http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(6): 513–518 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2014.900001
ORIGINAL ARTICLE
Leading team learning: what makes interprofessional teams learn to work well? Carole Chatalalsingh1 and Scott Reeves2 The College of Dietitians of Ontario, Toronto, Ontario, Canada and 2Faculty of Health, Social Care and Education, Kingston University and St George’s, University of London, Kingston Upon Thames, Surrey, UK
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Abstract
Keywords
This article describes an ethnographic study focused on exploring leaders of team learning in well-established nephrology teams in an academic healthcare organization in Canada. Employing situational theory of leadership, the article provides details on how well established team members advance as ‘‘learning leaders’’. Data were gathered by ethnographic methods over a 9-month period with the members of two nephrology teams. These learning to care for the sick teams involved over 30 regulated health professionals, such as physicians, nurses, social workers, pharmacists, dietitians and other healthcare practitioners, staff, students and trainees, all of whom were collectively managing obstacles and coordinating efforts. Analysis involved an inductive thematic analysis of observations, reflections, and interview transcripts. The study indicated how well established members progress as team-learning leaders, and how they adapt to an interprofessional culture through the activities they employ to enable day-to-day learning. The article uses situational theory of leadership to generate a detailed illumination of the nature of leaders’ interactions within an interprofessional context.
Interprofessional collaboration, interprofessional teams, leaders, situational leadership, team learning
Introduction Leadership is increasingly recognized as playing a key role in determining the performance and success of an organization (e.g. Block, 2003; Fullan, 2001; Kotter, 1996; Senge, 1990; Yukl, 1981, 2010). Historically, leadership studies have been aligned with business and management theories and have had, as their primary focus, corporate and organizational leadership approaches based on popular theories such as the trait approach, the visionary, transformational, or charismatic approach; and, more recently, the ethical and emotional intelligence approaches (Avolio, 2010; Dulewicz & Higgs, 2000; Handy, 1993; Northouse, 2004; Partington, 2003). In healthcare, leaders are viewed as central in influencing clinical team practice, patient safety and quality care (e.g. Reeves, Lewin, Espin, & Zwarenstein, 2010). Some authors have argued that clinical effectiveness is a function of the interpersonal competence of different clinicians, and the extent to which the team leader develops behaviours to help their colleagues be open and candid in their communication (e.g. Argyris & Schon, 1996; Goleman, Boyatzis, & McKee, 2002; Hackman, 2002; Marshall, 1995). Generally, most studies of leadership in health care portray the leader as someone who is responsible for maximizing team performance as a strategic resource within their organization (Day, Gronn, & Salas, 2004; Hackman, 2002). According to Yukl (2010), leaders in healthcare influence and facilitate the work of
Correspondence: Carole Chatalalsingh, PhD, The College of Dietitians of Ontario, 5775 Yonge Street, Suite 1810, Box 30, Toronto, Ontario M2M 4J1, Canada. E-mail: [email protected]
History Received 1 March 2013 Revised 6 September 2013 Accepted 27 February 2014 Published online 21 March 2014
their colleagues, and ensure that they are ready to meet future patient care-related challenges. Situational leadership One approach that may help understand the complexities of healthcare leadership is Hersey and Blanchard’s (1993) notion of situational leadership. According to these authors, there is no single ‘‘best’’ style of leadership, and that effective leadership involves adapting one’s style to situational and contextual needs. For others (e.g. Graeff, 1997; Luthans, 1992; Vecchio, 1987), an underlying concept of this approach is that leaders need to be able to ‘‘diagnose’’ the demands of their situation and adapt accordingly. Situational leadership classifies the behaviour of team leaders into two distinct dimensions: task behaviour and relationship behaviour (Hersey & Blanchard, 1993). Task behaviour is the extent to which leaders engage in unidirectional communication by explaining what each follower is to do, as well as when/where/ how tasks are to be accomplished. Relationship behaviour is the extent to which a leader engages in a more open communication style by providing support and personal encouragement based on the individual’s needs to complete the task. Hersey and Blanchard (1993) divided these two broad dimensions into four specific categories – directing, coaching, supporting and delegating – that are employed depending upon the situational needs of individuals. For example, in the directing approach, the leader gives specific task directions with less emphasis on the relationship behaviour. In the coaching approach, the leader is focused on both task and relationship behaviours, whereas in the supporting approach, the leader emphasizes relationships over the completion of tasks. Finally, in the delegating approach, the leader places a
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limited emphasis on task and relationships to allow team members to accept responsibility for their actions.
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Leading in an interprofessional context From a leadership perspective, enabling effective interprofessional teamwork in clinical practice is a particularly complex and challenging task. One significant element of their work is that team leaders are expected to have the knowledge, skills and ability to help members from various professions learn how to be team members by integrating their theoretical knowledge, skills, and attitudes, professional and regulatory obligations into team practice (e.g. Day et al., 2004; Ellis et al., 2003). As team learning is a social process through which knowledge is shared, created, and sought in order to benefit both the individual, and the team as an entity (Senge, 1990), learning in interprofessional teams is a process that involves a community of health professionals, staff members, students and trainees, and family caregivers. The interprofessional team is focused on communication, mutual respect, interaction and participation. However, although considerable research has been devoted to demonstrating the values of healthcare team leadership (e.g. Browne & Miller, 2003; Carroll & Edmondson, 2002; Day et al., 2004), rather less attention has been paid to systematically assessing the effects of leading interprofessional team learning (Bleakley, 2006; Bucic, Robinson, & Ramburuth, 2010). In attempting to fill this gap in the literature, this article explores the role of leaders in well-established specialist teams in an academic health care organization. It employs the situational approach to leading to help illuminate how members from various health professions are encouraged to learn together from each other on a day-to-day practice.
