Healthcare teams as complex adaptive systems: understanding team behaviour through team members’ perception of interpersonal interaction

Complexity science belongs to the latest generation systems thinking, studying complex systems [1], also called Complex Adaptive Systems (CAS), by focusing on the relations and interconnections of the system components, rather than on the individual components themselves. Applied to the world of termites, for instance, the communication and collaboration between termites is more important than the characteristics of every individual termite. Complexity science has been introduced in healthcare as a theoretical framework to better understand complex situations [2–5]. Using complexity science to study healthcare has provided insights that could not have been reached when only using the traditional explanatory model in medicine based on scientific positivism that describes the linear cause-effect relationship between two isolated events [1]. The way clinicians handle uncertainty during the diagnostic process, the way physiological processes regulate, for instance, blood glucose levels and the way healthcare practices organize themselves according to a number of simple rules are examples of complex system behaviour that cannot be fully understood through linear thinking alone [1, 3]. As such, many healthcare concepts (e.g. diseases) and systems (e.g. hospitals) have subsequently been described as CAS [1, 6, 7]. Also interdisciplinary healthcare teams have been studied through the lens of complexity science [6]. The relationship patterns between individuals resulting in local interaction strategies that affect the quality of care delivery, the rate of information flow and the adaptability during uncertain conditions have been studied in great detail [8–11]. As such, it has been illustrated that the inter-individual interaction is a driving force and a defining factor for the whole system behaviour. So far, most of the studies have focused on a few - usually three or four - selected attributes of complexity theory, with relationships, self-organization and diversity being the most studied ones [6]. Studies do not, however, systematically evaluate all of the CAS characteristics in a team. Additionally, the learning effect of collaboration, the so-called workplace learning, as an emergent behaviour has been described by focusing on collective competence as a distributed capacity of a system or by describing adaptive practices based upon case descriptions [11–13]. Thanks to the quality of the relationships, feedback loops are created and information is shared which, in turn, influences knowledge growth and generates new behaviour in a team [9]. The factors influencing this workplace learning process require further exploration. With some exceptions, another common feature of most studies is that they report on steady healthcare teams working in one institution, such as hospital or nursing home [6, 11, 14]. An example of distributed teams already described in literature as CAS are the palliative home-care teams (PHCTs) [10, 15]. Internationally, palliative home-care teams have been introduced to deliver expert palliative care to patients at home, in collaboration with the regular primary healthcare professionals [16]. These interdisciplinary teams are performing demanding tasks in ever-changing working environments that require high adaptability of the teams [10, 15]. The network structure, where the collaborating team is geographically spread across different organisations, is distinctive for the PHCTs. Previous research has shown that during this collaboration, workplace learning occurs [15]. Exploring through the CAS lens how this learning occurs as emergent behaviour might provide us with additional insights and pave the way for optimizing the learning network feature of this collaboration.

Our study described the team members’ interactions based upon the complexity science framework. We explored the origin of healthcare team behaviour and the factors influencing workplace learning as emergent behaviour. Studying healthcare team members’ perception of their interprofessional interaction during day-to-day teamwork through the lens of complexity science helps us to understand how and why healthcare professionals behave in this way as “perceptual information guides our decisions and actions, and shapes our beliefs” [19]. This understanding cannot be derived from studies describing behaviour through observation. Our study allowed us to map internalized views of healthcare providers that define team behaviour. Healthcare teams do not always function as a CAS. In clinical situations where problems and their solutions can be addressed by drawing on procedures and guidelines, teams work in a plan-and-control way, instructions are being given and executed in a straightforward way. Under circumstances where there is uncertainty about how to best deal with the situation, thinking outside the box and trying out different approaches is the most efficient strategy [20]. In these cases, teams work as a CAS. In our study, we found examples of the plan-and-control actions; however, for the purpose of the paper we only focus on accounts of collaborative practice as a CAS [20, 21]. Some of our results are confirmed by literature, both from studies using complexity science as a framework and by studies based upon general learning theories. We will first describe them briefly. Later on, we will focus on the functioning of the team as a learning network and on the understanding of the origin of workplace learning as an emergent behaviour, as we believe that complexity theory can advance our understanding of this theme [5].

