were one or more than one care providers interacting with/about patients or family members were analyzed further in order to determine whether they demonstrated patient-engaged care as defined in this study. A thematic analysis was conducted of the identified characteristics and situational factors (Chesluk & Holmboe, 2010) using a modified constant comparison method (Glaser & Strauss, 1967) to identify patterns of similarity and difference between the identified characteristics and within the various data sources.

Enhancing patient-engaged teamwork

DOI: 10.3109/13561820.2014.940038

Table II. Number of participants by type.

Type of participant Providers Laboratory technician Nutritionist Occupational therapist Pastoral care specialist Pharmacy technician Physicians and surgeons Physiotherapist Physiotherapist aid Radiology technician Recovery room nurse Registered nurse Registered practical nurse Total Patients and family Family member Patients Total Hospital support personnel Food services personnel Housekeeping staff Human resource specialist Maintenance support personnel Materials management personnel Total Clinical support personnel Clinical manager Clinical specialist Discharge planner Infection control coordinator Manager diagnostic services Pharmacy manager Volunteer Ward clerk Total Education specialists Continuing education specialist Diabetic educator Total Students Medical students Student nurses Student paramedic Student physiotherapist Total Grand total

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Table III. Number of interaction events with patients/family.

Number of participants Interviews Observations 1 1 1 1 1 16 2 1 2 6 23 13 67

– – – – – 1 – 1 – – 2 1 5

1 1 1 1 1 16 2 1 2 6 23 13 67

1 21 22

– 2 2

1 20 21

6 10 1 4

– – – –

6 10 1 4

3

–

3

24

0

24

2 1 1 1 1 1 2 3 12

1 – 1 – – – – 1 3

2 1 1 1 1 1 2 3 12

1

–

1

2 3

– 0

2 3

3 6 1 1 11 140

2 2 1 1 6 16

1 6 0 1 8 136

Both sets of data (observational and interviews) were analyzed together. Themes and categories were only retained if there was consensus between the research team members and included at least three different professional perspectives. These categories were then articulated using the concept of knotworking (Engestro¨m, 2005) to form patterns of patient-engaged care. The categories linked to situational factors were then described in relation to the patterns of patient-engaged care. The team presented the emerging data to study site’s staff at regular intervals during the study to solicit feedback and input. These member checking activities occurred (1) at staff meetings, (2) through the hospital’s newsletter and (3) at senior management staff meetings. A detailed audit trail was kept consisting of data collection details, meeting minutes from analysis meetings and documented evolution of the data interpretation.

Type of service

One provider

4One provider

Operational

Total

44 50 0 0 94

76 81 5 6 168

58 23 0 0 81

178 154 5 6 343

Medical-surgical acute care Continuing complex care Day surgery and obstetrics Education program Total

Each transcript in day surgery, obstetrics and education program was treated as a single event as it represented one continuous interaction with a patient or multiple patients and family members.

Ethical considerations The study received Research Ethics Board approval from the research university with an internal review from the participating site.

Results Analysis of the observation transcripts yielded 343 events where providers were interacting with or exchanging about patients. Of these events, 81 were operational exchanges and were not further analyzed, 94 involved one provider and 169 involved more than one provider (Table III). Results data have been divided into two main categories: emerging patterns of teamwork strategies and situational factors. Emerging patterns Healthcare providers were observed transitioning between several different identifiable patterns of team behaviors over the course of the workday. In this paper, we report on the patterns that demonstrated patient-engaged care and this section describes three of the main patterns of teamwork that emerged from the data. Distinctive characteristics of the patterns include the types of providers, number of providers and degree of interaction.1 Pattern 1: Uniprofessional This pattern was observed when a situation required a single healthcare professional to collaborate with one patient and/or family. The provider appropriately assessed the situation, and teamed up with the patient to address the situation without the involvement of other care providers: Provider N22 is preparing a patient for an investigative procedure off the unit: ‘‘Now, are you good to go without oxygen, or would you like your portable tube?’’ Patient says she hasn’t needed oxygen while walking for a while now, so the oxygen is removed by the nurse (observation data). Examples of other observed health situations that were addressed by pattern 1 included: bathing a patient; taking a blood sample; taking a blood pressure and addressing a financial situation. Pattern 2: Multiprofessional This pattern was observed when a situation required more than one care provider from different professions or disciplines to assess the patient’s situation, each working collaboratively with the patient (and family, when appropriate) to achieve the patient’s goal. The providers communicated their individual plans to each other to coordinate care. In this pattern, each provider was observed to