Methods Ethnographic methods were used to provide a better understanding of the importance of the leaders’ role in the daily clinical activities of their interprofessional teams. Since ethnography focuses on the study of social interactions, behaviours, and perceptions that occur within teams, organizations and communities (Hammersley & Atkinson, 1995; Reeves, Kuper, & Hodges, 2008), it seemed a highly suitable way to develop an understanding of the social processes and perceptions of team leaders. Study context Two nephrology teams were recruited for this study. The first was a peritoneal dialysis team that consisted of around 15 members (Team A). The second was a chronic kidney disease team consisting of around 20 members (Team B). Both teams were well-established (each in existence as defined by the patient population they served for more than 10 years), and based in ambulatory care units within a single large teaching hospital. Collectively, these teams provided care to around 500 adult patients per year, whose health conditions ranged from early to late stage kidney disease. The two teams involved in this study consisted of regulated health care team members including nephrologists, nurses, dietitians, medical laboratory technicians, social workers, pharmacists, and a chiropodist. Other non-regulated team members were support staff, clinical researchers, students and trainees, and volunteers. All of the professionals in this study had worked together in the teams for at least 2 years at the time of the study. These teams, by virtue of their interprofessional perspectives, continually planned and designed services to meet the needs of the patient populations they served. A value of education was inherent in the teams’ goals as they focussed on mentoring
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through team approaches and ongoing communication to a diverse student placement population specializing in nephrology. Within both teams there were various opportunities and tasks involving patient care, research and education for team members to truly learn, create, and contribute to the transfer and sharing of information pertaining to the team learning. Data collection This study involved the collection of data by ethnographic observations and interviews, as well as the collection of documents. In total, 550 h of data collection took place over 9 months for both teams. The primary author (C. C.) adopted a participant-observer approach which involved focussing on who was there; details of the physical space; details of team members’ and leaders’ interactions and important verbatim comments of interest to this study. Observations began with broad descriptions of context and action, which became progressively more focused over time (Denzin & Lincoln, 1994). Observations were undertaken on 3–4 h sessions, and sessions were undertaken at varying times of the day between 8 am and 4 pm. Observations focused on weekly clinics, informal planning sessions, formal team meetings, education and research rounds, ad-hoc accreditation and continuous quality improvement meetings to reflect the breadth of activities team leaders and members undertook on a daily basis. Field notes were taken in situ, and immediately following each session, these notes were elaborated and expanded upon. This process allowed emerging analytical considerations to be added, which in turn produced a set of notes that comprised concrete details of events and actions, methodological and theoretical considerations as well as personal reflections related to the study. Formal in-depth interviews that aimed to elicit candid accounts from the team members were also gathered. To identify interview participants, the study proposal was presented at education rounds for each team, which all members attend. At these presentations, team members were asked to confidentially nominate leaders – they saw involved in the day-to-day activities on the front line – whom they felt exemplified qualities that helped facilitate learning in the team. Four participants from Team A were identified, and three agreed to be interviewed. In Team B, ten participants were identified and nine agreed to be interviewed. Ninety-minute interviews were scheduled with these identified ‘‘learning leaders’’. Interviews consisted of open-ended questions that were naturalistic in nature and allowed a ‘‘conversation’’ to evolve naturally. Each participant was interviewed separately to provide them with the opportunity to share positive and negative experiences about interprofessional team learning and the role of leaders. All interviews took place at the hospital and occurred when there were no patient interactions. Interviews were audiorecorded, then later transcribed and analyzed. Documentary data, in the form of the accreditation reports, students’ handbook, manuals, and teams meeting minutes (all of which were available on the departmental intranet) were also gathered to generate additional insights into the nature of team leadership and learning. Analysis An inductive thematic analysis, as described by Hammersley and Atkinson (1995), was employed to analyze the data. This approach focused on the inductive emergence of meaning from data by searching for themes descriptive of the phenomena and based on a constant comparative approach. This process started by deconstructing the dataset to identify broad, emerging categories as soon as data collection began. Field notes, interview transcripts and documents were analyzed for emergent categories using Microsoft Office WORD and EXCEL tables. Analysis involved
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generating meaning from data, but was also framed by the situational leadership perspective, as described above. Quality issues
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To help enhance the quality of this ethnographic study, a number of qualitative techniques were adopted. For example, the study adopted an iterative approach, whereby insights gained in the initial rounds of data collection were used iteratively to clarify subsequent data collection activities and analysis. In addition, observational data were triangulated with interview and documentary data to help generate a more detailed and richer study account of team leading and learning actions and activities. Furthermore, the study was reflexive in nature, and dealt with researcher’s previous insider’s knowledge of Team A (where she had worked as a nephrology professional for several years) to help clarify belief systems, assumptions and subjectivities. These data were carefully compared with data gathered from Team B (where the researcher was an outsider).
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elements are presented: leadership as directing, coaching, supporting and delegating. Although the findings are presented in separate sections, it must be noted, that both formal and informal learning leaders in this study shifted the use of these different leadership actions in their daily work, as the needs of their team and its members changed to local demands. Leading by directing learning about tasks The notion of ‘‘directing’’ refers to a leader’s ability to focus on specific task-learning directions, at the expense of a focus on learning about relationships. This study revealed that most formal and informal leaders at times displayed an ability to prioritize and pay more attention to the day-to-day practice that is focused directly on the immediate needs and tasks at hand. For example, as seen in a discussion with three team members in the hall-way about which professional had the authorization for prescribing a patient a certain treatment, an in-formal leader intervened to direct a learning opportunity related to the task of prescribing:
Ethical considerations Ethics approval for this study was granted by the research ethics boards of participating hospital and university institutions. The study was initially presented at education rounds and information sheets were provided to all team members, students, and trainees. It was made clear that participation in this study was voluntary and, although the administrative consent allowed observation of the teams, any individual team member or student could refuse to be part of the study. Written consent was obtained from all participants who were interviewed. During the 9 months study period, on observation days patients in the clinics were fully apprised of the researcher’s presence and study aims.
Findings This section offers findings from the study in two main sections. First, data relating to the differing characteristics of the team leaders is presented. The second section offers details related to how these leaders engaged in various activities linked to Hersey and Blanchard’s (1993) situational leadership approach. Characteristics of team leaders The data indicated that leadership in these two teams involved 12 individuals from two professions – medicine and nursing. Of these individuals, three were ‘‘formal leaders’’ – clearly identified as being responsible for exercising primary leadership roles such as director or manager positions within the organization. These formal leaders were organizational representatives, and they created the structures that allowed the teams to function as cohesive units. In contrast, the data suggested that the nine informal leaders who were not organizational leadership representatives, took on the role of practising experts, by caring for patients, generating change and motivating others as learning leaders and strategy builders. Informal leaders were able to situate and adapt their actions and interactions with other members of the teams. In this sense, they were leading as clinicians with the teams. However, the data did suggest that, in general, both informal and formal leaders showed a willingness to adapt to the team’s needs in learning to function as a collective. The nature of their approach to leading team learning is considered in more depth below. Team leaders, team learning and situational leadership The following four sub-sections offer details from the analysis of data, which as previously noted was framed by the situational leadership perspective (Hersey & Blanchard, 1993). Four
