Study framework

A systematic literature review was conducted using standard literature search techniques for the years 1995 to 2005. Online computer searches of relevant computerised bibliographic databases were completed, using the key words "team, teamwork, inter-professional collaboration, multidisciplinary, competency and communities of practice". These computer searches were supplemented by exploration of documented teamwork competencies used for human resources management and management education purposes.

The research tends to be focused on improving team performance but few studies were identified with either randomised or control methods that enabled generalisation. In addition studies tended to rely on subjective measures of team performance [20]. This is confounded by the finding that team members tend to be overly positive in their assessment of the performance of their group; yet this positive performance assessment is not generally supported by objective performance measures [21]. There were no sound empirical studies that confirmed the teamwork competencies related to successful teamwork performance, in general, or specifically related to health care. Therefore to develop the competency framework to be tested in this study a large number of experimental and non-experimental papers were reviewed with the intent of building a model that was comprehensive in outlining potential teamwork competencies as it was not possible to develop a model that was empirically supported.

Management competencies, the basis for healthcare management education, are generally considered to comprise skills, knowledge, traits (including attitudes) and motives (including values)[22, 23], and therefore these four categories formed the basis for the model. Through the detailed literature review 18 skills, nine knowledge areas, 18 traits and 15 motives were identified as having relevance for effective teamwork (see Figure 1).

Survey

Survey methodology was used to ascertain the competencies perceived by health service managers to contribute to effective team participation in healthcare. The survey respondents were requested to identify the top quartile of each of the skills (5 out of 18), knowledge (3 out of 9), traits (5 out of 18) and motives (4 out of 15) from the lists in Figure 1 that they perceived to be most associated with the effective performance of a member of a management/administrative or clinical care team in which they participated. The ranking approach was used as it has been shown to result in higher quality data than ratings [24]. Instead of ranking the entire list, the respondents were requested to identify only the top quartile to limit the primacy effect often found with ranking studies [24]. The reliability analysis provided Cronbach alpha of over 0.8.

Based on the nature of health care, where clinical care teams are the main work teams responsible for producing healthcare services, and management teams are responsible for the organizational work through coordination and direction setting [25], the respondents were asked to focus their responses to either a management or a clinical team in which they had participated. The respondents were asked to only consider ongoing teams; project and other teams with one-time outputs were not included. Ethics approval was granted from the La Trobe University Ethics Committee. Data analysis comprised descriptive statistics and univariate chi-square using SPSS.

Study population

Pre-testing was completed by a small sample of five individuals drawn from the target population to identify the time requirements to complete the questionnaire and ensure the clarity of the questions. The questionnaire was then distributed by email to the 680 members of the Victorian State Branch of the Australian College of Health Service Executives (College). Membership of this College requires current study in or completion of an accredited health service management course and/or employment as a senior health service manager in a recognized position. Based on error messages in transmission and emails returned to source it was estimated that around 600 members received the emailed questionnaire. The completed surveys were emailed to an administrative mailbox where all identifying information was removed before the surveys were provided for data entry and analysis. Eleven completed questionnaires were returned by post.

Skills

Knowledge

Traits

The female respondents were significantly more likely than the male respondents to consider positive attitude as an important trait (χ² = 7.154 1 df p = 0.007). The male senior and middle management respondents were significantly more likely to include self-directed learning (χ² = 22.721 3 df p = 0.000) than the CEO and other male respondents. The male CEO and female senior manager respondents were less likely to include respect for others (male: χ² = 13.810 3 df p = 0.003, female: χ² = 11.592 3 df p = 0.009) as a trait as compared to the respondents from the other male and female management categories.

Motives

There were no significant motive differences among male and female respondents. The CEO respondents for both males and females were significantly more likely to indicate commitment to organization (male: χ² = 13.553 3 df p = 0.004 female: χ² = 13.031 3 df p = 0.005) and significantly less likely to indicate task completion (male: χ² = 20.426 3 df p = 0.000 female: χ² = 11.106 3 df p = 0.011) as key motives.

Management and clinical teams may require different competencies

While the under-representation of clinical care teams in the sample made it difficult to test if the observed differences in the reported competencies between the management and clinical teams were statistically significant, the fact that a sample of health service managers distinguished between competencies for clinical and management teams is an important finding and needs further study. Previous teamwork research has confirmed that the type of team influences the factors related to effectiveness [25, 32] and this study suggested that within healthcare settings there are perceived differences in the competencies important for management and clinical teams.

