Introduction

The scenarios in this suit, Diamonds, are designed to facilitate discussion about teamwork, communication and culture within teams. The answers to these scenarios are less prescriptive than those in the other suits because there is not the same level of professional consensus on the underlying principles compared to the scenarios that are more explicitly linked to an ethical topic. Therefore, this reader is used to support all of the cards in this suit.

All these scenarios are based around a common framework.

‘You are to lead a new multi-national hospital to be deployed as part of the UN Peacekeeping mission. The personnel will have a one-week training period in the capital of the country before deploying to set up the hospital in a remote and austere location. Three countries have agreed to provide personnel working to you representing the ‘lead nation’ though you will report to the multinational UN HQ’.

Effective teamwork is an essential pre-requisite to safe healthcare. Relationships with colleagues is a core element of medical ethics. The World Health Organisation website on patient safety has some excellent material on factors that impact on patient safety including teamwork, communications and culture. Rosen et al’s paper provides a good introductory review of the subject, covering the characteristics of individuals and teams, processes and cultures for effective teams, and the evidence of benefits from investment and training of teams towards clinical outcomes, and team and organisational health. The US Fundamentals of Military Medicine from the Textbook of Military Medicine Series has a number of chapters on leadership and ethics in military medicine that are highly relevant. This is a substantial subject, and so these scenarios and this reader are designed to merely introduce the subject and provide signposts to further reading.

Leadership – personal and within a team

All armed forces invest significant resources in developing teams and their leaders. This includes the processes in initial training, especially for officers, and subsequent career development for all ranks. As part of your discussion, you might review these and discuss how the armed forces develop organisational values and standards as the foundations for personal and team behaviours. You might also consider how leadership is taught, as well as any frameworks or principles that are used to communicate leadership ideas. The Further Reading provides links on this topic.

Multi-cultural and multi-national issues

It is common practice for medical units to be staffed with personnel from different countries. This might be as a result of individuals volunteering or being employed from different parts of a global organisation (common across humanitarian organisations) or as a formal collaboration between nations as a coalition or alliance (common in military medicine). Whilst such arrangements can be very successful, consider the factors from the previous discussions that need to be addressed to ensure successful teamwork. Develop a list of mitigations that the leadership team for a medical facility to address these. The chapter in the Textbook on Military Medicine by Bricknell discusses some of these issues.

Culture and barriers to teamwork

Analyses of communication within teams frequently identifies culture and interprofessional relationships as potential barriers to effectiveness. One solution is to create common systems of work within teams, particularly for high stress, procedural activities. This is a recognised solution in the aviation industry and has been applied in aspects of healthcare. The widespread introduction of checklists, such as the WHO Safe Surgery Checklist, is an example of creating procedures that reduce the risk of communication failures amongst teams in healthcare. In the military, the system of field training for medical teams, such as the UK HOSPEX, is an example of using simulation and training to reduce barriers to teamwork. However, it is ‘organisational culture’ that is the strongest opportunity or barrier to teamwork. The paper by Weller examines this in healthcare and the paper by Bricknell analyses culture from a military medical context.

Ethical principles:

WMA INTERNATIONAL CODE OF MEDICAL ETHICS at: https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/

A PHYSICIAN SHALL behave towards colleagues as he/she would have them behave towards him/her.

World Health Organisation. Patient Safety. At: https://www.who.int/patientsafety/education/en/

Rosen MA, DiazGranados D, Dietz AS, et al. Teamwork in healthcare: Key discoveries enabling safer, high-quality care. Am Psychol. 2018;73(4):433-450. doi:10.1037/amp0000298

Fundamentals of Military Medicine. The Borden Institute. At: https://www.cs.amedd.army.mil/borden/bookDetail.aspx?ID=a875991f-3640-4cab-afa5-66f02f917333

Leadership and Leadership Development in Health Care:

The Evidence Base. 25 February 2015. Faculty of Medical Leadership and Management, The King’s Fund and the Center for Creative Leadership. At: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/leadership-leadership-development-health-care-feb-2015.pdf accessed 10 Feb 20

Healthcare leadership model. NHS Leadership Centre. At: https://www.leadershipacademy.nhs.uk/resources/healthcare-leadership-model/ accessed 20 Apr 20.

Kline R. Leadership in the NHS. BMJ Leader 2019;3:129-132. http://dx.doi.org/10.1136/leader-2019-000159 Podcast at: https://soundcloud.com/bmjpodcasts/why-inclusion-and-diversity-are-key-to-great-teams

The Army Leadership Code. An Introductory Guide. British Army. 2015. At: https://www.army.mod.uk/media/2698/ac72021_the_army_leadership_code_an_introductory_guide.pdf

The Defence Leadership Framework: Growing Leaders at all Levels. 12 Mar 2010. Department of Defence, Australia. At: https://www.defence.gov.au/publications/docs/DLFBooklet.pdf accessed 10 Apr 2020

Multi-cultural and multi-national issues:

Bricknell, M. C. M. Combined Health Services Support Operations,: in Fundamentals of Military Medicine, 2019. O'Connor, F. Shoomaker, E. & Smith, D. (eds.). San Antonio: Borden Institute, p. 193-201 (Textbook of Military Medicine). https://www.cs.amedd.army.mil/borden/FileDownloadpublic.aspx?docid=88938f0a-37c6-40e8-9bf9-91234db4f8a3

Culture and barriers to teamwork:

WHO Safe Surgery Checklist. https://www.who.int/patientsafety/topics/safe-surgery/checklist/en/

S. J. Mercer, C. L. Whittle, P. F. Mahoney, Lessons from the battlefield: human factors in defence anaesthesia, BJA: British Journal of Anaesthesia, Volume 105, Issue 1, July 2010, Pages 9–20, https://doi.org/10.1093/bja/aeq110

HOSPEX Video at: https://www.youtube.com/watch?v=JC5LlHeUjZ4

Weller J, Boyd M, Cumin D. Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare. Postgraduate Medical Journal 2014;90:149-154. http://dx.doi.org/10.1136/postgradmedj-2012-131168

Bricknell MC. The cultural challenge of leading in military medicine. Military Medicine. 2019 At: https://military-medicine.com/article/3839-the-cultural-challenge-of-leading-in-military-medicine.html