The informal nurse leader suggested that team members should seek profession specific information about who can prescribe calcium. The leader mentioned that scope of practice of each profession is determined by a combination of legislation and regulation. The response from the informal leader was a direction for sharing as a form of teaching from the regulated team members who had access to information and to share with others who were not expected to have this knowledge. (Field notes, September-08, Team B) Directing learning is something which was observed in informal conversations, daily dialogue and social interactions of team members, as well as more formal team activities such as education and patient-care rounds. By focusing extensively on the task and less on team relations, leaders were able to identify specific cases where information was incorrect, missing or unclear. In the following example, concerning legal issues that could result in charges of malpractice, the formal leader who is legally responsible talked about being firm in conveying her perspective. This expression included information pertaining to the broad relevance of the basic team’s tasks, and as a personalized teaching event for imparting knowledge: ‘‘I really encourage new perspectives and learning. However, if I disagree [with a suggestion], which happens, I will disagree. In the end, if there is a malpractice suit, it is not the social worker or the nurse that is going to be sued. I am the one who will be sued. Therefore, I think, I have to at times be sincere and say I disagree’’. I think of our work in determining the right dialysate to avoid fluid overload in patients. (Interview, Nov-07, Team A) Leading as coaches of team learning relationships and tasks ‘‘Coaching’’ refers to leaders’ ability to adapt by enabling learning that leads members to have a collective understanding involving both tasks and relationships activities. Although leaders had the ability to be highly focused on the team tasks, as presented above, many were also able to place equal and simultaneous importance on learning to foster good team relationships. Sometimes situations were so complicated that no individual member possessed all the information necessary to interpret the situation properly. Leaders enabled learning by coaching members to learn as a team. This was achieved with a view to improving the collective learning processes – both task and
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relationship on a routine basis. This example at a clinic discussion between a nurse and a social worker, the leader focused on coaching a complicated situation where members needed information to resolve a disagreement involving both task and relationships learning:
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An informal nurse leader was talking about the value of attending patient care rounds, especially since the social worker expressed disagreement with a treatment plan by another team member. The leader went on to suggest that, at times, professional opinions will differ. When this happens, each member of the team bears the same responsibility to engage collaboratively to address the disagreement in the patient’s best interests. Participation and involvement in patient care rounds often provides an appropriate forum to engage in respectful sharing of information. (Field notes, Nov-07, Team A) All leaders in this study had a similar shared philosophy of responding to change in coaching members to see how their respective roles could contribute to the performance of their team. Here, an informal leader attached importance to the evidence of learning from team members and her vision for enabling a collective understanding by coaching others to learn team tasks and relationships: I am not the dietitian or the social worker or the pharmacist and I cannot do my job without the expertise of these other very important team members. I value input from every member, even the students. In a sense, these various members belong . . . together . . . so that we could learn from each others’ skills and knowledge, as we develop working relations to care for our patients. (Informal Nurse Leader Interview, Apr-08, Team B) Similarly, because the leaders recognized and valued the importance of both task and relationship learning behaviour, some members in turn expressed the importance of having the leaders as part of their day-to-day routine work within the team – this interpretation confirms a focus on enabling learning that leads members to have an understanding of the leaders’ role within the team. A leader reflected on a conversation she had with a team member earlier in the week: I really valued her opinion and saw her as a strong nurse that I trusted. She said that she realized that I needed to take time off when I needed to take it but she just hated it when I took two weeks or more at a time. She said that I was the glue that held the team together and . . . so in a sense, I was a member of the group, not the boss. (Team Member Interview, Jan-08, Team A) Often, the leaders in the study adapted their behaviours based on the needs of the team’s changing situations. For example, team members often need a better understanding of what it means to be a team member by focusing equally on the tasks and relationships. Here a leader attempted to understand a situation with a question, this lead to spontaneously information sharing and learning: During clinic, the physician leader asked a question which was directed to a few interprofessional team members and to no one in specific, ‘‘Why aren’t the fellows from hemodialysis here?’’ An informal nurse leader who was close-by responded by saying that they [the fellows], left a message to say they made a decision to go where there were more patients to be seen. The physician listened, nodded and walked towards the patient who was waiting to be assessed. The ward secretary,
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who was also close-by, got on the phone and paged the fellows to come to the unit. Later, the physician leader coached the fellows on the importance of learning how the clinic operates. She explained that it was not only about seeing more patients, in different parts of the hospital; it was also learning the clinic routine and how the team worked to get the job done. (Field notes, Aug-08, Team B) Leading by supporting team learning relationships ‘‘Supporting’’ according to Hersey and Blanchard (1993) refers to leaders’ ability to adapt by emphasizing themselves as mentors and role models in developing their relationships with others. Frequently, when the team leaders needed to pay attention to developing cohesiveness among members, they focused on acting like interprofessional mentors. As integrated members of the teams, it was found that the leaders not only participated as clinicians, but also showed a willingness to both share and learn from others despite positions. Both informal and formal leaders made mentoring an integral part of the team’s mandate. The following is taken from an interview with a leader following clinic observations: As you saw from clinic, our team members need support to develop an awareness of one another’s roles and abilities. When we are not operating as a team, they may be reluctant to learn from each other because of misunderstanding. I [formal nurse leader] am comfortable learning and teaching about efficiency and quality improvements, as these are always compelling arguments for learning to practice as a team. We learn from listening to colleagues because we most certainly do not know everything—none of us knows it all. Learning from and truly listening to each other...together we have force as a team. (Interview, Sept-08, team B) Both teams in the study seemed to possess attributes that appeared to elicit the spirit of sharing and collaboration. For example, observations of interactions between the leaders and team members were non-hierarchical in nature. Similarly, team members were observed to share the responsibility of caring for each other and understanding professional perspectives. In this example as team members interact, the interpretation of relevant knowledge leads members to learn. Here an informal team leader supported meaningful learning relationships: During patient care rounds, the informal physician leader appeared mindful to the time demands of the nursing students by rearranging the order in which patient files were placed for discussion. He then, at various times, checked with the other team members to see if everyone was ready to discuss the next clinic patient’s chart. Usually 25–30 clinic patients were discussed at each rounds and this leader encouraged discussion when key members were ready. (Field Notes, October 2007, Team A) In being supportive, the data suggested that these teams operated in a ‘‘no blame’’ environment. Therefore, team members could feel psychologically safe to ask questions that supported their learning, and also ensured safe patient care. As the following extract indicates: I think it is okay to say, ‘‘I don’t know’’. I would rather hear the dialysis technician say ‘‘I am having trouble with this machine’’ at the hospital rather than when they are with the patient during their treatment. It saves time and money.
