Abstract
Executive Summary
Introduction
This project titled ‘Teamworking: Understanding barriers and enablers to supportive teams in UK health systems’ was commissioned by the General Medical Council (GMC) and was
completed between December 2022-July 2023. The report provides an overview of key
findings to answer the research questions, considerations and implications for future work.
Background
Healthcare is delivered by a range of different healthcare professionals and many teams
across primary, secondary, private and community care settings. Within these teams,
doctors play a variety of roles. Team working is a central aspect to protecting patients.
Research has found that teams that exhibited fewer teamwork behaviours were found to
contribute to a higher risk of complications and death (Mazzocco, et al., 2009).
In this report, teamwork refers to how individuals work together to communicate, solve
problems and tackle conflicts, to ultimately achieve collective aims. A team can be defined
as two or more individuals who interact with each other and exhibit interdependence towards
achieving one or more common goals. Teamwork may be at a workplace level,
organisational level and broader system level with doctors and/or other healthcare
professionals.
Recent GMC focus has been on supporting essential and diverse groups within the UK
healthcare workforce. In particular, looking where the workforce is growing in the form of
locally employed (LE) doctors and doctors with non-UK primary medical qualifications
(PMQs). In addition, the GMC now has a better understanding of speciality and specialist
(SAS) doctors (SoMEP Workforce Report 2022). However, there is also a need to
understand more about other healthcare professionals such as physician associates (PAs),
anaesthesia associates (AAs), as well as advanced healthcare practitioners who are
becoming more of a feature of the healthcare workforce, in order to increase capacity to
provide care (SoMEP Workplace Report 2023). It is therefore important to understand how
these new roles are being integrated within teams.
Study aim, questions and objectives
The aim of this study was to explore how doctors work together and across wider teams, in
order to identify what factors contribute to effective team working and the elements that
make it more challenging. Research questions:
A. In reality, how do doctors work together, and with others in teams across the
UK health systems?
B. What are the enablers of effective teamworking with, for and about doctors?
C. What are the barriers to effective teamworking with, for and about doctors and
what factors lead to team breakdown?
D. How have external/contextual factors shaped teamworking with doctors over
time?
Page 5 of 77
E. What are the implications for the GMC to enhance doctors teamworking?
Research objectives:
1. To identify the different types of teams doctors are involved in, in leading,
delivering and planning care, and exploring how these vary by career stage
and register type.
2. To explore doctors’ experiences and perceptions of how effective doctor
focused teamworking enables safe patient care.
3. To identify the critical elements of effective team working between doctors,
looking at what contributes to good practice and the roles of team members at
all levels in ensuring this is established and maintained.
4. To further understand doctors’ roles in multidisciplinary teams (MDTs),
including the range of roles doctors have in MDTs, both doctor and wider
healthcare professional led.
5. To review how new team members are brought on board and supported,
particularly those who are new to practice and/or new to working in the UK.
6. To examine how doctor led teams have and are integrating PAs and AAs, and
other similar ‘para-medical’ roles into their teams.
7. To explore the factors that can lead to team breakdown, and how these are
addressed and minimised to turn teams around.
8. To explore what possible interventions and approaches may be most effective
to address these breakdowns.
Study design and methods
To explore what is meant by teamwork, and the elements and dimensions contributing to
effective and ineffective outcomes, we followed a realist methodology (Pawson and Tilley,
1997). Realist approaches incorporate a focus on four key questions: what works, for whom,
in what circumstances, and how?
A two-phase study was undertaken (Figure 1). Phase one included scoping interviews and a
rapid literature review. Phase two used qualitative interviews to explore experiences of
teamworking in the UK healthcare system. Seventy-two interviews were conducted with
doctors, healthcare professionals, relevant groups and teamwork experts from across the
UK.
The analysis prioritised the identification of key contexts (C), mechanisms (M) and outcomes
(O). Context describes the conditions that may influence the mechanisms to produce a
particular pattern of outcomes. Mechanisms refer to underlying entities, processes, or
structures which operate in particular contexts to generate outcomes of interest. Outcomes
include the intended and unintended consequences.
Page 6 of 77
Figure 1. Research approach overview
Main findings
We found a range of enablers for effective teamwork (Figure 2). Key factors included
ensuring the time and structures are in place to allow teams to meet regularly, a positive and
supportive culture, effective communication, leaders who are understanding and
approachable, clearly defined roles and respect for all team members, and continuity and
experience of those in newer roles.
