Leadership

Evident within the literature is the impact of effective leadership on team dynamics.^{Reference Salas and Rosen15} Effective leadership is dependent on numerous variables such as staff, values, beliefs, as well as the organisational structure and values. Poor leadership can result in loss of productivity, poor morale, staff satisfaction and potentially a root cause of increased costs to the organisational healthcare system.^{Reference Castka, Bamber and Sharp16–Reference Landry18}

Aligning with the literature, the Harvard Business School highlights six characteristics of an effective leader that include transparency, ability to influence others, has integrity, is innovative, responsible and ethical.^{Reference Edmonds19} Ezziane et al. (2012)^{Reference Ezziane, Maruthappu and Gawn11} suggest leadership as an important requirement in building an effective team and to alleviate the many barriers faced in healthcare teams today. Leadership can provide interconnected goals and direction to help define the team and its purpose. An effective leader should model the behaviour, provide coaching and ensure accountability to all staff members to promote respect and civility within the workplace. Within RT, leadership plays a large part in defining the team and ensuring role clarity to ensure safe clinical practice.

Civility and respect

Civility and respect are becoming an important mantra that is slowly being embedded in organisational cultures today. Civility is ‘a collection of positive behaviours that produce feelings of respect, dignity and trust’.^{Reference Edmonds19} Team dynamics will be enhanced through the promotion of civility as a culture; achieved through effective communication, education, autonomy and mutual trust.^{Reference Pearson and Porath20}

Civility and respect includes displaying care, esteem and consideration to each individual as well as recognising the attributes that each individual brings to the team.^{Reference Osatuke, Moore and Ward21} This includes valuing yourself and being valued by others. Osatuke et al. (2009)^{Reference Osatuke, Moore and Ward21} notes civility is especially important in health care due to the high demands and emotional impact of the job. The article further links incivility to burnout, absenteeism, errors, poor job performance, patient outcomes and patient satisfaction.

The role civility plays within team dynamics is crucial as it has a large impact on trust, communication and how the team interacts as a whole.^{Reference Porath, Gerbasi and Schorch2,Reference Tsz-Sum Lee and Doran22} Trust is the foundation of team dynamics, as lack of trust could negatively impact communication, respect, productivity, loyalty and empowerment.^{Reference Hakanen and Soudunsaari23} Companies within the private industry, such as Google are promoting civility as a culture that is now manifesting into the healthcare profession. In 2018, an article by the Human Executive Resource made headlines with a report on Google and its enforcement and policy change of promoting civility in the workplace. Google sent employees guidelines on how to interact with each other respectfully such as ‘no name calling, using blanket statements, understand more not be right’.^{Reference Coletta24} While Google has received push back on the integration of such policies, they continued with key messaging on civility in the workplace to improve overall team dynamics.^{Reference Coletta24} The impact of incivility within the team has been linked to patient wait times, staff sick time, overtime, complaints and overall staff performance, similarly observed in RT.^{Reference Osatuke, Moore and Ward21}

Communication

Communication is a fundamental part of team dynamics. 91% of adverse events can be attributed to poor communication and lack of team cohesiveness due to interpersonal factors and relations such as perception bias, beliefs, trust and respect.^{Reference Tsz-Sum Lee and Doran22,Reference O’Leary, Ritter and Wheeler25} Within health care, 70–80% of errors are caused by human factors (environment, teamwork, stress, fatigue and decision-making) with as high as 50% avoidable through improved communication.^{Reference Xyrichis and Ream26}

Professional hierarchy can be a root cause of poor communication and is counterproductive in the development of good team dynamics.^{Reference Babiker, El Husseini and Al Nemri9,Reference Srivastava27} Physicians or healthcare professionals in higher authority may override suggestions from the team in clinical situations and their presence alone may result in individuals unable to speak up due to fear of reprisal.^{Reference Ezziane, Maruthappu and Gawn11} It is difficult to dispel professional hierarchy as it can inherent to the culture of the department or organisation. Individual team members perceive team dynamics differently, specifically physicians rate teamwork among their team as highly collaborative, whereas conversely allied health professionals within the same team would rate it low.^{Reference O’Leary, Sehgal and Terrell28} Within RT, the hierarchy can be seen within RT teams, such that junior radiation therapists may find it difficult to voice their opinion or concerns to more experienced RTs. This becomes more evident during difficult situations when decision-making needs to be done at the moment and quickly. There is also the hierarchal relationship between physicians, physicists and radiation therapists that can create barriers within RT team dynamics.

Interprofessional collaboration and education

Over the last 15 years in health care, there has been a shift from individual professional training to interprofessional team training. Team training provides shared knowledge to facilitate improved team efficiency and overall team dynamics.^{Reference Gorman29} Most team learning occurs through team discussions and interactions.^{Reference White and Kane14} There is supporting evidence on the linkage of team training to improved team dynamics and patient safety.^{Reference Goh, Chan and Kuziemsky4,Reference Salas and Rosen15} Treatment delivery in RT requires an interprofessional approach, yet education and training tend to be siloed by profession.

