TEAMWORK, PROFESSIONISM AND EFFECTIVE HEALTH CARE DELIVERY IN NIGERIA
BEING PAPER DELIVERED AT THE 2nd
ANNUAL MHWUN GUEST LECTURE
OF THE MEDICAL & HEALTH WORKERS’ UNION
AT SHERATON HOTELS & TOWERS, ABUJA ON
APRIL 11, 2013
_________________________________________________________________
INTRODUCTION
Team
work has been recognised as the indispensable ingredient of success whenever
and wherever people have to come together to achieve their personal goals
because on their own, either they would be unable to achieve those goals at all
or achieve them only sub-optimally.
In the
health profession where various forms of collaboration and hence
interdependence are mandatorily required to achieve certain health outcomes,
team work is the essential requirement for success. This statement is confirmed by research
evidence.
For
example, the study into ‘Teamwork in Healthcare: Promoting Effective
Teamwork in Healthcare in Canada’ by the Canadian Health Services
Foundation in 2006 concluded that:
‘A healthcare system that supports
effective teamwork can improve the quality of patient care, enhance patient
safety, and reduce workload issues that cause burnout among healthcare
professionals… Improved teamwork and collaborative care have been shown to
improve performance in many aspects of the healthcare system, including primary
healthcare and public health.’
Various
reports on health human resources have suggested that teamwork might be an
effective way of improving the quality of care and patient safety as well as
reducing staff shortages and stress among healthcare professionals (Hayward,
Forbes, Lau, and Wilson, 2000; Hackman,1987; Canadian Institute for Health
Information; 2001)
Other
research has shown that teamwork can significantly reduce workloads; increase
job satisfaction and retention; improve patient satisfaction; and reduce
patient morbidity (Borrill, West, Shapiro & Rees, 2000; Zwarenstein,
Reeves, & Perrier, 2005)
The weight of this evidence is not only true for other
contexts; it has clear implications for health care delivery in Nigeria. This
implication is that better teamwork among health professionals in Nigeria will reduce
negative health outcomes for patients, improve the system of care and deliver benefits
to individual members of the health team. In short, it will improve the health
status of Nigerians.
The
purpose of this discussion is to highlight the relevance of teamwork for
effective health care delivery in Nigeria, explore the factors that currently
limit teamwork and suggest solutions as to how some the problems may be
addressed. To achieve this purpose, the rest of the presentation is structured
as follows:
First,
we shall present data on the health situation in Nigeria.
Next
we shall explore the factors that are seen to contribute to the existing health
status of Nigerians
Thirdly,
we shall argue that one of these major factors is the level of teamwork
currently existing among the different groups involved in health care delivery
We shall
then define what a team is, how teams differ from groups, the nature of teamwork and effective teamwork
characteristics in health care.
We
shall then seek to establish the level of teamwork that exists among members of
the health team in Nigeria
This will
be followed by analysis of the possible reasons for the observed level of
teamwork
As
part of the discussion of the possible reasons, we shall focus particular
attention upon a problem hitherto unidentified in the literature: the problem
of professionism
This
discussion will then serve as the background for suggestions as to how teamwork
can be improved for better health outcomes in the Nigerian setting.
2 THE HEALTH STATUS OF NIGERIANS
Various
assessments of the health status of Nigerians indicate that it is not only
dismal; efforts to improve it over the years have been insignificant (Ogunkelu,
2002).
•
Nigeria
lags behind many other African countries on various health indicators. A World
Health Organisation evaluation of the health situation in different parts of
the world placed Nigeria 187 out of 191 countries that were surveyed in 2000
(FMOH, Health Sector Reform Program: 2004 -2007).
•
Compared
with South Africa and Ghana, the indices for life expectancy, infant mortality
and maternal mortality rates are much higher in Nigeria than in these other
countries.
For
the 2000- 2005 period:
•
Life
expectancy at birth was estimated at 43.3 years for Nigeria compared to 56.7
years for Ghana and 49 years for South Africa.
•
Infant
mortality rate was estimated at 98 per 1000 live births for Nigeria. In Ghana
and South Africa, the comparative figures were 59 and 53.
•
Under
five mortality rate per 1000 live births stood at 265 in Nigeria compared to
186 for Ghana in 2003.
•
The
probability at birth of surviving to age 55 for females in Ghana (52.9 percent)
was almost twice that of Nigeria (33.2 percent).
