Stress and Performance in Health Care Project Teams

Project Management Institute

Stress and Performance in Health Care Project Teams

François Chiocchio, PhD, PMP, CHRP

Paule Lebel, MD, MSc, CRMCC

Pierre-Yves Therriault, PhD, OT(C), CCCPE

Andrée Boucher, MD, FRCPC

Carolyn Hass, MSc, PhD (candidate)

François-Xavier Rabbat, PhD (candidate)

Jean-François Bouchard

Library of Congress Cataloging-in-Publication Data

Stress and performance in health care project teams / François Chiocchio, PhD, PMP, CHRP, Paule Lebel, MD, MSc, CRMCC, Pierre-Yves Therriault, PhD, OT(C), CCCPE, Andrée Boucher, MD, FRCPC, Carolyn Hass, MSc, PhD (candidate), François-Xavier Rabbat, PhD (candidate), Jean-François Bouchard.

pages cm

Includes bibliographical references.

ISBN 978-1-935589-64-8 (alk. paper)

1. Health care teams—Management. 2. Medical personnel—Job stress. I. Chiocchio, François.

R729.5.H4S78 2012

362.1068'3—dc23

2012035399

ISBN: 978-1-935589-64-8

©2012 Project Management Institute, Inc. All rights reserved.

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10 9 8 7 6 5 4 3 2 1

Table of Contents

Acknowledgments

Preface

List of Tables

List of Figures

List of Acronyms and Their Translation

Chapter 1Why Focus on Interprofessional Health Care Project Teams?

Multiple Paradoxes

A Challenge for Each Paradox

Embedded Paradoxes

Why This Book?

Target Audience and Objectives of this Book

Organization of the Book

Chapter 2Interprofessional Teams in Health Care: A Response to Complexity

From Complex Health Problems to an Efficiency-Seeking Health Network

Challenges

An Answer to Challenges: Interprofessional Collaboration as an Emerging Concept

Difficulties with conceptualizations of collaboration

The importance of teams, teamwork and taskwork

Defining interprofessional collaboration and related constructs

From multidisciplinarity, to interdisciplinarity, to transdisciplinarity

Interprofessional collaboration: a constellation of practices

Positive Outcomes of Interprofessional Collaboration

Pitfalls Associated with the Implementation of Collaborative Practices

Turning Towards Project Work

Chapter 3Study Process, Projects and Participants

Ethics Reviews

Recruitment and Admissibility

Study Design and Process

Sample

Projects

Teams and Team Members

Chapter 4Training Efficacy

The Challenge

Fundamental Criteria

Comprehensiveness

Specificity

Just-in-time

Relatedness

Design of Training Sessions and Materials

Workshop 1. Start Your Project

Workshop 2. Plan the Project

Workshop 3. Execute Your Project

The Impact of Training: Main Hypotheses

Methods

Process

Measures of Training Efficacy

Measures Onto Which Training Efficacy Are Assessed

Job demands, job control, and stress

Collaboration

Conflict

Behavioral performance

Project performance

Results

Self-efficacy, Satisfaction, and Transferability

Job Demands, Control, and Perceived Stress

Collaboration

Conflict

Performance

Behavioral performance

Project performance

Results Summary and Preliminary Discussion

Chapter 5Workload, Demands, Control and Perceived Stress: A Longitudinal Quantitative Examination

Introduction

Project Workload, Job Demands, Job Control, and Stress

Psychological Health

Support

Organizational Support

Social Support

Social support and performance

Social support, workload, demands, control, and stress

Collaboration

Conflict

Conflict Management

Manifestations of Conflict

Performance

General Determinants of Performance

Task interdependency

Goal clarity and goal similarly

Behavioral Performance

Project Performance

Methods

Process

Measures

Project workload

Job demands, job control, and perceived stress

Psychological health: Anxiety and depression

Organizational support

Social support

Collaboration

Conflict handling style

Conflict

Task Interdependency

Goal clarity and similarity

Behavioral performance

Project performance

Results

Descriptive Results

Psychological health: Anxiety and Depression

Support

Organizational support

Social support

Collaboration

Conflict

Conflict handling

Manifestations of conflict

Performance

General determinants of performance

Behavioral performance

Project performance

Results Summary and Preliminary Discussion

Levels and Consistency of Project Workload, Job Demands, Job Control, Stress, and Psychological Health

