Academic collaboration, I’ve learned over the years, is something of an oxymoron. More often than not, what is described by that term is really non-collaborative, or worse, pseudo-collaborative work, driven by the long-standing rituals of institutional seniority and professional and financial incentives to build higher silos and thicker walls.1
Collaboration and teamwork have become buzzwords in the health professions, yet they remain poorly understood terms. Students and trainees are exhorted to be collaborative and to be team players, and educators evaluate them for attaining these attributes, which are considered core competencies. But how are these attributes interpreted, contextualized, and evaluated? The health professions have tended to portray collaboration and teamwork mostly in positive terms like cooperation, synergy, harmony, and altruism, with scant attention given to their veiled features like competition and conflict.2
In the health professions, conflict is often considered disruptive, inefficient, unprofessional, and a potential source of error that can impact patient safety.3 Whereas business management has long appreciated the inevitability of conflict and realized its innovative potential in organizations,4,5 the health professions have struggled to reconcile conflict with efficiency, ingrained views of professionalism, and concerns about safety, and thus tend to avoid conflict or resolve it quickly. Does conflict have a constructive role in the health professions, or should health professionals try to avoid it?
In this article, I will describe how perspectives on collaboration and teamwork have changed in recent decades as health care systems have grown in complexity.6,7 I will discuss how the health professions have neglected to appreciate the positive attributes of conflict for reasons that include (1) individuals’ fears about being negatively perceived and the potential negative consequences in an organization of being implicated in conflict, (2) constrained views and approaches to professionalism and to evaluation and assessment, and (3) lingering autocracies and hierarchies of power that view conflict as a disruptive threat. I will then present three alternative approaches to more effectively integrating conflict into collaboration and teamwork in the health professions.
I will refrain from defining collaboration and teamwork (given the complexity of these topics) and instead use these terms in their broadest sense, while understanding that they are distinct terms (e.g., collaboration can occur between individuals independent of a team or teamwork). Likewise, I will use conflict in its broadest sense to encompass associated terms such as dissent, negativity, and contradiction, and I will avoid its multifarious cultural dimensions8–10 by focusing mostly on the U.S. context. Finally, this is not an article about conflict management or resolution but, rather, a framework of perspectives for rethinking an integrative role for conflict in collaboration and teamwork in the health professions.
Changing Perspectives of Collaboration and Teamwork
The concept of teams obscures, rather than reveals, the real relationship challenges our organizations face. Teams are a fiction, a verbal convenience, rather than a useful description of how people in a firm cooperate and collaborate to create value.11
Health care systems have become increasingly more complex.12–14 These changes have impacted the health care work environment and how health professionals collaborate and work in teams. At the same time, perspectives on collaboration and teamwork have been changing. For example, the very notion that teams are more effective and always outperform individuals has been cogently challenged by Hackman5 and others15,16:
Many people act as if being a team player is the ultimate measure of one’s worth, which it clearly is not. There are many things individuals can do better on their own, and they should not be penalized for it.5
Engeström,7 a Finnish sociologist, argued that teams are no longer stable entities but have become akin to knots that are “formed, dissolved … and reformed.” Some have suggested that viewing teams as knots allows for a fluidity that may be conducive to collaboration,17 but others insist that “clear boundaries and demarcations” between teams is essential for effective collaboration.18
Some evidence suggests that unstable teams, in which members have not had time to get to adjust to one another, are more prone to error and accidents. For example, a study of cardiac surgeons who operated at hospitals that were not their home base with teams that they had not previously worked with had higher patient mortality rates than those who operated at their home base with familiar teams.19,20 Were these newly formed, error-prone teams also more conflict ridden? Or was some other factor responsible for their higher error rate?
Rethinking the Role of Conflict in Teamwork and Collaboration
One fallacy about teams is that, to be successful, everyone must be friends. The research says it’s the other way round: team performance drives the quality of relationships. When teams are failing, this poor performance upsets their members—and they take their frustration out on one another.21
Most studies of conflict in the health professions purport to demonstrate that it reduces a team’s performance by, for instance, causing dissatisfaction, distracting members, and inhibiting open discussion.22,23 When conflict arises, health professionals tend to address it as a symptom to be treated and eradicated rather than trying to understand its root causes and eliciting its innovative potential.