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It prevents errors. I am open and honest and I expect the same. It is not about finding faults and blaming. (Interview, Jan-08, Team A)
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Leading by delegating task and relationship learning activities Regardless of their differing approaches to leadership, as described above, there were situations when the leaders needed to delegate to the team members. For Hersey and Blanchard (1993) ‘‘delegating’’ refers to leaders’ ability to adapt to the team’s need by limiting their involvement in providing support on tasks and relationships, and in effect, allowing members to accept responsibility for learning. The leaders in this study employed delegation on a regular basis with their teams. The leader’s decision to limit their involvement in providing support on tasks and relationships was often taken to assure timely, appropriate and coordinated team learning. As observed in education team presentation, a leader talked about the development of protocols and procedures as mechanisms to enable patient safety: A formal medicine leader described that the appropriate order sets, also known as pre-printed orders, are a form of delegation that allows some team members to go ahead and suggest specific treatment recommendations. To explain, as a protocol in our team, recommended dietary supplements are included in admission order sets when ambulatory care patients are admitted as inpatients within the acute setting. This saves time in having the physician rewrite new orders when the patient goes from out-patient unit to in-patient unit. This delegation allows for patient care continuity. (Field Notes, May-08, Team B) Formal leaders in both teams spoke about a form of letting go and thereby trusting others. By letting go, formal leaders recognized that they did not need to feel pressure of knowing everything. Team leaders talked about enabling learning, teamwork and cooperation by trusting which underpins the act of delegating. Here a formal nurse leader said: You have to let go and trust others. Trusting instils a sense of teamwork and cooperation. I have to give trust to earn trust . . . it takes time to do this but soon people start to see it and feel it. This allows others to be accountable and accept responsibility for actions. (Interview, December 2007, Team A) Team leaders confirmed that it was not always easy to identify barriers to learning when they limited their team involvement by delegating. One clear example that we share was in a general discussion about stereotyping and learning: Stereotypes do exist and I have seen examples in our team. In the early days, the nurses felt that the dietitians’ only concerns were around food delivery to the unit. The nurses took control over teaching nutrition. Today it is different; the dietitians are experts in nutrition assessments and teaching. This has a huge impact on the patients’ outcomes and recognizing members’ knowledge. Over time we learn not to label others. (Interview, October 2007, Team A)
Discussion As described above, team leaders involved in this study participated in a range of clinical and team-learning activities
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linked to the four activities of leadership – variously directing, coaching, supporting and delegating. Team leadership therefore involved the ability of the leader to adapt to the local teams’ needs as both an authoritative figure and also as a peer/colleague. Not only did these leaders adapt to the learning needs of their respective interprofessional teams, they also worked with their members to help find solutions, problem-solve, and deal with shifting clinical situations. As a result, in their daily work, these leaders – both formal and informal – could be regarded as functioning in the role of facilitators of learning who promoted a team-learning environment. The use of Hersey and Blanchard’s (1993) situational leadership perspective has helped to illuminate how the leaders of interprofessional teams can employ a range of different approaches to their leadership. For example, the directing style within this context was used to help focus the team’s activities and tasks. Leaders were also seen using a coaching style to guide team members towards collective learning. The leaders were also able to shift to a supportive role in dealing with the challenges of incorporating team members’ individual knowledge by helping them to build on each other’s contributions through ongoing connections and relationships. They could, in addition, employ delegation to encourage team members to take responsibility for delivering patient care. Despite engaging in these different activities, leaders maintained an integrated role in working within the teams. Both formal and informal leaders were engaged in daily learning with the team in a diverse, and sometimes transformative, way from the ground up. Study teams had a clear focus on its tasks and every member felt a sense of responsibility towards the success of the team. These teams’ cohesiveness depended on the members’ working and learning relationships with each other and because of the way team leaders adapted, developed and integrated into the working relationships. Much of the literature provides only partial insight into leading health care team performance. For example, Kosinska and Niebro´j (2003) agree that no teamwork performance can be effective without a leader. Similarly, in research focused on leadership style and its impact on the team performance, Dierckx de Casterle, Willemse, Verschueren, and Milisen (2008) argues that effective leadership promotes effective communication, greater responsibility, empowerment and job clarity in nursing teams. These authors suggest that a participatory style of clinical leadership seemed also to influence patient-centered communication, continuity of care and collaboration. McCallin (2003) suggests that a well-functioning team in which clinicians work as ‘‘memberleaders’’ can foster improvements in the performance of patient outcomes. In addition, most studies of team leadership portray the team leader as someone who is responsible for determining and implementing the functions needed to allow the team to maximize its performance (Lim & Ployhart, 2004; Zaccaro, Rittman, & Marks, 2001). However, if leaders emphasize a top-down approach too strongly then a hierarchy might be created that can cause members to feel fear, thus leading to the inhibition of their performance as a team (Huber, 2000; Marshall, 1995). In this view, the team leader is one who is in a position to influence the progress of the team. Unquestionably, this is an important aspect of leadership in the health professional domain for the purposes of improving administrative leadership. However, such a focus under-represents the critical function in health care delivery of leadership at the level of clinical teams, and the process of leading by adapting to the learning needs from within the team, as indicated in this study. Another way of understanding leadership practices is to focus on the organizational context in which team learning is enabled. Arguably, the success of teams depends not only on the leaders
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being able to adjust their behaviours across a continuum of support and direction, but also they need to be able to adjust team functions and structures in response to changing situational factors. As such situational leaders can enable learning rather than control it. In contrast to the hierarchical emphasis in corporate leaders (e.g. Block, 2003; Field, 2004; Fullan, 2001; Senge, 1990), the leaders in this study facilitated learning within and across the interprofessional teams. This view represents a shift away from the traditional view of leader based just on position and authority (Marshall, 1995). As described above, the adoption of a situational approach to leadership, through the use of differing approaches to team leadership (directing, coaching, supporting, delegating), helps foster team interaction and team learning. Despite attempts to produce a high quality ethnographic study, there were inevitably a number of limitations. For example, the two teams involved in this study – both well established, stable teams – could be considered unusual as there is often a high member turnover in interprofessional teams. This factor may limit the applicability of findings from this work to other interprofessional teams. In addition, the focus of this study is leaders’ experiences and perceptions; this study did not gather in-depth perspectives of other team members on leadership – another factor which limits the applicability of this work. In summary, this article described an ethnographic study that explored the nature of leadership and team learning. The use of Hersey and Blanchard’s (1993) situational leadership approach suggested that effective leadership involves leaders’ ability to adapt to changes in local context. This perspective helped illuminate the nature of leadership within an interprofessional healthcare team environment.
Declaration of interest The authors report no conflict of interest. The authors are responsible for the writing and content of this article.
