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Chapter 1
Why Focus On Interprofessional Health Care Project Teams?
Multiple Paradoxes
A Challenge for Each Paradox
The field of health care is in the midst of a universal transformation. This transformation presents new challenges, but interestingly, as Burns, Bradley, and Weiner put it, “perhaps not so new challenges and opportunities” (2012, p. xi). On the one hand, health care is more than ever focused on providing the most effective care in the most efficient way. On the other hand, health care's growing complexity requires that an ever-increasing number of highly specialized individuals work together to solve increasingly complex problems. These two trends collide and require all those working in health care—physicians and nurses, many other health care professional and technicians, managers, support staff, IT technicians, etc.—to continuously, reflexively, and relentlessly work to maximize the way they collaborate with each other. However, several paradoxes hamper health care workers’ efforts to collaborate.
Ask your colleagues and co-workers what collaboration is. Ask them to give you examples of what they or others did in good—or not so good—situations where people worked collaboratively. Everybody will have a definition and a few good stories—no matter what their job is or their position in the organization. Collaboration is like parenting. Parenting is the most difficult job in the world. We know what it is, we know it is complex, we know we need to do it better; yet we seem to never quite grasp all its complexities, and feel we are failing more often than not. Similarly, collaboration is not new and we already know what to do to be better at it: people must learn to work together. Yet, we rarely fully succeed. There's the first paradox.
As the whole of health care (re)focuses its attention on increased and improved collaboration, organizations and their employees are challenged to improve their day-to-day work. Hence, as managers, health care professionals and all others who contribute to deliver health services struggle to work collaboratively in the first place, they must also understand enough about collaboration to address needed improvements, solve complex service coordination and delivery issues, and do so across management, professional, and disciplinary boundaries. In other words, to improve collaborative practices, health care workers must also work well collaboratively. But how can we succeed at improving collaborative practices if, as in the first paradox, we have difficulties with collaboration in the first place? This is the second paradox.
Health care professionals are trained to deliver services. Service work is complex and involves multiple, relatively short, discreet work episodes (Sundstrom, McIntyre, Halfhill, & Richards, 2000) aimed directly at patients (e.g., medical staff caring for critically ill patients) or at other people in the organization (e.g., radiologists providing X-ray reports to physicians) (Chiocchio, Dubé, & Lebel, 2012). From the organizations’ perspective, service work is ongoing because units have predictable operations and well-defined processes and procedures. Collaboration's main challenge in service work is the acute need for coordination between specialties (Grieshaber, 1997) so that knowledge and expertise converge in high quality decision-making designed to adequately respond to patients’ needs (Sicotte, D'Amour, & Moreault, 2002).
While working collaboratively is difficult (first paradox) and working collaboratively to continuously improve collaborative practices is also difficult (second paradox), health care workers have some measure of success improving health care service delivery because the challenges of continuous improvement do not depart substantially from their training, knowledge, and experiences, and thus from the regular ways they are trained to solve day-to-day problems. In a sense, continuous improvement is the status quo. Ambiguity remains, however. Since health care workers were—and still are—always engaged in continuous improvement, how is it then that the problem is not solved and that it is still necessary to improve? This is the third paradox.
One reason for the unremitted need to improve on collaborative practices—in addition to increasing complexity of health care needs—is that in some instances, gradual improvements are not enough. Sometimes, abrupt, radical, and disruptive changes are required. While continuous improvements involve much of the same processes health professionals are trained to carry out, the challenge is much steeper when radical change is necessary because radical change improvement requires distancing oneself from the status quo. Henriksen and Dayton remind us of the difficulties of challenging the status quo: “Whether it is adopting a new clinical process, designing a new product, or managing one's portfolio of mutual funds, it is very difficult to break away from the seemingly magnetic pull of the status quo. Maintaining the status quo is comfortable and requires no further action. Breaking away and taking a different course of action requires decision making, uncertainty, doubt, and renewed responsibility.” (2006, p. 1544). In our view, these difficulties are compounded by the fact that implementing a radical change operates on a completely different logic than “regular” service work and continuous improvement: the logic of a project.
A project has five essential features (Chiocchio, Dubé, et al., 2012; Turner & Müller, 2003). First, contrary to continuous improvements which are by definition ongoing, a project is undertaken to deliver some kind of beneficial change at a given time. It follows that at some point in time in the future, the change will be delivered. Hence, a project is a temporary endeavor. Second, a project is a transient organization within the organization. A project is carried out by a team (unlike crews or people involved in shift work) characterized as a stable core of individuals assembled across functions, disciplines, or professions that self-organize over months or years in parallel to their regular duties. Third, the change to be delivered represents a high degree of novelty—nothing quite like it was ever done by these people for that purpose at that time. Fourth, because of the novelty and uniqueness of the proposed change, both the deliverables and the processes to deliver them are elaborated progressively as the project unfolds in time. The fifth feature is very salient when it comes to describing projects in health care. Although ultimately a project's outcome is aimed at patients, a project's outcome is actually delivered to the organization first (which signals the end of the project). In other words, it is only once the project's outcome is implemented and becomes “the new way we work now” that it starts exerting its impact on patients.
