the concept of collaborative health
TRANSCRIPT
The concept of collaborative health
HAKAN SANDBERG
School of Health, Care and Social Welfare, Malardalen University, Eskilstuna, Sweden
AbstractBased on empirical research about teamwork in human service organizations in Sweden, the concept ofcollaborative health (CH) encapsulates the physical, psychological and social health resources the individualuses in teamwork; resources which at the same time are influenced by the teamwork. My argument built onempirical research leading up to identifying and defining the core concept in this article, is thatteamwork affects team members’ health and this in turn affects the teamwork and its outcome. In thispaper collaborative health is viewed from a social constructionism perspective and discussed in relationto earlier concepts developed in social psychology and working life research, including psychosocialstress and burnout. The paper also introduces the concept of functional synergy, which in this contextis defined as the simultaneous presence of sharp goal-orientation and synergy in teamwork. The needfor a holistic team theory is emphasized as a tool in research on teamwork. Such a theory relies onidentifying sound and illuminating constituent concepts. I suggest that collaborative health could be auseful concept for better understanding the complex collaborative and co-operative teamwork ofhuman service organizations of today.
Keywords: Collaborative health, teamwork, working climate, interprofessional collaboration
Introduction
This paper focuses on the concept collaborative health (CH), a concept thus far not used in
today’s working life research. The concept has its current base in Scandinavian teamwork
research in the period 1995–2009 (Berlin & Carlstrom, 2004; Berlin, Carlstrom, &
Sandberg, 2009; Sandberg, 1995, 2004a, 2004b, 2006, 2009). Presented for the first time in
a research report (Sandberg, 2004a, p. 97), with the Swedish term ‘‘samarbetshalsa’’,
collaborative health was defined as:
. . . the physical, psychological and social health resources the individual uses in teamwork
and, at the same time, health resources which are influenced by the teamwork.
In short collaborative health is synonymous with health aspects of co-operation within a working
group of frequently interacting colleagues, such as a team.
Correspondence: Hakan Sandberg, School of Health, Care and Social Welfare, Malardalen University, SE-631 05 Eskilstuna,
Sweden. E-mail: [email protected]
Journal of Interprofessional Care,
November 2010; 24(6): 644–652
ISSN 1356-1820 print/ISSN 1469-9567 online � 2010 Informa UK, Ltd.
DOI: 10.3109/13561821003724034
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This paper also briefly introduces the concept of functional synergy as a stepping-stone to
demonstrating the nature of collaborative health: it also arose from the empirical studies
listed above in relation to the identification of the concept of collaborative health. The idea
of functional synergy has not previously been used in studies of teamwork, although the term
is used a little differently in disciplines as diverse as biochemistry and yoga. In this paper
functional synergy is defined as occurring when two qualities of teamwork occur at the same
time: sharp goal-orientation and the creation of synergy (Sandberg, 2006).
The aims are to show the concept collaborative health as a logical consequence of inductive
reasoning from empirical studies of interprofessional teams and to point out general
applications for this concept. The concept is related to team research and especially
examined through a social constructionism approach. This illuminates the conceptualization
of collaborative health by relating it to the conceptualization of psychosocial stress and
burnout. Collaborative health is also discussed in terms of justification and usefulness,
thereby examining arguments behind the creation of the concept.
Origin of the concept ‘‘collaborative health’’
Studies conducted between 1995 and 2006 clearly indicated the influence teamwork had
upon team members’ wellbeing, which in turn influenced the outcome of their teamwork. I
developed the term collaborative health to express this (Sandberg, 2004a, 2006). Since self-
reported wellbeing indicates an important aspect of the individual’s psychological health, a
link between health and teamwork is established.
A closer look at the nature of teamwork clarified those aspects of teamwork which had a
general connection to wellbeing (Sandberg, 2004b, 2006). These were divided into essential
qualities, structural qualities and process qualities. It is possible to make a distinction
between them for analytical purposes, but there is no sharp dividing line. Structural qualities
in teamwork are, for example, the number of team members, the team’s financial
prerequisites, formal management and where the team meets, in short physical,
administrative and economic conditions. The process qualities of the team include
communicative aspects of working lives such as constructive controversies and the working
climate. The main focus of this article though is on the essential qualities.