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operate within a clearly defined pool of duties demonstrating little collaboration with other professions or disciplines except for sharing information. In our data, surgical teams provided common examples of multiprofessional teamwork: Provider C1: ‘‘Patient ZZ, she lives in an apartment, but has a supportive family. Dr. X was wondering how she’s doing.’’ Provider P2: ‘‘She has hip pain and she needs help for transfers.’’ Provider N1: ‘‘No, she’s doing transfers on her own now. The only thing she can’t do are her stockings, but it’s because they’re so tight. She needs minimal assistance.’’ Provider P2: ‘‘She can probably go home then. She’s waiting to see a doctor, but that shouldn’t keep her here.’’ Provider N2: ‘‘She’s going to live with one of her daughters temporarily, then she’s going to live with the second one. The second one is building a sort of suite for her.’’ Provider P2: ‘‘[Are] there stairs?’’ Provider N2: ‘‘I’m not sure.’’ Provider P2: ‘‘Because if there’s stairs then I can help her with that.’’ (Observation data)

Pattern 3: Interprofessional This pattern was observed when a situation required that the knowledge and expertise of care providers from different professions be integrated together, and included the knowledge and expertise of the patient and/or family. In this pattern, data showed that decision-making was shared and the team (which included the patient) set common goals of care using a collaborative approach. The providers, patient and/or family worked together from their own areas of expertise to define an integrated strategy that enabled them to achieve common team goals. In this pattern, behaviors of the team members demonstrated continual communication, shared decision-making with consensus between team members, and shared expertise: During a team meeting, the patient’s goal is brought to the group’s attention. Provider D1: ‘‘The wife still thinks he’s going home.’’ Provider N33: ‘‘She said she wants to get him used to it and she wants to put a pole in his room for support.’’ Everyone looks at each other and they do not want to put a pole in because they do not think he will be able to use it. Provider N33: ‘‘Well why aren’t we doing that if she wants it?’’ Everyone at the meeting pause, then say, ‘‘OK, let’s do it.’’ Provider P2: ‘‘So, [provider O1], you’ll do it?’’ Provider O1: ‘‘Is he ready?’’ Provider P2: ‘‘As ready as he’ll ever be.’’ Provider O1: ‘‘It will at least make her happy. Then we can reevaluate things and all be on the same page.’’ Provider N33: ‘‘And you know what? Maybe she can take him home. It’s up to us to solidify things.’’ (Observation data) Teams providing complex continuing care were commonly observed engaging in interprofessional collaboration. These patient circumstances frequently required attention not only to the physical but also to psychosocial, cultural and spiritual domains of patient care. Those different domains contributed to the complexity of the situation and teams needed to develop a plan of care for each unique patient situation, rather than use clinical pathways and pre-determined care plans. Interprofessional patterns demonstrated collaboration and communication between all team members and achieved the goal of patient-engaged care.

