Context matters: groupthink and outcomes of health care teams

Abstract

It's good to have assumptions challenged. Much of health care has accepted that teamwork is beneficial, but in this issue Kaba et al., in ‘Are we at risk of groupthink in our approach to teamwork interventions in health care?’,1 encourage us to take a pause and consider that it might also be harmful or inconsequential. After reviewing the paucity of experimental evidence supporting teamwork interventions and interprofessional education (IPE) in health care, the authors raise concerns about teamwork competencies related to collaborative decision making, such as shared mental models, team orientation and mutual trust. Drawing on the psychology literature, they reveal that these competencies have risks, including cognitive overload (too many ideas during brainstorming), social loafing (some team members are not engaged), groupthink (pressure to conform) and group conformity bias (preference for consistency). They suggest that context determines whether or not collaborative decision making is good (improves decision making), bad (leads to poor decisions) or neutral, and that focusing on context and exploring interventions that lessen the risks may improve outcomes. Invoking the utilitarian perspective of the value of IPE, they assert that patient outcome measures should solely determine the effectiveness of teamwork and IPE. Finally, the authors propose an experimental research agenda for teamwork and IPE to define ‘which outcomes can be achieved by which interventions in which context’.1 Context matters, and the complexity of health care teams may help to mitigate the risks identified by the authors. Although the concerns about cognitive overload, social loafing, groupthink and conformity bias are based on well-designed studies from the psychology literature, most of these studies were conducted in relatively homogenous teams (often students). These results may not necessarily translate to the health care context, where teams are heterogeneous and team members bring a variety of perspectives, experiences and roles. As a result of their diversity, teams in the health care context may be more prone to the beneficial wisdom of crowds than the hazards of collaborative decision making. Although the wisdom of crowds is one phenomenon that is likely to improve teamwork in health care, there are other mechanisms that have an impact on team functioning. For example, collaborative decision making may decrease redundancy across team member efforts and the associated errors.2 Collaborative decision making may also reduce wasted resources by streamlining treatment plans and interventions among and across professions. Additionally, health care providers who engage in effective collaborative decision making may experience a variety of consequences that indirectly lead to improved team performance. For example, a sense of shared responsibility and shared burden may lead to higher job satisfaction, decreased burnout and a reduction in job turnover. A good team sets the culture of the work environment and can have an impact on the performance of other individuals, groups or teams. The development of trusting relationships over time can positively affect team performance, and perhaps even counter any of the potential negative group phenomena such as social loafing and pressure to conform. Hence, process outcomes (how well a team functions) cannot necessarily be dismissed when evaluating the impact of teamwork and teamwork interventions. We may want to consider carefully what patient outcomes we should look at, and collaborative practice may change our ideas in this regard That is not to say that patient outcomes should not be front and centre. A happy team providing insufficient care to an unhealthy patient misses the point. However, we may want to consider carefully what patient outcomes we should look at, and collaborative practice may change our ideas in this regard. Outcomes such as decreased length of stay, morbidity and readmission rates only represent one perspective, which is in some ways quite physician centric. A study of interprofessional teamwork illustrated this with an example of a social worker who focused on outcomes related to patients’ overall well-being, whereas the physician was perceived as primarily interested in medication compliance and disease resolution.3 Thus, interprofessional teams can bring a broader perspective on important outcomes. Additionally, important patient-centred outcomes not typically tracked include whether care is provided in a coordinated or timely fashion, whether a patient's questions and uncertainties are addressed, and whether family members are informed and involved. Many of these may be reflected by patient satisfaction, but often they are not measured at all. Considering such different endpoints will be necessary if we want to evaluate the impact of teamwork in a meaningful, truly patient-centred manner. Considering […] different endpoints will be necessary if we want to evaluate the impact of teamwork in a meaningful, truly patient-centred manner This diversity of outcomes of health care teams generates a complexity that requires careful consideration of how we study the impact of teamwork interventions. Straightforward randomised controlled trials (RCT) with a pre‒post design are probably not very helpful, and looking at standardised patient outcomes such as disease markers, mortality and hospital readmission rates will miss important information. As the authors suggest, the context matters, and a realist approach (what works, for whom, in what context) may be what is needed.4 An opportunity to reconsider the important outcomes of teamwork and IPE beyond what we have been measuring, and avoid groupthink about outcomes It's indeed good to have assumptions challenged. Kaba et al. remind us about the limited evidence for and the potential risks of teamwork interventions. This gives us an opportunity to reconsider the important outcomes of teamwork and IPE beyond what we have been measuring, and avoid groupthink about outcomes.1 The article states: ‘…as clinicians and educators, we must demonstrate that interventions improve the delivery of health care’. We agree and would add ‘as measured by a broad spectrum of outcomes through a variety of evaluation approaches’. Not all teams are good teams, and not all teamwork interventions result in ideal teams. Ignoring this can be detrimental to health professions education, if we expose students to teams or teamwork interventions that do not teach what we want students to learn.5 The work ahead is to skillfully determine what is effective and assure that our interventions are beneficial, not harmful or inconsequential. The work ahead is to skillfully determine what is effective and assure that our interventions are beneficial, not harmful or inconsequential