Page 7 of 77
Figure 2. Key enablers of effective teamworking
Barriers to effective teamwork included high service demands and work pressures, power
imbalances and negative hierarchy, a lack of inductions and support for those new to teams
and organisations, poor communication, poor leadership, a lack of mutual respect, a lack of
appreciation and understanding of the needs of differing groups within teams, and finally
Equality, Diversity and Inclusion (EDI) issues (Figure 3). There were particular issues for
SAS doctors and those in newer roles regarding how they fit into teams.
Page 8 of 77
Figure 3. Key barriers to effective teamworking
Concerningly, team members often felt unable to speak out and communicate effectively
with other team members. Hierarchy, generational differences, seniority, and role type
clearly had an impact on this and how individuals fitted into the team. Doctors as ‘outsiders’
(e.g. Foundation doctors and locums who are unable to fully embed into teams) are evidently
affected by lack of stability. Virtual teams have assisted teamworking in some contexts but
Page 9 of 77
have also been a barrier at times in referral communications between primary and
secondary care.
Based upon the participant narratives of effective teamworking, we found that doctors work
in numerous ‘types’ of teams that are linked to teamwork. These include teams that are
stable, static, transient, dynamic, informal, administrative, management, senior
management, patient-focused, multidisciplinary integrated, peer grade, non-clinical and
virtual. Moreover, doctors hold multiple professional identities in teams such as leader, teamworker, insider, workhorse, gatekeeper, villain, outsider, informant and advocate. These
types of teams and professional identities in teams were important in how they linked to
differing enablers and barriers to effective teamworking.
All of the factors discussed were found to either positively or negatively impact upon both
staff and patient outcomes. Additionally, our rapid literature review highlighted the
importance of effective communication, leadership, psychological safety, team dynamics,
staff workload and wellbeing for effective teamwork.
Summary
Overall, we found that when teams work together within a positive and supportive culture,
with effective communication and approachable leaders, the team produces better patient
care; often through effective handovers, streamlined processes and effective multidisciplinary team approaches. Continuity, familiarity and experience also impact upon how
members of the team work together.
Transient teams, where there is a lack of mutual respect and support, dysfunctional and
unapproachable leadership and poor communication, can negatively impact team dynamics.
There are clear difficulties in how doctors understand and work with members in newer roles, and the ways in which team members are integrated into teams.
Based on research data, a number of considerations to enhance teamworking, particularly between doctors and newer members of the healthcare team are discussed.
Introduction
This project titled ‘Teamworking: Understanding barriers and enablers to supportive teams in UK health systems’ was commissioned by the General Medical Council (GMC) and was
completed between December 2022-July 2023. The report provides an overview of key
findings to answer the research questions, considerations and implications for future work.
Background
Healthcare is delivered by a range of different healthcare professionals and many teams
across primary, secondary, private and community care settings. Within these teams,
doctors play a variety of roles. Team working is a central aspect to protecting patients.
Research has found that teams that exhibited fewer teamwork behaviours were found to
contribute to a higher risk of complications and death (Mazzocco, et al., 2009).
In this report, teamwork refers to how individuals work together to communicate, solve
problems and tackle conflicts, to ultimately achieve collective aims. A team can be defined
as two or more individuals who interact with each other and exhibit interdependence towards
achieving one or more common goals. Teamwork may be at a workplace level,
organisational level and broader system level with doctors and/or other healthcare
professionals.
Recent GMC focus has been on supporting essential and diverse groups within the UK
healthcare workforce. In particular, looking where the workforce is growing in the form of
locally employed (LE) doctors and doctors with non-UK primary medical qualifications
(PMQs). In addition, the GMC now has a better understanding of speciality and specialist
(SAS) doctors (SoMEP Workforce Report 2022). However, there is also a need to
understand more about other healthcare professionals such as physician associates (PAs),
anaesthesia associates (AAs), as well as advanced healthcare practitioners who are
becoming more of a feature of the healthcare workforce, in order to increase capacity to
provide care (SoMEP Workplace Report 2023). It is therefore important to understand how
these new roles are being integrated within teams.
Study aim, questions and objectives
The aim of this study was to explore how doctors work together and across wider teams, in
order to identify what factors contribute to effective team working and the elements that
make it more challenging. Research questions:
A. In reality, how do doctors work together, and with others in teams across the
UK health systems?
B. What are the enablers of effective teamworking with, for and about doctors?
C. What are the barriers to effective teamworking with, for and about doctors and
what factors lead to team breakdown?
D. How have external/contextual factors shaped teamworking with doctors over
time?
Page 5 of 77
E. What are the implications for the GMC to enhance doctors teamworking?
Research objectives:
1. To identify the different types of teams doctors are involved in, in leading,
delivering and planning care, and exploring how these vary by career stage
and register type.
2. To explore doctors’ experiences and perceptions of how effective doctor
focused teamworking enables safe patient care.
