Advances in Health Sciences Education

, Volume 22, Issue 5, pp 1085–1099 | Cite as

Pulling together and pulling apart: influences of convergence and divergence on distributed healthcare teams

  • L. LingardEmail author
  • C. Sue-Chue-Lam
  • G. R. Tait
  • J. Bates
  • J. Shadd
  • V. Schulz
  • For the Heart Failure/Palliative Care Teamwork Research Group


Effective healthcare requires both competent individuals and competent teams. With this recognition, health professions education is grappling with how to factor team competence into training and assessment strategies. These efforts are impeded, however, by the absence of a sophisticated understanding of the the relationship between competent individuals and competent teams . Using data from a constructivist grounded theory study of team-based healthcare for patients with advanced heart failure, this paper explores the relationship between individual team members’ perceived goals, understandings, values and routines and the collective competence of the team. Individual interviews with index patients and their healthcare team members formed Team Sampling Units (TSUs). Thirty-seven TSUs consisting of 183 interviews were iteratively analysed for patterns of convergence and divergence in an inductive process informed by complex adaptive systems theory. Convergence and divergence were identifiable on all teams, regularly co-occurred on the same team, and involved recurring themes. Convergence and divergence had nonlinear relationships to the team’s collective functioning. Convergence could foster either shared action or collective paralysis; divergence could foster problematic incoherence or productive disruption. These findings advance our understanding of the complex relationship between the individual and the collective on a healthcare team, and they challenge conventional narratives of healthcare teamwork which derive largely from acute care settings and emphasize the importance of common goals and shared mental models. Complex adaptive systems theory helps us to understand the implications of these insights for healthcare teams’ delivery of care for the complex, chronically ill.


Teamwork Collaboration Competence Complex chronic care Grounded theory Qualitative research 



The study reported in this article was supporting by peer-reviewed grant funding from the Canadian Institutes for Health Research (CIHR) and the Academic Medical Organization of Southwestern Ontario (AMOSO). We would like to thank the patients, family members and healthcare providers who participated in this study. Jeremy Chitpin provided support for the creation of narrative profiles during a summer research training program at the Schulich School of Medicine and Dentistry.

The Heart Failure/Palliative Care Teamwork Research Group

is a multi-institutional group of co-investigators and collaborators who collaborated on this research project: The authors acknowledge the support from the Heart Failure/Palliative Care Teamwork Research group: Malcolm Arnold, Fred Burge, Samuel Burnett, Karen Harkness, Gil Kimel, Kori LaDonna, Donna Lowery, Denise Marshall, Allan McDougall, Robert McKelvie, Laura Nimmon, Stuart Smith, Patricia Strachan and Donna Ward.

Supplementary material

10459_2016_9741_MOESM1_ESM.pdf (87 kb)
Supplementary material 1 (PDF 86 kb)
10459_2016_9741_MOESM2_ESM.pdf (111 kb)
Supplementary material 2 (PDF 110 kb)
10459_2016_9741_MOESM3_ESM.pdf (197 kb)
Supplementary material 3 (PDF 197 kb)


