INTERPROFESSIONAL COLLABORATIVE PRACTICE (IPCP) models are an effective and innovative way to deliver care to complex patient populations. An IPCP model harnesses the talents of multiple professions working together thus facilitating the teamwork needed to deliver the highest quality of care across the health care continuum.1 Success of high performing IPCP teams is dependent on compassionate, authentic leaders who invest in helping their teams thrive amidst complex and challenging conditions. This investment requires a concerted leadership effort to create structures and processes for helping members of the interprofessional team learn with, from, and about each other. Achieving sustainable outcomes within an IPCP model is hard work, and successful efforts require consideration for team training and attention to clinician well-being. Unfortunately, many health care providers have not received formal training to prepare them to practice effectively within IPCP models. Further, even for those who have been taught IPCP team competencies or related specialized content, translating this knowledge into everyday practice can be a challenging transition. Ongoing leadership support and development in team dynamics are needed for team members to hardwire team building content into their practice. Outcome measurement systems are needed for monitoring the evolution of teams and for deploying targeted strategies to build high performing IPCP teams.
In this article, the integration of an authentic leadership lens to facilitate building high performing IPCP teams is discussed. An overview of forces driving the creation of innovative IPCP models is provided along with a guide for using authentic leadership theory and evidence-based strategies for building high performing teams. Within the context of a grant-funded study, the authors share their experiences with identifying needs for, and subsequently deploying, targeted high performing IPCP team building strategies.
BACKGROUND AND OVERVIEW
Sweeping changes introduced with the Patient Protection and Affordable Care Act of 2010 resulted in federal reimbursement shifts that reward value over volume.2 These changes have necessitated health care delivery system transformation, which emphasizes the care continuum to minimize costs and enhance quality, safety, patient experience, and health outcomes. Transformation in health care requires teamwork to align multiple, seemingly competing, dimensions, if it is to achieve system integration and alignment.
The 2016 Manatt Report, commissioned by the American Association of Colleges of Nursing, discusses the unique role that Academic Health Centers (AHCs) play, working in partnership with schools of nursing, to advance system integration and improve performance outcomes.3 One area where academic-practice partners can collaborate for impressive results is in the creation and evaluation of innovative care delivery models that dramatically change health care from an acute care focus to a population health emphasis. Using the talents of professionals from multiple disciplines, the AHC partners can join forces to achieve boundary spanning, synergistic results using IPCP models.4
Facilitating transformation within an AHC requires leaders who are open to change. These individuals must be able to work collaboratively to energize their teams in an optimistic, supportive, and disciplined way. Authentic leaders can work across the academic-practice partnership to create work environments that align people with resources toward a common purpose. Authentic leadership is defined as a “pattern of leader behavior that draws upon and promotes both positive psychological capacities and positive ethical climate.”5(p94) The Authentic Leadership Questionnaire (ALQ), developed in 2007, identifies 4 subscales to measure authentic leadership: self-awareness, internalized moral perspective, balanced processing, and relational transparency.5Self-awareness addresses the need for individuals to know themselves and to understand how those around them see them. Internalized moral perspective addresses self-regulation of behaviors and alignment with values. Balanced processing is the ability to objectively examine relevant data for decision-making. Relational transparency refers to the ability to demonstrate transparency, collegiality, and trustworthiness in relationships.
Use of the authentic leadership theory, along with the 4 subscales within the ALQ, informs evidence-based strategies that may be deployed to enhance team functioning. Specifically, using authentic leadership–inspired strategies to enhance individual team member self-awareness, internalized moral perspective, balanced processing, and relational transparency, strengthens not just individuals, but also the team. Authentic leadership builds trust that inspires team members, and creates work environments that decrease burnout and team member intent to leave.6 Ultimately these targeted strategies contribute toward building teams capable of achieving the Institute for Healthcare Improvement's Triple Aim outcomes7 of patient experience, population health, and cost of care. They also impact clinician well-being, which addresses the Quadruple Aim.8
In 1965, Tuckman represented the evolution of team dynamics by describing stages of group development.9 Tuckman noted that small groups, such as IPCP teams, evolve over time, following a series of progressive stages. The team members move from forming, to storming, to norming, on their way to performing. Although the stages are fundamentally sequential, even high performing teams may cycle through the stages due to changes in leadership or membership within the team.