The major essential qualities are synergy and goal-orientation: the team creates synergy
and there is a sharp goal-orientation in the teamwork. As an example of this, I heard a
presentation at a conference by a management team, consisting of three persons at a teacher
education program, describing their problem-solving processes as intensive and open
minded dialogues with a way of really listening to each others ideas, taking the best from
each one’s proposition to propose a new solution. After iterative improvements the team
reaches the optimal solution, a ‘‘bing’’, which no one of them was close to from the
beginning.
Without qualities of synergy and sharp goal-orientation, a working group might be in
action, but certainly not a team. As mentioned above, I proposed the use of the term and
concept functional synergy (Sandberg, 2006) when describing synergy and sharp goal-
orientation at the same time in teamwork. Goal-direction in an intensively interactive team
resulting in synergy can consume psychological and physical energy as well as provide these
energies. Two short examples from empirical studies of psychiatry teams (Sandberg, 1995,
1997, 2004a) illustrate this. These studies will be described in more detail in the next
section; meanwhile the short examples below describe contrasting teams.
The first comprises four therapists located in a small town, one physician, two
psychologists and one social worker. They consider resources, patients and the organization
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as reasonable. They judge the collaboration, co-operation and working climate as a strong
support for successful work. CH follows as a resource, supporting successful teamwork and
continued wellbeing and health. The other team has 15 therapists located in a suburban area
of a big city. Six are psychologists, two physicians, five social workers and two nurses. They
consider their resources as limited, patients as too many and a teamwork complicated by
heavy conflicts. This latter team is often divided into formal and informal sub-teams. Sharp
goal orientation to shared goals is frequently lacking and the creation of synergy is sporadic.
Thus the teams differ in the extent to which they can create functional synergy. An inductive
conclusion is that wellbeing differs in favour of the small town team. This was supported by
empirical data showing that the team members in the two teams expressed different attitudes
toward each other, different judgements concerning their common values and different
levels of communication supporting a common solving process; with a stronger internal
dialogue in the former team (Sandberg, 1995).
Inductive reasoning from another example also makes the concept of CH plausible
(Sandberg, 2004a). A university lecturer describes two situations. In the first a group of
university teachers discuss the organization and content of a course in occupational therapy:
We talked in a very open manner. No one tried to prove that she/he was right. . . . We
could be critical but constructive. We shared goals and objectives and had similar
professional experiences. . . . You did not feel manipulated; your knowledge was used in
the discussion . . . . You could be yourself. It was very satisfying . . . . There was an open
space.
The other situation, describing collaboration between team members and the manager, is
experienced in a very different way:
Neurosis combined with bureaucratic thinking. Decisions are implemented through
manipulation . . . and opposition leads to isolation and exclusion from courses and
conferences. . . . The working group is made into some kind of family. An academic
discussion is experienced as a way to . . . destroy good climate. . . . You have to survive
somehow.
This interview clearly shows that the two different working climates also lead to different
consequences, such as wellbeing and a willingness to work together and with high
aspirations (the positive climate) or avoiding cooperation with some colleagues, putting less
energy into work and a lack of wellbeing (the negative working climate).
Three studies leading to the CH concept
This section describes three studies I employed to explore the concept of CH. In the
reported studies, current ethical codes in social science were applied. Before approving the
implementation of the studies, the management of the organizations were informed about
the aim of the studies, the methodological and ethical aspects and how and when the studies
should be reported. The persons being asked to be informants in the studies were also fully
informed before giving their approval as well.
My first study (Sandberg, 1995), published as a PhD thesis using a case study approach
(Merriam, 1988), reports 13 cases of out-patient child and youth psychiatry. In this study,
questionnaires based on interviews, comprising open questions with ample space for
reflective responses, were distributed to psychiatry team members during work place visits.
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The study participants included social workers, physicians, psychologists and nurses. The
questionnaires focused on the prerequisites for goal-oriented work. The response frequency
was 100 out of 101. The analysis of the questionnaires was performed in six steps. First, the
activities at each institution were summarized case by case. Second, categories or factors
were created by processing the material from the first four cases studies (visited in 1989–
90). In the third analytic step, the remaining nine case studies (visited in 1992) were related
to what had emerged at step two. The fourth step consisted of a qualitative evaluation of
the possibilities for goal-orientation and goal-fulfilment at each institution (case). This
evaluation was based on interpretations of the answers provided by the actors at the
different institutions. In a fifth step the categories from step three, together with
background data from the institutions, were related to the assessed prerequisite conditions
for goal-oriented work. Finally, a model was developed which categorized the prerequisites
for goal-orientation and goal-fulfilment in teamwork in three dimensions: external factors,
cooperative conditions, and the therapists’ competence emotionally, socially and intellec-
tually. The dimension ‘‘cooperative conditions’’ had the strongest presence in the data set
and contained aspects of what I later defined as collaborative health.