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Dierckx de Casterle, B., Willemse, A., Verschueren, M., & Milisen, K. (2008). Impact of clinical leadership development: A case study. Journal of Nursing Management, 16, 753–763. Dulewicz, V., & Higgs, M.J. (2000). Emotional intelligence: A review and evaluation study. Journal of Managerial Psychology, 15, 341–368. Ellis, A.P.J., Hollenbeck, J.R., Ilgen, D.R., Porter, C.O.L.H., West, B.J., & Moon, H. (2003). Team learning: Collectively connecting the dots. Journal of Applied Psychology, 88, 821–835. Field, L. (2004). Rethinking learning organizations. In Foley G. (Ed.), Dimensions of adult learning: Adult education and training in a global era (pp. 201–218). Berkshire, England: Open University Press. Fullan, M. (2001). Leading in a culture of change. San Francisco: JosseyBass. Goleman, D., Boyatzis, R., & McKee, A. (2002). The new leaders: Transforming the art of leadership into the science of results. London: Little, Brown. Graeff, C.L. (1997). Evolution of situational leadership theory: A critical review. Leadership Quarterly, 8, 153–170. Hackman, J.R. (2002). Leading teams: Setting the stage for great performance. Boston: Harvard Business School Press. Hammersley, M., & Atkinson, P. (1995). Ethnography: Principles in practice (2nd ed.). New York: Routledge. Handy, C. (1993). Understanding organizations. Harmondsworth, England: Penguin. Hersey, P., & Blanchard, K.H. (1993). Management of organizational behavior: Utilizing human resources (8th ed.). Englewood Cliffs, NJ: Prentice Hall. Huber, D.L. (2000). Leadership and nursing care management (2nd ed.). Philadelphia: W. B. Saunders. Kosinska, M., & Niebro´j, L. (2003). The position of a leader nurse. Journal of Nursing Management, 11, 67–68. Kotter, J. (1996). Leading change. Boston: Harvard Business School Press. Lim, B., & Ployhart, R.E. (2004). Transformational leadership: Relations to the five factor model and team performance in typical and maximum contexts. Journal of Applied Psychology, 89, 610–621. Luthans, F. (1992). Organization behavior (5th ed.). New York: McGrawHill. Marshall, E. (1995). Transforming the way we work: The power of the collaborative workplace. New York: American Management Association. McCallin, A. (2003). Interdisciplinary team leadership: A revisionist approach for an old problem? Journal of Nursing Management, 11, 364–370. Northouse, P.G. (2004). Leadership: Theory and practice (3rd ed.). Thousand Oaks, CA: Sage. Partington, D.A. (2003). Managing and leading. In J.R. Turner (Ed.), People in project management. Aldershot, UK: Gower. Reeves, S., Kuper, A., & Hodges, B.D. (2008). Qualitative research methodologies: Ethnography. British Medical Journal, 337, 512–514. Reeves, S., Lewin, S., Espin, S., & Zwarenstein, M. (2010). Interprofessional teamwork for health and social care. Oxford: Wiley-Blackwell. Senge, P.M. (1990). The fifth discipline: The art and practice of the learning organization. New York: Doubleday Currency. Vecchio, R.P. (1987). Situational leadership theory: An evaluation of a prescriptive theory. Journal of Applied Psychology, 72, 444–451. Yukl, G.A. (1981). Leadership in organizations. Englewood Cliffs, NJ: Prentice-Hall. Yukl, G. (2010). Leadership in organizations (7th ed.). New Jersey: Prentice Hall. Zaccaro, S.J., Rittman, A.L., & Marks, M.A. (2001). Team leadership. The Leadership Quarterly, 12, 451–483.
ORIGINAL ARTICLE
Leading team learning: what makes interprofessional teams learn to work well? Carole Chatalalsingh1 and Scott Reeves2 The College of Dietitians of Ontario, Toronto, Ontario, Canada and 2Faculty of Health, Social Care and Education, Kingston University and St George’s, University of London, Kingston Upon Thames, Surrey, UK
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Abstract
Keywords
This article describes an ethnographic study focused on exploring leaders of team learning in well-established nephrology teams in an academic healthcare organization in Canada. Employing situational theory of leadership, the article provides details on how well established team members advance as ‘‘learning leaders’’. Data were gathered by ethnographic methods over a 9-month period with the members of two nephrology teams. These learning to care for the sick teams involved over 30 regulated health professionals, such as physicians, nurses, social workers, pharmacists, dietitians and other healthcare practitioners, staff, students and trainees, all of whom were collectively managing obstacles and coordinating efforts. Analysis involved an inductive thematic analysis of observations, reflections, and interview transcripts. The study indicated how well established members progress as team-learning leaders, and how they adapt to an interprofessional culture through the activities they employ to enable day-to-day learning. The article uses situational theory of leadership to generate a detailed illumination of the nature of leaders’ interactions within an interprofessional context.
Interprofessional collaboration, interprofessional teams, leaders, situational leadership, team learning
Introduction Leadership is increasingly recognized as playing a key role in determining the performance and success of an organization (e.g. Block, 2003; Fullan, 2001; Kotter, 1996; Senge, 1990; Yukl, 1981, 2010). Historically, leadership studies have been aligned with business and management theories and have had, as their primary focus, corporate and organizational leadership approaches based on popular theories such as the trait approach, the visionary, transformational, or charismatic approach; and, more recently, the ethical and emotional intelligence approaches (Avolio, 2010; Dulewicz & Higgs, 2000; Handy, 1993; Northouse, 2004; Partington, 2003). In healthcare, leaders are viewed as central in influencing clinical team practice, patient safety and quality care (e.g. Reeves, Lewin, Espin, & Zwarenstein, 2010). Some authors have argued that clinical effectiveness is a function of the interpersonal competence of different clinicians, and the extent to which the team leader develops behaviours to help their colleagues be open and candid in their communication (e.g. Argyris & Schon, 1996; Goleman, Boyatzis, & McKee, 2002; Hackman, 2002; Marshall, 1995). Generally, most studies of leadership in health care portray the leader as someone who is responsible for maximizing team performance as a strategic resource within their organization (Day, Gronn, & Salas, 2004; Hackman, 2002). According to Yukl (2010), leaders in healthcare influence and facilitate the work of
Correspondence: Carole Chatalalsingh, PhD, The College of Dietitians of Ontario, 5775 Yonge Street, Suite 1810, Box 30, Toronto, Ontario M2M 4J1, Canada. E-mail: [email protected]
History Received 1 March 2013 Revised 6 September 2013 Accepted 27 February 2014 Published online 21 March 2014
their colleagues, and ensure that they are ready to meet future patient care-related challenges. Situational leadership One approach that may help understand the complexities of healthcare leadership is Hersey and Blanchard’s (1993) notion of situational leadership. According to these authors, there is no single ‘‘best’’ style of leadership, and that effective leadership involves adapting one’s style to situational and contextual needs. For others (e.g. Graeff, 1997; Luthans, 1992; Vecchio, 1987), an underlying concept of this approach is that leaders need to be able to ‘‘diagnose’’ the demands of their situation and adapt accordingly. Situational leadership classifies the behaviour of team leaders into two distinct dimensions: task behaviour and relationship behaviour (Hersey & Blanchard, 1993). Task behaviour is the extent to which leaders engage in unidirectional communication by explaining what each follower is to do, as well as when/where/ how tasks are to be accomplished. Relationship behaviour is the extent to which a leader engages in a more open communication style by providing support and personal encouragement based on the individual’s needs to complete the task. Hersey and Blanchard (1993) divided these two broad dimensions into four specific categories – directing, coaching, supporting and delegating – that are employed depending upon the situational needs of individuals. For example, in the directing approach, the leader gives specific task directions with less emphasis on the relationship behaviour. In the coaching approach, the leader is focused on both task and relationship behaviours, whereas in the supporting approach, the leader emphasizes relationships over the completion of tasks. Finally, in the delegating approach, the leader places a
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limited emphasis on task and relationships to allow team members to accept responsibility for their actions.
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Leading in an interprofessional context From a leadership perspective, enabling effective interprofessional teamwork in clinical practice is a particularly complex and challenging task. One significant element of their work is that team leaders are expected to have the knowledge, skills and ability to help members from various professions learn how to be team members by integrating their theoretical knowledge, skills, and attitudes, professional and regulatory obligations into team practice (e.g. Day et al., 2004; Ellis et al., 2003). As team learning is a social process through which knowledge is shared, created, and sought in order to benefit both the individual, and the team as an entity (Senge, 1990), learning in interprofessional teams is a process that involves a community of health professionals, staff members, students and trainees, and family caregivers. The interprofessional team is focused on communication, mutual respect, interaction and participation. However, although considerable research has been devoted to demonstrating the values of healthcare team leadership (e.g. Browne & Miller, 2003; Carroll & Edmondson, 2002; Day et al., 2004), rather less attention has been paid to systematically assessing the effects of leading interprofessional team learning (Bleakley, 2006; Bucic, Robinson, & Ramburuth, 2010). In attempting to fill this gap in the literature, this article explores the role of leaders in well-established specialist teams in an academic health care organization. It employs the situational approach to leading to help illuminate how members from various health professions are encouraged to learn together from each other on a day-to-day practice.
