Journal of Evaluation in Clinical Practice ISSN 1356-1294
The 20-minute team – a critical case study from the
emergency room
Johan M. Berlin MA PhD1 and Eric D. Carlström MA PhD2
1
Senior Lecturer, Director of Studies, Assistant Director of Research, Göteborg University, School of Public Administration, Göteborg, Sweden
Senior Lecturer, Director of Research, University West, Department of Nursing, Health and Culture, Trollhättan, Sweden
2
Keywords
cooperation, health care, semi-synchronous,
teamwork
Correspondence
Johan M. Berlin
School of Public Administration
Göteborg University
Göteborg
Sweden
E-mail: johan.berlin@spa.gu.se
Accepted for publication: 13 June 2007
doi:10.1111/j.1365-2753.2007.00919.x
Abstract
Rationale In this article, the difference between team and group is tested empirically. The
research question posed is How are teams formed? Three theoretical concepts that distinguish groups from teams are presented: sequentiality, parallelism and synchronicity. The
presumption is that groups cooperate sequentially and teams synchronously, while parallel
cooperation is a transition between group and team.
Methods To answer the question, a longitudinal case study has been made of a trauma
team at a university hospital. Data have been collected through interviews and direct
observations. Altogether the work of the trauma team has been studied for a period of
5 years (2002–2006).
Results The results indicate that two factors are of central importance for the creation of
a team. The first is related to its management and the other to the forms of cooperation. To
allow for a team to act rapidly and to reduce friction between different members, clear
leadership is required.
Conclusions The studied team developed cooperation with synchronous elements but
never attained a level that corresponds to idealized conceptions of teams. This is used as a
basis for challenging ideas that teams are harmonious and free from conflicts and that
cooperation takes place without friction.
Introduction
One of the main challenges for organizational research is defining
what a team is and how it is formed. One difficulty has been that
the characteristics of a team have rarely been studied as it develops
and matures [1]. Therefore ideal descriptions of teams as frictionless, unilaterally harmonious, free of conflicts and goal-oriented
have been presented, which have been criticized [2–4]. Conceptions of ideal teams have had a major influence in the public sector.
This has found expression not least in organization of the health
and medical services, where teams have been regarded as reliable
success strategies for opening up conservative and unwieldy organizations [5]. Exploration of the development process from group
to team in this study enables critical analysis of whether teams
really attains a state of frictionless cooperation. This is undertaken
by studying how teams form in extremely short periods. The
question posed in this article is therefore How are teams formed?
The purpose is to test the difference between group and idealistic
assumptions about team forming.
To provide an answer to the question posed in the article the
trauma team at a Swedish university hospital has been studied
closely. The trauma team offers especially interesting conditions in
terms of research, particularly as the transition from one phase of
cooperation to another can be recorded minute by minute during
the team’s intensive activity. This makes it possible to examine
different phases of cooperation between the members of the team.
Theoretical framework
Groups and teams
An alternative concept to ‘team’ that is used for entities consisting
of individuals is ‘group’. Both the concepts of group and team are
not infrequently used without definition and as synonyms [1,6].
Confusion exists because ‘team’ carries the connotation of both
sequential cooperation, where the members have minimal interaction, and synchronous cooperation, where the members take
advantage of each other’s skills without aspiration of prestige [7].
Procter and Mueller [8] describe how team has developed from a
socio-technical tradition in which autonomous groups were considered to have an optimizing effect on organizations. Expressions
that can be found in this context are work group, autonomous
group and group process. The word ‘group’ is defined as ‘a number
of people or things located, gathered, or classed together . . .’ [9].
© 2008 The Authors. Journal compilation © 2008 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 14 (2008) 569–576
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One difference between the concepts is that a group need not
consist of individuals but may just as easily refer to abstract things
that are in the same place. However, a team always involves
individuals. Another difference between the concepts is that a team
is considered to be more focused than a group and to display a
greater degree of homogeneity. Team also presupposes the joint
action of its members to solve a shared task, which is not always
the case for groups [10].
What by definition distinguishes a team from a group is that
every member of the team needs to know what is to be achieved
jointly [11]. The task should be sufficiently explicit for all the
members of the team to understand their own functions and have
the scope to take their own initiatives. The tasks should not be
susceptible to varying interpretations by the members of the team
but easy to focus and agree on [12–15]. Another factor in the
formation of a team is that its members are given the scope to
function as a team. This makes certain demands when it comes to
independence, authorization and the specific composition of the
members of the team [16,17]. However, idealized descriptions of
teams go one step farther. Here it is maintained that the members
of the team have a collective aim, have shared goals and that the
members of the team are committed [18].
This contradicts the argument of Cyert and March [19] that
individuals have goals while organizations do not. In many cases
the goals of an organization are the same as those expressed by its
leaders, which need not have any relation to others involved in the
organization [3,20]. Katzenbach and Smith [18] claim, however,
not only that teams work best when they are clearly demarcated
and have clear tasks. They also assert that teams distribute tasks
internally and in agreement with each other. Literature dealing
specifically with teams in the health and medical services offers
similar descriptions. The members of a team are said to devote
themselves jointly and simultaneously and in agreement with each
other to interrelated tasks. Opie [21] describes how the members of
health care teams representing different disciplines jointly assess,
treat and examine the caring needs of individuals. Another
example is Antoniadis and Videlock [21], who define an efficient
health care team as one that displays a relaxed atmosphere while at
the same time there are regular discussions between its members,
who are eager to listen to each other. It is emphasized that in this
type of team differences of opinion and criticism are permitted.
They display few hidden agendas and leadership is shared [21,22].