•
In
the year 2000, the maternal mortality ratio (adjusted) per 100,000 live births
in Nigeria was 800. The corresponding figures for Ghana and South Africa were
540 and 240. By 2003, the maternal mortality ratio in Nigeria had risen to
948/100,000.
•
Indeed, with a range of 339/100,000 to
1.716/100,000) Nigeria’s maternal mortality rate is considered to be ‘one of
the highest in the world’ (FMoH Health Sector Reform Program, p.2).
•
The
maternal mortality rates in 1999 by geo-political zones in Nigeria showed that
the North West (1,549/100,000) and North West (1,025/100,000) had particularly
high rates.
•
By
comparison, the South East recorded 286/100,000 live births while the South
West stood at 165/100,000 live births.
•
The
major causes of maternal mortality in these areas were hemorrhage (23%),
infections (17%), malaria (11%), anemia (11%), abortions (11%), toxemia (11%),
cephalo pelvic disproportion (11%) and others (5%) (Ogunkelu, 2002:4).
•
These figures have changed but a little
between 2005 and 2013. Thus for 2013, average life expectancy at birth in
Nigeria has remained at 43.83 years; 33.7% of the population had a probability
that they would not reach age 40 while only 42.1% of the male population had
the probability of reaching age 65; infant mortality rate is 70.49 and higher
than the figures for Ghana (59) and South Africa (53) in 2005 (http://www.nationmaster.com/country/ni-nigeria/hea-health).
3 EXPLAINING THE HEALTH STATUS OF NIGERIANS
To
explain the parlous status of health in Nigeria, the following reasons are
usually advanced:
} Poor funding,
} Insufficient numbers of health personnel,
} Corruption,
} The social conditions of health (poverty
status of patients, their gender, cultural backgrounds, level of education)
For
the Federal Ministry of Health, the factors responsible for the dismal
performance of the health system in Nigeria are:
} The civil service which constitutes a big
constraint on personnel recruitment, remuneration, accountability,
responsibility, transparency and annual budget preparation
} The information system which is inadequate
and weak.
} The PPP framework which is ineffective
} The organisational structure and reporting
relationships which have become too ‘complex and obtuse’
} The budgeting process which exists simply
to fulfill all sense of righteousness rather than provide a true sense of the
cost of health care.
} The chaos in the production and
distribution of pharmaceutical and medical products.
} The management capacity for the health care
system which is weak, inefficient and ineffective.
} Health management that is characterised by
‘a culture of corruption and self- interest’.
} Available human resources for the health
system that are grossly inadequate to meet the needs in quality, quantity,
commitment, motivation and job satisfaction.
Very
importantly, the Federal Ministry of Health (FMoH) review recognised the
following factors:
} Absence of collaboration between the
various government departments whose activities intersect with those of the
FMOH.
} Lack of synergy between the various levels
of government in health matters even though a policy exists.
} Mutual suspicion between the operators of
the health system at the various levels of government.
The
three factors (absence of collaboration, lack of synergy and mutual suspicion) suggest
very strongly that poor teamwork is a major constraint on the effectiveness of
the health care delivery system and health care outcomes in Nigeria. In effect,
the FMoH review recognised that the absence of teamwork as a major factor that
limits the effectiveness of health care delivery in Nigeria. But what is
teamwork?
4 TEAM: DEFINITIONS
To
grasp the essence and importance of teamwork, we must understand the essence of
a team. A team has been defined as:
•
‘Collections
of people who must rely on group collaboration if each member is to experience
the optimum of success and goal achievement’ (Dyer, 1987 – Team Building:
Issues and Alternatives)
•
Key
words: collections of people, group collaboration, optimum success
•
A
small number of people with complementary skills who are committed to a common
purpose, performance goals, and approach for which they hold themselves
mutually accountable’ (Katzenbach and Smith, 1993 – The Wisdom of teams)
•
Key
words: small number of people, complementary skills, committed to a common
purpose, hold themselves mutually accountable
•
A
collection of individuals who are interdependent in their tasks, who share
responsibility for outcomes, who see themselves and who are seen by others
as an intact social entity embedded in one or more larger social systems
and who manage their relationships across organizational borders (Cohen and
Bailey, 1997)
•
Key
words: interdependence, shared responsibility for outcomes, perception,
embedded
The
definitions show that a team is different from a group. A group is a collection
of two or more people who relate with one another for a definite purpose over a
period of time and who develop and share an ideology, values, beliefs and norms
that serve to regulate their relationship with each other and with others who
are not members of the group. Being a group does not mean that it is a team.