Support

Collaboration

Conflict

Performance

Chapter 6Recognition, Autonomy and Power: A Qualitative Retrospective Examination

The Psychodynamics of Work

Working Towards Unmet Objectives as a Source of Pleasure and Pain

Psychological Health as a Result of Recognition, Autonomy and Power

Summary and Hypotheses

Method

Process

Procedure

Results

Positive Impact of Recognition, Power and Autonomy

Recognition

Power

Autonomy

All three taken together

Negative Impact of Recognition, Power and Autonomy

Recognition

Power

Autonomy

All three taken together

Results Summary and Preliminary Discussion

Chapter 7Addressing Paradoxes of Interprofessional Health Care Project Teams

Overview and Summary of Results

Training Efficacy

Project Workload, Job Demands, Job Control, and Stress from Quantitative and Qualitative Perspectives

Quantitative results

Qualitative results

Bridges between two theoretical models and approaches

Practical Implications

Competencies in Interprofessional Collaboration

Project Management in Interprofessional Health Care Project Teams: Impossible Without Addressing Human Factors

Project Management: More that Individual and Team Sustainability

Future Research

Program Evaluation

A More Balanced Approach to Research on Psychological Health

Testing for More Complex Hypotheses

Concluding Remarks

Project Work: True Transdisciplinary Collaboration?

A first step

References

Appendix 1: Understanding Our Statistical Indices

Coefficient Alpha: Internal Consistency

Pearson's Correlation Coefficient: How Variables Are Related

Alpha Level: Statistical Risk Management

Appendix 2: Training Efficacy Component Questionnaires

Self-efficacy

Satisfaction and Transferability

Appendix 3: Workload, Demands, Control and Stress Component Questionnaires

Questionnaire A (Time 0)

Questionnaire B (Times 1 and 2)

Appendix 4: Demands, Control and Stress Component Interview

Appendix 5: Project Charter Template

Appendix 6: Activity Planning Template

Appendix 7: Risk Analysis Template

Appendix 8: Multi-Sources Feedback Report

Appendix 9: Study Limitations

Sample Size

Varying Membership

Individual versus Team Level of Analysis

Reliability

Inter-rater Reliability

Internal Consistency

Univariate Statistics

List of Tables

List of acronyms and their translation

Table 2.1:Definitions of Interprofessional Collaboration and Related Concepts

Table 2.2:Types of Teams and Degree of Collaboration Within a Team Based on a Continuum of Professional Autonomy

Table 2.3:The Four–Dimensional Model of Collaboration

Table 3.1:Synthesis of Measurements

Table 3.2:Project Descriptions

Table 3.3:Number of Team Members and Research Participants Across Research Phases

Table 4.1:Fundamental Criteria for the Design and Delivery of Effective Project Team Training in Health Care

Table 4.2:Core Project Management Principles

Table 4.3:Outline of Training Modules

Table 4.4:Descriptive Statistics and Intercorrelations of Training Efficacy Measures

Table 4.5:Correlations Between Measures of Training Efficacy and Job Stress, Demands, and Control

Table 4.6:Correlations Between Measures of Training Efficacy and Collaboration

Table 4.7:Correlations Between Measures of Training Efficacy and Conflict

Table 4.8:Correlations Between Measures of Training Efficacy and Performance Behaviors

Table 4.9:Correlations Between Measures of Training Efficacy and Project Performance

Table 4.10:Synthesis of Results for Training Efficacy

Table 5.1:Means, Standard Deviation, and Intercorrelations for Scores on Measures on Project Workload, Demands, and Control with Age, Years of Experience and Tenure, Preference for Group Work, and Informational Role Self-Efficacy

Table 5.2:Means, Standard Deviation, and Intercorrelations for Scores on Measures on Project Workload, Demands, Control, and Stress

Table 5.3:Means, Standard Deviation, and Intercorrelations for Scores on Measures on Project Workload, Demands, Control, and Stress on Anxiety and Depression