Several studies show that making space for conflict and dissent on teams can promote the relay of important information and improve group decision making and performance.24,25 Such studies suggest that embracing rather than avoiding conflict pays off and that organizations should create appropriate environments and develop strategies for integrating conflict. Studies of high-performing teams, such as world-class orchestras, have shown that rivalry and competition may render members more demanding of themselves and their team members, keeping the team’s purpose (rather than the individual’s own interests) in sharp focus.26,27
In contrast to the health professions, the business professions have long recognized that conflict is not only unavoidable but can also be a source of learning and innovation.24 Several terms have been coined in business to convey the positive side of conflict, including constructive controversy,28 creative abrasion,29 defensive pessimism,30,31 and the obligation to dissent.32
According to Lencioni, trust is a crucial quality for teams to develop to engage in constructive dissent and embrace conflict:
… teams that trust one another are not afraid to engage in passionate dialogue around issues and decisions that are key to the organization’s success. They do not hesitate to disagree with, challenge, and question one another, all in the spirit of finding the best answers, discovering the truth, and making great decisions.33
Teams with a trust deficit may strive to avoid conflict, but such conflict avoidance can aggravate the distrust and may lead to an artificial harmony that diminishes team performance.31,33 Bronson and Merryman21 warn about the hazards of avoiding conflict for the sake of maintaining harmony:
Constant harmony may even be cause [for] alarm. A conflict-free team means that no one is bringing anything to the table that might engender controversy. The team members aren’t focused on the team’s purpose; instead they are focused on protecting the group’s relationships.
The health professions need to take a more integrative view of conflict to realize its constructive potential.
Forced Collaboration Versus Think Different
How then might health professionals begin to reconceptualize conflict in a more integrative way? Leavitt and McKeown34 discuss the concept of collaborative intelligence (CI), distinguishing this concept from notions of harmony, being nice, and being cooperative:
CI is more than being friendly or having a cooperative attitude. While there is nothing wrong with these traits, we’ve also worked with irascible, dogmatic, sarcastic people who had high levels of CI.
Iconoclast Steve Jobs of Apple Inc. quintessentially evinced such “negative” character traits, yet he had a high CI. Despite his temperamental leadership style, he developed a highly collaborative culture at Apple that allowed employees to “dignify the differences”35 in how they worked together and thought about approaching challenges, epitomized in Jobs’s aphorism “Think different.”36
Recent studies indicate that creative and innovative individuals are often nonconformists and this may put them at odds with their teams.31 Owens37 illustrates this point with his useful distinction between adaptive innovators, who work within the conforming parameters of team dynamics, and radical innovators, who challenge the team or organization by thinking differently. Radical innovators may “threaten group cohesion and cooperation,” and yet they enhance the group’s performance and drive its success.37
Other studies have shown that teams that strive to resolve conflict by forcing consensus have an unrealistic view about the ease of attaining consensus and are prone to the most interpersonal conflict.4 Members of a team have a need to have their participation recognized and their opinions heard and appropriately considered; forcing collaboration and consensus may ignore this need and, by extension, process fairness (or procedural justice).38 Collaboration that is forced in this manner may be gauged by artificial measures, such as members being friendly or nice,4,34 and can engender artificial harmony33 or cordial hypocrisy39 among collaborators.
