We organised our data into four themes: theme 1 represents students’ sense-making
of the contextual factors driving team behaviours; themes 2 and 3 evaluations of negative
and positive team behaviours; and theme 4 students’ take-forward learning. These themes
map onto the Formation (theme 1), Description (themes 2 and 3) and Impact (theme 4)
categories of Haidet and Teal’s model for evaluating the hidden curriculum (16), and
are displayed in Figure 1.
Theme 1: Insights into contextual factors driving team behaviours
Students described tensions affecting interprofessional working practices, created
by shifting teams, temporary workers, rota gaps, IT infrastructure and workload. They
demonstrated insights into how these impact on quality of care, patient safety and
Students described how time pressures, overcrowding and staff shortages appeared to
drive clinicians to limit their communication, rendering interprofessional boundaries
more acute and problematic “...there is often a pressure such as timing or understaffing that leads to bad communication.
In these situations, individuals begin to only communicate with members of staff within
their surrounding group… This leads to much confusion about the needs of individual
patients and the status of each patient within the ward… Unfortunately, issues such
as this seem to arise due to the pressures faced by the NHS, and not the fact that
healthcare professionals are incapable of communicating with one another” (R216).
Understaffing was seen to affect team communication and behaviour negatively. For
example, locum workers covering rota gaps were seen as creating team tensions, despite
being highly qualified, as students felt they lacked knowledge about the people, structure
and practices of the healthcare facility. They were seen to slow the usual flow of
work as they had to keep asking others for information, in one case resulting in a
patient safety incident due to unfamiliarity with local handover practices.
Students demonstrated insights into how interpersonal dynamics are shaped by organisational
context, comparing fractured interprofessional relationships within shifting hospital
teams to more integrated and stable primary care teams: “I have noticed that the [hospital] doctors generally get on well with each other and
the nurses do also but there is not much interaction between the two groups… The team of staff working at the [GP] surgery remains much more consistent... they
have the opportunity to get to know each other and become friends, not just colleagues”
Students described how time constraints meant that staff often failed to read what
others had written in the notes, affecting patient care and interprofessional dynamics.
Time constraints were also seen to impact on wellbeing, for example, a nurse was described
as not being granted time to recover from a traumatic death affecting their ability
to participate fully in a meeting. Students also described how the lack of IT infrastructure,
particularly at the interfaces between services, meant that work was often duplicated
and expertise lost. They described teams improvising to resolve IT shortfalls, for
example junior doctors resolving absences and IT breakdowns using informal messaging
Workforce pressures were described as impacting on education, with some clinicians
offering to teach outside their working hours, some failing to communicate absence
from teaching, and others simply refusing to teach: “…he interrupted me with "what do you want?" quite abruptly and then when I explained
that we had been asked to shadow him, he told us he didn't have time for us...” (R078).
Theme 2: Criticism of suboptimal interpersonal interactions
Students expressed insights into how hierarchy within professions and tribalism between
professions are damaging to patient care, patient safety and staff wellbeing. For
example, a junior team member was reported as unable to call on their senior for support
after being abused by a patient, which was attributed to hierarchy. Consultants were
observed at times to lack respect for junior doctors: “While all the consultants I observed were polite with patients some were less so with
their juniors using them purely as typists and not engaging them at all, in the worst
cases they barely even looked at them” (R027); and “During a ward round I witnessed a consultant humiliate a FY1 in front of the multidisciplinary
team around a patient’s bedside” (R078). Students were critical of teams that did not respect or support junior members of
staff, or staff from other professions, with several students evaluating such practices
as ‘old fashioned’.
Students reported clinicians keeping allied health professionals ‘out of the loop’,
which they felt impacted on clinical care. For example, observing an interprofessional
rift in a maternity unit, a student expressed concern that junior midwives appeared
nervous to escalate the level of care or ask for help (R004).
Students reported occasionally witnessing interprofessional and interpersonal micro-aggression,
resentment and disrespect: “I was shocked at how much of an impact issues within the healthcare team had on the
communication skills of this particular doctor, but one thing for sure was that it
highlighted how vital good team dynamics are for anyone working within healthcare” (R021).
Students reflected on the clash between what is taught and what is practised, noting
that faculty teaching espouses respect, empathy and good communication, however in
practice they experienced “miscommunication or no communication between certain disciplines within the hospital” (R254), and practices such as “the nurse and doctor… blaming each other for the error in front of the patient - this
is not uncommon” (R104). Students also reported adversarial encounters between nursing and medical students
during campus-based interprofessional education. They commented on how tribalism between
the professions extended into social relationships, with friendships tending to form
within but not between professions.