Table 5.4:Means, Standard Deviation, and Intercorrelations for Scores of Measures of Project Workload, ‘Demands, Control, and Stress on Organizational Support

Table 5.5:Means, Standard Deviation, and Intercorrelations for Scores of Measures of Project Workload, Demands, Control, and Stress on Social Support

Table 5.6:Means, Standard Deviation, and Intercorrelations for Scores on Measures of Project Workload, Demands, Control, and Stress on Collaboration

Table 5.7:Means, Standard Deviation, and Intercorrelations for Scores of Project Workload, Demands, Control, and Stress on Conflict-Handling Style

Table 5.8:Means, Standard Deviation, and Intercorrelations for Scores of Project Workload, Demands, Control, and Stress on Conflicts

Table 5.9:Means, Standard Deviation, and Intercorrelations for Scores of Project Workload, Demands, Control, and Stress on Determinants of Team Performance

Table 5.10:Means, Standard Deviation, and Intercorrelations for Scores of Project Workload, Demands, Control, and Stress on Behavioral Performance

Table 5.11:Means, Standard Deviation, and Intercorrelations for Scores on Measures of Project Workload, Demands, Control, and Stress on Project Performance and Regular assessments of Project

Table 5.12:Synthesis of Results for Workload, Job Demands, Job Control, and Stress

Table 6.1:Synthesis of Results for Qualitative Results

List of Figures

Figure 1:Schematic View of the Research Design and Process

Figure 2:Graph of a co-variation

List of Acronyms and their Translation

All work domains are plagued by the use of acronyms and we are no exception. Because this study was conducted in Quebec – a francophone province of Canada – the use of acronyms is compounded by difficulties in translating names (e.g., in French, institution names are not translatable) and acronyms (e.g., capitalization rules differ in French and English). We chose to keep the original French acronyms in the body of the book. The following list shows these acronyms, their French meaning and an English translation.

Acknowledgments

We are thankful to the Project Management Institute for choosing to finance our project among the 187 submissions it received from research teams across the world following the 2009-2011 cycle's call for proposals. In addition to the financial support, the support of Carla Messikomer (manager, academic resources) and her team and collaborators (Brianne Bangma, Deedra Goldsmith, and Marge Combe) was invaluable. This project was also partially funded by the Social Sciences and Humanities Research Council of Canada (SSHRC).

Thanks also to Donn Greenberg, Barbara Walsh and Dan Goldfischer, of PMI's publishing department for their help in transforming our manuscript into this book.

This project would not have been possible without the participation of the CPASS. Its mission as promoted by a wealth of passionate educators, qualified scientists and practitioners, and devoted administrative personnel was key throughout our project.

Many key players help us gain access to teams:

Guylaine Tremblay, deputy-director of learning and development directorate (HMR)

Sylvie Martel, coordinator of professional affaires, multidisciplinary services (HMR)

Bernard Deschênes, assistant deputy director of organizational transformation and development (CSSS-SL)

Brigitte St-Pierre, director ethics review committee (CHUM)

Many graduate students worked on this project; we thank them all: Tania Arieira (occupational therapy), Hélène Essiembre (psychology), Isabelle Tremblay (psychology), and Laurence Tremblay (occupational therapy).

Stacey McNulty, PhD, was instrumental with the entire writing process.

We cannot list all those who participated in the research itself in order to maintain their anonymity. We nonetheless thank all of them for believing that our training sessions were going to be beneficial to their respective projects. We know that making time to answer questionnaires and participating in interviews was not easy. Anonymity does not prevent us from naming the institutions who accepted to include teams in our study. Thanks to

Université de Montréal

Centre hospitalier de l'Université de Montréal (CHUM)

Hôpital Maisonneuve-Rosemont (HMR)

Centre de santé et de services sociaux du Sud de Lanaudière (CSSS-SL)

Institut universitaire de gériatrie de Montréal (IUGM)

Preface

This book is the result of an interprofessional project team's efforts to improve the health care sector's project success rate. As a team, we share all the characteristics of the teams we wanted to help with our action-research project. Our team members represent multiple professions such as industrial-organizational psychology and organizational behavior, rehabilitation, and medicine – and within medicine, many disciplines, such as endocrinology, geriatrics, and community health care. Like many projects, our team is comprised of people that have different statuses: some are confirmed academics and well-respected practitioners, others are graduate students headed for careers as scientists or practitioners; others play an administrative role. Like almost all teams, our roles evolved throughout the project and some members left the project while other joined. Often we thought we understood each other, only to realize later that in fact we were not quite on the same page. Our project required that we learn from each other, which took time and energy. Like all project teams, we knew going in that we would face important challenges.