In the forming stage, team members initially meet to get acquainted with each other and the opportunities they will pursue together. Team members at this stage are usually on their best behavior, but tend to be focused on themselves rather than on the team. In the storming stage, team members communicate with each other and begin to express their opinions. Under ideal circumstances, the storming stage leads to team members understanding each other's working style and a positive, polite culture ensues. When conflict and power struggles arise between team members, personality clashes and disagreements may occur that adversely affect team dynamics. In the norming stage, team members accept other viewpoints, comply with the rules of the group, and achieve a spirit of cooperation. A danger of the norming stage is that when members become exclusively focused on avoiding conflict, they may become reluctant to share controversial ideas that might be pertinent to informed, shared decision-making. In the performing stage, team members are competent; group norms are well-established; and the team works together efficiently toward goal achievement.
In 1977, Tuckman, in collaboration with Jensen, expanded the original 4 stages of forming, storming, norming, and performing to include a fifth stage, the adjourning stage.10 In the adjourning stage, team members complete the tasks that first brought them together and a new evolution of the team ensues, perhaps including new members.
As part of the experiences with the IPCP team formation described here, a sixth stage was identified. Dubbed the honeymooning stage, it occurs before the forming stage. The honeymooning stage happens early, when team members first come together and experience the excitement of working together to create something new. In this stage, it was noted that team members experienced uncertainty through an optimistic lens, resulting in high expectations and positivity in the absence of clarity. This stage was when challenges had not yet been identified or experienced.
Integration of authentic leadership lens and team dynamics
In examining 6 stages of team development (honeymooning, forming, storming, norming, performing, and adjourning), it is assumed that thoughtful attention to navigating the various stages is important toward building a high performing IPCP team. This assumption is consistent with literature that asserts effective leadership is invaluable for overcoming critical juncture points to team development.11 Monitoring team performance along the stages of team evolution has previously been noted to be an essential component for team development.12 In the study findings described in this article, authentic leadership was the lens chosen to shape evidence-based strategies to build a high performing IPCP team. This was incorporated into an approach to the concept's 4 defining subscales: self-awareness, internalized moral perspective, balanced processing of information, and relational transparency (Table 1). There is evidence in the literature to suggest that authentic leadership contributes toward creating healthy work environments that are conducive to positive nurse, patient, and organizational outcomes.6,13
An action research design was used to test the efficacy of an innovative nurse-led clinic that deployed an IPCP care delivery model. The overall intent of the IPCP model was to address the Quadruple Aim of improving patient experience, enhancing patient health outcomes, reducing cost of care, and addressing clinician well-being.8 A driving force for the IPCP model implementation was the reduction of 30-day hospital readmissions in a complex heart failure patient population. This article discusses use of an authentic leadership lens to identify and implement targeted strategies to develop the high performing IPCP team needed for achieving Quadruple Aim outcomes and caring for the identified patient population.
The study took place at an AHC in the southeastern United States within the auspices of a robust academic-practice partnership. The academic-practice partners included nurse leaders from the school of nursing and the affiliated 1157-bed quaternary teaching hospital. The hub for the IPCP team was an approximately 1500 square foot ambulatory clinic located within the main hospital campus, which provides services 18 hours per week. The clinic was initially funded through a 3-year Health Resources and Services Administration Nurse Education, Practice, Quality, and Retention (NEPQR) grant from July 1, 2014 to June 30, 2017.
To create the IPCP team, health care professionals were selected from 7 different disciplines: nursing (nurse practitioners, clinical nurse leader), medicine, public health, social work, health services administration, information technology, and other health professions. The team was augmented with nonlicensed individuals, including patient care technicians and community health workers. A total of 8 team members were considered to be direct caregivers. These were the team members whose performance was assessed in this study.
The IPCP team provided chronic heart failure disease management to over 250 mostly uninsured patients, emphasizing transitional care services across the health care continuum in the hospital (predischarge patient identification and referral), clinic (ongoing care post hospital discharge), home (home visits within 7 days of hospital discharge), and community (heart failure patient support group). Prior to development of the IPCP model, this uninsured population of heart failure patients frequently had used the hospital's emergency department for routine services.