Addressing the first study aim, we can state that the CAS principles can be identified in team members’ accounts of their perception of the way they interact on a day-to-day basis in the team. We notice that every CAS principle is to be found in the three professional groups’ accounts of their perception of team interaction, indicating the relevance of the principles for each professional background. Principle number 1 (team members act autonomously, guided by internalized basic rules) and 7 (attractors shape the team functioning) are illustrated by more fragments from more interviews than the other principles. A reason might be that these principles are most relevant for the daily collaborative practice of the team and, as such, most discussed and most accessible for reflection during the interviews. The shared aim and purpose of teamwork is a major topic to be actively discussed repetitively by team leaders, as is the construction of shared mental models in order to collaborate effectively [22, 23]. These two principles have a structuring quality on the team functioning and behaviour. This structuring quality can also be found in principle 3 (A team has a history and is sensitive to initial conditions) and principle 6 (A team is an open system and interacts with its environment), and both have a large number of fragments and interviews. The other, lesser illustrated principles (e.g. 2. Team members’ interactions are non-linear), focus more on the result of the structuring principles and may be less prone to be discussed in daily practice. Equally, team survey instruments do not always capture these dynamic aspects of behavioural processes and emergent states but focus only on the tangible end result [24].

Addressing the second study aim, we can say that healthcare team functioning can indeed be described according to the CAS principles based upon the team members’ perception of their day-to-day interaction. Moreover, this way of analyzing the interviews adds an explanatory understanding of the origin of team functioning based upon individual’s interactions on top of the descriptive representation in literature [25, 26]. Below, we discuss the different principles according to the frequency they have been identified with within the participants’ accounts.

The themes represented under CAS principle 1 (Team members act autonomously guided by internalized basic rules) and 7 (Attractors shape the team functioning) relate to the issue of professional and interprofessional identity. Internalized basic rules and the choice of attractors, to some extent, define people as professionals. During professional identity formation, the characteristics, values and norms of the profession are internalized, which results in an individual acting accordingly [26, 27]. This relates to CAS principle 1. Individuals can, however, develop a dual identity, encompassing both a professional and interprofessional identity [28, 29]. This interprofessional identity builds on the professional identity and helps individuals as they work in teams become part of a collective identity, with agreed goals for the delivery of high-quality patient care [30] . This relates to the attractors of CAS principle 7, which shape the team functioning.

The Interprofessional Education Collaborative (IPEC) has introduced Core Competencies for Interprofessional Collaborative Practice to guide educationalists in designing interprofessional curricula and provides us with an important framework to look at interprofessional collaboration [31]. Sharing one’s personal values with team members and trying to find common ground for a shared aim in teamwork matches competencies 1 (Values/Ethics for Interprofessional Practice) and 4 (Teams and Teamwork) of the Core Competencies for Interprofessional Collaborative Practice of the competency framework. Respect for one another’s values in teamwork is also one of the most commonly assessed dimensions of teamwork survey instruments, as described in a recent review [24]. As such, the patterns found in our results match the literature in identifying major foci for collaborative practice and add an extra layer of meaning to the competencies and measurement instruments described above. The insights from our study can thus be used to clarify and illustrate at a practice-based level the competencies and measurement instruments during interprofessional education or evaluation of team functioning. Understanding how team members’ interaction influences team behaviour is of importance in designing team training and crew resource management training [32, 33].

Another well represented CAS principle in our study is number 3 (The team has a history and is sensitive to initial conditions). The fact that all professional groups mention previous experiences as a major factor shaping current collaboration illustrates the importance of this principle and has been described before [34]. The team culture and the leadership style influence the way experiences contribute to the functioning of a team [35]. In accordance with the IPEC Core Competency 4 (Team and Teamwork), the results of our study call for due attention to team composition and longitudinal collaborative experiences. This is of importance in fixed teams, like those on hospital wards, but equally and more challenging in teams with ever-changing compositions, the so-called fluid teams, as is often the case in primary-care settings, where team composition is decided upon according to the patient’s care needs [21]. Additionally, the initial conditions of a single collaborative episode seem important. Therefore, regular team meetings to discuss the collaboration, and not only the patient care, are of great value. These discussions need to make initial conditions explicit but also serve to regularly evaluate collaboration as building on to the team history and preparing the next initial conditions for a future collaborative episode [22, 35]. Although team design and group cohesion, as part of the team’s history, receive attention during team evaluation, the focus on initial conditions modulating a team’s behaviour could be addressed more explicitly, especially in larger collaborative groups or fluid teams [24]. A major aspect of teamwork, as mentioned by our participants, is the agreement on tasks and responsibilities (see CAS principle number 1 – results step 2), and reflects IPEC Core Competency 2 (Roles and Responsibilities) [31] and one of the most commonly assessed dimensions of team measurement instruments [24]. Even though this aspect should be a primary topic on team meeting agendas to prevent conflicts on this issue, it does not always seem to receive the attention it deserves [25, 36, 37]. Lack of clarity on roles and responsibilities hampers effective collaboration [38]. Our study shows that the discussions and agreements on tasks and responsibilities are linked to one’s internalized basic rules, which may partly explain the sometimes challenging team discussions on this topic.

