Collective Leadership & Teams

The context: When there is purposeful consideration of team membership and recognition of the need for physicians to be engaged and the intervention uses a range of strategies to invite members or to seek volunteers with deliberate engagement of physicians and key influencers… 

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The mechanism: These conditions enact feelings of being valued through recognition of need for diverse contributions, knowledge competency and new perspectives and recognition that physician engagement and support is key to success through empowering, motivating and engaging team members through a shared sense of ownership and purpose.

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The outcome: This results in more timely buy-in by other team members; more acceptable solutions with an increased chance of success; explicit acknowledgement and appreciation for others’ skills and contributions; evidence of willingness to share ownership of burden and wider participation of physicians through peer influence.

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“I would say it’s . . . it was very empowering for the more junior faculty, who kind of felt like [they were] a little bit rudderless before this. . . . . It was very empowering for many of the Advanced Nurse Practitioners to make them feel part of the team. I . . . I’ve seen the engagement level of the nurses definitely increased with feeling part of that team.”

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The context: When there is recognition that there is underperformance or poor-quality care and there is a readiness to engage in change effort and the intervention ensures clear and consistent communication of goals, timelines and schedule of events; regular re-iteration and review of goals; effective use of data to evaluate progress; introduction of strategies and tools to communicate effectively and to ensure participation…

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The mechanism: These conditions enact shared understanding; shared situational awareness; clarity of roles and responsibilities; perceptions of confidence and trust in the intervention; motivation to question, understand and speak up.

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The outcome: This results in active engagement of the team members at meetings; use of a shared language; better relationships and team culture as evidenced by interactive behaviours; implementation of agreed solutions; speaking up and effective conflict resolution.

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“So I think the data was key and at the end of the day somebody said afterwards that we’re all scientists in one way, shape or form. If you give us data you can show us up or move us along. So I think that was probably one of the more important things.”

 Consultant

“I think I’m getting better, as evidenced by this past weekend, at kind of just standing up and sticking my neck out and saying, “Oh, I really think that we should do X”, instead of kind of letting it pass by. Like this past weekend, the physician that I was on for rounds wasn’t necessarily an adopter of the process. But I just put my big girl pants on and I said, “Hey. We should go into the room and do rounds.” . . . . whereas before I just would’ve kind of let it slide and done the easy thing.”

Advanced Nurse Practitioner

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The context: When there are busy schedules and competing demands for the team and inter or intraprofessional tensions and rivalries and the intervention events are pre-planned in advance using thoughtful and engaging strategies (e.g., effective use of

data, workshop content), to stimulate interest in attendance with a commitment to find suitable times to meet and/or staff are supported to attend key champions and sponsors of the intervention are used as sound boards and supports…

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The mechanism: These conditions enact self-interest, ability to focus, enjoyment, sense of fun, motivation and commitment to participate and a fear of missing out and inability to contribute if not present.

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The outcome: This results in increased attendance and ability to participate meaningfully in reflective practice, interactivity and acknowledgment of fun elements and building of inter- and intraprofessional relationships for team members.

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“I must say I never liked thinking that someone was planning how my service should work for me and not engaging me in it.”

Consultant

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“We were doing critical thinking. We were actually up there on the board. We were dialoguing. And I just thought that that was incredibly powerful, and then the way we shared those at the end I also thought was incredibly reflective and kind of set the stage for this shared knowledge about processes and the way we work as teams”.

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Advanced Nurse Practitioner

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The context: When the intervention team and facilitators are dedicated, enthusiastic and are collaborative in their approach and the intervention is co-designed/decided by consensus; is patient-centred, relevant and problem-focused; is flexible in its application and the facilitators know when to engage or to step back and hand over ownership,

using data effectively to communicate progress…

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The mechanism: These conditions enact self-awareness, mutual trust, shared understanding and ownership, giving a sense of credibility, logic, psychological safety and perception of being associated with something that might work as well as fear of missing out on ability to contribute if not present. 

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The outcome: This results in engagement with and progression of the intervention and implementation of a new co-designed approach to provision of patient care

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“There is a feeling that always one of our team would be there because you would be afraid that some decision might be made you know which would affect you so we would always, one of us would always try and represent us there.”

Consultant

“They felt they had ownership and they felt they could do something about it themselves and I think they felt this is ours… they never thought it was within their gift to give and make this change themselves. I think it did empower them a little bit . . . here they were very much brought on board with “you own this, you’re part of it, you deliver it”, they co-designed the solution.”

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The context: When there is a strong driver for the intervention at the organisational level, team goals are aligned with organisational goals, there is leadership support in the form of

tangible resources and where there are experienced facilitators who know the key moments when support of organisational leadership is required, there is regular appraisal and sharing of performance data with organisational leadership and acknowledgement and recognition for the team by organisational leadership when successes are noted…

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The mechanism: These conditions enlighten and interest leaders and motivates and empowers the team, giving a sense of influence, gravitas, validity and legitimacy to the intervention, reluctance to be perceived as inhibiting progress and connectedness and confidence in the process. 

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The outcome: This results in evidence of team pride and camaraderie, easier implementation, team members demonstrating interest in sustainability and stating the potential to spread to other areas and/or to build on the success, public endorsement of the team’s work.