5 CHARACTERISTICS OF TEAMS
A team
is a high performing group whose high performance is made possible by a number
of characteristics. Whenever a group has these characteristics, it becomes a
team. These characteristics include:
•
Goal
clarity
•
Openness
(honesty and objectivity) in communication and self appraisal
•
High
membership participation
•
Characteristics
of Teams
•
Skilled
and multi-skilled membership
•
High
level of interpersonal trust
•
Mutual
respect
•
Open
and honest feedback that promote learning
•
Synergy
6 DEFINING TEAMWORK
•
‘A
cooperative or coordinated effort on the part of a group of persons acting
together as a team or in the interests of a common cause; unison for a higher
cause; people working together for a selfless purpose.’ (Dictionary definition)
•
The
practice of people working together cooperatively as a team in order to
accomplish shared goals / objectives
•
A
process that aligns employee mindsets in a cooperative and usually selfless
manner towards a specific but shared purpose.
Applied
to health care:
•
Teamwork
is the interaction or relationship of two or more health professionals who work
interdependently to provide care for patients. Teamwork means that members of
the health team:
•
Are
mutually dependent;
•
See
themselves as working collaboratively for patient-centred care;
•
Have
respect for each other
•
Benefit
from working collaboratively to provide patient care;
•
Share
information which may lead to shared decision-making; and
•
Know
when teamwork should be used to optimize patient-centred care
7 REASONS FOR TEAMWORK IN HEALTH CARE
DELIVERY
To
appreciate the importance of teamwork in health care delivery, we need to know
why it is indispensable for health outcomes.
•
The
reason arises from the nature of the tasks that are performed in health care
•
Different
types of tasks demand different types of relationships. One major
characteristic of a task is the degree of interdependence that its performance
requires from individuals.
Thus
some tasks or activities require:
•
A
high level of independence for the role performer (Co-acting teams /
Counteracting teams – I see my dentist, then my surgeon)
•
Serial
interdependence between role performers (Interacting teams – I see my dentist
who refers me to a surgeon )
•
Pooled
interdependence between role performers (mutual acting teams – I have surgery
that requires that the anesthetist, the nurse and surgeon are present at the
same time to provide care)
•
The
requirement for collaboration and hence teamwork increases as we move from independence
to interdependence when providing health care. (See Annexure 1).
Health
care delivery is unique because it not only requires all forms of collaboration
but frequently requires pooled interdependence between members from diverse
professional backgrounds to produce successful health outcomes for individual
patients.
These characteristics make teamwork in health care
delivery mandatory and the most essential requirement for the success of the
health team Requirements for effective teamwork in health care delivery.
As we
have also shown, while not all health giving situations require the collaboration
of different health professionals, most however do. However, where team effort is required, studies show
that:
(i)
The
best health outcomes occur when teamwork is used Requirements for effective
teamwork in health care delivery
(ii)
Teamwork is most effective when the health team has:
•
a
clear purpose;
•
good
communication;
•
good
co-ordination;
•
protocols
and procedures;
8 REQUIREMENTS FOR EFFECTIVE TEAMWORK IN
HEALTH CARE DELIVERY
•
Functional
/ contingent distribution of inequality
•
Effective
mechanisms to resolve conflict when it arises.
•
Active
participation of all members
•
See
accountability as a collective responsibility.
•
Share
a common interest for fairness and equity in the distribution of rewards
•
Requirements
for effective teamwork in health care delivery
•
The
professional and personal contributions of all members are recognised
•
Individual
development and team interdependence are promoted;
•
Team
members recognize the benefits of working together;
•
Patients
and their families are (i) seen as important team members with an important
role in decision-making and (ii) helped to learn about how to participate in
the team; how to obtain information about their condition; and how each
healthcare professional will contribute to their care.
•
The
influence of organizational culture is recognised and a clear organizational philosophy on the
importance of teamwork exists that seeks to promote collaboration by
encouraging new ways of working together; provides for the development of
common goals; and mechanisms for overcoming resistance to change and turf wars
about scopes of practice.
•
The
larger policy context promotes teamwork by providing consistent government
policies and approaches; health human resource planning; legislative frameworks
to break down silos; and models of funding/remuneration that encourage
collaboration.