The Collaborative Practice Assessment Tool (CPAT), a product of the Queen's University School of Nursing,14 was administered from 2015 to 2017 to direct caregiver IPCP team members and used to monitor evolution of the IPCP team. The CPAT measures 8 dimensions (Table 2) using a 7-point Likert scale (Strongly Disagree = 1 to Strongly Agree = 7).14 Of the 8 dimensions assessed in the CPAT, 3 dimensions were used for evaluating team development: communication and information exchange; decision-making and conflict management; and patient involvement in team care. CPAT results on these 3 dimensions were trended and patterns observed over time. CPAT scores, together with daily observations of team dynamics and tracking of IPCP team member concerns of team conflicts, provided invaluable insights for the study leadership team and guided team development interventions.
In addition to the CPAT, the Patient Satisfaction Questionnaire, developed by the research team, was used to monitor the patient experience with the IPCP team. This 15-item instrument asked patients about ease of appointment scheduling; if they were treated with respect; if they felt they were listened to; and if they were satisfied with their clinic visit (Strongly Disagree = 1 to Strongly Agree = 5). The questionnaire also included open-ended questions asking what patients liked or disliked about their clinic experience.
Approval for this study was obtained from the institutional review board at the university. The CPAT was administered from 2015 to 2017 to direct caregiver IPCP team members twice per year and used to monitor evolution of the IPCP team. The Patient Satisfaction Questionnaire was completed by patients at each clinic visit. In addition to formal tracking of team performance and patient experience, anecdotal and critical incidence tracking of team dynamics and conflict were informally captured by leadership as conflicts occurred and team members approached leaders for advice, intervention, or resolution.
Targeted strategies deployed to build a high performing IPCP team included 4 categories of interventions based on authentic leadership theory (Table 1). Four authentic leadership dimensions informing the targeted team building strategies included self-awareness, internalized moral perspective, balanced processing of information, and relational transparency. Twelve specific targeted strategies were used to build the IPCP team. These were designed on the basis of the authentic leadership subscales of the ALQ as delineated in Table 1.
Results specifically associated with evolution of the IPCP team and reported in this article include CPAT scores (Table 3). Over time these ranged as follows: communication and information exchange (4.0 to 6.8), decision-making and conflict management (2.3 to 7.0), and patient involvement in team care (5.7 to 7.0). The CPAT scores reported coincide with the opening of the clinic in December 2014 (baseline measures in January 2015), and the ending of the grant funded period in June 2017 (ending measures in July 2017).
In the Communication and Information Exchange dimension, the highest scores (reflective of better IPCP team alignment) were associated with all stages of team dynamics, depending on the subscale, with the exception of the adjourning stage where the scores were lowest (Table 3). This one precipitous drop in scores was associated with the end of the grant-funding period and the uncertainty related to concerns about future sustainability of the clinic.
In the Decision-making and Conflict Management dimension, the highest scores were mostly associated with the honeymooning stages of team dynamics. The lowest scores were noted in the norming stages of team dynamics, although low scores were seen again in the adjourning stages. The range of scores, from 2.3 to 7, demonstrated this dimension had the most variability in scores over time (Table 3). Drops in scores coincided with team member concerns expressed to the grant leaders. Concerns recorded were usually associated with 2 types of issues: disruption due to the addition of new team members, or when conflict arose relative to overlap of roles and responsibilities.
In the Patient Involvement in Team Care dimension, high scores were evident across all stages of team dynamics (Table 3). This dimension had the highest scores and least variability. Scores remained constant independent of challenges with communication and information exchange, and decision-making and conflict management. The stability of scores in the patient involvement in team care dimension matched the stability of scores for patient satisfaction with care (n = 215) where patient ratings of satisfaction with their care ranged from 4.4 to 5.0 (5 is highest score) for 3 consecutive years, from 2015 to 2017 (see the Figure).
Understanding the analysis
CPAT scores, together with daily observations of team dynamics and tracking of IPCP team member concerns of team conflicts, provided invaluable insights for the project leadership team. They also guided team development interventions. By utilizing the CPAT scores over time, leaders were able to not only identify when to intervene but also determine if interventions were successful. While success was also anecdotally tracked by reductions in team conflict concerns, the CPAT provided an independent confirmation through observed changes in subscale scores.
Application of the authentic leadership lens was a continual process that provided feedback nudges to support team dynamics and development. However, there were several critical points within IPCP team development that invited a more substantial, innovative approach and directly targeted specific developmental needs. Below we highlight 2 of these occasions.
