‘The patient at the centre of the team’ is a much-used phrase when discussing health care.  It derives from the concept of patient-centred care for which there is no consensus or succinct definition.  Does being at the centre of a team give the person team membership?  In which case there is a unique team with each patient.  

In my previous post I considered some different configurations of health care teams.  An additional type is one in which the team is built around a task rather than a particular patient.  Team membership is fluid and based on team roles rather than specific individuals.  Two examples of this kind of team working are cardiac arrest teams and surgical teams in the operating theatre (room). 

Cardiac arrest teams consist of designated doctors (typically from critical care/emergency medicine/anaesthetics at different levels of seniority), nurses (eg nurse practitioner) and sometimes a physician assistant.  The members are paged to attend a patient who has an abrupt loss of heart function – the heart has stopped beating or is beating irregularly.  The team may vary each day depending on who is ‘on call’.  The personnel are different but the task, and the roles to undertake it, are the same. 

The way that many health care teams change membership depending on the context has been labelled ‘knotworking’, a variation on networking.  Engeström introduced the term ‘negotiated knotworking’: ‘rapidly pulsating, distributed, and partially improvised orchestration of collaborative performance between otherwise loosely connected actors and activity systems.’ ^[i] This definition is as complex as the system it describes.  Think of an intern (first year doctor) reviewing patients on a ward with a nurse and a pharmacist working together (one knot).  She is then paged to attend a cardiac arrest somewhere else in the hospital – she unties one knot and then reties into another with that day’s cardiac arrest team.       

To continue the metaphor, the patient may be thought of as the centre around which the knot is formed and each knot is unique. 

Many health professions education programs now include content about team working.  Health professional students usually have prior experience of working with others on school projects, on a sports team, in a choir or orchestra… They can discuss the similarities and differences amongst these various ‘teams’, consider what is teamwork and how it relates to health care practice.

Many definitions of a team emphasise that membership should be between about 4 and 9 people.  The hallmark of a well-functioning team is that it has a shared commitment to a goal that is transparent.  Roles and responsibilities of each member are clear and understood, and everyone actively participates.  There is good communication and regular, effective team meetings take place.  Members value, respect and trust each other, while maintaining professional relationships.  If conflict does occur, this is dealt with through negotiation to a resolution.  

Many of the above attributes are facilitated when teams are co-located in a single shared space. However, knotworking is practice enacted in time and space,^[ii] different health professionals coming together at varying times and in diverse locations according to patient and institutional needs.  

Health care practice is team-based to a certain extent, but in many contexts ‘team’ does not sufficiently reflect the complexities of practice nor the role of the patient/consumer in making each ‘team’ unique. 

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^[i] Engeström Y. From teams to knots: Activity-theoretical studies of collaboration and learning at work. Cambridge: Cambridge University Press, 2008.

^[ii] Bleakley A. Working in ‘teams’ in an era of ‘liquid” healthcare’: What is the use of theory? Journal of Interprofessional Care 2013; 27(1): 18-26. DOI: 10.3109/13561820.2012.699479