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Situational factors Analysis revealed a number of situational factors that influenced providers’ engagement with patients, with their families and with each other. The three main categories of observed factors gleaned from the data were: patient’s cognitive status, patient’s disease status and social dynamics of teams. Patient cognitive status The data illustrated that cognitively-able patients were routinely included in most healthcare decisions: Physician MD11 walks into the Day Surgery room and speaks with the patient before surgery. Patient 16: ‘‘I wanted to make sure if anything needed to come out, that you do it.’’ Physician MD11: ‘‘You want me to remove [organ] no matter what?’’ Patient 16: ‘‘I am getting a lot of pain on the right side.’’ Physician MD11: ‘‘I can remove the whole [organ] if you like. Did you ever try [medication]?’’ Patient 16: ‘‘Yes, I did.’’ Physician MD11: ‘‘Did it help?’’ Patient 16: ‘‘I still had pain . . . I kind of think we’d better just get rid of it.’’ Physician MD11: ‘‘O.K. let’s do that.’’ (Observation data) In contrast, cognitively impaired patients, as well as their families, were often not included in goal setting or in the decisionmaking process, despite the complexity of the health situation. Decisions were often made without the integration of the perspectives of the patient, the family or of other significant team members. The data showed examples of providers feeling, rightly or wrongly, that they were in the best position to make decisions for these patients and their families. The following is a representative excerpt of interview responses with care providers, when asked if patients with complex and chronic illnesses should be part of the team: They have to understand why they’re making this choice and why they can’t go back home. And sometimes, you know, you’d be talking to somebody and they’ll . . . ‘Well I’m just going to go home, and live like I was and I’m fine, and I can do this . . .’ and they can’t, they are not capable of doing it. So they haven’t got insight into what’s going to happen when they go home. So those people aren’t capable of making their own decisions because they are making poor decision[s].’’ (N12, Formal interview data)

Patient disease status The data demonstrated that providers fully engaged healthier and functionally active patients along with other team members in the care planning. For example, education specialists encouraged patients and their family to engage in shared decision-making with the care providers within their circle of care. Education specialists presented the various providers as coaches able to assist patients with their decisions: Education specialists discuss diabetes management with a group of patients. Provider E1: ‘‘Myth: the doctor is in charge of your diabetes. The doctor is part of your diabetes team just like me & [Provider E2] are, but you are in charge of your body . . . The healthcare professionals are there as coaches. We’ll provide you the

Enhancing patient-engaged teamwork

DOI: 10.3109/13561820.2014.940038

information, but it’s up to you to be in charge,. . . you should have a discussion with your doctor about cholesterol and your monthly average . . . We are going to create a sheet about the tests you need and the numbers you should have. Would you feel comfortable asking [the doctor] that information?’’ Patients respond they would feel more comfortable if they had the sheet, because otherwise, they forget. Provider E1: ‘‘There was one patient whose cholesterol was high and not checked for 2 years. We sent a note [to the doctor] saying, ‘We notice the test wasn’t done. Would you check into this and ask the patient?’ The doctor was very happy that we checked and reminded him. It’s because they’re busy. It’s up to you to be in charge. You’re the big boss.’’ (Observation data) Alternatively, decisions were often made without engaging the patient and/or family if patients were less healthy and less functionally active such as patients who receive complex continuing care: Provider N15 follows a physician’s order: ‘‘Patient N, Dr. X ordered no more oxygen, so you’re not going to have any more.’’ Provider N15 leaves the room for a minute then returns. ‘‘Patient N, do you want a bath? Patient N? Patient N? I didn’t do anything to you. Well I’m gonna take the oxygen away. I don’t have time to sit here and argue with you. It’s doctor’s orders.’’ The oxygen is removed (Observation data) Social dynamics of teams In interviews, participants expressed the perception that trust was paramount to their satisfaction with teamwork. Providers described how trust must be developed when they are unfamiliar with the other team members including the patient and/or family. During an interview, a physician discussed trust as part of team function: ‘‘I know what [nurse’s name] personality is like so I know that I can rely on her to do x, y, and z but not necessarily a, b, and c, and that’s not necessarily a bad thing. It’s just that’s their skill set, that’s their personality, that’s their whatever, and that does make a big, big difference.’’(MD6, Formal interview data) Although interview data confirmed health providers valued trust, which was usually established over a long time of working together, observational data suggested this social capital could affect the team’s focus. Team meetings sometimes evolved into social discussions rather than a discussion of the patient’s health situation: Patient and family requested to return home and the team decides not explore this option Provider N33: ‘‘[Patient’s name] is probably the best that [Patient’s name] has ever been. I know because he used to be my neighbour when I was growing up.’’ Provider D1: ‘‘You have weird neighbors!’’ Provider N33: ‘‘He lived at home until he was 45, married late, then he got into the sauce.’’ (Observation data) It was common for the healthcare providers in the rural hospital observed in this study to know the patients in social settings outside of care delivery. Social knowledge of patients could have positive or negative impact on care decision-making and the degree of engagement of patients and family in the process.