The health professions are far from embracing a culture of dissent. Embracing conflict and contradictions presents a challenge to traditional authoritarian hierarchies. Leveling such hierarchies and democratizing the health professions may allow space for creative disruption and innovation.40–42
Power Hierarchies and the Constraints of Professionalism, and Evaluation and Assessment
Constraints of professionalism
Bleakley43 suggests that the “structural legacy of autocracy and autonomy” in the health professions has resulted in constrained conceptions of professionalism resistant to democratic participation in the profession. Students and trainees are tacitly acculturated into these hierarchies under the guise of professionalism, and these hierarchies persist because they come “disguised as meritocracies.”43
Collaboration and teamwork are often regarded as core competencies44,45 in professional development that trainees must attain to be considered professional. But tools for evaluating and assessing these attributes remain inadequate.46 While Ginsburg et al47 argue that “Conflict has … long been identified as a critical component of professional development,” professionalism has generally taken a negative view of conflict. For instance, “unprofessional” behaviors associated with conflict are often adjudged without realizing how inextricably they are linked to the “exigencies of contexts.”46
Lucey and Souba48 suggest that current views of professionalism may be constrained by a preference for simplistic, technical solutions to unprofessional behavior and conflict that “solve” the problem quickly, rather than shared, adaptive solutions that take contexts and perspectives into account. Technical solutions are easier to devise and execute, whereas adaptive solutions demand a more considered approach to conflict. Adaptive solutions attempt to reintegrate unprofessional individuals into the health system and therefore take time and effort. Such solutions, however, are more consistent with collaboration:
Tackling the problem of professionalism as a complex adaptive challenge begins with developing a shared vision (the desired future state) and a shared understanding of the problem (the current reality).48
Such a shared vision of collaboration more readily embraces conflict, contradiction, and dissent, allowing space for the conflicting viewpoints of seemingly uncollaborative individuals. Thus Collins’s49 well-known adage about teamwork, “Get the right people on the bus and the wrong people off the bus,” can be a simplistic, technical solution rather than a shared, adaptive vision. It may allow little space for individual adaptation and is often too readily invoked as an excuse for firing or demoting nonconforming individuals who are perceived to be uncollaborative or poor team players. Adaptive solutions aim to integrate diverse individuals and viewpoints into teams and organizations and to understand the importance of contexts, which may place different demands on individuals and thus elicit different collaborative skills sets.50
Constraints of evaluation and assessment
Teams and individuals in organizations are constantly evaluated and assessed (both formally and informally), and this can make them feel insecure and unsafe.51 The threat of evaluation and assessment can affect how teams and individuals approach and avoid conflict. As high achievers, health professionals and students nurture their professional image and reputation and generally fear being perceived, especially by those in power, as negative or fomenting conflict.52 For example, a trainee requiring an evaluative letter of reference would be careful not to be perceived as argumentative with his referee, and a physician being considered for departmental promotion would try to avoid arguments with the department chair.
Moving toward less hierarchical and “safer” models of evaluation and assessment may allow for better integration of conflict into collaboration and teamwork.53,54 Mann et al54 stress “the importance of making it safe to ask for feedback and of providing careful … (and) credible feedback … based on … relationships of mutual respect.” However, studies suggest that such safety is still lacking in evaluation and assessment and in feedback models.52
Constrained views of professionalism and of evaluation and assessment, in the setting of hierarchies of power in the health professions,55 have impeded effective integration of conflict into collaboration and teamwork. In the sections that follow, I discuss three approaches to more effectively integrating conflict into models of teamwork and collaboration.
Three Approaches to Integrating Conflict Into Collaboration and Teamwork in the Health Professions
Making interpersonal risk-taking safe (psychological safety)
One approach to integrating conflict and mitigating the adverse effects of the constrained views detailed above is through the development and nurturance of psychological safety (PS). PS was originally defined by Edmondson51 as “a shared belief held by members of a team that the team is safe for interpersonal risk-taking.” The level of PS in an organization is “the degree to which people perceive their work environment as conducive to taking (these) interpersonal risks.”51 Edmondson initially developed this concept in the late 1990s in the context of business management. Recently, the concept has resurfaced as the unanticipated finding of an intensive five-year study by Google Inc. that aimed to discover the attributes of the perfect team. Google’s search for the perfect team’s attributes had initially proved elusive until the study revealed that the single most important attribute of high-performing teams was PS.56
Although PS has “much in common” with trust, Edmondson52 is careful to distinguish the terms. For instance, PS is focused on more immediate consequences (e.g., it being safe to speak up in a meeting), whereas trust operates over a longer time frame; further, PS is focused on how safe and accepted one feels in a group, whereas trust is focused on how one feels about others.