Theme 3: Respect for team members’ attitudes and behaviours
Criticisms were greatly outnumbered by appreciative evaluations where students expressed
admiration for team members who understood each other’s roles and were comfortable
drawing on the expertise around them. Students described team members as mutually
respectful, supporting each other, keeping the interests of the patient as their primary
concern, fluidly adapting to their environment, collectively managing complexity,
and with seniors supporting juniors: “This experience made me very happy as it shows despite understaffing and the obvious
strains on the NHS and healthcare professionals, with efficient management patient
care can be maximised and the healthcare professionals can enjoy working in the department.
It was also nice that the staff were very keen on getting myself and my fellow medical
student involved and part of the team on the ward rather than an inconvenience. This
experience will always stick with me in the future showing me how effective communication
and collaboration can be in improving not only patient outcomes but improving the
working environment of healthcare professionals” (R266).
Students described insights into how trust and ownership of a task engender responsibility
and engagement, and how trust facilitates easy checking with colleagues, enhancing
patient safety and effective sharing of the workload across the team. They described
patient care as a uniting factor “all the people involved in the care of a patient, from the porters to the most senior
of consultants ultimately have the same goal of improving the patient’s health and
experience in our healthcare system” (R083). There were insights into how improved cross-disciplinary communication supported
practitioner wellbeing as well as patient safety and experience. For example, effective
integration and cross-checking between obstetricians and midwives was seen ‘to alleviate the tension caused in uncertain births’ (R004).
Students described and analysed many of the structured interprofessional practices
that they observed such as ward rounds, board rounds, hand overs, and multidisciplinary
team (MDT) meetings, praising their interprofessional participatory nature and positive
impact on patient care. There were insights into how informal social communication
and personal friendship mitigated against the adverse impacts of hierarchy or tribalism.
Mutual respect was described as facilitating shared leadership and active participation.
Students commented positively on communication taking place in different registers:
informally over refreshment breaks, and formally during case reviews “I have seen fascinating discussions happen both in meetings and other informal settings
that have prevented a lot of problems that could otherwise have had a negative impact
on the patient’s experience” (R083).
Theme 4: Students’ take-forward learning
Students described wanting to emulate and spread interprofessional behaviours and
practices that they had positively evaluated and to address the drivers of interprofessional
tensions. Examples of learning included wanting to express gratitude and praise more often,
and wanting to cross-check actions with allied professionals as well as seniors and
peers. Students suggested new practices, improved practices, and the further sharing of successful practices that they witnessed
elsewhere (summarised in Table 1). These new or improved approaches were suggested
in response to the perceived complexities of care and the many factors detracting
from practitioners being or becoming familiar with colleagues. Improved communication
between and within professions was linked to patient dignity and better patient care:
for example giving ‘patients a voice by improving communication between ourselves as health care practitioners’
Students described affective responses to suboptimal behaviours: “nurses have told me that it is often the junior doctors, which don’t treat them with
respect... I felt sad for the nurses when they were spoke to rudely.” (R219) They expressed a desire to engage in positive change even after negative experiences:
“… after much deliberation I have come to the conclusion that these experiences have
only served to provide me a deeper insight into the type of doctor I do not want to
be,” (R254) demonstrating engagement in critical analysis and constructive suggestions, rather
than detached resignation. Students’ affective response to positively evaluated team behaviours was linked to
an alignment towards and identification with those behaviours: “The brilliant communication on the labour ward made me feel extremely proud that
the concepts of patient centeredness and team work are thriving within clinical practice,
and that as a profession, we have distanced ourselves from the previous style of paternalistic
medicine that too often affected patient interactions.” (R057)
Students described role modelling, interprofessional education, multi-professional
socialisation and previous work experience in ancillary roles as positively influencing
their attitudes to and relationships with allied healthcare professionals. As they had rotated through multiple sites and services, students were able to compare
different interprofessional practices and to identify outlying examples for good or
suboptimal practice. Having witnessed ‘best practice’ or a ‘good idea’, students were keen to recommend
this for adoption across the system. Suggestions included team lunches and other social opportunities to build functioning teams, proactive
engagement of juniors by team leaders, verbal team updates/huddles, effective use
of ward whiteboards to improve task prioritisation and flow, and ward rounds and meetings
that actively include the wider multidisciplinary team.
Students discussed how the benefits of multidisciplinary working also enhance primary
care, suggesting and witnessing MDT approaches to complex patients. They advocated
shared electronic records between primary, secondary and emergency services; and dedicated
communication channels to facilitate interdisciplinary discussions between GPs and
specialists “to reach an appropriate specialist within minutes instead of having to write to the
consultant and waiting days for a response or sending the patient to hospital” (R166). Some students not only proposed improvement ideas but also researched evidence and
constructed detailed plans for implementation.