9 CAUSES OF POOR TEAMWORK IN HEALTH CARE
DELIVERY IN NIGERIA
Following our previous observation that poor teamwork
has been observed as a constraining factor on health processes, practices and
outcomes in Nigeria, we must now ask the following question: What factors are
responsible for the observed level of teamwork that exists in the health team
in the Nigerian care giving situation?
It can be suggested that the poor level of teamwork
among health teams in Nigeria is occasioned by:
•
Weaknesses
in the larger policy context
•
Problems
in the organisational context / organizational philosophy about teamwork
•
Factors
responsible for poor teamwork in health care delivery in Nigeria
•
Political
distribution of inequality
•
Ineffective
mechanisms for resolving conflicts when they arise.
•
Turf
protection practices
•
Etc,
Etc
10 PROFESSIONISM
While many other factors may be cited, the most
important factor appears to be the emergence of a new but as yet unappreciated
and untheorised phenomenon among health professionals in Nigeria: professionism.
In my view, unless this problem is addressed, all efforts to achieve higher
levels of teamwork among the different groups involved in providing health care
will fail. But what is Professionism?
By
professionism, I mean the process and state of creating and sustaining an
identity for a profession and its members that makes the profession and its
members superior to other professions and their members with whom the
profession and its members are involved in relations of dependence.
The process thus includes building attributes,
orientations and privileges for the profession that are then seen to be natural
to the profession and which are then used to rationalise the superiority of the
profession relative to other related professions. The success of this process
means that over time, members of the profession will come to believe that by
the nature of the profession, they are superior to members of other professions
with whom they share relations of dependence. In its extreme form,
professionism may foster, maintain and rationalise relations of superiority and
inferiority with members of other professions.
In
this sense, professionism will function as an ideology in much the same way in
which sexism and racism function to rationalise the superiority of the man over
the woman (in the case of sexism) and the superiority of members of one race
over members of another race (racism).
Although both have their roots in a profession,
professionism differs markedly from professionalism. Professionalism is the art
of exhibiting the qualities of a professional or the characteristic tenets of
the profession such as reasonable work morale and motivation, high standard of
professional ethics, appropriate treatment of relationships with colleagues in
the same or other professions, and being an expert or master in the field.
Professionism
means that the members of one professional group feel and believe that they are
superior to members of other professions and act out this belief in their
relationships with members of these other professional / occupational groups;
they thus act with a superiority – inferiority mindset in relation to members of
related or other professions with whom they share an interdependent practice.
I want
to suggest that within the health care delivery system in Nigeria,
professionism is the greatest cause of low teamwork, conflicts within the
health team and poor health outcomes. In particular, professionism creates the
following problems among others:
•
Compromises
the autonomy of other professions
•
Encourages
feelings of deprivation among subordinated groups; increases the potential for
more conflict within the health team
•
Fosters
mistakes in patient care and defensive behaviours among health
professionals
•
Encourages
increased turf protection
•
Blocks
reform
On the
basis of a number of case examples, and pending the results of a much more
robust ongoing investigation, I would want to suggest that among all the
professional / occupational groups in the health care delivery system in
Nigeria, members of the medical profession in general and medical doctors in
particular tend to exhibit the most, the characteristics of professionism.
10.1 Three Case Examples:
•
The
Rejection of the election of a Professor of Physiology as Provost of a College
of Medicine
•
Imprisonment
of the Faculty of Basic Medical Sciences in the College of Medicine
•
A
resolution from the Health Summit Organised by the NMA in February, 2013
10.2 Consequences of Professionism
Professionism has definite consequences for
members of the professional group that exhibits professionist behaviours the
most. In our ongoing study of teamwork and professionist behaviours in health
care delivery which involves a sample of medical officers, administrators,
pharmacists, laboratory scientists, nurses and health personnel classified as
medical and health workers (medical technologists, pharmacy technicians etc),
from three public sector hospitals, members of the medical profession were:
•
Perceived
as the most important (48.0%), most
powerful (66.7%), credited the most with the success of the health team (43.4%)
and provide leadership for the health team (52.6%)
•
At
the same time they were also perceived as causing the most problems for other groups
(66.67%), causing the most conflict in the health team (56.9%); being most
responsible for the poor performance of the health team (55.9%).
•
Members
of the Nursing Profession were seen as the most important (16.3%); the most
powerful (17.0%); credited the most with the success of the health team
(19.8%); should provide leadership for the health team (9.5%) by the
respondents.
