4 Leadership and teamworking

Box 4.1

A junior doctor was asked to examine a child with blunt chest trauma, and correctly identified that the chest movement was asymmetrical and that the percussion note was resonant at the front of the chest and dull at the back of the chest. However, he failed to report this back to the team leader. The team leader noticed the asymmetrical chest appearance of a tension pneumothorax 5 minutes later, after the oxygen saturation had deteriorated, and a needle thoracocentesis and chest drain insertion were performed later than was ideal.

Leaders may need to resolve conflicts within the team. It is expected that there will be differences in priorities between different staff and specialities, but this must be addressed and managed. It is helpful to focus on what is right for a patient rather than who is right.

Teamwork

Good teamwork has these elements (Flin et al. 2008):

supporting others
solving conflicts
exchanging information
coordinating activities

These are in addition to performing individual technical tasks.

Supporting Others

We need to be aware when others need help, as well as being prepared to ask for it ourselves. A change in body language, a decrease in communication or altered tone may be a clue to a team member being task saturated. Support may be:

practical (filling in the request forms for bloods or assisting with a procedure)
emotional (‘You are doing well, carry on!’)
or take the form of advice

Solving Conflicts

Conflicts can be positive or negative. Differing teams often have different perspectives on an issue. This may allow options that would otherwise have been neglected to be identified and used. Discussing options can be experienced as threatening and requires that suggestions are made assertively rather than aggressively. Failure to discuss the issues may lead to resentment in both the short and long term and failure to be involved in the work of the team. Sometimes this discussion can take place at the time and sometimes it needs to be followed up later.

A different problem should be considered in an obviously cohesive team. New members who seek to be accepted may fail to raise objections to plans and inhibit rational criticisms in case they are rejected, leading to poor decision making and performance. Janis (1982) described this phenomenon as groupthink. He described issues of overestimation of the power of the group, a closed-mindedness and pressures towards uniformity within the group.

Exchanging Information

Teams achieve coordination by information being exchanged. The information can be both verbal and non-verbal. With teams that work together frequently doing a routine task, this exchange can be implicit. However, when a situation is not routine, it is even more important to exchange information explicitly. Communication is typically diminished when stress increases, so a specific effort is required to maintain team coordination.

Communication should be open and supportive. A steep authority gradient can be a barrier to good communication. A trainee who is barked at every time they make a suggestion soon learns that their contribution is not welcome.