The trainee and the team
As a trainee, job rotations are vitally important for the development of my learning and education. But this frequent movement, often between hospitals, coupled with concerns over the quality of departmental inductions and gapped, intense rotas makes junior doctors a vulnerable group when it comes to perceptions of teamwork and team behaviours.
The benefits of high-quality teamwork within healthcare are well recognised, with impacts on medical error reduction,[1] improved patient safety and reduced mortality rates [2,3]. Optimal team working is also linked to reduced stress levels, increased job satisfaction and staff motivation [4]. Despite the organisational importance placed on teamwork in healthcare, in 2016 the Royal College of Physicians (RCP) recognised that a key factor in the low morale and disengagement of junior doctors was the loss of the medical team structure [5].
Not isolated to medical teams, surgery has also been hit in terms of the loss of a team-based structure with, among other factors, the introduction of the European Working Time Directive (EWTD) labelled as a key contributor. Furthermore, factors such as increased locum reliance and an expanding multi-disciplinary membership have all added complexity to the traditional team model. Other specialities may have previously been less reliant on an inherent team function. But at a time of high workload and increased pressures improving teamwork could be the key mechanism through which to re-engage and enhance the working lives of all junior doctors.
Reports of an absence of junior doctors from the wards due to a high percentage of on-calls, difficulties with continuity for patients and a perceived detrimental impact on training have not gone unnoticed. A proposal in 2016 from the then Health Secretary Jeremy Hunt to NHS Providers announced a plan to reintroduce the best parts of the medical ‘firm’ system as part of measures to improve junior doctor’s morale [6].
Ask anyone in healthcare if they work in a team and they will probably say yes. However the reality is this figure is nearer 40% [7]. Effective clinical teams demonstrate a number of features; clear team identity and objectives, clarity of roles, effective team processes in decision making, communication, constructive debate and creative conflict, effective inter-team working and clear leadership [8]. These key features will not be familiar to many trainee rotations and working experiences, where few rotas are team-based. The RCP Being a Junior Doctor report specifically highlighted that ‘junior doctors spoke about it being unusual to work an out-of hours shift with the same people twice’ [5]. This has a significant impact on the concept of being part of a team and if extrapolated from one department to repeated rotations it is easy to see why junior doctors are a disengaged workforce.
While departmental rotations may have detrimental impact on the immediate sense of team, there are important benefits for breaking down professional silos and stereotypes that should be appreciated. The Acute Common Care Stem training provides a clear example of this. Rotations in emergency medicine, acute medicine, anaesthetics and intensive care, all specialities with a high degree of interoperability, develops appreciation and professional empathy for each role.
As those trainees embarking on leadership training or aspiring to future roles we must take an enthusiastic and proactive role in promoting good teamwork. The first step to do this is to acknowledge that teams in healthcare are not automatic. Organisational factors can often not be altered and therefore a conscious effort has to be made by each of us to promote and foster effective team working within our environments. Whilst this should begin from foundation years that responsibility will increase with progression through training.
There are plenty of resources and training available to learn about different models of teamwork and what good teamwork should be in healthcare [9,10]. This theoretical education coupled with experiential learning should be recognised as an important aspect of personal leadership development alongside the mandated training curriculum competencies.
But I believe there are also some very simple steps we can all do to promote teamwork and our sense of belonging in each rotation. This will benefit not only how we feel at work but hopefully positively influence those around us and ultimately provide benefit to our patients.
1. Meet the team
Ward managers, charge nurses and sisters set the culture and ways of working within an organisation. In my 4 years as a junior doctor, I have never had an induction presentation from a ward manager or senior nurse. This is a significant missed opportunity that could allow for key information on how the department functions to be delivered and where a sense of belonging is instilled. The outcome of this absence is two fold; they don't feel responsible or in a position of leadership for you and junior doctors don't feel that they belong to the departmental team. Make sure you know who the senior management team is for your department and if you don't get an introduction from them, try to arrange one.
A healthcare team is bigger than you think. Identify who else plays an important role for your patients and don't let it be months before you discover the physiotherapists’ office or say hello to the ward clerk.
2. Clarify your roles
It should be obvious but often doesn't happen, so understand with whom you are working with, especially if you haven’t worked with them before. Do a round of introductions and ensure everyone has an understanding of the skill and competency mix of the team. Initial positive communication between team members creates an open culture and will make it easier for later issues to be raised and then solved as a team. This is also an ideal opportunity for trainees to identify educational opportunities they need to experience on that shift.
3. Be part of the team
Teams with a positive, supportive, humorous and appreciative environment have been shown to deliver better care and impact on staff wellbeing and morale. Trainees can play a key role in this but often feel disengaged from the area they are working in. Try to make time to attend department or clinical governance meetings, not only will you gain a greater understanding of the current issues or challenges but they are also good learning opportunities.
Most hospitals do regularly try to engage with staff through emails or face-to-face events e.g. tea with matron. These events can have a positive effect on the sense of organisational belonging by staff but uptake by Junior Doctors is usually very low resulting in the views of a key staff group missing from discussions.
Find out what is going on locally in your hospital and take time to engage with it. It could be a greatix, where staff can nominate another member of staff for excellence in the workplace, or the social movement 15s30m where staff are encouraged to spend 15 seconds doing a job now to save someone else 30 minutes later [11]. Even something as simple as having lunch in the ward staff room instead of the doctors office or mess can have a positive impact.
Summary
Good teams are essential for all in healthcare. Despite often not being part of a defined team, trainees can, and should, actively promote teamwork. Acknowledging the effort required to create a team alongside conducting some simple actions to meet the team and clarify roles at the start of each shift or rotation can have a small but positive impact on our working environment and those around us.
FMLM TSG Armed Forces Representative
1. Manser, T. (2009). Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiologica Scandinavica, 53(2), 143-151.
2. Firth-Cozens J. (2010). Cultures for improving patient safety through learning: the role of teamwork. Quality and Safety in Health Care journal.10.(suppl 2):ii26–ii31.
3. West, M.A., et al. (2002). The link between the management of employees and patient mortality in acute hospitals. International Journal of Human Resource Management, 13(8), 1299–1310.
4. Borill C.S., Carletta J., Carter A. J. et al. (2000) The effectiveness of health care teams in the National Health Service. Department of Health. London.
5. Royal College of Physicians. (2016) Being a junior doctor. London. Accessed 07/09/18 https://www.rcplondon.ac.uk/guidelines-policy/being-junior-doctor
6. Rimmer A. (2016) Return of the “firm” gets cautious welcome. BMJ ;355:i6554
7. West, M.A., Lyubovnikova, J. (2013). Illusions of team working in health care. Journal of health organization and management, 27(1), 134-142.
8. Lynn, M., West, M.A., Swanwick, T., McKimm, J.. (2011) Leading groups and teams. ABC of Clinical Leadership: 14-18.
9. Resources, Faculty of Medical Leadership and Management. Accessed 07/09/18 https://www.fmlm.ac.uk/resources
10. Resources, NHS Leadership Academy. 2018. Accessed 07/09/18 https://www.leadershipacademy.nhs.uk/resources/
11. 15 seconds, 30 minutes. Accessed 07/09/18 http://15s30m.co.uk.