Methods Ethnographic methods were used to provide a better understanding of the importance of the leaders’ role in the daily clinical activities of their interprofessional teams. Since ethnography focuses on the study of social interactions, behaviours, and perceptions that occur within teams, organizations and communities (Hammersley & Atkinson, 1995; Reeves, Kuper, & Hodges, 2008), it seemed a highly suitable way to develop an understanding of the social processes and perceptions of team leaders. Study context Two nephrology teams were recruited for this study. The first was a peritoneal dialysis team that consisted of around 15 members (Team A). The second was a chronic kidney disease team consisting of around 20 members (Team B). Both teams were well-established (each in existence as defined by the patient population they served for more than 10 years), and based in ambulatory care units within a single large teaching hospital. Collectively, these teams provided care to around 500 adult patients per year, whose health conditions ranged from early to late stage kidney disease. The two teams involved in this study consisted of regulated health care team members including nephrologists, nurses, dietitians, medical laboratory technicians, social workers, pharmacists, and a chiropodist. Other non-regulated team members were support staff, clinical researchers, students and trainees, and volunteers. All of the professionals in this study had worked together in the teams for at least 2 years at the time of the study. These teams, by virtue of their interprofessional perspectives, continually planned and designed services to meet the needs of the patient populations they served. A value of education was inherent in the teams’ goals as they focussed on mentoring
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through team approaches and ongoing communication to a diverse student placement population specializing in nephrology. Within both teams there were various opportunities and tasks involving patient care, research and education for team members to truly learn, create, and contribute to the transfer and sharing of information pertaining to the team learning. Data collection This study involved the collection of data by ethnographic observations and interviews, as well as the collection of documents. In total, 550 h of data collection took place over 9 months for both teams. The primary author (C. C.) adopted a participant-observer approach which involved focussing on who was there; details of the physical space; details of team members’ and leaders’ interactions and important verbatim comments of interest to this study. Observations began with broad descriptions of context and action, which became progressively more focused over time (Denzin & Lincoln, 1994). Observations were undertaken on 3–4 h sessions, and sessions were undertaken at varying times of the day between 8 am and 4 pm. Observations focused on weekly clinics, informal planning sessions, formal team meetings, education and research rounds, ad-hoc accreditation and continuous quality improvement meetings to reflect the breadth of activities team leaders and members undertook on a daily basis. Field notes were taken in situ, and immediately following each session, these notes were elaborated and expanded upon. This process allowed emerging analytical considerations to be added, which in turn produced a set of notes that comprised concrete details of events and actions, methodological and theoretical considerations as well as personal reflections related to the study. Formal in-depth interviews that aimed to elicit candid accounts from the team members were also gathered. To identify interview participants, the study proposal was presented at education rounds for each team, which all members attend. At these presentations, team members were asked to confidentially nominate leaders – they saw involved in the day-to-day activities on the front line – whom they felt exemplified qualities that helped facilitate learning in the team. Four participants from Team A were identified, and three agreed to be interviewed. In Team B, ten participants were identified and nine agreed to be interviewed. Ninety-minute interviews were scheduled with these identified ‘‘learning leaders’’. Interviews consisted of open-ended questions that were naturalistic in nature and allowed a ‘‘conversation’’ to evolve naturally. Each participant was interviewed separately to provide them with the opportunity to share positive and negative experiences about interprofessional team learning and the role of leaders. All interviews took place at the hospital and occurred when there were no patient interactions. Interviews were audiorecorded, then later transcribed and analyzed. Documentary data, in the form of the accreditation reports, students’ handbook, manuals, and teams meeting minutes (all of which were available on the departmental intranet) were also gathered to generate additional insights into the nature of team leadership and learning. Analysis An inductive thematic analysis, as described by Hammersley and Atkinson (1995), was employed to analyze the data. This approach focused on the inductive emergence of meaning from data by searching for themes descriptive of the phenomena and based on a constant comparative approach. This process started by deconstructing the dataset to identify broad, emerging categories as soon as data collection began. Field notes, interview transcripts and documents were analyzed for emergent categories using Microsoft Office WORD and EXCEL tables. Analysis involved
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generating meaning from data, but was also framed by the situational leadership perspective, as described above. Quality issues
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To help enhance the quality of this ethnographic study, a number of qualitative techniques were adopted. For example, the study adopted an iterative approach, whereby insights gained in the initial rounds of data collection were used iteratively to clarify subsequent data collection activities and analysis. In addition, observational data were triangulated with interview and documentary data to help generate a more detailed and richer study account of team leading and learning actions and activities. Furthermore, the study was reflexive in nature, and dealt with researcher’s previous insider’s knowledge of Team A (where she had worked as a nephrology professional for several years) to help clarify belief systems, assumptions and subjectivities. These data were carefully compared with data gathered from Team B (where the researcher was an outsider).
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elements are presented: leadership as directing, coaching, supporting and delegating. Although the findings are presented in separate sections, it must be noted, that both formal and informal learning leaders in this study shifted the use of these different leadership actions in their daily work, as the needs of their team and its members changed to local demands. Leading by directing learning about tasks The notion of ‘‘directing’’ refers to a leader’s ability to focus on specific task-learning directions, at the expense of a focus on learning about relationships. This study revealed that most formal and informal leaders at times displayed an ability to prioritize and pay more attention to the day-to-day practice that is focused directly on the immediate needs and tasks at hand. For example, as seen in a discussion with three team members in the hall-way about which professional had the authorization for prescribing a patient a certain treatment, an in-formal leader intervened to direct a learning opportunity related to the task of prescribing:
Ethical considerations Ethics approval for this study was granted by the research ethics boards of participating hospital and university institutions. The study was initially presented at education rounds and information sheets were provided to all team members, students, and trainees. It was made clear that participation in this study was voluntary and, although the administrative consent allowed observation of the teams, any individual team member or student could refuse to be part of the study. Written consent was obtained from all participants who were interviewed. During the 9 months study period, on observation days patients in the clinics were fully apprised of the researcher’s presence and study aims.