  1. Alper, S., Tjosvold, D., & Law, K. S. (1998). Interdependence and controversy in group decision making: Antecedents to effective self-managing teams. Organizational Behavior and Human Decision Processes, 74(1), 33–52.CrossRefGoogle Scholar
  2. Bissell, P., May, C. R., & Noyce, P. R. (2004). From compliance to concordance: Barriers to accomplishing a re-framed model of health care interactions. Social Science and Medicine, 58(4), 851–862.CrossRefGoogle Scholar
  3. Bleakley, A. (2013). Working in “teams” in an era of “liquid” healthcare: What is the use of theory? Journal of Interprofessional Care, 27(1), 18–26.CrossRefGoogle Scholar
  4. Boreham, N. (2004). A theory of collective competence: Challenging the neo-liberal individualization of performance at work. British Journal of Educational Studies, 52, 5–17.CrossRefGoogle Scholar
  5. Capra, F. (1996). The web of life: A new scientific understanding of living systems. In 1st Anchor Books. New York: Anchor Books.Google Scholar
  6. Dey, Ian. (1999). Grounding grounded theory: Guidelines for qualitative inquiry. San Diego, CA: Academic Press.CrossRefGoogle Scholar
  7. Gillespie, B. M., Gwinner, K., Chaboyer, W., & Fairweather, N. (2013). Team communications in surgery—creating a culture of safety. Journal of Interprofessional Care, 27(5), 387–393. doi: 10.3109/13561820.2013.784243. (Epub 2013 May 14).CrossRefGoogle Scholar
  8. Haynes, A. B., Weiser, T. G., Berry, W. R., et al. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine, 360(5), 491–499.CrossRefGoogle Scholar
  9. Henkin, S., Chon, T. Y., Christopherson, M. L., Halvorsen, A. J., Worden, L. M., & Ratelle, J. T. (2016). Improving nurse-physician teamwork through interprofessional bedside rounding. Journal of Multidisciplinary Healthcare, 2(9), 201–205. doi: 10.2147/JMDH.S106644.Google Scholar
  10. Janss, R., Rispens, S., Segers, M., et al. (2012). What is happening under the surface? Power, conflict and the performance of medical teams. Medical Education, 46, 838–849.CrossRefGoogle Scholar
  11. Kannampallil, T. G., Schauer, G. F., Cohen, T., & Patel, V. L. (2011). Considering com-plexity in healthcare systems. Journal of Biomedical Informatics, 44(6), 943–947.CrossRefGoogle Scholar
  12. Kernick, D. (2002). Complexity and healthcare organisation. In K. Sweeney & F. Griffiths (Eds.), Complexity and healthcare: An introduction (pp. 93–122). Oxford: Radcliffe Medical Press, Ltd.Google Scholar
  13. Kitto, S., & Grant, R. (2014). Revisiting evidence-based checklists: Interprofessionalism, safety culture and collective competence. Journal of Interprofessional Care, 28(5), 390–392. doi: 10.3109/13561820.2014.916089.CrossRefGoogle Scholar
  14. LaDonna, K., Bates, J., Tait, G., McDougall, A., Schulz, V., & Lingard, L. (2016). Who is on your health-care team?’ Asking individuals with heart failure about care team membership and roles. Health Expectations. doi: 10.1111/hex.12447.Google Scholar
  15. Lansing, J. S. (2003). Complex adaptive systems. Annual Review of Anthropology, 32, 183–204.CrossRefGoogle Scholar
  16. Lingard, L. (2012). Rethinking competence in the context of teamwork. In B. Hodges & L. Lingard (Eds.), The question of competence: Medical education in the 21st century. Ithaca, NY: Cornell University Press.Google Scholar
  17. Lingard, L., Espin, S., Rubin, B., Whyte, S., Colmenares, M., Baker, G. R., et al. (2005). Getting teams to talk: Development and pilot implementation of a checklist to promote safer operating room communication. Quality and Safety in Health Care, 14, 340–346.CrossRefGoogle Scholar
  18. Lingard, L., McDougall, A., Levstik, M., Chandok, N., Spafford, M., & Schryer, C. (2012a). Representing complexity well: A story about teamwork, with implications for how we teach collaboration. Medical Education, 46(9), 869–877.CrossRefGoogle Scholar
  19. Lingard, L., McDougall, A., Schulz, V., Shadd, J., Marshall, D., Strachan, P. H., et al. (2012b). Understanding palliative care on the heart failure care team: An innovative research methodology. Journal of Pain and Symptom Management. doi: 10.1016/j.jpainsymman.2012.04.006.Google Scholar
  20. Loeb, A. E. (2016). Teamstepps: A case study using a complex adaptive systems framework. Columbia University, ProQuest Dissertations Publishing, 10013899.Google Scholar
  21. McDougall, A. G. (2015). A sociomaterial analysis of team-based care for patients with advanced heart failure. Electronic Thesis and Dissertation Repository. Paper 3439.Google Scholar