One major problem in health care is that most of its workers are largely unaware of differences between service work and project work, and do not have a clear understanding of what these differences entail. Health care workers are trained to enact their expertise so that they can help many patients in real time on an ongoing basis. In other words, the beneficiaries of health care workers’ expertise are patients. When interprofessional collaboration is deficient, it is an organization, a part of an organization, a system of services, or a unit of health care workers that need fixing and healing, not patients. Sadly, people in health care are inefficient at focusing on understanding and addressing process issues and inadequate system interdependencies (Henriksen & Dayton, 2006).
As with the previous paradoxes, ambiguities and contradictions arise here too. While all recognize that projects to improve interprofessional collaboration require the knowledge and expertise of the very professionals embedded in the system that needs fixing, their expertise remains an unrefined raw material for project work until two changes occur. First, their expertise and knowledge must be translated from experiences in ongoing service work to building solutions in the course of temporary progressively elaborated project work. Second, the target of the expertise must shift from healing patients to healing an organization (or a part of an organization). So, while projects cannot do without professionals to deliver a change in interprofessional collaboration, how can health care workers appropriately engage in project work if they are unaware of what project work is or entails? Furthermore, even if all health care workers were fully aware of all the intricacies of project work, nobody knows how to transcend “regular “professional expertise in to the kind of expertise health care professional must inject to a project for it to succeed. There is the fourth paradox.
Our analysis of the difficulties with managing interprofessional project teams in health care can be summarized into these four paradoxes. First, although apparently clear, collaboration is actually very complex. Second, professionals need good interprofessional collaboration to improve collaborative practices. Third, since continuous improvement in interprofessional collaboration is at the core of what being a professional is, why aren't things “improved” already? Finally, how can professionals inject their expertise in a project without the knowledge or ability to reframe their expertise in a way pertinent for the needs of the project? More fundamentally, how can they do so if they are unaware of what a project is?
Embedded Paradoxes
In addition to the challenges specific to each of these paradoxes, there is a fifth paradox: a successful project is dependent upon resolving all four paradoxes. To successfully deliver change projects in the way health care workers collaborate interprofessionally, they must solve the fourth paradox of figuring out how to transcend their expertise in order to help the project, despite the fact they might not even know they need to morph—or have morphed—into a project team. To do that, health care workers must “step up” their continuous improvements efforts, despite the fact these efforts were not successful, at least up to the point the need for a radical change arose. To “step up” efforts necessary to deliver the change, health care workers must collaborate exceptionally well interprofessionally. Although health care workers have an intuitive knowledge and accumulated wisdom of what interprofessional collaboration is and how to improve it, interprofessional collaboration remains somewhat an elusive reality.
These paradoxes make life difficult for members of interprofessional health care project team, hindering their health, and their ability to manage projects successfully.
Why This Book?
This book is about helping health care workers spin out of these intertwined paradoxes and succeed at their projects. What you are reading stems from our passion for and experience with interprofessional health care project teams. In our experience, health care workers involved in radical change endeavors, although correct in their analysis of the need for change, are ill equipped to plow through the challenges of a project. Our observation of health care workers’ efforts to radically improve how the work is performed in their area or unit is that they deploy two types of solutions depending on the extent to which they understand the difference between service and project work.
When those differences are unknown or unrecognized, health care workers take footing on their usual concepts of work (i.e., service work and continuous improvements) and apply them to implementing radical changes. Grieshaber states it differently: “policies, procedures, and rules are not appropriate” to manage a project (1997, p. 25). In other words, they “more intensely” engage in continuous improvements efforts, yet fall prey to our third paradox without actually being able to clearly or satisfactorily implement a change. To use a metaphor, health care workers used to walking on trails simply “walk harder” when they realize they are going uphill. The steeper the hill, the more vigorous the walk. Before long—and especially if the hill is actually a mountain—“walking harder” ends up being less about walking and more about sitting on the side of the trail catching their breath.
When health care workers have intuitive knowledge that the change initiative is a different kind of work than what they are used to, they make efforts to remove themselves from day-to-day hustle and bustle in order to “meet.” They recognize they need to “plan” and they assign “tasks” to others on “the team,” all the while not fully grasping the meaning of these concepts and activities in terms of project management. In other words, these steps are part of project management, but they are usually not done sufficiently well for projects to succeed.