Application of the leadership lens: year 1
Early in the clinic's Forming stage, when the clinic team was slowly developing and building up to full strength, concerns regarding team conflicts began to percolate up to leadership. These conflicts had one aspect in common: they all related to role clarity. The CPAT scores indicated that certain aspects of the Communication and Information Exchange subscale were declining rapidly. Specifically, the team's trust in the accuracy of information reported among team members dropped from 6.8 to 6.3 (Internal Moral Perspective and Self-Awareness), while effectiveness of team communication strategies dropped from 6.3 to 6.0 (Relational Transparency). Similar drops were observed in the Decision-Making and Conflict Management subscale. This included a substantial drop from 6.0 to 4.3 in perceived processes to quickly identify and respond to problems dropped (Balanced Processing of Information). In response to this, a team building intervention was implemented. Each of the team members was invited to share job duties on a white board. As overlap in roles was identified, team members could amicably decide under what circumstances these responsibilities would fall to a specific person. While the immediate feedback from the team was highly positive, success was corroborated by revisiting the CPAT scores at the next survey administration. Accuracy of information reporting rebounded from 6.3 to 6.8, and effective communication strategies climbed from 6.0 to 6.4. Similarly, perceived processes to respond to problems increased from 4.3 to 6.2. Each of these substantial improvements in CPAT subscales supported the impact of the intervention on IPCP function.
Application of the leadership lens: year 2
In its second year of operation, the clinic team continued to evolve, simultaneously adjusting to changes in clinic staffing and working through the Storming phase into Norming. During this time, another significant upswing in conflict, concerns, and corresponding CPAT declines were encountered. This time, the declines in the Decision-Making and Conflict Management subscale were even more substantial, with the overall subscale mean score dropping from 5.23 to 3.47. While some decrease in scores is expected when moving through the Storming phase into the Norming phase, the leadership team decided to develop and implement a new team intervention to assist with decision-making and conflict management. An intervention was developed that tapped into the power of simulated conflict, allowing the clinic IPCP team to analyze, troubleshoot, and come to consensus on best practices for handling both routine and nonroutine conflicts in the clinic. The exercise focused on patient-staff conflicts to provide a pretext for resolution discussions without playing out more emotionally charged staff conflict scenarios. The result of this role-playing intervention was promising. Overall improvement in the Decision-Making and Conflict Management subscale mean score of the CPAT was achieved, moving from the a mean of 3.47 to a more favorable 4.20.
Synthesis of major findings
In this study, 5 major findings enhanced our understanding related to building IPCP teams, as well as the design and timing of targeted evidence-based strategies using an authentic leadership lens. These findings were grouped into 4 categories: ongoing challenges, team evolution over time, clinician well-being synonymous with long-term success, and patients above team harmony.
Challenges to team building in IPCP are ongoing. This requires vigilant leadership that can be objective, empathetic, compassionate, and humanistic while remaining accountable for delivering on targeted outcomes. Caring for a high resource, high need population predisposes team members to stress that could be manifested in a decreased ability to handle team conflict. In equipping team members to handle conflict effectively, authentic leaders work toward supporting their people and maintaining a healthy work environment free of toxic behaviors and relational issues.
Team evolution over time
Evolution of teamwork within IPCP does not happen overnight and requires leadership investment to build capacity. The CPAT is a helpful tool to monitor the evolution of team growth and to identify challenges that might need timely interventions. Through the IPCP team evaluation component of this study, the addition of new team members to the IPCP team was disruptive. A learning from this disruption is that additional proactive team support measures could be timed to facilitate team development during transitions. In addition, leaders learned that mastery in conflict resolution is a skillset that develops over time. It requires both didactic instruction, and experience with simulated situations and mediated conversations before this ability is well-developed. Using Tuckman's stages of team development allowed leaders to monitor team dynamics through observation, CPAT measures, and patient satisfaction scores.9,10 The combination of these observations and measures provided a solid assessment of how to design, deploy, and modify targeted strategies to keep the IPCP team focused and effective in caring for a complex patient population.
