title: Pulling together and pulling apart: influences of convergence and divergence on distributed healthcare teams.
abstract: Effective healthcare requires both competent individuals and competent teams. With this recognition, health professions education is grappling with how to factor team competence into training and assessment strategies. These efforts are impeded, however, by the absence of a sophisticated understanding of the the relationship between competent individuals and competent teams . Using data from a constructivist grounded theory study of team-based healthcare for patients with advanced heart failure, this paper explores the relationship between individual team members' perceived goals, understandings, values and routines and the collective competence of the team. Individual interviews with index patients and their healthcare team members formed Team Sampling Units (TSUs). Thirty-seven TSUs consisting of 183 interviews were iteratively analysed for patterns of convergence and divergence in an inductive process informed by complex adaptive systems theory. Convergence and divergence were identifiable on all teams, regularly co-occurred on the same team, and involved recurring themes. Convergence and divergence had nonlinear relationships to the team's collective functioning. Convergence could foster either shared action or collective paralysis; divergence could foster problematic incoherence or productive disruption. These findings advance our understanding of the complex relationship between the individual and the collective on a healthcare team, and they challenge conventional narratives of healthcare teamwork which derive largely from acute care settings and emphasize the importance of common goals and shared mental models. Complex adaptive systems theory helps us to understand the implications of these insights for healthcare teams' delivery of care for the complex, chronically ill.
authors.affiliation: Centre for Education Research and Innovation, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Room 112, Health Sciences Addition, London, ON, N6A 5C1, Canada. lorelei.lingard@schulich.uwo.ca.
authors.forename: L
authors.initials: L
authors.lastname: Lingard
authors.affiliation: Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
authors.forename: C
authors.initials: C
authors.lastname: Sue-Chue-Lam
authors.affiliation: Department of Psychiatry and Division of Medical Education, Dalhousie University, Halifax, NS, Canada.
authors.forename: G R
authors.initials: GR
authors.lastname: Tait
authors.affiliation: Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
authors.forename: J
authors.initials: J
authors.lastname: Bates
authors.affiliation: Division of Palliative Care, Department of Family Medicine, DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
authors.forename: J
authors.initials: J
authors.lastname: Shadd
authors.affiliation: Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada.|Western University, London, ON, Canada.
authors.forename: V
authors.initials: V
authors.lastname: Schulz
mesh_terms: D003299:Cooperative Behavior; D066296:Grounded Theory; D006126:Group Processes; D006333:Heart Failure / Q000628:therapy; D006801:Humans; D007398:Interpersonal Relations; D007407:Interviews as Topic; D010348:Patient Care Team / Q000458:organization & administration; D036301:Qualitative Research
keywords: Collaboration; Competence; Complex chronic care; Grounded theory; Qualitative research; Teamwork