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Discussion The results indicated that care providers worked mostly in ‘‘groups’’ or pseudoteams, as defined by Reeves et al. (2010). However, three patterns of teamwork emerged within this acute rural healthcare setting that achieved patient-engaged care. Although the patterns correspond with existing literature on different types of teamwork (Beach, Inui, & The RelationshipCentered Care Research Network, 2006; Choi & Pak, 2006; Jelphs & Dickenson, 2008), this study highlighted the daily navigation of providers between teamwork patterns, as described by Bleakley (2013). To effectively engage the patient and family in one of the teamwork patterns, providers needed to properly assess the patient’s health situation especially in regards to situational factors (overall health and functional status, cognitive abilities, social dynamics of team members and social knowledge of the patient and family). The data showed that care providers had, under some circumstances, developed an awareness of situations that could be best addressed by a solo practitioner working completely within his/her scope of practice as well as other situations that could best addressed by a team of providers. Although not consistently applied, whether to engage in a multior inter-professional approach was determined by the complexity of the presenting health situation. We observed the ritual acts of ‘‘teamwork’’ (e.g. team meetings) as well as examples of ‘‘true’’ collaborative work (e.g. shared decision making) (Lewin & Reeves, 2011). In this study and setting, navigation between teamwork patterns, where the patient was considered as a team member, required that care providers properly assess situational factors, in order to develop situation awareness as described by Bleakley (2006, 2013). Based on Edwards’ writings (2005), in order to achieve consistent situational awareness, each team member would need to regularly examine the embedded particularities within each health situation, which can continually change, and to explicitly determine which pattern of team interaction could best address the needs with available resources. Care providers must be able to recognize their own strengths, roles and limits to adapt to different teamwork patterns (Paradis et al., 2013). In the context of frequently changing team members, providers must find means to achieve functional, trusting relationships, often without the luxury of time. Therefore, navigating between teamwork patterns is a dynamic process dependent on each care provider’s ability to apply the construct of situational awareness and relational competence (Bleakley, 2013). Although not the focus of this study, research is needed to identify factors and conditions that trigger the transitions between the patterns for individual health care providers (Lingard et al., 2012). These findings suggest that interventions to strengthen teamwork should focus on enhancing the abilities of healthcare providers to engage patients, families and other team members in this dynamic care process. Drawing on previous work by Hall, Weaver, and Grassau (2013), a number of theories and approaches can help inform the development of appropriate interventions. These include: (1) The identified patterns of patient-engaged care in this study showed that providers recognized, respected and valued each different perspective brought to the healthcare situation, including those of the patient and family (Engestro¨m, 2005; Petrie, 1976). Small group activities that highlight multiple perspectives, minimize the potential for hierarchical power differentials and develop relational competencies as suggested by Reeves et al. (2010) under ‘‘relational interventions’’. These could cover complex case discussions, story-telling exercises or reflections on poetry, literature, art, specific team building exercises or team retreats. (2) The situational factors described in the study illustrate some of the complexities that can