Edmondson also distinguishes team PS from group cohesiveness,52,57 and insists that PS “does not imply a cozy environment in which people are necessarily close friends, nor does it suggest absence of pressure or problems.” Whereas cohesiveness can interfere with the willingness to disagree and challenge others’ views because of closer affiliations or connections, PS does not compromise individual accountability. Excellence and achievement are rewarded without sanctioning poor performance, while acknowledging that “imperfection and error … are inevitable under conditions of uncertainty and change.”52
By making it safe for team members to take interpersonal risks, PS allows them to approach conflict without fear of being negatively judged by the group or perceived as being disruptive. Among the benefits of fostering PS in health professional organizations is that it improves patient safety by reducing medical error:
… reluctance to take interpersonal risks can create physical risks in high-risk industries … where admitting mistakes and asking for help may be essential for avoiding catastrophe … particularly … in organizations where lives are at stake, such as in hospitals.52
In a controlled study of medication errors in hospitals, PS was found to improve team members’ level of comfort in reporting errors, which ultimately led to a reduction in errors.58 In surgical operating rooms, teams evincing PS allowed nonsurgeons to more readily voice their opinions within the health system power hierarchies, which led to reduced error rates.59 Speaking out could be seen as introducing conflict into teams, but this was contained and mitigated by the presence of PS.60 A lack of PS can impede the collective and iterative learning process that is essential for ensuring patient safety.60,61 Edmondson et al59,62 showed that cardiac surgery teams with PS were more likely to implement innovative technologies, such as minimally invasive cardiac surgery, which improved patient safety.
According to Edmondson,52 “The best tactic for establishing psychological safety is demonstration by a team leader.” Team leaders can affect PS and team learning by enabling team members to take interpersonal learning and communication risks and by embracing error in a productive, nonpunitive manner. In doing so, leaders manage conflict in their teams. Moreover, leaders can manage power “in both directions … by empowering those in lower-status positions to speak up and … by minimizing the domineering tendencies of high-power individuals.”52 PS thus allows for interpersonal risk-taking that mitigates conflict on teams and helps integrate it (and its innovative potential) into teams.
Viewing conflict as a source of learning and innovation (activity theory and expansive learning)
A second approach to integrating conflict in collaboration and teamwork in the health professions comes from activity theory (AT), which offers a workplace theory that views conflict (or “contradiction”) not as a problem to be resolved but as a resource for learning and innovation.7,63 Engeström7 uses the term “contradiction” to describe the various conflicts and tensions in the workplace that generate disturbances, which may lead to positive change.
A version of AT known as cultural-historical activity theory considers, as its basic unit of analysis (or activity system), the social contexts of work. An activity system at work entails a “community of multiple points of view, traditions and interests”64 that may become a source of contradiction. AT views these contradictions as positive learning opportunities that can lead to transformative change. When such change leads to something entirely new, the process is called learning by expanding or expansive learning.64 While conflict does not always lead to expansive learning, it does cause an axial shift that can open up innovative opportunities. Individuals and teams should, therefore, not shy away from conflict but, rather, view it as a source of creative innovation.
One area in health care that can be a source of both conflict and expansive learning is medical error. While making mistakes can generate conflict, paradoxically it can also be a source of learning and transformative change.65 For example, with morbidity and mortality rounds, the learning environment is designed to transform medical errors from finger-pointing sources of conflict into transformative learning experiences designed to reduce errors, improve care, and potentially introduce innovations.
A hindrance toward achieving such transformative learning experiences, Engeström7 argues, is that health care teams and their operating contexts have “traditionally been very centralized and dominated by strong autocratic leaders, by physicians, and increasingly by professional business managers.” I turn now to a discussion of an approach for dealing with such impeding autocracies of power in the health professions.
Democratizing hierarchies of power (health humanities)
The health humanities offer a third approach to integrating conflict into collaboration and teamwork in the health professions by enabling the democratization of power hierarchies.40,66 Bleakley40 and colleagues67 have argued that the culture of medicine remains historically conditioned with authoritarian and hierarchical power structures. They ascribe such lingering autocracies of power to medicine’s paternalistic learning structures (in which knowledge is transmitted from “knowing” teachers to “deficient” trainees), positivist distrust of uncertainty and ambiguity, and historical “oppressive post-colonial contexts.”67 Conflict poses a threat to hierarchies of power. Autocracies, therefore, tend to avoid or rapidly resolve conflict rather than embrace it. Lingard et al68 and Whitehead69 have likewise grappled with trying to democratize the health professions, given the professions’ “well-ingrained incentives for keeping structural hierarchies in place.”68
Bleakley40 and others66,70 believe the health humanities have an essential role to play in “democratizing medical culture.”40 The humanities, they insist, are better placed than the science, technology, engineering, and medicine disciplines to provide the imaginative conditions that underlie democratic values, such as tolerance, empathy, and critical consciousness.71 These conditions and values are antithetical to autocracies of power.
