Tackling troubled teams

Team working is now enshrined in Good Medical Practice as part of the duties of a doctor. Effective and safe patient care depends on good teamworking, as Jennifer King explains

Introduction

Why do many clinical teams struggle? What makes a team dysfunctional, and what can be done to help them? The approach described here focuses on interpersonal relationships and behaviour, which are so often central to a team's difficulties.

What makes a team effective?

Understanding what makes teams work well is an important starting point when trying to help teams in trouble. The literature on teamworking in health care is extensive¹, and identifies several characteristics of effective teams (box 1²). These provide a guide to measure how well a team is performing and a number of questionnaires exist for this purpose.³

Why do teams get into difficulties?

When teams get into difficulties it is generally due to at least one of the following³:

• Lack of clarity or mutual understanding of roles;
• Lack of structure in the team or team task;
• No clear shared vision and explicit goals;
• Inadequate resources;
• Poor organisational climate;
• Poor/lack of leadership; or
• Perceived inequalities.

Typical scenarios

Scenario 1 – A consultant appoints his registrar to join his team as a newly appointed consultant. He then persists in treating him as though he were still his registrar. The relationship deteriorates.

Scenario 2 – Two consultants working together in a department have a history of conflict, and a third consultant is appointed to reduce the workload and "dilute" the conflict. The new consultant ends up taking sides with one party and the conflict escalates.

Scenario 3 – A general practitioner with several roles outside the practice is often absent at conferences and educational events. Other partners become frustrated that the general practitioner is not taking on her fair share of the workload. Opinions and loyalties become polarised and tensions escalate.

In our recent work two main themes emerge: firstly, behavioural issues, rather than clinical incompetence, cause most disruption in teams. Secondly, there is the question of leadership. Troubled teams almost invariably lack leadership. In hospital departments, the role of the clinical director is crucial.^{4 5} Our approach focuses on tackling the behavioural issues as well as helping teams to formalise the leadership role that is so crucial to successful teambuilding.

Case study: how teams can tackle their difficulties

The presenting problems

• Department with clinicians working across two sites in a merged acute trust;
• Entrenched and polarised styles of working, with clear site cultures;
• Festering resentments about management;
• Vote of no confidence in the clinical director;
• Resentment concerning disparities in workload.

Stage 1: Understanding the problems

A rigorous diagnosis of what has occurred is essential to remedy team difficulties. Individual interviews elicit confidential views from each team member about what they see as the challenges facing the team, what they contribute to the team, and their opinions of the other team members. Psychometric measures are also used to identify the personal styles, motivations, and values of each member and their views about the performance of the whole team.

Stage 2: Setting a new direction

The team meets together with a facilitator to focus on the following questions:

• What do we want to achieve together?
• What is helping and hindering us in achieving our goals?
• What do we need to do to move forward?

Case study: The underlying problems

Myers Briggs Type Indicator (MBTI) profiles revealed some clear personality differences in the team.^6 7 For example: most people were introvert and analytical (thinkers), with many good ideas but not always explicitly communicating their decisions. Little attention was paid to interpersonal sensitivities and there was a clear preference for structure. The deposed clinical director, however, operated in a more flexible manner, and was labelled as "chaotic" by his colleagues.

A further personality measure looking at motivation and values⁸ showed that most team members had little interest in building relationships or personal recognition. Tensions existed between dominant power seekers and those averse to power or influence. The result was a group of individuals who, although highly conscientious, were remote and unappreciative, showed little collaboration, and could not agree on how to exercise power in the team. Therefore the team lacked leadership. Making these differences explicit enabled this team to discuss their differences constructively and agree how they could use them for their mutual benefit. This was a major breakthrough for this team.

Some important considerations in helping troubled teams

Clear messages must come from the top of the organisation

A clear statement from the chief executive at the start of a team meeting about what is negotiable and what is not, can be vitally important to setting the tone for the team rebuilding process.

Focus on the future, learn from the past

Sometimes festering wounds needs lancing before the team can heal. This requires skilful handling but the following will help:

• Keep blame out of the dialogue by using the IDS technique: Identify the event ("You asked me to manage your patient while you were away"); Describe how it made you feel ("When you changed my instructions I felt undermined"); offer a possible Solution to prevent it recurring ("Next time it would help me if you could tell me clearly what you want me to do")
• Use "positive enquiry": invite an individual to talk about an issue that has bothered him or her, for a minute or two uninterrupted. Encourage others not to react defensively but instead to ask questions such as "What did we do to make you feel that way?" "Tell me how you would like me to change" "Can you help us understand why this caused you a problem?" or "How can we work on this together?" This approach promotes listening and understanding and defuses much of the negative emotion
• Keep the focus on the behaviour and on solutions not problems. Feedback should be about what the person did ("Your actions have caused me to lose confidence"), accompanied by a constructive suggestion for change ("If you have a problem with my work it would help me if you could come and talk to me about it first").

A team code of behaviour

Where behavioural issues are central, it is important to agree an explicit code of behaviour or "teamship" rules,⁹ to which all members sign up. This should be accompanied by some agreed actions for how to handle unacceptable behaviour. This provides clarity and focus, but to succeed it must have the full support of senior management. Box 2 shows an example of a code of behaviour.

Practical tips for team members to prevent further difficulties

A well facilitated team meeting is an essential spring-board for renewed focus, direction and energy—but team rebuilding is not a one-shot effort and must consist of more than a few neatly worded flip charts. For sustainable success, the following are essential:

• Neutral and robust facilitation;
• Full participation of all team members;
• Clear team rules for behaviour during and after the meeting;
• Keeping the focus on the future not the past;
• Keeping the responsibility and ownership with the team;
• Clear and agreed priorities, objectives and criteria for success;
• Documented actions, individual accountabilities and regular reviews.

Finally – remember to reward success in the team.

References

1. West M, Borrill C. The influence of teamworking on doctors' performance. In: Cox J, King J, Hutchinson A, McAvoy P, eds. Understanding doctors' performance. Oxford: Radcliffe Medical Press (in press, 2005).
2. West MA. Effective teamwork. Oxford: Blackwell, 1994.
3. West M, Markiewicz L. Building team-based working: a practical guide to organizational transformation. Oxford: BPS Blackwell, 2004.
4. Peskett S, King J. Leadership and performance: Doctors in Difficulty. In: Edmonstone J, ed. Clinical leadership: a book of Readings. Chichester: Kingsham Press. 2005.
5. Empey D, Peskett S, Lees P. Medical leadership. BMJ 2002;325(suppl): S191. (Career Focus)
6. Briggs Myers I, Myers PB. Gifts differing. Mountain View, CA: Consulting Psychologists Press, 1988.
7. Houghton A. Type and teams. BMJ Careers 2005;330: 18-9.
8. Hogan R, Hogan J. Motives, values, preferences inventory. Jacksonville, FL: Hogan Assessment Systems, 1996.
9. Woodward C. Winning! Hodder and Stoughton, 2004.