  22. Paradis, E., Leslie, M., & Gropper, M. A. (2016). Interprofessional rhetoric and operational realities: An ethnographic study of rounds in four intensive care units. Advances in Health Sciences Education: Theory Practice, 21(4), 735–748. doi: 10.1007/s10459-015-9662-5. (Epub 2015 Dec 24).CrossRefGoogle Scholar
  23. Paradis, E., & Whitehead, C. R. (2015). Louder than words: Power and conflict in interprofessional education articles, 1954–2013. Medical Education, 49(4), 399–407. doi: 10.1111/medu.12668.CrossRefGoogle Scholar
  24. Pronovost, P., Berenholtz, S., Dorman, T., Lipsett, P. A., et al. (2003). Improving communication in the ICU using daily goals. Journal of Critical Care, 18(2), 71–75.CrossRefGoogle Scholar
  25. Rice, K., Zwarenstein, M., Conn, L. G., Kenaszchuk, C., Russell, A., & Reeves, S. (2010). An intervention to improve interprofessional collaboration and communications: A comparative qualitative study. Journal of Interprofessional Care, 24(4), 350–361. doi: 10.3109/13561820903550713.CrossRefGoogle Scholar
  26. Saliski, M., Hunt, E. A., & Pronovost, P. J. (2008). The daily goals communication sheet: A simple and novel tool for improved communication and care. Joint Commision Journal on Quality and Patient Safety, 34(10), 608–613.CrossRefGoogle Scholar
  27. Stacey, R. D. (2003). Strategic management and organisational dynamics: The challenge of complexity (4th ed.). Harlow: Pearson Education Ltd.Google Scholar
  28. Stacey, R. D. (2006). Ways of thinking about public sector governance. In R. D. Stacey & D. Griffin (Eds.), Complexity and the experience of managing in public sector organizations. London: Routledge.Google Scholar
  29. Stewart, A., Petch, A., & Curtice, L. (2003). Moving towards integrated working in health and social care in Scotland: From maze to matrix. Journal of Interprofessional Care, 17(4), 335–350.CrossRefGoogle Scholar
  30. Sutcliffe, K. M., Paine, L., & Pronovost, P. J. (2016). Re-examining high reliability: actively organising for safety. BMJ Quality and Safety. doi: 10.1136/bmjqs-2015-004698. (Epub ahead of print).Google Scholar
  31. Suter, E., Goldman, J., Martimianakis, T., Chatalalsingh, C., DeMattaeo, D. J., & Reeves, S. (2013). The use of systems and organizational theories in the interprofessional field: Findings from a scoping review. Journal of Interprofessional Care, 27, 57–64.CrossRefGoogle Scholar
  32. Tjosvold, D., & McNeely, L. T. (1988). Innovation through communication in an educational bureaucracy. Communication Research, 15(5), 568–581.CrossRefGoogle Scholar
  33. Weller, J., Boyd, M., & Cumin, D. (2014). Teams, tribes and patient safety: Overcoming barriers to effective teamwork in healthcare. Postgraduate Medical Journal, 90(1061), 149–154. doi: 10.1136/postgradmedj-2012-131168.CrossRefGoogle Scholar
  34. Weller, J. M., Cumin, D., Civil, I. D., Torrie, J., Garden, A., MacCormick, A. D., et al. (2016). Improved scores for observed teamwork in the clinical environment following a multidisciplinary operating room simulation intervention. New Zealand Medical Journal, 129(1439), 59–67.Google Scholar
  35. West, M. A. (2002). Sparkling fountains or stagnant ponds: An integrative model of creativity and innovation implementation in work groups. Applied Psychology, 51(3), 355–387.CrossRefGoogle Scholar
  36. Zimmerman, B., Lindberg, C., & Plesk, P. (2008). Edgeware: Lessons from complexity science for health care leaders (2nd ed.). Irving: V H A, Incorporated.Google Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2017

Authors and Affiliations

  • L. Lingard
    • 1
    Email author
  • C. Sue-Chue-Lam
    • 2
  • G. R. Tait
    • 3
  • J. Bates
    • 4
  • J. Shadd
    • 5
  • V. Schulz
    • 6
    • 7
  • For the Heart Failure/Palliative Care Teamwork Research Group
  1. 1.Centre for Education Research and Innovation, Department of Medicine, Schulich School of Medicine and DentistryWestern UniversityLondonCanada
  2. 2.Schulich School of Medicine and DentistryWestern UniversityLondonCanada
  3. 3.Department of Psychiatry and Division of Medical EducationDalhousie UniversityHalifaxCanada
  4. 4.Department of Family Practice, Faculty of MedicineUniversity of British ColumbiaVancouverCanada
  5. 5.Division of Palliative Care, Department of Family Medicine, DeGroote School of MedicineMcMaster UniversityHamiltonCanada
  6. 6.Department of Anesthesia and Perioperative MedicineLondon Health Sciences CentreLondonCanada
  7. 7.Western UniversityLondonCanada

Personalised recommendations