TEAMS, HEALTHCARE

A healthcare team is two or more health professionals (and, when appropriate, other lay or professional people) who apply their complementary professional skills to accomplish an agreed-upon goal. Coordinated, comprehensive patient care is the primary goal of most teams. Other goals may include education of health professionals, patients, or families; community outreach; advocacy; abuse prevention; family support; institutional planning; networking; and utilization review in hospitals. The team approach to patient care has been viewed as a means of building and maintaining staff morale, improving the status of a given profession (for example, nurses and allied health professionals may become team collaborators with the physician rather than working under the physician), or improving institutional efficiency.

Some teams are ongoing, such as a psychiatric care team, home visit team, ventilator patient care team, child development team, or rehabilitation team. Such teams may be responsible for following the person throughout the entire process of healthcare interventions, including diagnosis, goal setting and planning, implementation, evaluation, follow-up, and modification of goals for the patient. Other teams form around an event (for example, a disaster plan team or organ transplant team), or focus on a single function, such as discharge planning or the initiation of renal dialysis. Some teams are undisciplinary; others are multidisciplinary, and may include lay people.

Though taken for granted today, a team approach to healthcare has appeared only recently in many places where Western medicine is practiced. The development of team approaches in the United States reflects the history of that development in North America and Europe as well. In the first period, between World War I and World War II, a multiprofessional approach appeared that later developed into the team model. Major sources of impetus included the proliferation of medical specialties, an increase in expensive, complex technological interventions, and the ensuing challenge of providing a coordinated and comprehensive approach to patient care management. A second period of development occurred between the 1950s and the 1980s, when teamwork became the norm: healthcare became increasingly hospital-based, enabling a large corps of health professionals in one place to minister to the patient. In addition, new professional groups were generated in the belief that healthcare should be attentive to patients' social as well as physical well-being. The third period, which continues to the present, has focused on the appropriate goals and functions of the healthcare team and evaluation of the team's effectiveness (Brown).

Ethical issues regarding teams arise in four major areas: challenges arising from the team metaphor itself; the locus of authority for team decisions; the role of the patient as team member; and mechanisms for fostering morally supportable team decisions.

The Team Metaphor

It is generally agreed that the healthcare team idea and rhetoric arose from assumptions about sports teams and military teams (Nagi; Erde). This metaphor is not completely fitting because the healthcare team is not in competition with another team. However, it is fitting insofar as members experience their affiliation as entailing team loyalty, a moral obligation to other members and to the team itself. They may believe that they have voluntarily committed themselves to a type of social contract requiring a member not only to perform maximally but also to protect team secrets, thereby promoting a tendency for cover-ups or protection of weaker members. In the military team, obedience to and trust in the leader is an absolute.

A troubling ethical conflict arises when the member's moral obligation of faithfulness to other team members or "captain" does battle with moral obligations to the patient. This may manifest itself in questions of whether to cover up negligence or a serious mistake by some or all of the team. Overall, holding peers morally accountable for incompetence or unethical behavior may be made more difficult by the team ideal. Therefore, teams must foster rules that require and reward faithfulness to patient well-being, and balance and value of team membership with that of maintaining high ethical standards.

Feminist analyses of bureaucratic structures and bioethical issues highlight a related ethical challenge. The team metaphor entails assumptions about relationships, rules, and "plays" that often exclude women from full participation because their childhood and later socialization did not prepare them for this "game" and its insiders' rhetoric. Noteworthy is the sports or military team ethos of ignoring the personal characteristics of fellow team members (within limits), provided each person is technically well suited to carry out assigned functions. Many women find it almost impossible to function effectively with team members whom they judge as morally deplorable, no matter the latter's technical skills; for such women, the relationships among and integrity of team members is as important as the external goal (Harragan).

Sometimes a further breakdown of communication and effectiveness accrues because of the team leader's allegiance to scientific rigor and specificity at the expense of subjective attentiveness to caring. Since many team leaders are physicians, on multidisciplinary teams the problems may become interpreted as pointing to serious differences in orientation between physicians and other healthcare professionals (addressed in the next section). Whatever its cause, marginalization of some team members results in team dysfunction.

Locus of Authority for Decision Making

Roles involve ongoing features and conduct appropriate to a situation, and create expectations in the self and others regarding that conduct. Each role has an identity and boundaries, giving rise to the question of whose role carries the authority for team decision making (Rothberg). The challenge applies to both unidisciplinary and multidisciplinary teams but is highlighted in multidisciplinary ones, particularly those involving physicians and other health professionals. Traditionally the physician was the person in authority by virtue of his or her office. The team metaphor reinforces the nonmovable locus of authority vested in one who holds such office (for example, captain).

At the same time, the team metaphor created expectations of more equality among members based on competence to provide input. Each member becomes an authority on the basis of professional expertise instead of office, and should be in a position to provide leadership at such time as expertise indicates it. In ethical decisions regarding patient care, the question of authority must be viewed in terms of who should have the morally authoritative voice. Technical expertise does not automatically entail ethical expertise. In both types of decision-making situations, the locus of authority is movable.

Clarification of role identity and boundaries helps to create reasonable expectations and mitigate this type of conflict regarding locus of authority (and concomitant locus of accountability) regarding team decisions (Green). A further complication arises, however, because teams usually have several members. A critical question regarding such collective decision making is whether team decisions are the sum of individual members, with accountability allocated only to the individuals, or whether a team itself can be regarded as a moral agent (Pellegrino). Lively debate continues regarding this topic (Abramson; Newton; Green).

Sometimes teams have difficulty coming to consensus about the appropriate course of action. The moral responsibility of the team members is to assure that further role clarification, further attempts at consensus building, and other collective decision-making mechanisms are instrumental only to maximizing patient well-being (or any other appropriate goal of teamwork). Negotiation strategies must be built into the team process so that the authority of any one or several members, or even the team as a whole, does not govern at the cost of the competent, compassionate decision geared to the appropriate ends of that team's activities.

The Patient as Team Member

There is much discussion about whether and in what respect patients/clients and their families are members of healthcare teams. The doctrine of informed consent and its underlying legal and ethical underpinnings dictate that patients and families should have input into decisions affecting themselves and their loved ones. At the same time, much of the team's work proceeds without direct involvement of patients and families. Some have argued that a primary care orientation places the patient as focus and arbiter of the care, and that present team practices fall short of that essential condition (Smith and Churchill). Others argue that conceptually a primary care approach is consistent with the goals of good teamwork (Barnard).

Moral Education for Teams

The team ideal provides a widely used model for effective and efficient patient care. Ethical issues are an inherent part of clinical decision making. In preparation for facing ethical issues the team can (1) develop a common moral language for discussion of the issues; (2) engage in cognitive and practical training in how to articulate feelings about pertinent ethical issues; (3) clarify values to uncover key interests among team members; (4) participate in common experiences upon which to base workable policies; and (5) refine a decision-making method for the team to use (Thomasma).

It appears that team approaches to a wide variety of healthcare issues and events will continue to develop and grow. The emergence of ethics committees as a type of team approach focusing explicitly on ethical decisions should help further in these deliberations.

ruth b. purtilo (1995)

bibliography revised

SEE ALSO: Consensus, Role and Authority of; Long-Term Care; Medicine, Profession of; Nursing, Profession of; Palliative Care and Hospice; Trust; Women as Health Professionals

BIBLIOGRAPHY

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