the concept of collaborative health

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The concept of collaborative health HA ˚ KAN SANDBERG School of Health, Care and Social Welfare, Ma ¨ lardalen University, Eskilstuna, Sweden Abstract Based on empirical research about teamwork in human service organizations in Sweden, the concept of collaborative health (CH) encapsulates the physical, psychological and social health resources the individual uses in teamwork; resources which at the same time are influenced by the teamwork. My argument built on empirical research leading up to identifying and defining the core concept in this article, is that teamwork affects team members’ health and this in turn affects the teamwork and its outcome. In this paper collaborative health is viewed from a social constructionism perspective and discussed in relation to earlier concepts developed in social psychology and working life research, including psychosocial stress and burnout. The paper also introduces the concept of functional synergy, which in this context is defined as the simultaneous presence of sharp goal-orientation and synergy in teamwork. The need for a holistic team theory is emphasized as a tool in research on teamwork. Such a theory relies on identifying sound and illuminating constituent concepts. I suggest that collaborative health could be a useful concept for better understanding the complex collaborative and co-operative teamwork of human 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 & Carlstro ¨ m, 2004; Berlin, Carlstro ¨m, & 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 ‘‘samarbetsha ¨lsa’’, 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: Ha ˚kan Sandberg, School of Health, Care and Social Welfare, Ma ¨lardalen 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 Ó 2010 Informa UK, Ltd. DOI: 10.3109/13561821003724034 J Interprof Care Downloaded from informahealthcare.com by Technische Universiteit Eindhoven on 11/22/14 For personal use only.

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Page 1: The concept of collaborative health

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

650 H. Sandberg

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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.

References

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D’Amour, D., Ferrada-Videla, M., San Marting Rodriquez, L., & Beaulieu, M-D. (2005). The conceptual basis for

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