Findings This section offers findings from the study in two main sections. First, data relating to the differing characteristics of the team leaders is presented. The second section offers details related to how these leaders engaged in various activities linked to Hersey and Blanchard’s (1993) situational leadership approach. Characteristics of team leaders The data indicated that leadership in these two teams involved 12 individuals from two professions – medicine and nursing. Of these individuals, three were ‘‘formal leaders’’ – clearly identified as being responsible for exercising primary leadership roles such as director or manager positions within the organization. These formal leaders were organizational representatives, and they created the structures that allowed the teams to function as cohesive units. In contrast, the data suggested that the nine informal leaders who were not organizational leadership representatives, took on the role of practising experts, by caring for patients, generating change and motivating others as learning leaders and strategy builders. Informal leaders were able to situate and adapt their actions and interactions with other members of the teams. In this sense, they were leading as clinicians with the teams. However, the data did suggest that, in general, both informal and formal leaders showed a willingness to adapt to the team’s needs in learning to function as a collective. The nature of their approach to leading team learning is considered in more depth below. Team leaders, team learning and situational leadership The following four sub-sections offer details from the analysis of data, which as previously noted was framed by the situational leadership perspective (Hersey & Blanchard, 1993). Four
The informal nurse leader suggested that team members should seek profession specific information about who can prescribe calcium. The leader mentioned that scope of practice of each profession is determined by a combination of legislation and regulation. The response from the informal leader was a direction for sharing as a form of teaching from the regulated team members who had access to information and to share with others who were not expected to have this knowledge. (Field notes, September-08, Team B) Directing learning is something which was observed in informal conversations, daily dialogue and social interactions of team members, as well as more formal team activities such as education and patient-care rounds. By focusing extensively on the task and less on team relations, leaders were able to identify specific cases where information was incorrect, missing or unclear. In the following example, concerning legal issues that could result in charges of malpractice, the formal leader who is legally responsible talked about being firm in conveying her perspective. This expression included information pertaining to the broad relevance of the basic team’s tasks, and as a personalized teaching event for imparting knowledge: ‘‘I really encourage new perspectives and learning. However, if I disagree [with a suggestion], which happens, I will disagree. In the end, if there is a malpractice suit, it is not the social worker or the nurse that is going to be sued. I am the one who will be sued. Therefore, I think, I have to at times be sincere and say I disagree’’. I think of our work in determining the right dialysate to avoid fluid overload in patients. (Interview, Nov-07, Team A) Leading as coaches of team learning relationships and tasks ‘‘Coaching’’ refers to leaders’ ability to adapt by enabling learning that leads members to have a collective understanding involving both tasks and relationships activities. Although leaders had the ability to be highly focused on the team tasks, as presented above, many were also able to place equal and simultaneous importance on learning to foster good team relationships. Sometimes situations were so complicated that no individual member possessed all the information necessary to interpret the situation properly. Leaders enabled learning by coaching members to learn as a team. This was achieved with a view to improving the collective learning processes – both task and
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relationship on a routine basis. This example at a clinic discussion between a nurse and a social worker, the leader focused on coaching a complicated situation where members needed information to resolve a disagreement involving both task and relationships learning:
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An informal nurse leader was talking about the value of attending patient care rounds, especially since the social worker expressed disagreement with a treatment plan by another team member. The leader went on to suggest that, at times, professional opinions will differ. When this happens, each member of the team bears the same responsibility to engage collaboratively to address the disagreement in the patient’s best interests. Participation and involvement in patient care rounds often provides an appropriate forum to engage in respectful sharing of information. (Field notes, Nov-07, Team A) All leaders in this study had a similar shared philosophy of responding to change in coaching members to see how their respective roles could contribute to the performance of their team. Here, an informal leader attached importance to the evidence of learning from team members and her vision for enabling a collective understanding by coaching others to learn team tasks and relationships: I am not the dietitian or the social worker or the pharmacist and I cannot do my job without the expertise of these other very important team members. I value input from every member, even the students. In a sense, these various members belong . . . together . . . so that we could learn from each others’ skills and knowledge, as we develop working relations to care for our patients. (Informal Nurse Leader Interview, Apr-08, Team B) Similarly, because the leaders recognized and valued the importance of both task and relationship learning behaviour, some members in turn expressed the importance of having the leaders as part of their day-to-day routine work within the team – this interpretation confirms a focus on enabling learning that leads members to have an understanding of the leaders’ role within the team. A leader reflected on a conversation she had with a team member earlier in the week: I really valued her opinion and saw her as a strong nurse that I trusted. She said that she realized that I needed to take time off when I needed to take it but she just hated it when I took two weeks or more at a time. She said that I was the glue that held the team together and . . . so in a sense, I was a member of the group, not the boss. (Team Member Interview, Jan-08, Team A) Often, the leaders in the study adapted their behaviours based on the needs of the team’s changing situations. For example, team members often need a better understanding of what it means to be a team member by focusing equally on the tasks and relationships. Here a leader attempted to understand a situation with a question, this lead to spontaneously information sharing and learning: During clinic, the physician leader asked a question which was directed to a few interprofessional team members and to no one in specific, ‘‘Why aren’t the fellows from hemodialysis here?’’ An informal nurse leader who was close-by responded by saying that they [the fellows], left a message to say they made a decision to go where there were more patients to be seen. The physician listened, nodded and walked towards the patient who was waiting to be assessed. The ward secretary,
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who was also close-by, got on the phone and paged the fellows to come to the unit. Later, the physician leader coached the fellows on the importance of learning how the clinic operates. She explained that it was not only about seeing more patients, in different parts of the hospital; it was also learning the clinic routine and how the team worked to get the job done. (Field notes, Aug-08, Team B) Leading by supporting team learning relationships ‘‘Supporting’’ according to Hersey and Blanchard (1993) refers to leaders’ ability to adapt by emphasizing themselves as mentors and role models in developing their relationships with others. Frequently, when the team leaders needed to pay attention to developing cohesiveness among members, they focused on acting like interprofessional mentors. As integrated members of the teams, it was found that the leaders not only participated as clinicians, but also showed a willingness to both share and learn from others despite positions. Both informal and formal leaders made mentoring an integral part of the team’s mandate. The following is taken from an interview with a leader following clinic observations: As you saw from clinic, our team members need support to develop an awareness of one another’s roles and abilities. When we are not operating as a team, they may be reluctant to learn from each other because of misunderstanding. I [formal nurse leader] am comfortable learning and teaching about efficiency and quality improvements, as these are always compelling arguments for learning to practice as a team. We learn from listening to colleagues because we most certainly do not know everything—none of us knows it all. Learning from and truly listening to each other...together we have force as a team. (Interview, Sept-08, team B) Both teams in the study seemed to possess attributes that appeared to elicit the spirit of sharing and collaboration. For example, observations of interactions between the leaders and team members were non-hierarchical in nature. Similarly, team members were observed to share the responsibility of caring for each other and understanding professional perspectives. In this example as team members interact, the interpretation of relevant knowledge leads members to learn. Here an informal team leader supported meaningful learning relationships: During patient care rounds, the informal physician leader appeared mindful to the time demands of the nursing students by rearranging the order in which patient files were placed for discussion. He then, at various times, checked with the other team members to see if everyone was ready to discuss the next clinic patient’s chart. Usually 25–30 clinic patients were discussed at each rounds and this leader encouraged discussion when key members were ready. (Field Notes, October 2007, Team A) In being supportive, the data suggested that these teams operated in a ‘‘no blame’’ environment. Therefore, team members could feel psychologically safe to ask questions that supported their learning, and also ensured safe patient care. As the following extract indicates: I think it is okay to say, ‘‘I don’t know’’. I would rather hear the dialysis technician say ‘‘I am having trouble with this machine’’ at the hospital rather than when they are with the patient during their treatment. It saves time and money.