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significantly impact patient care and challenge health care providers daily. Reflective practice supports revisiting these types of experiences in the context of real-world practice, and learning to improve and grow from them (Scho¨n, 1983). Individual care providers should be supported to actively engage in reflective practice exercises (e.g. personal diaries, portfolios). Time could be dedicated for some of these activities during regular team meetings. (3) Based on the results in this study, the application of situational awareness, especially in the context of frequently changing team members, challenges providers to achieve the desired functional, trusting relationships necessary for patient-engaged care. The concept of Knotworking (e.g. Bleakley, 2013; Bunniss & Kelly, 2013; Engestro¨m, 2005; Lingard et al., 2012) suggests that clinical and educational interventions need to be developed that highlight the dynamic nature of each therapeutic encounter, and that identify the ebb and flow of the relationships involved including the role of nonanimate objects, such as telephones, pagers, computers and electronic patient records (Latour, 2007). Low or high fidelity simulated learning experiences can make these complexities and the fluidity of situations explicit (Liaw, Zhou, Lau, Siau, & Chan, 2014; Sawyer, Laubach, Hudak, Yamamura, & Pocrnich, 2013). (4) The results of this study suggest that care providers would benefit from interventions and strategies aimed at developing relationship-centered care competencies to increase their situation awareness skills. Yet, effecting innovation and change is complex, especially at a system level (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004). On a smaller scale, planning interventions to facilitate change in the practice of individual care providers requires a detailed examination of the relationship between structure (i.e. administrative), context (i.e. type of patients) and process (i.e. communication strategies). Illeris (2003) suggests that an individual will not adopt new ways of working or apply new knowledge unless there is some tension introduced into the situation. External pressures and organizational interventions (Reeves et al., 2010) such as performance indicators, quality improvement programs and accreditation can serve as a catalyst for change. Exercises and interventions such as those suggested above can help providers develop necessary knowledge, attitudes and skills to facilitate situation awareness, relational competence and the navigation of team members between the described patterns of teamwork; and effectively engage the patient and his or her family in the care process. The study has a number of limitations. For example, while a few night shifts were observed, as well as staff hand-over in the early morning hours; the study took place primarily during daytime working hours and may not reflect the patterns or the situational factors that occur at other times. The results may not be representative of other services or other care settings than those examined in this study. In the interview data, there was a significant representation of students, as they were more readily available to volunteer interview time as compared to the busy staff, patients and families. This may have skewed interview data, however, the study used both observational and interview data to inform the results, and saturation of data was achieved. The research team interpreted the data based on the successful inclusion of patient-engaged care that could, despite the diversity of the researchers, be limited in its perspective. The bias of each individual research team member cannot be ignored in any qualitative study. This bias was attenuated by the research team’s varied professional backgrounds, the consensus approach to data interpretation and the validation of the interpretations by the participants, managers and senior staff members. Future research should critically analyze less successful patterns of clinical teamwork so that such pitfalls can be avoided. Additionally, other care settings should be explored to determine

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if similar teamwork patterns emerge that demonstrate successful patient-engaged care. In addition to exploring how transitions occur between patterns and the factors that trigger them, the application of theoretical models to enhance this dynamic model of teamwork requires further study.

Acknowledgements The authors wish to thank Tracy Gierman, Anne Brasset-Latulippe and Dana Cross of the Academic Health Council Champlain Region for their assistance and support throughout the project. Thanks to Enkenyelesh Bekele and Marc Bergeron for their assistance with the graphic design. Thanks to all the staff, physicians, administrators, students, patients and families at the study site for their partnership and participation in this study.

Declaration of interest The authors report no declarations of interest. The authors are responsible for the writing and content of this paper. This study was funded by HealthForceOntario.

Note 1. Illustrations of these patterns can be viewed in English at http:// www.ahc-cas.ca/wp-content/uploads/2013/05/Patterns-of-Teamwork_Hall-et-al-_2013_EN_Acc.pdf or in French at http://www.ahc-cas.ca/ wp-content/uploads/2013/05/Patterns-of-Teamwork_-Hall-et-al-_2013 _FR_Acc.pdf. These images are located on the Academic Health Council, Champlain region website http://www.ahc-cas.ca. Quotes from observations have been selected to illustrate typical examples of the patterns.

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