The phase 1 observation data provided insight into three areas: the shifting notion of team, the fluctuating levels of collaboration and tension on the team, and the catalysts underlying such fluctuations (previously reported) [9
]. Thematic analysis of the focus group data extended our understanding of these three areas, in particular revealing team members' perceptions of the mechanisms by which collaboration is achieved or undermined. Two dominant mechanisms were recurrently described and were categorized in our analysis as 'the perception of ownership' and 'the process of trade'. The findings reported here describe these mechanisms as revealed by the focus group data and supported by the observational data; implications for team collaboration and conflict are emphasized.
Perception of ownership
This category included references to team members' perceived ownership of valued constructs or commodities, including specialized knowledge, technical skills, equipment, clinical territory and even the patient himself or herself. These constructs and commodities formed the basis of negotiation or exchange during interprofessional interactions. The title of 'ownership' rather than the more traditional concept of 'role' was selected to reflect the participants' emphasis on possession.
Ownership was perceived as both collective (for example, ownership by the ICU team) and individual (for example, ownership by a nurse or by nursing as a profession). Shared perception of collective ownership was portrayed by participants as the foundation of the group's identity. It promoted collaboration between members of the ICU team and was often established by contrast with those outside the core team such as surgeons, internists, or nurses from the wards. For example, nurses explained the team's collective ownership of the patient in contrast to interlopers from outside the unit:
'We don't negotiate in the ICU because we are ultimately responsible for the patient, so there is no negotiating when you are in charge of that patient' (Nurse FG1).
Individual ownership was also a dominant issue and included instances where team members recognized their own or others' possession of valued commodities. For instance, respiratory therapists acted in a proprietary manner regarding the ventilator, and this ownership was recognized and respected by other team members. One resident acknowledged that:
'The RTs' role is probably essential, because, uh, as a medicine resident, we don't know much about the ventilators ... we don't have the time to learn the specifics that they know, so they contribute in areas that we– –we can't...' (Resident FG1).
In cases like this, the recognition of others' possession of knowledge and skills is part of the smooth collaborative functioning of the team. However, individual ownership can also create interdisciplinary tension when team members feel that their ownership of particular knowledge and skills is not recognized:
Nurse: 'And we're the ones who do keep track because we're there 24 hours a day. It'll be like: "Well order a blood culture", well we did one just yesterday. Or "Order a thyroid test." They just did them 2 days ago. You know?' (Nurse FG4).
In both observations and focus group data, the designation of ownership was a complex mechanism and frequently a site of tension. In some cases, the allocation of ownership was defended by a particular group and in others, chafed at:
Intensivist: 'At the end of the day the staff [intensivist] is the bottom line. I mean for better or for worse. I am not necessarily saying that it's the right thing but ... the amount of control you relinquish is really wholly dependent on how strong you feel these other members of the team are' (Intensivist FG1).
Nurse (describing a situation at morning rounds): 'The staff intensivist asked the nurse, are there any issues, any concerns for the patient going to the floor?" The nurse started up, and she was talking about blood pressure issues. The staff intensivist interrupts to say, "Oh well, that's a medical issue. No, I mean specifically a nursing issue. So shot her down immediately' (Nurse FG2).
The staff intensivist in the first example asserts his ultimate responsibility for patient care. In the latter example, however, the knowledge designated as nursing territory by the intensivist was perceived by the nurse as inappropriately constrained, signaling a conflict between the two professional domains.
Although the recognition of others' ownership of commodities frequently facilitated smooth team function, it also served as a provocation for usurpation and theft. For instance, nurses reported situations in which residents sought nursing knowledge but later portrayed that knowledge as their own:
'They rely on our notes and our talking to them in the morning to give them the physical assessment of the patient but then they totally disregard you when it comes to rounds as part of the team as though they've done this assessment themselves and nothing you say is worthwhile' (Nurse FG4).
Participants' discussions of ownership illustrated key problems on an interprofessional team, problems that revolve around respecting the interface between individual and collective knowledge and the balance between individual and collective responsibility.