Clinician well-being synonymous with long-term success
For long-term success of the IPCP team, clinician well-being cannot be ignored. While the original focus for the clinic's team development was on the Triple Aim, it was quickly realized that clinician well-being is essential. This had to be monitored and acted on when concerns and conflict caused stress for team members. This study's finding is supportive of the emphasis on clinician resilience and well-being that has resulted in a major national initiative to address these concerns.15
The Quadruple Aim will be emphasized in future IPCP team development. In addition, other measures will be added for monitoring progress. These include resilience, receptiveness to change, and adeptness at conflict resolution. Resilience and change management training will be added to our targeted strategies and measured across the evolution of team dynamics. Simulations will be incorporated for practice and mastery of advanced conflict management scenarios. These efforts will promote a culture of conflict resolution with compassion and caring for team members. Relational transparency will be emphasized within and outside of the work setting to improve team member interactions.
Patients above team harmony
The CPAT scores in the patient involvement dimension and the patient satisfaction scores remained high despite IPCP team members experiencing ongoing conflict and concerns. This finding suggests that health care professionals keep the welfare of patients in the forefront despite the distress they might be experiencing. Further, this finding is consistent with the health care professional's ethos of putting patients first. For sustainable clinician well-being, however, authentic leaders have an obligation to help members of the IPCP team address stress and conflict to minimize the risk of burnout.
The analysis of targeted evidence-based interventions to impact IPCP team development had 2 limitations. First, the measures used monitored trends and associations over time rather than more robust correlations or causation. Given that the sample size of IPCP team members was limited to the clinic staff (n = 8), there was fundamentally not enough power to allow for calculation of statistical significance (eg, t-tests). Second, multiple targeted strategies to build the IPCP team were deployed, making it difficult to determine which strategy, alone or in combination, was most impactful.
CONCLUSIONS AND IMPLICATIONS
This article discussed the use of targeted strategies incorporating an authentic leadership lens to develop a high performing IPCP team. In deploying evidence-based strategies, observations of team dynamics, reports of team member concerns, and quantitative data (CPAT, patient satisfaction) were used to monitor their effects on IPCP team evolution. By being vigilant to the needs of the IPCP team and incorporating thoughtful strategies to enhance well-being, problems were identified early so that impactful strategies could be implemented to help the team and clinic thrive.
Through our efforts, we also validated that an innovative IPCP model of care is an effective approach to improve health outcomes and care transitions, however, it may not be fully successful if health care professionals practicing within these models cannot collaborate effectively or maintain personal well-being over time. The value of using an authentic leadership lens to guide IPCP team development cannot be underestimated. Our study emphasized the need for leadership supportive of healthy work environments and practices to achieve desirable outcomes.
The outcomes achieved by the IPCP model would not have been possible without health professionals dedicated to interprofessional practice. Partial financial outcomes attributed to a reduction in cost of care associated with the model are reported elsewhere.16 In addition, enhanced access to care (100% of patients seen within 7 days of hospital discharge), exceptional patient experience (95% or above outpatient satisfaction ratings), improved patient self-reported physical and mental health outcomes over time, and reduced 30-day hospital re-admissions (14% all cause readmission, less than the 29% national benchmark) were also documented as a result of the IPCP model. These outcomes contributed to making the business case for sustaining the clinic beyond the grant funding period, which ended in 2017. As a result, the hospital continues to fund the nurse-led HF clinic and services to vulnerable patients have gone uninterrupted. An essential ingredient to the clinic's success has been the work of authentic leaders to develop, study, and mitigate the challenges of interprofessional team development.
The nurse-led HF clinic has continued to focus on sustainability and scalability. As of 2018, the clinic's physical space has doubled in size; additional members of the team have been hired; and the clinic currently operates 40 hours per week. Care is provided to a continually growing patient population that has doubled in size. All metrics reported during the grant funding period continue to be monitored. The authentic leadership lens is a fixture in an effort to continuously focus on sustaining a high performing IPCP team.
Nurses and other clinicians are frequently involved in clinical research trials and studies. The study shared here is an example of a health system leadership study. Clinical research is conducted to find better interventions or best practices for patient care. Leadership studies support the evolution of leadership theories and best practices for leading or developing healthy workplaces and care models. The success of clinical care for patients is partially dependent on the competencies of those who lead clinical team members. Patients and those who care for them deserve evidence-based leadership, and that requires studying and monitoring the results of interventions, based on theories such as authentic leadership.