3. To identify the critical elements of effective team working between doctors,
looking at what contributes to good practice and the roles of team members at
all levels in ensuring this is established and maintained.
4. To further understand doctors’ roles in multidisciplinary teams (MDTs),
including the range of roles doctors have in MDTs, both doctor and wider
healthcare professional led.
5. To review how new team members are brought on board and supported,
particularly those who are new to practice and/or new to working in the UK.
6. To examine how doctor led teams have and are integrating PAs and AAs, and
other similar ‘para-medical’ roles into their teams.
7. To explore the factors that can lead to team breakdown, and how these are
addressed and minimised to turn teams around.
8. To explore what possible interventions and approaches may be most effective
to address these breakdowns.
Study design and methods
To explore what is meant by teamwork, and the elements and dimensions contributing to
effective and ineffective outcomes, we followed a realist methodology (Pawson and Tilley,
1997). Realist approaches incorporate a focus on four key questions: what works, for whom,
in what circumstances, and how?
A two-phase study was undertaken (Figure 1). Phase one included scoping interviews and a
rapid literature review. Phase two used qualitative interviews to explore experiences of
teamworking in the UK healthcare system. Seventy-two interviews were conducted with
doctors, healthcare professionals, relevant groups and teamwork experts from across the
UK.
The analysis prioritised the identification of key contexts (C), mechanisms (M) and outcomes
(O). Context describes the conditions that may influence the mechanisms to produce a
particular pattern of outcomes. Mechanisms refer to underlying entities, processes, or
structures which operate in particular contexts to generate outcomes of interest. Outcomes
include the intended and unintended consequences.
Page 6 of 77
Figure 1. Research approach overview
Main findings
We found a range of enablers for effective teamwork (Figure 2). Key factors included
ensuring the time and structures are in place to allow teams to meet regularly, a positive and
supportive culture, effective communication, leaders who are understanding and
approachable, clearly defined roles and respect for all team members, and continuity and
experience of those in newer roles.
Page 7 of 77
Figure 2. Key enablers of effective teamworking
Barriers to effective teamwork included high service demands and work pressures, power
imbalances and negative hierarchy, a lack of inductions and support for those new to teams
and organisations, poor communication, poor leadership, a lack of mutual respect, a lack of
appreciation and understanding of the needs of differing groups within teams, and finally
Equality, Diversity and Inclusion (EDI) issues (Figure 3). There were particular issues for
SAS doctors and those in newer roles regarding how they fit into teams.
Page 8 of 77
Figure 3. Key barriers to effective teamworking
Concerningly, team members often felt unable to speak out and communicate effectively
with other team members. Hierarchy, generational differences, seniority, and role type
clearly had an impact on this and how individuals fitted into the team. Doctors as ‘outsiders’
(e.g. Foundation doctors and locums who are unable to fully embed into teams) are evidently
affected by lack of stability. Virtual teams have assisted teamworking in some contexts but
Page 9 of 77
have also been a barrier at times in referral communications between primary and
secondary care.
Based upon the participant narratives of effective teamworking, we found that doctors work
in numerous ‘types’ of teams that are linked to teamwork. These include teams that are
stable, static, transient, dynamic, informal, administrative, management, senior
management, patient-focused, multidisciplinary integrated, peer grade, non-clinical and
virtual. Moreover, doctors hold multiple professional identities in teams such as leader, teamworker, insider, workhorse, gatekeeper, villain, outsider, informant and advocate. These
types of teams and professional identities in teams were important in how they linked to
differing enablers and barriers to effective teamworking.
All of the factors discussed were found to either positively or negatively impact upon both
staff and patient outcomes. Additionally, our rapid literature review highlighted the
importance of effective communication, leadership, psychological safety, team dynamics,
staff workload and wellbeing for effective teamwork.
Summary
Overall, we found that when teams work together within a positive and supportive culture,
with effective communication and approachable leaders, the team produces better patient
care; often through effective handovers, streamlined processes and effective multidisciplinary team approaches. Continuity, familiarity and experience also impact upon how
members of the team work together.
Transient teams, where there is a lack of mutual respect and support, dysfunctional and
unapproachable leadership and poor communication, can negatively impact team dynamics.
There are clear difficulties in how doctors understand and work with members in newer roles, and the ways in which team members are integrated into teams.
Based on research data, a number of considerations to enhance teamworking, particularly between doctors and newer members of the healthcare team are discussed.
| Original language | English |
|---|---|
| Commissioning body | GENERAL MEDICAL COUNCIL |
| Publication status | Published - 15 Apr 2024 |
Keywords
- Teamwork
- Realist evaluation