A subsequent study (Sandberg, 1997) used 20 individual interviews with members of teams
working in pre-schools, schools, health services, child and youth psychiatry and the police. The
study aimed to map and describe activities and outcomes in public sector teams. Interviews
were analysed inductively by listening to the recorded interviews repeatedly, transcribing the
interviews to text, reading the text with the intention of finding out and expressing different
qualitative aspects (categories) of the focused phenomena and continuing until new data no
longer changed the meaning of the category. This study concluded that the working climate in
teamwork was very important. The working climate was expressed in terms of respect or
disrespect, cooperation or lack of cooperation, how and if feedback worked, positive feedback
from the management and how information was disseminated in the organization and in the
team. A further conclusion was that a highly successful team is a social forum signified by
positive cooperative qualities and a good spirit.
The third empirical study (Sandberg, 2004a), pursued these insights into the
importance of working climate and built upon a theoretical study of working climate
(Sandberg, 2000). It aimed to illuminate how the working climate relates to teamwork.
There were two strands of data collection. First, nine face-to-face, individual, semi-
structured interviews with therapists from different parts of Sweden, different
organizations and a range of professions (psychologist, social worker, health adminis-
trator, nurse, physician, physiotherapist and teacher), which followed directly after the
interviewees had written about one team situation with a bad working climate and one
team situation with a good working climate (narratives) to be used as inspiration in the
interviews. Seven of the nine interviewed were women, which represents the gender
balance among public sectors workers in Sweden. Analysis of the initial interviews
underpinned the subsequent case study focus groups.
The second strand of data collection involved a case study strategy with five teams in focus
groups: One medical team working at a hospital; one elderly care team in a community; one
heart rehabilitation team at a hospital; one primary school team; one out-patient child and
youth psychiatry team. In all 39 team members joined focus groups, of whom 33 were female.
Their professions were assistant nurse, secretary, physiotherapist, social worker, occupational
therapist, nurse, student, preschool teacher, headmaster, teacher, and physician. Subsequent
inductive analysis used recordings from the written narratives, the audio-recorded interviews
and field notes from the focus groups. Analysis focused on the most frequently occurring and
most strongly emphasized themes. The core findings were:
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(1) As a phenomenon, the working climate summarizes the way communication in the
team as a whole is experienced. It is experienced in terms like respect, interaction and
safety;
(2) The working climate is formed through organizational conditions such as, for
example, meetings and conferences, management style and competence, schedules
and differences in status depending on educational background and salaries.
Relations within the team also shape the working climate. If for example, two team
members do not get along with each other or fall in love, this affects the working
climate;
(3) Individuals with their various competencies (professional, cooperative, emotional) are
emphasized as the most influential creators of the working climate. An analysis of the
entire pattern nevertheless leads to the conclusion that the working climate is a result
of the interaction between organizational prerequisites, relations within the team and
the competencies of the individual team members;
(4) The working climate in teamwork has strong implications: the empirical data clearly
showed that the wellbeing of the individual team members is directly affected. Added
to this, it seems that the efficiency and productivity of the work is affected largely
through the intermediation of the individuals’ states of wellbeing, which in turn are
affected by the working climate.
Synthesis of the studies
Data from these three studies were synthesized by creating categories and relating them to a
methodological model consisting of essential, structural and process qualities (Sandberg
2004b). The conclusions drawn from the studies as a whole are based on the significant and
comparable result in each study, an analysis which is facilitated through the methodological
similarities of the studies.
Discussion
The examples above show that achieving functional synergy in teamwork requires a set of
supporting structural and process factors. These factors include working roles, the patients’
needs, general resources, competence, internal support and working climate. In
Nancarrow’s (2004) study of 26 intermediate care staff including physiotherapists,
occupational therapists, nurses, a social worker and support workers Nancarrow argued
that both confidence in their own roles and understanding the roles of other workers were
necessary to avoid feeling threatened, particularly in a situation where roles might
legitimately overlap. I would argue that feeling threatened is a factor that can be directly
linked to the health consequences of stress and thus to impaired collaborative health. Feeling
threatened also reduces the possibility of creating functional synergy and again, diminishes
collaborative health.