Process of trade
This second category captured instances in which team members traded valued commodities as they negotiated their collaborative work. Such trade commonly involved concrete, physical commodities, including equipment and resources, and abstract, social commodities, including respect, goodwill and knowledge.
The trade of scarce physical resources was a catalyst for tension on the team. In many cases, this tension was amplified by its recurrence and by the infuriating smallness of some of the issues under debate:
Nurse: 'I'll give you an example: I need a pump because my patient's blood pressure is dropping and some nurse is hoarding all of them and saying she needs it too. And I say, "I don't think you need it", so I just yank it out and get it because I know this is just a regular drip' (Nurse FG1).
Trade in such mundane resources was a commonplace ritual as team members negotiated to locate the items required for everyday patient care. In other cases, tension was amplified by the critical importance of the resources. Trade in beds, for example, was fraught with tension, particularly for trainees:
Resident: 'There is always a shortage of nurses and they're always closing beds and we [trainees] sort of have to bear the brunt ... and get caught in a bed war' (Resident FG1).
Nurse: '[There was] a new resident on call and the ER calls him, he accepts the patient. And then after he accepts the patient he comes to me to say, "Well, we have a patient", and I say, "No, you don't do that. You ask me first, do we have any beds?" Things like that. They're learning the rules' (Nurse FG2).
As the latter example illustrates, the trade in physical resources is governed by implicit, social rules, such as who can authorize a trade. Trainees frequently had difficulty in recognizing and negotiating these implicit rules.
Alongside the trade of concrete resources was trade in more abstract commodities. For the nursing group, the most dominant currency for trade was 'respect', which they described themselves expecting in return for information, knowledge, resources and goodwill. The failure of other team members to present the currency of respect was often met with revenge strategies in the form of an embargo of trade. For instance, a nurse might refrain from offering her knowledge if appropriate respect was not proffered first:
Nurse: '[Consultants to the ICU should] introduce themselves, to say what service they're from, and to ask some questions about the patient as you're the primary caregiver. And ... then they would learn so much more and it would save a lot of time, instead of digging through all this information ... they're flipping, flipping, trying to find bloodwork, but they're not asking me, so I'm not going to help, you know? You find it yourself' (Nurse FG2).
Such trade of knowledge for goodwill occurred not only among team members but also between the ICU team and consulting teams. This critical sort of trade was recognized and discussed by all team members in the study. Failure to engage in such trade could mean that 'a good team approach was lost' (Nurse FG2). It could also be seriously detrimental to an individual team member's success. For instance, residents expressed that
'Your name can be ruined or made on one ... encounter, so ... you have to be very careful, because if you create one enemy you can end up having a tough time with a lot of people, and if they love you, then they love you mostly for whatever the time that you're here ... so it's a bit of a social game; you have to be careful' (Resident FG1).
The process of trade was a constant and at times difficult social game with potentially long-term consequences. The constancy of trade caused it to be a source of accumulated tension and perceived historical injustices, with a single trade event causing a ripple effect that might impact other patients, other team members, other hospital services, or other events later in time. For instance, based on experience, one nurse asserted that
'When you want to transfer a patient in a hurry there will be an obstruction there ... you know there will be excuses. You know sometimes we feel like they're [ward nurses] prolonging it ... so I say, "Well, I'll call housekeeping for you." Of course they don't like that...' (Nurse FG1).
The environmental tensions endemic to the ICU served to make the successful negotiation of trade more difficult but also more essential. As one staff intensivist put it:
'... we deal with a lot of conflict and you have to learn how to control yourself and how to become adept at conflict resolution. And not through intimidation and humiliation of the colleagues you have but honestly listening to them and trying to understand where they are coming from and trying to be respectful of them although ... that is tough sometimes when you are not feeling particularly patient or magnanimous towards these folks that you are talking with and, you know, you are tired, you're sleep deprived ... and you may be getting hassled from all sorts of people because of resource issues' (Intensivist FG1).