•
Members
of the Nursing Profession were seen, on the other hand, as ‘causing the most
problems for the health team’ (21.4%); most responsible for the conflict in the
health team (31.9%); most responsible for the poor performance of the health
team (9%) by the respondents
•
Medical
and Health Workers were seen as the most important (1.6%); the most powerful
(1.7%); credited the most with the success of the health team (5.7%); should
provide leadership for the health team (0.0%) by the respondents.
•
Medical
and Health Workers were also seen on the other hand as ‘causing the most
problems for the health team (2.7%); most responsible for the conflict in the
health team (1.7%); most responsible for the poor performance of the health
team (0.0%) by the respondents
11 IMPROVING
TEAMWORK: DEALING WITH PROBLEMS
•
How
can teamwork be improved among health teams in health care delivery in Nigeria?
•
How
can professionism among health professionals in health care delivery be
combated in Nigeria?
11.1 Teamwork can be improved by building the
characteristics of effective teams into health teams:
•
Better
communication through, for example, cross functional / professional group
meetings,
•
Reducing
the workload of individual team members
•
Improving
Teamwork: Dealing with problems
•
Establishing
more effective mechanisms for conflict resolution
•
Reducing
inequality and inequity in conditions for members of health teams
•
Engaging
the organisational and larger policy environment.
•
Specific
interventions (team building, training in team skills, etc).
11.2Improving Teamwork: Combating Professionism
Combating
professionism requires two forms of action: Technical action and Political
action.
•
Technical
action relates to
practices that are meant to enhance the status of a profession on the basis of
demonstrated expertise and spectacular achievements by members of the
profession
•
Political
action relates to
practices that are meant to enhance the power position of a profession on the
basis of deploying existing sources or creating one or more new sources of
power.
Forms
of technical action
•
Encourage
more members to acquire more skills and expertise in their areas of
specialisation
•
Encourage
members to provide error free work within the multi-professional team
•
Showcase
the spectacular achievements of members
•
Seek
professional status for the occupation: How well an occupation is currently
organised or whether, in the first instance, it has indeed acquired the characteristics
of a profession, is a source of power. If a practice or an occupation has not
yet acquired the status of a profession, one way of enhancing the power of
members in that practice would be to work to develop the practice or occupation
into a profession. Members of the Medical and Health Workers’ union, for
example, could seek professional status for their different occupations.
Forms
of political action:
•
Create
talk on the problem: Generate awareness
of the problem by talking about the problem
•
Encourage
/ help those members of the interdisciplinary practice who are most
characterised by professionism to engage in a discourse on the matter first
among themselves and then with others who are affected by it.
Being ‘helped’
means:
•
Providing
arguments and evidence that enable professionists to see that professionism is
a harmful departure from professionalism and that a return to the latter is the
only guarantee for truly experiencing the professional fulfillment, besides
other better team outcomes, that the professional calling offers.
•
Objectivity
in our assessment of the roles and responsibilities of members of the health
team. For example, there is no doubt that in terms of performing the task of
care giving and relating with individual patients, leadership of the health
team must be provided by medical doctors. The question of who provides
leadership in this regard cannot be a matter of dispute.
•
Taking
correct political decisions when relating with members of other
professions
•
Taking
the case for change to the regulators that regulate the regulators through
lobbying, legal action and organised mass action among others.
•
Taking
action within individual health care institutions that challenge the existing
culture of care delivery that professionism enables.
•
Unions
to which members of the professional group belong can educate the members about
the need to ensure justice in the relations between members of the team
12 CONCLUSIONS
The
health care delivery situation in Nigeria is in a parlous state. Although many
factors are responsible, low levels of teamwork and harmony among the diverse
members that make up the health team are major contributory factors.
It is
important, indeed urgent, that measures are taken to improve teamwork in all
facets and among all groups involved in providing and receiving health care in
Nigeria.
Professionism
plays a prominent role in undermining both teamwork and more satisfying health
outcomes in health care delivery in Nigeria. Professionism must therefore be
actively combated through both technical and political forms of action Patients,
nurses, administrators, pharmacists, medical and health workers, regulators,
policy makers, and most importantly, doctors must be involved in combating
professionism. Indeed, the country as a
whole must be involved in combating professionism. This will be the only way to
ensure that Nigerians get the health care delivery outcomes that they deserve.
Thank
you for being part of this experience.
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