course materials

1. NURS 706 Healthcare Professional & Clinical Environment
NURS 706 Healthcare Professional & Clinical EnvironmentNURS 706 Healthcare
Professional & Clinical EnvironmentQuestion 1: How should we prepare health professional
students so that they are able to be an effective Interprofessional team member in the
clinical environment?Question 2: How can/does emotional intelligence influence
interprofessional collaborative practices? Please share your results only as you are
comfortable.Question 3: What strategies can be used to disable the hierarchies and allow a
shared leadership approach? Have you seen the physician role changeover time in your
clinical experiences? How should the care coordination responsibilities be shared
effectively in a collaborative situation?Question 4: Finally, reflect on your capstone project
from this standpoint. In your work with other professionals, as you prepare for your
capstone project how can you encourage a shared leadership approach?Please see attached
resources to helpORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE PAPERSTeams
Conflicting Messages: Examining the Dynamics of Leadership on Interprofessional Teams
Lorelei Lingard, PhD, Meredith Vanstone, PhD, Michele Durrant, RN, MSc, Bonnie Fleming-
Carroll, RN (EC), MN, NP-Paeds, Mandy Lowe, OT Reg (Ont), MSc, Judy Rashotte, RN, PhD,
Lynne Sinclair, PT Reg (Ont), MA, and Susan Tallett, MB BS, FRCPC, MEd Abstract Purpose
Despite the importance of leadership in interprofessional health care teams, little is
understood about how it is enacted. The literature emphasizes a collaborative approach of
shared leadership, but this may be challenging for clinicians working within the
traditionally hierarchical health care system. Method Using case study methodology, the
authors collected observation and interview data from five inter- professional health care
teams working at teaching hospitals in urban Ontario, Canada. They interviewed 46 health
care providers and conducted 139 W ith the advent of interprofessional care, new questions
about leadership 1,2 and teamwork have arisen. How should responsibility be shared and
power differentials mitigated? How has the physician’s role changed?3 How do health care
teams view these dimensions of their work? Without insight into these issues, we can’t
know how best to educate physicians and other clinicians regarding their responsibilities
on collaborative teams. The growing body of literature on interprofessional care
emphasizes the essential nature of collaboration4 and contains a strong discourse of Please
see the end of this article for information about the authors. NURS 706 Healthcare
Professional & Clinical EnvironmentCorrespondence should be addressed to Dr. Lingard,
Centre for Education Research and Innovation, University of Western Ontario, Room 112,
Health Sciences Addition, London, ON N6A 5C1; telephone: (519) 661-2111 ext. 88999; fax:

2. (519) 858-5131; e-mail: Lorelei.Lingard@schulich.uwo.ca. Acad Med. 2012;87:1762–1767.
First published online October 22, 2012 doi: 10.1097/ACM.0b013e318271fc82 1762 hours
of observation from January 2008 through June 2009. the presence of hierarchies on their
teams. Results Although the members of the inter- professional teams agreed about the
importance of collaborative leadership and discussed ways in which their teams tried to
achieve it, evidence indicated that the actual enactment of collaborative leadership was a
challenge. The participating physicians indicated a belief that their teams functioned
nonhierarchically, but reports from the nonphysician clinicians and the authors’
observation data revealed that hierarchical behaviors persisted, even from those who most
vehemently denied Conclusions A collaborative approach to leadership may be challenging
for interprofessional teams embedded in traditional health care, education, and medical-
legal systems that reinforce the idea that physicians sit at the top of the hierarchy. By
openly recognizing and discussing the tensions between traditional and interprofessional
discourses of collaborative leadership, it may be possible to help interprofessional teams,
physicians and clinicians alike, work together more effectively. partnership, shared
leadership, and team interactions that are horizontal, relational, and situational.5–8 Some
articles even equate the terms “member” and “leader.”5,9 Long and colleagues10 have
named this orientation “clinical democracy,” a term that emphasizes the collective
ownership of goals11 and decision making. Although this model of interprofessional
practice may be enacted in different ways on different teams, it generally calls for sharing
power on the basis of knowledge and experience rather than roles.12 Rather than following
distinct leaders, team members work together interdependently, relying on each other’s
expertise to accomplish goals and carry out tasks.13 This model is echoed in the Canadian
Interprofessional Health Collaborative’s Interprofessional Competency Framework, which
suggests that team leadership ought to change according to the requirements of each
situation.14 This discourse has also been taken up within medicine. The Royal College of
Physicians and Surgeons of Canada,15 for example, instructs physicians to learn to work in
partnership with other providers, to reflect on the function of the interprofessional team,
and to demonstrate leadership where appropriate. Some research has examined
interprofessional practice and leadership more critically, analyzing the historical, economic,
political, and social professionalization challenges to collaboration.16,17 This work
acknowledges the factors influencing power differentials to be outside the control of the
team’s professionals, making collaboration difficult18 or even undesirable.3 NURS 706
Healthcare Professional & Clinical EnvironmentThese external factors may contribute to the
dissonance sometimes observed between articulated desires for collaboration and actions
that undermine those desires.19 To better understand the role of “physician leadership” in
the evolving landscape of collaborative health care, we looked at how five interprofessional
health care teams perceived and demonstrated leadership in their daily practice. We report
our findings in this article. Academic Medicine, Vol. 87, No. 12 / December 2012 Teams
Method In this study, we used a multiple instrumental case study research design
embedded within ethnography, which facilitates the exploration of complex, real-world
phenomena.20 After receiving research ethics approval from the review boards at three
teaching hospitals affiliated with two universities in urban Ontario, Canada, we asked