There is one main difference between our team and all the teams we worked with during the course of this study: we had knowledge and experience in collaborative work and project-based work. Our team is made up of individuals with a solid track record of success implementing collaborative practices in education or health care – with prizes and recognition to boot. One of us is a Project Management Professional (PMP)® credential holder. We used project management tools and techniques to help us navigate the complexities of our endeavor. Our experience and our knowledge of the research on teamwork, collaboration in health care, and project success in general reminded us of the importance of – and the mechanisms to – span real or socially-constructed boundaries created by professional, disciplinary, status-driven silos. In a nutshell, our project's objective was to help other teams acquire our knowledge and implement simple, yet proven practices so they could improve how they managed their project and ultimately the success of their projects.

What scientists seek reflects their frame of reference, and each

discipline teaches its own. To the outsider the divisions and

subdivisions of other fields are likely to appear minor and the

differences among them trivial. To the dweller within each

specialized area, however, the boundaries are important and the

differences may be irreconcilable.

Daniel Katz and Robert L. Kahn

The Social Psychology of Organizations,

(1978, p. 186)

Many believe that interdisciplinarity is synonymous

with collaboration. It is not.

Julie T. Klein

A Taxonomy of Interdisciplinarity,

(2012, p. 19)

Chapter 1

Why Focus On Interprofessional Health Care Project Teams?

Multiple Paradoxes

A Challenge for Each Paradox

The field of health care is in the midst of a universal transformation. This transformation presents new challenges, but interestingly, as Burns, Bradley, and Weiner put it, perhaps not so new challenges and opportunities (2012, p. xi). On the one hand, health care is more than ever focused on providing the most effective care in the most efficient way. On the other hand, health care's growing complexity requires that an ever-increasing number of highly specialized individuals work together to solve increasingly complex problems. These two trends collide and require all those working in health care—physicians and nurses, many other health care professional and technicians, managers, support staff, IT technicians, etc.—to continuously, reflexively, and relentlessly work to maximize the way they collaborate with each other. However, several paradoxes hamper health care workers’ efforts to collaborate.

Ask your colleagues and co-workers what collaboration is. Ask them to give you examples of what they or others did in good—or not so good—situations where people worked collaboratively. Everybody will have a definition and a few good stories—no matter what their job is or their position in the organization. Collaboration is like parenting. Parenting is the most difficult job in the world. We know what it is, we know it is complex, we know we need to do it better; yet we seem to never quite grasp all its complexities, and feel we are failing more often than not. Similarly, collaboration is not new and we already know what to do to be better at it: people must learn to work together. Yet, we rarely fully succeed. There's the first paradox.

As the whole of health care (re)focuses its attention on increased and improved collaboration, organizations and their employees are challenged to improve their day-to-day work. Hence, as managers, health care professionals and all others who contribute to deliver health services struggle to work collaboratively in the first place, they must also understand enough about collaboration to address needed improvements, solve complex service coordination and delivery issues, and do so across management, professional, and disciplinary boundaries. In other words, to improve collaborative practices, health care workers must also work well collaboratively. But how can we succeed at improving collaborative practices if, as in the first paradox, we have difficulties with collaboration in the first place? This is the second paradox.

Health care professionals are trained to deliver services. Service work is complex and involves multiple, relatively short, discreet work episodes (Sundstrom, McIntyre, Halfhill, & Richards, 2000) aimed directly at patients (e.g., medical staff caring for critically ill patients) or at other people in the organization (e.g., radiologists providing X-ray reports to physicians) (Chiocchio, Dubé, & Lebel, 2012). From the organizations’ perspective, service work is ongoing because units have predictable operations and well-defined processes and procedures. Collaboration's main challenge in