Contrary to the notion that power hierarchies sustain an essential chain of command to avert medical errors and ensure patient safety, evidence indicates that rigid hierarchies may actually increase errors and jeopardize safety by impeding communication and the flow of information.72 It has been repeatedly shown in the airline industry, where hierarchies have been associated with an increased risk of plane crashes, that hierarchies can jeopardize the efficacy of teams.73
Bleakley12,40 insists that power hierarchies in the health professions present unnecessary impediments that should be leveled. The humanities, he suggests, may serve a crucial role in leveling these hierarchies and democratizing the health professions as they educate toward the “creation … (and) … tolerance of ambiguity and uncertainty.”40 Intolerance of ambiguity is the hallmark of authoritarian resistance of democracy; the humanities serve to counter such authoritarianism through open debate and tolerance of ambiguity and differences40,74:
The humanities diagnose social ills, such as unproductive authoritarian behavior grounded in intolerance of ambiguity, and suggest cures, such as tolerance of difference, through open debate and collaborative activities.40
Nussbaum66 concurs that the humanities are the discipline most suited for promoting democracy as they draw attention to social problems, question authority, and favor diversity and tolerance of differences.
To more effectively integrate conflict as a source of innovation in collaboration and teamwork, and as an emancipation from the adverse effects of power hierarchies, humanities programs should not be relegated to the periphery of the health professions curriculum (nor treated just “as compensation for an overdose of science”63). They should, instead, occupy a central position in the health professional curriculum. (The Plymouth University School of Medicine and Dentistry in the United Kingdom introduced the humanities as a core part of an integrated curriculum in 2001–2002, and appears to be the only medical school where the humanities occupy such a core position in the curriculum.40) Such a central curricular position does not insinuate intellectual predominance but, rather, positions the humanities as intellectually accessible to the other disciplines and as an interdisciplinary resource for analyzing complex topics and for conceptual revitalization.63 Designed to deal with complexity, uncertainty, and ambiguity, the humanities are better equipped than are the science, technology, engineering, and medicine disciplines for substantive conceptual analysis and for challenging autocracies of power.
Conclusions: Rethinking Collaboration and Teamwork
The health professions have been slow to integrate conflict into their models of collaboration and teamwork. Among the reasons for such conflict aversion are (1) individuals’ fears about being negatively perceived and the potential negative consequences in an organization of being implicated in conflict, (2) constrained views and approaches to professionalism and to evaluation and assessment, and (3) lingering autocracies and hierarchies of power that view conflict as a disruptive threat. Given the complexity and rapidity of change in health care and the associated turmoil entailed, the health professions need to consider how to more effectively integrate conflict into collaboration and teamwork.
In this article, I have proposed three approaches to integrating conflict into teamwork and collaboration in the health professions: (1) cultivating PS on teams to make space for interpersonal risk-taking without undue fear of the negative consequences of conflict; (2) viewing conflict as a source of expansive learning and innovation (through models such as AT); and (3) democratizing hierar chies of power through education in the humanities, which provide the imaginative conditions for the tolerance of ambiguity and uncertainty, and ideally by advancing the humanities to the core of the curriculum.
Collaboration and teamwork remain poorly understood attributes (or sociopolitical constructs75) for which educators have scant measurement tools and which, therefore, remain freighted with assumptions and myths. (In Table 1, I present 10 such myths with their associated reality checks.) Whether conflict enhances or impedes these attributes may depend on complex intersections of individual and contextual factors. Conflict is nonetheless inevitable, and the health professions should learn to embrace and harness its educational and innovative potential.
Finally, conflicts are often relatively minor disagreements that get exaggerated. Freud76 suggested, “It is precisely the minor differences in people who are otherwise alike that form the basis of feelings of strangeness and hostility between them.” Blok77 referred to this as the narcissism of small differences, while White and Langer78 have called it horizontal hostility. Understanding that many conflicts arise from such relatively insignificant differences is reassuring and emancipating as it softens the perceived threat of conflict. Moreover, it opens a path toward embracing and integrating conflict into collaboration and teamwork in the health professions.
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