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It prevents errors. I am open and honest and I expect the same. It is not about finding faults and blaming. (Interview, Jan-08, Team A)
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Leading by delegating task and relationship learning activities Regardless of their differing approaches to leadership, as described above, there were situations when the leaders needed to delegate to the team members. For Hersey and Blanchard (1993) ‘‘delegating’’ refers to leaders’ ability to adapt to the team’s need by limiting their involvement in providing support on tasks and relationships, and in effect, allowing members to accept responsibility for learning. The leaders in this study employed delegation on a regular basis with their teams. The leader’s decision to limit their involvement in providing support on tasks and relationships was often taken to assure timely, appropriate and coordinated team learning. As observed in education team presentation, a leader talked about the development of protocols and procedures as mechanisms to enable patient safety: A formal medicine leader described that the appropriate order sets, also known as pre-printed orders, are a form of delegation that allows some team members to go ahead and suggest specific treatment recommendations. To explain, as a protocol in our team, recommended dietary supplements are included in admission order sets when ambulatory care patients are admitted as inpatients within the acute setting. This saves time in having the physician rewrite new orders when the patient goes from out-patient unit to in-patient unit. This delegation allows for patient care continuity. (Field Notes, May-08, Team B) Formal leaders in both teams spoke about a form of letting go and thereby trusting others. By letting go, formal leaders recognized that they did not need to feel pressure of knowing everything. Team leaders talked about enabling learning, teamwork and cooperation by trusting which underpins the act of delegating. Here a formal nurse leader said: You have to let go and trust others. Trusting instils a sense of teamwork and cooperation. I have to give trust to earn trust . . . it takes time to do this but soon people start to see it and feel it. This allows others to be accountable and accept responsibility for actions. (Interview, December 2007, Team A) Team leaders confirmed that it was not always easy to identify barriers to learning when they limited their team involvement by delegating. One clear example that we share was in a general discussion about stereotyping and learning: Stereotypes do exist and I have seen examples in our team. In the early days, the nurses felt that the dietitians’ only concerns were around food delivery to the unit. The nurses took control over teaching nutrition. Today it is different; the dietitians are experts in nutrition assessments and teaching. This has a huge impact on the patients’ outcomes and recognizing members’ knowledge. Over time we learn not to label others. (Interview, October 2007, Team A)
Discussion As described above, team leaders involved in this study participated in a range of clinical and team-learning activities
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linked to the four activities of leadership – variously directing, coaching, supporting and delegating. Team leadership therefore involved the ability of the leader to adapt to the local teams’ needs as both an authoritative figure and also as a peer/colleague. Not only did these leaders adapt to the learning needs of their respective interprofessional teams, they also worked with their members to help find solutions, problem-solve, and deal with shifting clinical situations. As a result, in their daily work, these leaders – both formal and informal – could be regarded as functioning in the role of facilitators of learning who promoted a team-learning environment. The use of Hersey and Blanchard’s (1993) situational leadership perspective has helped to illuminate how the leaders of interprofessional teams can employ a range of different approaches to their leadership. For example, the directing style within this context was used to help focus the team’s activities and tasks. Leaders were also seen using a coaching style to guide team members towards collective learning. The leaders were also able to shift to a supportive role in dealing with the challenges of incorporating team members’ individual knowledge by helping them to build on each other’s contributions through ongoing connections and relationships. They could, in addition, employ delegation to encourage team members to take responsibility for delivering patient care. Despite engaging in these different activities, leaders maintained an integrated role in working within the teams. Both formal and informal leaders were engaged in daily learning with the team in a diverse, and sometimes transformative, way from the ground up. Study teams had a clear focus on its tasks and every member felt a sense of responsibility towards the success of the team. These teams’ cohesiveness depended on the members’ working and learning relationships with each other and because of the way team leaders adapted, developed and integrated into the working relationships. Much of the literature provides only partial insight into leading health care team performance. For example, Kosinska and Niebro´j (2003) agree that no teamwork performance can be effective without a leader. Similarly, in research focused on leadership style and its impact on the team performance, Dierckx de Casterle, Willemse, Verschueren, and Milisen (2008) argues that effective leadership promotes effective communication, greater responsibility, empowerment and job clarity in nursing teams. These authors suggest that a participatory style of clinical leadership seemed also to influence patient-centered communication, continuity of care and collaboration. McCallin (2003) suggests that a well-functioning team in which clinicians work as ‘‘memberleaders’’ can foster improvements in the performance of patient outcomes. In addition, most studies of team leadership portray the team leader as someone who is responsible for determining and implementing the functions needed to allow the team to maximize its performance (Lim & Ployhart, 2004; Zaccaro, Rittman, & Marks, 2001). However, if leaders emphasize a top-down approach too strongly then a hierarchy might be created that can cause members to feel fear, thus leading to the inhibition of their performance as a team (Huber, 2000; Marshall, 1995). In this view, the team leader is one who is in a position to influence the progress of the team. Unquestionably, this is an important aspect of leadership in the health professional domain for the purposes of improving administrative leadership. However, such a focus under-represents the critical function in health care delivery of leadership at the level of clinical teams, and the process of leading by adapting to the learning needs from within the team, as indicated in this study. Another way of understanding leadership practices is to focus on the organizational context in which team learning is enabled. Arguably, the success of teams depends not only on the leaders
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being able to adjust their behaviours across a continuum of support and direction, but also they need to be able to adjust team functions and structures in response to changing situational factors. As such situational leaders can enable learning rather than control it. In contrast to the hierarchical emphasis in corporate leaders (e.g. Block, 2003; Field, 2004; Fullan, 2001; Senge, 1990), the leaders in this study facilitated learning within and across the interprofessional teams. This view represents a shift away from the traditional view of leader based just on position and authority (Marshall, 1995). As described above, the adoption of a situational approach to leadership, through the use of differing approaches to team leadership (directing, coaching, supporting, delegating), helps foster team interaction and team learning. Despite attempts to produce a high quality ethnographic study, there were inevitably a number of limitations. For example, the two teams involved in this study – both well established, stable teams – could be considered unusual as there is often a high member turnover in interprofessional teams. This factor may limit the applicability of findings from this work to other interprofessional teams. In addition, the focus of this study is leaders’ experiences and perceptions; this study did not gather in-depth perspectives of other team members on leadership – another factor which limits the applicability of this work. In summary, this article described an ethnographic study that explored the nature of leadership and team learning. The use of Hersey and Blanchard’s (1993) situational leadership approach suggested that effective leadership involves leaders’ ability to adapt to changes in local context. This perspective helped illuminate the nature of leadership within an interprofessional healthcare team environment.
Declaration of interest The authors report no conflict of interest. The authors are responsible for the writing and content of this article.
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