Teamwork is signified by frequent interaction in a wide range of communication (e.g.,
Mickan & Rodger, 2005). Intensity in teamwork interaction, for example in constructive
controversies (Tjosvold, 1995), requires an interpersonal strength backed up by
individual physical and mental resources. The capacity for this interaction is arguably
determined by the collaborative health of team members and, in turn affects the
subsequent collaborative health of the team: a feedback loop. Kira (2003), studying
human resource consumption and regeneration in the post-bureaucratic working life,
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concludes that since teamwork demands interconnectedness of people and tasks, a kind
of control built on internal dialogue and negotiations is necessary to avoid negative
health consequences.
Lawson (2004, p. 234) finds that ‘‘collaboration . . . takes many years to develop and even
longer to institutionalize. It’s very costly’’. He concludes that collaboration has several
transaction costs. From my research findings (Sandberg 1995, 1997, 2004a, 2006),
summarised in this article, collaborative health is undoubtedly an important transactional
cost for the team member and the teamwork. When positive, collaborative health is an
important support for the team member. However, poor collaborative health has negative
consequences for teamwork and team members’ states of wellbeing.
A literature review by D’Amour and colleagues (2005) found certain concepts
repeatedly mentioned in definitions of collaboration: sharing, partnership, interdepen-
dency and power. Mickan and Rodger (2005) argue that the effective health care team
has a well-defined and forward looking purpose and goals focusing the team’s task and
specifying how the team can achieve patient care outcomes. They also argue that
functional leadership and communication together with a high level of mutual respect
within the team are characteristics of effective health care teams. Without making the
question of the team members’ health explicit in these two studies, the components of
inter-professional collaboration that they identified make it possible to understand
the value of the team members’ wellbeing and health. This is in line with my
empirical data that point out both positive and negative consequences of teamwork:
although, as Howard and colleagues (2003) point out, the positive values often are taken
for granted.
For team members with the ambition of working as effective health care teams, in which
constructive controversies foster collaboration, what they gain as a team also comes with the
cost of health consequences, which can be positive as well as negative depending on a variety
of circumstances, such as the number of team members, leadership, the allocation of
resources and working climate. Interprofessional teams in health care are tightly coupled
systems (Weick, 1976), in which changes in one part of the team have a direct impact in the
other parts of the team.
A concept is not born in a vacuum. It is created in a scientific context where humans
express themselves in a way that is adequate for a phenomenon which otherwise would be
‘‘silent’’. Compared to the idea of using terms like ‘‘workplace health’’ (Leiter, 2007) or
‘‘teamwork-related health’’, collaborative health has the advantage of referring to
collaboration, the core process of teamwork. Another advantage of choosing the term
CH, though primarily observed in the teamwork context, is that it also can be applied to
collaborative situations outside what is called ‘‘teamwork’’. This shift of context though
demands a careful description of the new circumstances at hand.
The usefulness of CH becomes obvious when relating to established concepts such as
control, demand and social support (Marmot, 1997; Theorell & Karasek, 1996),
psychosocial work characteristics (Hoogendorn et al., 2000) and burnout (Leiter, 1991;
Shirom, 1989). These concepts have been used in connection with stress-related problems
such as coronary heart disease, fatigue and back pain. The described contexts related to
these consequences are generally a mixture of heavy work load, unrealistic administrative
expectations, a lack of social support and job control, etc. Even though a general systemic
perspective is expressed in research related to these concepts, ‘‘human factors’’ dominate
these stories. Collaborative health illuminates this aspect and emphasizes the need for more
specific knowledge of what and how in collaboration, supports or obstructs health and also
the context associated with these processes.
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Social constructionism refers to the fact that society and organizations based on teamwork
are created by humans in interaction. Berger and Luckmann (1966) describe teamwork as
an organizational construction of the labour market that might be influenced by scientific
reports (‘‘evidence’’) as arguments added to ideological, political and efficiency related
points of view. From this perspective CH can be viewed as a construction in the interaction
between organizations and employees in the public sector and myself as a researcher. The
sustainability of such a concept as collaborative health is dependent on the usefulness in the
current context of teamwork and research upon teamwork. In this context collaborative
health is a way of focusing a certain gestalt (form). The social processes of teamwork and
doing research into teamwork is a basic prerequisite for the construction of collaborative
health as a concept, and from this perspective an analytic and critical attitude is implicated,
based on the contextualization of CH.