In 2014, Weaver et al.^{Reference Weaver, Dy and Rosen30} conducted a review of the literature on the current state of team training in the healthcare setting. Team training has been shown to improve patient safety and healthcare outcomes but sustainability and long-term follow-up are lacking. It is also important to note there is a lack of robust clinical evidence on the impact of team training approaches. One must also acknowledge that research methodologies may not capture the complexity of team training. The approach to team training is not simplistic. One must consider gaps in skills and knowledge, as well as both the psychomotor and didactic component to provide a holistic approach to team training. Within health care, team training needs to be evidence and practice based, incorporating feedback and measurement tools to be impactful.^{Reference Salas and Rosen15}

Highlighted in the literature the domains of effective team training includes education, standardised communication, standardised processes, as well as a structural understanding that include role clarification, leadership and support.^{Reference Salas and Rosen15} Much of the literature related to team training is simulation based or trainee focused, lacking the inclusion of the efficacy and long-term impact. Some articles identified a specific linkage to patient outcomes. One example is a large multi-institutional study by Neily et al. (2010)^{Reference Neily, Mills and Young-Xu31} who noted an 18% decrease in mortality rates from surgical procedures after the completion of a comprehensive formalised team training programme. Team training was conducted using an aviation theoretical model, whereby teams trained together to develop a safety culture with specific training focused on communication, conflict resolution and checklist guided briefings. The study design included 1-year follow-up identifying an associated reduction in mortality rates across 108 facilities. Neily et al. reported mortality rates quarterly throughout a 1-year post-training period and compared rates from teams that completed team training versus non-trained teams at different institutions with a high confidence interval of their findings.^{Reference Neily, Mills and Young-Xu31}

Weaver et al.^{Reference Weaver, Dy and Rosen30} note an increasing publication trend in teamwork topics, yet there is still a gap in longitudinal evidence on the long-term impact and sustainability of team training that needs to be completed. One must also acknowledge the difficulty in applying quantitative measurements in team training, due to the complexity and nature of teams in health care. They can be fluid and dynamic with interchangeable variables such as staff and processes, which explains the under-reporting of team training in healthcare literature.^{Reference O’Leary, Sehgal and Terrell28}

Clinical implications for consideration

The recognition and the importance of team building in healthcare practice is gaining momentum. Quantitative measurement still poses an ongoing difficulty to provide evidence of sustainable change due to the complexity and changing dynamics of teams. Team dynamics are not only impacted by individuals (personalities) but situational demands, external factors, time and organisational structures.^{Reference Delice, Rouseeua and Feitosa32} Current empirical studies are weak, with no long-term follow-up and most rely heavily on self-reporting which does not provide evidence to support notable changes in team dynamics.^{Reference Delice, Rouseeua and Feitosa32}

In health care, working within a silo is not an option to deliver optimal patient care. Unfortunately, there can be many challenges that exist within healthcare teams that impact the team as a whole through lack of productivity, motivation and mistrust.^{Reference Yardley7} In RT practice, there is cross-boundary teamwork, yet the hierarchal model still exists and plays an impactful role on how the team functions.^{Reference White and Kane14} Furthermore, teams are placed in constant flux as RTs are placed on a team with little choice or transition time to meet the demands of the day-to-day work environment, staffing, workload and technology. High-performing teams is the most influential attribute of an organisations’ defined success. RT has the ability to create high-performing teams and deliver high-quality care in an engaging cohesive team environment with team building providing the foundation to support these teams in practice.

In Ontario, teamwork and collaboration are a standard of practice in the College of Medical Radiation and Imaging Technologists in Ontario (CMRITO). The CMRITO states ‘Members must be able to practice effectively within interprofessional care teams to achieve the best possible outcomes for the patient. Members are responsible for communicating about and coordinating care provision with other members of the team, and must be able to take the appropriate action to address gaps and differences in judgement about care provision’.³³ The importance of teamwork and collaboration is identified across professions and should be made inherent to practice, yet the culture of professional hierarchy within health care still exists. This can be seen in the evolution of RT professional practice and cross-boundary practice, adding another layer of difficulty in defining roles and dispelling professional hierarchy.^{Reference White and Kane14} Although an interprofessional approach to healthcare delivery has improved professional hierarchy it still needs to be addressed as the impact on patient safety and overall team performance is well acknowledged in the literature and continues to be a barrier today.

Strong leadership plays an integral role in team development as it has the ability to cultivate a cohesive team environment and build high-performing teams by effectively maximising team members’ abilities resulting in productivity, creativity and overall job satisfaction.^{Reference Castka, Bamber and Sharp16} The top factors discussed above have been established within business and the private sector; relevant literature in health care has yet to address these issues and the role it plays on team dynamics, leading to the importance of future scholarly evidence.