Management team competencies

The management team competencies were strongly consistent with previous studies on teamwork performance. Three motives received the highest ranking of all the skills, knowledge, traits and motives; commitment to working collaboratively (64.1%), commitment to a quality outcome (69.2%) and commitment to organization (64.6%). Although not unequivocally supported through controlled experimental design, cross-sectional and case studies have suggested that teams with a climate of psychological safety [5, 33] that encourages high levels of participation [34] toward clear goals [35, 36] that enable high performance and quality expectations [34, 37, 38] demonstrate better team performance [33, 39]. The respondents in this study consistently identified three motives that reflected these previous findings.

This study approached the issue of team performance from a different perspective than previous studies. Instead of team level analysis we focused on the perceptions of health care managers of individual characteristics that contributed most to team success, and yet the results still supported previous study. From the perspective of these respondent managers, individuals participating in management teams in health care organizations were considered to have the greatest impact on team performance when they demonstrated commitment to working collaboratively, commitment to the organization and commitment to a quality outcome. Of all of the skills, knowledge, traits and motives that were provided, the fact that over 60% of the management team respondents indicated the importance of these three motives lends strong support for team members who:

It is clear that more methodologically and statistically rigorous investigation is required to better confirm the relationships between the competencies identified in this study and the performance of teams in health sector organizations. While progressive human resource management promotes participation, training and teamwork consistent with the identified management competencies, healthcare organizations do not always provide best practice HRM [40–42], and the people side of management has often been ignored in the pursuit of health reform [43, 44]. In addition the traditional training and socialisation of health professionals tends to emphasise individual skills, accountability and achievement [45] and the healthcare system continues to foster individual [46] and discipline-specific rewards, supervision and education which consistently leads to difficulties with collaboration across professions, and reliance on hierarchy to manage coordination needs and mediate conflict [42]. The strong support for leadership skills among management team members in this study holds up the notion that within healthcare, leadership that rests at the top of an authority hierarchy needs to be refocused to develop leaders throughout the organization [47]. There needs to be a radical shift in HRM practice [40] in health care to train, performance manage and reward practices that result in clinical and management leaders through the organization – leaders that can foster the organizational commitment and psychological safety that is likely to improve teamwork outcomes.

In healthcare, employee relationships and behaviours are often influenced by the highly professional nature of the workforce, where there is often stronger alliance to the profession than to the organization. Many managers are professionally trained clinicians [48], and they often continue clinical practice even when they have assumed a management role. The findings of this study reinforce previous research that has identified the need for management training of clinician leaders [49–51]. Although many of the competencies developed in clinical education and ongoing clinical practice are transferable to management, there are skill and knowledge deficits [51]. The transition from clinician to manager requires a substantial cognitive shift from a primary commitment to individual care to a community/organizational focus [28].

This study also highlighted differences in perceptions among male and female health service managers that may influence team behaviours and ultimately team effectiveness. The differences noted in the responses of the male and female managers appear consistent with previous study.

For example, male leaders have been found to be more transactional and derive their power from their position on the formal organizational structure [26]. In contrast, women tend to be more transformational and derive their power from personal characteristics. In this study the male respondents demonstrated this transactional nature, identifying ability to influence as a key teamwork skill, while the female respondents suggested negotiation, self-awareness of strengths and weaknesses and positive attitude were important. Studies have suggested that women managers in male-dominated industries employ more 'masculine' management characteristics [27], and we found similarities between the women in CEO positions and male respondents. For example, the female CEOs were less likely than the female respondents at other organizational levels to identify negotiation as an important teamwork skill. While more study of these differences and the impact on team performance is warranted, these results provide some support for the differences in styles of male and female managers.

Different levels of health service managers require different competencies. It has been suggested that front line and/or entry level positions rely on technical expertise, middle managers require greater skills in human resource management and the senior level roles need greater conceptual skills [17, 28]. Often the senior roles are thought to focus more on managing output related organizational adaptation and change [29], while junior levels manage the technical operational aspects of the organization. The findings provided some support. The CEO respondents were more likely to stress commitment to the organization and less likely to indicate task completion. The senior and middle managers focused more on transactional skills, such as negotiation and these manager respondents also stressed self-directed learning to a greater extent.