Then they start. Before long—especially if people realize the “plan” is actually not working, and therefore “wrong”—people get frustrated and often fall back to continuous improvement mode. To continue with our metaphor, when people realize the trek will not be on flat trails but uphill, they go buy fancy shoes, maybe a walking stick. Then they start climbing. However, buying special shoes is not mountain climbing, and even the best shoes inflict blisters. Similarly, intuitive and expedited planning is not sufficient to manage a project.
All this wasted energy takes a toll on health care workers. One of our recent studies suggest that compared to those not involved in projects, health care workers involved in projects are more prone to higher levels of psychological distress and lower lever of psychological well-being (Chiocchio et al., 2010). Because the study also compared health care workers to workers in a field used to managing projects, and thus with people trained in project management, we thought that training in project management would help health care project teams succeed in their projects and reduce the toll project work exerts on their psychological health. We also believed that working on a project would be an excellent way to emphasize interprofessional collaboration. Consequently, we devised training that combines knowledge transfer and skill building in interprofessional collaboration and in project management.
Our interest and passion for these topics goes beyond training and development and there is another reason why we wrote this book. Apparent from our vision of the challenges health care workers face when working interprofessionally in project teams, problems are many and far reaching. As academics, we are also keen in contributing new knowledge on the health of health care workers, on how they work collaboratively, and on how their projects succeed or fail. This book is a response to the fact that not much research has been conducted on interprofessional health care project teams.
Target Audience and Objectives of this Book
In the true tradition of action-research—where uncompromisingly solid research is used to transfer knowledge to potential users of its results—we aim at providing human resource managers, project management office representatives, and members of interprofessional health care project teams with usable evidence to improve project management. In doing so we have purposefully chose to report a wide array of results in the most simple manner possible. As such, this book is not a long scientific article (or a series of scientific articles) academics might be accustomed to where, generally speaking, a few topics or variables are examined with complex methods. To the contrary, we rely on verbatim testimony and on one simple yet powerful statistical index to convey as much information possible: the correlation. Those unfamiliar with correlations can find an explanation of this statistical marvel in Appendix 1. Academics will recognize in what we present descriptive and univariate evidence (drawbacks to a univariate approach is briefly discussed in Appendix 9). We view this evidence as a starting point to multivariate hypotheses regarding how project workload, job demands, job control, and social support interact in the understudied context of interprofessional health care project teams.
Furthermore, research is often portrayed as hermetic and largely irrelevant. Our study is a testimony of the pertinence and utility of applied research conducted in partnership with the milieu. Our study comes in sharp contrast to the vast majority of studies that aim at addressing dynamic problems but only use static methods (i.e., cross-sectional data collection and analysis). We went to great lengths to capture the complexity of the aforementioned phenomena with measurements at multiple times across the life cycle of projects. Finally, most studies use a single conceptualization and a single method to trace phenomena. Specifically, a majority of studies use a positivist perspective and quantitative questionnaires to describe, understand, and predict phenomena. We invested much energy to examine our topics through a parallel process based on a constructivist qualitative stance. Triangulating research results that stem from two distinct theories is exciting from a scientific standpoint and—we believe—better.
With the target audience and general means by which we will govern our analysis in mind, it is important to state our objectives.
- Our first specific objective is to describe and report on our attempts to create and measure the impact of a training program designed to transfer project management and interprofessional collaboration knowledge. For us, managing a project and collaborating interprofessionally are inextricably related; both are necessary to the other.
- Our second objective is to describe and examine how the additional demands brought on by project workload, job demands, decision latitude (i.e., the power one has to make decisions and act accordingly), skill discretion (i.e., the autonomy one has in how one carries out his or her tasks) and perceived stress impacts important phenomena pertinent to teamwork of interprofessional health care project teams. We hope to shed some light on what fosters or impedes successful project completion in the health care context.
Organization of the Book
The organization of the book is straightforward. Chapter 2, titled “Interprofessional teams in health care: A response to complexity,” will dive into the issue of interprofessional collaboration. This is necessary because of our belief that health care sector challenges stem from embedded paradoxes regarding interprofessional collaboration, and that interprofessional collaboration is the great unknown, the process, and the end state all at once.
Chapters 3 provides an overview of our study process and general structure of the data we collected. It is important to understand our overarching study process since we decided to organize and present results in three distinct chapters.
Specifically, Chapter 4 tackles the issue of training health care workers in interprofessinal collaboration project management and if what we did actually works. Chapter 5 examines more broadly the issue of what effect the relationships workload, stress, and coping have on other important phenomena such as collaboration, social support, and performance. Chapter 6 examines the retrospective accounts of the people we trained and surveyed to better understand their behaviors and team dynamics.
In Chapter 7, titled “Addressing paradoxes of interprofessional health care project teams,” we step back, summarize our findings, return to our paradoxes and assess whether we succeeded in our own project.
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Chapter 2
Interprofessional Teams in Health Care: A Response to Complexity
From Complex Health Problems to an Efficiency-Seeking Health Network
Challenges
Various challenges have fostered the rise ...
