Table 8 Context coding framework pre-and post-implementation: Teamwork (Case A)

Team-Level Determinants

Teamwork:

The quality of communication within the team and relationships amongst its members.

• From the survey data it is evident that the team do not have a forum to meet regularly, share information and provide feedback, with potential tension acknowledged between disciplines with only 40% agreeing that the doctors and nurses collaborate well.

• From the interview data communication suggested as an issue- “something that needs to be worked on hugely”:

 ◦ Inter-professional communication poor (“communication gets muddled up a lot”).

 ◦ Mixed views in relation to the communication between front-line and senior management: noted to be a lack of feedback but acknowledged that communication has improved since the appointment of a new CEO who is commended for “praising where praise is due”.

 ◦ The personalities of people “in senior positions” suggested as impacting communication which leads to “a bit of clashing”

• From the interview data regarding relationships tensions were revealed within the team:

 ◦ Intra-professional tension: conflict in relation to the priorities of junior vs more senior members of staff: “…they are more about paperwork than the patient”

 ◦ Inter-professional tension: between disciplines; “I’m here to nurse, you’re here to do everything else”, “I have come across a nurse who is afraid of a doctor”

 ◦ Management and frontline tension: “Sometimes we are underappreciated by management”, “people above me…are meeting every day of the week. I don’t know what people do be meeting about but there are meetings every day, every hour of the week”-which is not fed back to staff.

• Relationships suggested to be impacted by the busyness of the ward, rotation of staff, and “personalities” within the team (one team member described as “a bit difficult” by some participants which impacts their ability to speak up)

• Few participants describe the relationships among the team positively characterising them as “open” and encouraging “mutual respect”

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Construct may be an impeding influence on implementation

• From the observational data communication suggested as an issue but improving-

 ◦ Open communication impacted by the fear culture within the team-impacting team member’s ability to speak up

 ◦ Written and verbal communication remains poor e.g. some staff report being the “middle-man” passing information between disciplines, noted that poor documentation is “part of the culture”

 ◦ Feedback from senior management noted to be unsatisfactory with information not being “filtered down” to staff on the ground

 ◦ However, sense that communication is improving between team members (e.g. doctors using the nurses’ first names)

 ◦ Improvements in communication recognised as being associated with improved relationships- “getting to know each other better” leading to greater ability to “voice {their} opinion quicker”

• From the interview data communication within the team is noted to be improving but some issues remain

 ◦ Communication is noted to be “disjointed” among some disciplines. It is suggested that although communication is good between most team members some consultants wouldn’t “value your opinion” and would change the plan of care without consulting the wider multidisciplinary team.

 ◦ During the implementation of collective leadership intervention team members report that communication has “opened a bit more” with participants reporting that they feel “allowed to say {their concern/opinion} and voice it”. This is supported by senior medical professionals who note that “anybody now can talk to you… there is no limit. There’s nothing between us”, “you have a bit more ear” in relation to listening to other disciplines within the team.

• From the observational data regarding relationships some tensions were revealed among the team members, but this is also improving:

 ◦ Inter-professional tension at times between team members across the multidisciplinary team.

 ◦ Noted that the team can “have banter now”, with one team member who was previously “standoffish”, “making an effort” with staff

• From the interview data relationships were acknowledged as improving.

 ◦ Participants suggested that there was greater “camaraderie” among team members.

 ◦ Participants noted that the sessions enabled participants to get to know each other on a more personal level which “brought down some barriers” and allowed staff to see each other “in a different light”, making staff more approachable; “you can say something”

• Relationships were noted to be dependent on the personalities of team members, a participant’s role within the team (health and social care professionals feel more “removed”) and the continuous rotation of staff

−1

Construct has a mixed effect but predominantly negative and may impede implementation