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“Because it made people realise the importance of the exercise. It’s not just a chat about or a moan about I’ve got too many patients to look after your patients, it was actually something that was very invested from the top down and I think it was, I think [name] being at those meetings, because he came to a lot of those meetings you know and I think it was, if you think about it, it was a really important move forward.”

Consultant

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“I think it assured them that this is going to happen, that the support was there and that this was you know not just being talked about and that you know it’s not going to look good for somebody to try and get out of this process.”

Consultant

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The context: When there is a lack of or inconsistent visibility of leadership at intervention events and/or inconsistent messaging from the team’s perspective despite intervention efforts…

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The mechanism: This condition enacts a perception of lack of shared ownership, feelings of disappointment and diminished motivation, lack of confidence and connectedness in the broader system 

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The outcome: This results in less impactful or less effective team performance and slower implementation because of the impact inconsistent attendance of team members at intervention events and less physician engagement. 

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“It takes much longer to get things done when the manager isn’t in the room.”

Speech and Language Therapist

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The context: When there is evidence of hierarchical structures or interprofessional/intraprofessional tensions and rivalries and a lack of understanding of others’ roles and responsibilities and the intervention creates opportunities for team members to be together in the same room, to develop relationships with each other and fosters an open and inclusive environment, where multiple methods are used for all team members to have an equal say and the need for interdependent work and relational co-ordination is made explicit…

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The mechanism: This condition enacts the building of personal connections; new insights and understanding of others’ roles and responsibilities; perception of being listened to and being supported; sense of an equal share, stake or ownership of the process; broader perspectives and mutual respect.

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The outcome: This results in staff reporting personal connections, more familiarity and less formality, more informal conversations and discussions, more staff speaking up and more collaborative practice, as evidenced by a team-based approach to care delivery and partnerships in delivery of patient care.

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“It’s really all about relationship building . . . which sounds hokey, but boy is it true.”

Advanced Nurse Practitioner

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“Quite often people stayed around for quite a long time after [meetings] and chatted and caught up and you wouldn’t normally get to do that, definitely it was good for relationships and better collaboration.”

 Consultant

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The context: When there is endorsement of the intervention and an expectation that staff will participate with positive intent and if there is evidence of peers not buying into the process and the intervention offers a mechanism for voicing concerns and escalation with rapid cycle quality and improvements in terms of corrective action…

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The mechanism: This condition can mitigate risk of feelings of being let down, a sense of disillusionment and a negative incentive for future participation.

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The outcome: This results in progression of the intervention towards successful outcomes or withdrawal from the intervention and poorer outcomes depending on the level of re-engagement of peers after the specific action to rectify the situation has been taken.

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“It was great to have a manager involved to escalate things when it was needed, especially when things felt like they were getting stalled.”

Administrator

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The context: Where there is observed dedication, tenacity and resilience of the intervention facilitators and a determination to keep going and adapting and flexing to changes in context over time and the intervention facilitators have expertise, are engaging and persuasive communicators and invest significant time and effort in the intervention…

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The mechanism: These conditions enact perceptions of credibility, recognition of investment and commitment, motivation, inspiration, respect and appreciation.

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The outcome: This results in greater willingness to engage in change momentum and sustained engagement and progression of the intervention.

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“And you guys sort of fortitude in saying, “We’re just going to keep doing this and trying to alter it as you did early on to make it shorter time periods so we could do it.” I mean it’s remarkable because it would have been very easy, I can only imagine, to get highly discouraged.” 

Advanced Nurse Practitioner

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The context: When there is readiness for and openness to an improvement culture and the intervention offers protected time and opportunities for the team to meet formally or informally over time, a new context evolves, which supports the development of positive interpersonal

relationships where there is increased familiarity and less formality among team members… 

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The mechanism: This condition enacts greater appreciation of and empathy for pressures on other team members, shared understanding of individuals’ skills and potential to contribute, a collective mindset, empowerment and a sense of psychological safety.

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The outcome: This results in a positive team morale and working environment, ease of communication, openness and honesty, ability to progress intervention issues informally, pro-active helping behaviours or burden sharing, explicit statement of skillsets and preferences, conflict resolution and quicker recovery from conflicts.

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“I mean it brings people together doesn’t it, I think that’s a positivity in that and sometimes there can be little chats in there about other patients. Or you know if you are particularly worried about somebody even that you’ve seen in a clinic so I think the cohesiveness, the fact that it brings people together is a positive.”

Consultant

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The context: When there is acknowledgment of success of the intervention and more positive working relationships and the interventions allows for demonstration and acknowledgement of success… 

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The mechanism: This condition enacts a sense of personal contribution, connection with something positive, team members aligning with this success and a boost to team morale or a feel good factor.

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The outcome: This results in evidence of camaraderie; a new way of working for the team, new staff adapting to this as embedded part of the culture; externally perceived credibility in the intervention and subsequent buy in from other staff; sustainability of the intervention and potential to spread; participants’ willingness to engage in other interventions.

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“Because like anything if you get a sense that something is successful in any small way then that will accelerate, that’s almost starting in the middle of the story.” 

Consultant

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