3. clinical and educational leaders in each hospital to identify interprofessional clinical health
care teams with reputations for strong collaborations and managerial/ administrative . We
purposively selected five teams, which represented the specialties of brain injury, complex
care, mental health, oncology, and stroke, and which were located within rehabilitative,
pediatric, and adult health care sectors. We invited all members of those teams to
participate. Participants included physicians, nurses, physical and occupational therapists,
speech language pathologists, dietitians, child and youth workers, social workers, and
psychologists. For stylistic ease, we will refer to the participants who were not physicians as
“clinicians,” a term that reflects the centrality of their roles to patient care. From January
2008 through June 2009, we iteratively collected and analyzed data, both within each team
study and across the team studies,20 which were spread out over several months (only the
third and fourth team studies overlapped significantly in time). Research assistants, trained
in qualitative techniques and without preexisting relationships with any of the teams,
observed each team’s work during daytime hours for three to six weeks, in blocks of 1 to 3
hours; across all five teams, they observed 139 hours of team interaction. Over the course of
observation, the teams experienced a natural degree of instability due to rotating learners
and staff schedules. These observations took place during team meetings, team rounds,
consultations, and while shadowing individual team members. During these activities, the
research assistants captured ethnographic data about the team members’ daily tasks, their
interactions with other colleagues and patients, and team dynamics. Learners on the teams
were observed when they interacted with staff team members, but they were not shadowed
or interviewed. While embedded in the workplace, the research assistants approached
individual team members to request interviews. Of the 54 members of the five teams, 46
were interviewed using a semistructured guide, which we refined for each interview on the
basis of observational data. We broadly explored the theme of leadership, asking
participants about the roles of each of their team members, congruencies and conflicts
between roles, and who they perceived to be the leader(s) of the team. We probed their
responses with follow-up questions that drew on the observational data. NURS 706
Healthcare Professional & Clinical EnvironmentThe interviews were audio-taped and
transcribed verbatim. As a member-checking mechanism, a qualitative research technique
used to elicit participants’ discussion of preliminary findings and seek further insider
insights to refine interpretations, we held focus groups for each team, which were audio-
taped and transcribed verbatim, with all interested and available team members. We
analyzed data using a constant comparative thematic approach, comparing categories
across teams, within teams, and by type of health care professional.21 Our analysis was
iterative, beginning with line-by-line coding, proceeding to focused coding, and evolving to
produce categories that responded to these codes. Individuals on the research team
conducted the analyses, meeting in small groups to compare approaches before refining the
categories to share with the research team as a whole. Results Amongst a number of
recurrent themes that arose in our analysis, team leadership emerged as a dominant issue,
consistently across all teams. Its importance was signaled both by its recurrence in field
notes and by the enthusiasm exhibited by interviewees as they discussed topics such as
professional status, hierarchy, collaboration, and decision making. Leadership in the five

4. teams took different forms; however, each team demonstrated a tension between the ways
in which they discussed leadership with us (in interviews and group sessions) and the ways
in which they actually enacted leadership in daily practice or talked about it amongst
themselves. Academic Medicine, Vol. 87, No. 12 / December 2012 Although the physicians
and clinicians we interviewed all acknowledged the hierarchical nature of the broader
health care system, they differed in their perceptions of leadership within their own teams.
The physicians tended to compare themselves favorably to the wider institution,
characterizing the leadership structures of their teams as democratic and nonhierarchical.
The clinicians, in contrast, tended to describe the assumption of physician leadership and
the presence of a medical hierarchy, although they often discussed ways in which all team
members, including physicians, worked against this hierarchy. Clinical expertise and
decision making were two points of tension between the explicit and implicit constructions
of leadership and hierarchy. Both physicians and clinicians recognized that hierarchies are
reified by institutional factors in the health care system, such as the requirement, currently
under review,22 for physician referrals to enable other professionals to work with patients.
Psychologist 3 (Team 2) remarked: “The physicians are on top, undeniably. Although they
are trying to not have that hierarchy, my referrals come from them.” Although clinicians felt
that these hierarchies influenced the way their own teams worked together, some
physicians, such as Physician 4 (Team 1) and Physician 3 (Team 5), thought that their own
teams avoided those hierarchical influences. NURS 706 Healthcare Professional & Clinical
EnvironmentThis is an unorthodox team. Leadership is not preordained, but shared by the
team members…. We are all in it together. You really need humility to do this work and,
because of this, it destroys hierarchical levels. Sometimes people’s previous experiences can
be one of the biggest obstacles. If they come from an environment which is much more
hierarchical, … it is harder to make the adjustment. Despite the physicians’ denial of
hierarchies on their own teams, our observational notes revealed many instances of
physicians behaving in hierarchical ways. For example, a representative note from Team 1’s
clinical rounds reported that “the conversation was dominated by the physicians, mostly
Physician 1 and Specialist Physician 1.” A detailed confirmation of this kind of behavior
came from the patient care coordinator, a nurse on Team 2, who 1763 Teams recounted
during an interview that nurses sometimes feel disrespected by physicians. Every two
weeks [the physicians] have their rotation, so every time a physician is on again, they rely
heavily on the nurses for patient updates. This is really hard on the nurses because they
have to take a lot of time to provide this information to the doctors. I don’t understand why
they don’t read the charts. It’s like they don’t want to because then they’re responsible if
there’s a mistake. It’s very (pause) passive– aggressive. If something isn’t done, or it’s done
improperly, they’ll blame the nurses, but they won’t actually come out and say it directly.
They’ll say things like “oh,