CAS principle number 6 (A team is an open system and interacts with its environment) stresses the interaction between the team and its environment. Working conditions based upon the organizational culture (e.g. communication strategies) or the broader societal rules (e.g. nurses being dependent on doctors for work prescriptions) are mentioned by participants in our study as moderating the team members’ interaction. Context and team culture are known to influence team functioning [35]. Team managers should be aware of this and take the interaction between their team and the broader context into account when discussing team functioning [39].

CAS principle number 5 (Interactions between team members can generate new behaviour) describes the new behaviour a team can show as a result of the interprofessional interaction (e.g. a whole-team meeting can be scheduled instead of relying on the ad hoc, one-to-one communication a team is used to having after a team conflict due to the fact that information on therapy decisions is not communicated adequately). In our study, we also found aspects of workplace learning, meaning the acquisition of new knowledge and skills during collaboration. A recent literature review on workplace learning in primary healthcare describes learning characteristics matching some of the CAS principles, like the influence of hierarchy and of contextual conditions on workplace learning [40]. Creating the conditions to foster workplace learning can shape the emerging team behaviour to optimize functioning and quality of care delivery. This also relates to principle number 6 (A team is an open system and interacts with its environment) as the working conditions are e.g. dependent on the organizational culture and influenced by the culture of educational institutions.

CAS principles number 2 (Team members’ interactions are non-linear) and 4 (Interactions between team members can produce unpredictable behaviour) are the least present in the participants’ accounts of collaboration. On the one hand, both principles 2 and 4 are described by complexity science as shaping normal CAS behaviour. As such, the general team’s behaviour (outside conflict episodes) might also be based upon these. This could not be illustrated, however, with the results of our study. On the other hand, unpredictability and non-linearity may be associated with team conflicts and moral distress. For instance, in order not to harm interprofessional relationships, CNs often hesitate to confront GPs with differing views on care plans, resulting in the perception of suboptimal care delivery by the CNs, ultimately leading to moral distress and professional dysfunctioning [41]. This relates to the overlap and occasional conflict we noticed between CAS principles 1 and 7. The internalized basic rules, influencing healthcare professionals’ identity as a healthcare provider, guide their actions and make them behave in a certain preferred way. This personal preference can sometimes be in conflict with team attractors requiring different behaviour or working strategies [41, 42]. Professionals can modify their behaviour according to the context and the needs of the situation. When team attractors diverge too much from a professional’s preferred behaviour or personal attractor (intrinsic motivation), tension can arise ultimately, leading to reduced professional well-being or team conflicts [43]. The management of the above-mentioned team conflicts relates to IPEC Core Competency 3, Interprofessional communication, and includes, among others, the subcompetencies of conflict resolution and feedback giving.

When it comes to the third study aim, we found many factors facilitating or hampering the information flow and the sharing of expertise, as fundamental conditions for workplace learning. Many of the factors (e.g. sharing the same values and goals, installing horizontal collaborative relationships) have been described already in literature using complexity theory or other conceptual frameworks [44–48]. Some factors however, such as contextual factors of extra fees or the dependency of nurses on doctors’ prescriptions for their job, are less known for influencing information exchange. These factors seem to be specific of the ever-changing team situation in the context of our study and need further exploration. In a similar way, framing the notion of personal wellbeing, acting as a trigger for a debriefing session after emotional or conflict experiences or as a condition for fostering workplace learning, requires further exploration. Finally, some participants stated that good interprofessional relationships, usually seen as the backbone of open communication, resulted at times in hampered communication [49]. While a good and trusting relationship is usually mentioned as being a prerequisite for open and effective communication, our results show that prioritizing this relationship can be done to such an extent that it prevents open communication [50]. This occurred, for instance, when nurses did not want to open a discussion on a doctor’s treatment decision in order not to jeopardize their good relationship with them, even when they were convinced that their decision was not correct. The ways in which health caregivers strike a balance between quality of patient care and safeguarding a good interprofessional relationship as attractors for professional behaviour requires further exploration.

A limitation of the study is that we only have data from one specific context. The comparison with literature, however, shows that our results might be generic and transferability to other contexts might be feasible, although this should be done with the necessary caution. Another limitation might be the fact that we performed a secondary analysis of interviews, conducted within another study. However, the focus of the primary study was similar to the current one, namely interprofessional collaboration. Moreover, we reached data saturation for most of the CAS principles (with ‘non-linearity’ as an exception), which illustrates the wealth of data.

A strength of our study is that we provide an explanatory model of team functioning based upon complexity science while looking at the perceived interaction of team members. Credibility and trustworthiness of the results are guaranteed by the strict analytical procedure on data from three different professions with a wide variety of personal characteristics, and executed by an interdisciplinary team [18, 51].

This study provides us with insights into the origin of team functioning by explaining how patterns of interactions between team members define team behaviour. Viewing healthcare teams as complex adaptive systems may offer explanations of different aspects of team behaviour with implications for education, practice and research.