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