In earlier decades, many working life concepts were detected, constructed or invented
depending on the labour market situation, political and ideological influences, research, and
priorities from the media etc. Two such concepts are psychosocial stress and burn-out, and
both can now be related to collaborative health. Selye (1956) drew attention to stress and the
concept was refined and contextualized in the industrialized countries during the following
decades as, for example psychic stress or psychosocial stress, applied in the Swedish working life
research tradition (Gardell, 1986; Theorell & Karasek, 1996). The concept of burnout
focused on the situation for professional ‘‘helpers’’ in the service sector in Western countries
(Freudenberger, 1974; Leiter & Maslach, 1988). Social circumstances play a major role in
both concepts, as causes, symptoms and as a way to solve the unwanted situation, for
example by social support. So we are expected to find psychosocial stress and burnout
existing at low levels of collaborative health.
By developing teamwork as an organizational tool over recent decades, social
determinants manifest in collaboration have become more important. This is important
for the employees in social services with more complex situations than ever before, which
demands a high degree of professionalism, including the skill of using each others
competence adequately.
Core concepts in behavioural sciences come and go. Olsson (1998) states that building
scientific knowledge about group processes requires theoretical concepts. These concepts
describe important aspects of the ‘‘invisible construction made up from the group as a whole’’
(p. 63, author’s translation). The concepts should at the same time be applicable to the
concrete and visible. To clarify this somewhat, two such concepts could be mentioned. The
concept of the ‘‘informal leader’’ describes group processes in which a group member de facto
manages the team without being authorized as manager. Then ‘‘group pressure’’ is a concept
describing a team when team members change attitude or take actions depending on the
majority’s choice more than on independent reasoning. It’s in a process like this CH is
motivated as a way of conceptualizing the earlier findings described in this paper. That is to say:
Teamwork affects team members’ wellbeing and health, and the team members’ wellbeing and
health affect the teamwork. Collaborative health is a useful core concept in order to clarify this.
During the past hundred years behavioural science concepts such as ‘‘unconscious’’,
‘‘conformity’’, ‘‘mobbing’’, ‘‘demand-control’’, ‘‘social support’’ etc. have summarized
findings in social psychology and working life research, giving us new perspectives and
starting new research traditions and debate. Now, what can collaborative health contribute to
team theory and practice? From a pragmatic point of view, team theory with relevant general
and specific context related concepts is a necessary tool in future team research studies. CH
is a part of this foundation and at the same time offers a bridge to other more familiar
concepts related to health and working life. CH brings into focus a question of importance
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for the wellbeing of the team and the team member, as well as for the success of the team.
It’s a part of a new discourse relevant for the human service organizations. It’s about not
only producing wellbeing for others but also achieving wellbeing for the team member.
Limitations
Even though collaborative health is a plausible and, from the research reported here, logical
concept, methodological limitations might make it less powerful. The area of research in the
reported research is largely limited to human services organizations, and even though it is
reasonable to think that an extension of the studies to, for example, trade and industry would
not change the major traits of this conceptualisation. It is possible that this limitation makes
relevant aspects of experience from collaboration overlooked in this paper. Even though the
foundation of this paper has been presented, discussed and adjusted by the help of conferences,
constructive manuscript readers and university seminars, a higher degree of inter-subjectivity in
data collection and analyses might interpret the data in a slightly different way.
Reflections and conclusions
To accept the concept of collaborative health as (a) relevant, (b) useful, and (c) generative,
requires a reliable scientific foundation and insights into the possibilities of further applications
where this concept can play a major role, both in practice and theory. Collaborative health has a
role to play in highlighting the new collaborative demands in the service sector and creates
space for a new perspective in research based on this knowledge. I conclude that there’s a need
for a scientific concept such as collaborative health. Added to the well known simultaneous
demands of human service organizations such as competence, quality and results, we also have
new ways of collaborating and co-operating. This creates the need for a new perspective into
the question of health in teamwork. By focusing on collaborative health, we might have gained
a somewhat new discourse in the area of working life health.
Acknowledgements
I would like to thank Professor Della Freeth, Associate Editor of the Journal of
Interprofessional Care for a most constructive discussion related to my research findings
and the most appropriate way of presenting them. I would also like to thank health therapist
Carin Ljungkvist for her way of bringing back my conclusions to the persons we really
should support in their teamwork efforts.
Declaration of interest: The author reports no conflicts of interest. The authors alone is
responsible for the content and writing of the paper.
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