Such ideal descriptions of how teams are formed describe a
frictionless interaction between leadership and the members in the
team’s development phase. One untested assumption is that teams
form spontaneously. Katzenbach and Smith [18] claim that it is
enough to assemble a group for a specific task for a team to be
created. In other words, teams become teams when a task or a
challenge is accepted and approached collectively. A group of
individuals with different characters can then move from individual treatment of the task into an intensive phase where there are
no considerations of prestige to prevent collective intervention in
each other’s tasks to enable joint solution of the problem. Seen in
this way, teams should only be organized by offering groups of
individuals challenges for them to group around. Autonomy and
trust will then guarantee that the participants will act spontaneously and in accord. It is asserted that given the right conditions
with regard to the individuals involved, their qualification, the task
and the intention, teams will gradually come into being. This
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approach has, however, contributed to the creation of teams that
have been teams only in name rather than in how they function.
Teams have been constructed, have jointly undertaken a task and
then been expected to develop mutual give-and-take with discouraging results. They have turned out to evolve into differentiated
groups with internal oppositions whose members develop sequential ways of working and shun the tasks undertaken collectively
[4]. Differentiated groups tend to be called ‘teams’, although the
members are independent of each other [7].
Katzenbach and Smith [18] also claim that leadership is shared
when a team is created. There is a shift from having a nominated
leader to a state in which all of its members can exercise control in
a spontaneous, not predetermined, alternating leadership. This
phenomenon has been confirmed in studies of palliative teams.
When the team convenes, its leadership alters informally as
various aspects of the patient’s situation are dealt with. When one
member can no longer contribute, another member of the team
takes over control on the basis of the patient’s needs [23]. In both
cases an anti-hierarchical attitude to leadership prevails. The team
leader has a passive role and it seems to be able to achieve consensus with all of the members taken into account. Team leadership therefore is said to be supporting rather than leading, and is
described by the term team coaching [24]. Here criticism has been
expressed by Benders and Van Hootegem [25], who asserts that
autonomous teams without leaders that make decisions hardly
exist. Nevertheless, the belief in autonomy and the harmonious
rotation of leadership survives as an ideal when teams are created.
The team terminology has come to overlap the group terminology. This has been criticized by Saltmans et al. [7], who distinguishes between team and group in the fact that team are
simultaneous and intersubjective, whereas groups are split up and
individual. This study is supported by the definitions mentioned
herein as synchronous and sequential. To this we add a mean form
which is simultaneous and individual cooperation. This mean
form, here called parallel, has been identified as common in acute
health care teams [7]. These three forms of cooperation are here
suggested to make out a reference frame which will then be used
to analyse the trauma team studied within the scope of this study.
Sequential cooperation
Sequential cooperation comprises a traditional step-by-step
working process in which each participant waits for her or his turn
to perform a specific task. Sequential cooperation has also been
called intra-organizational task division and decentralization [26].
This technique has its roots in scientific management traditions
which focus on individual performance and where collective, integrated cooperative methods are considered to lead to free riding
and slacking [27]. The definition of team used in this article means
that they do not involve sequential methods of working. Organizations with long historical traditions are more than likely,
however, to embody fragments of traditional sequential techniques. These administrative relics make it more difficult to establish teams [28]. The health care sector is one that offers examples
of organizations in which there are built-in unwieldy administrative processes that sustain a sequential approach to their operation
[29]. Good illustrations of this can be found in the Swedish health
care system, which is characterized by the predominance of
groups. For example, Westrin [30] describes how doctors in the
© 2008 The Authors. Journal compilation © 2008 Blackwell Publishing Ltd
J.M. Berlin and E.D. Carlström
The 20-minute team
Sequential
Figure 1 From sequential to synchronous
forms of cooperation.
• Group
• Relay-race division
Swedish health care system have helped to promote sequential
working methods. The most characteristic example is the system
of referral, in which specialists take over from each other in the
management of patient needs or the patients themselves are transferred from one specialist to another. Holmberg [31] offers a
similar description of how health care staff divided into professional, semi-professional and non-professional groups are separated from each other by a sequential organization of their tasks.
The distance between the groups is maintained by linguistic and
communication barriers and working processes in which each
group undertakes its own tasks [31,32]. This kind of situation can
also be encountered in groups of staff that describe themselves as
teams but which are never able to become more than loosely
connected groups that work sequentially.
Parallel cooperation
A team in which parallel cooperation takes place can succeed in
undertaking tasks at the same time but lacks the ability to perform
them jointly. This means that the members of the team act as a
group, which involves focusing on their own tasks and avoiding
consideration of the overall needs, but with the difference that the
tasks are performed at the same time. Lind and Skärvad [33]
describe parallel cooperation in what they call a role-integrated
team. By definition, a role-integrated team is as close to being a
group as to being a team. Tasks are divided strictly between the
members of the team and the work is undertaken in parallel in a
way that makes it impossible for the members of the team to
switch positions. The work is standardized on the basis of the
different roles allocated to the members. One example of parallel
cooperative techniques can be found in the allocation of roles
between the different members of the staff in an operating theatre.
The aim is to enable the participants to work according to their
own professional agendas with clearly defined tasks but that at the
same time these should interact seamlessly [34]. Indeed, standardization of tasks, which distinguishes parallel cooperation, has been
regarded as both hindering and enabling team creation. Adler &
Borys [35] maintain that standardization generally encourages
simplified and repeated behaviour that augments conformity
instead of stimulating individual thinking and creativity. Another
factor contributing to parallel techniques is high workload and
stress. A synchronous cooperation can during stress increase an
individual focus [36].
Synchronous cooperation
Synchronous cooperation is characteristic of the ideal descriptions
of teams. This differs from parallel cooperation in that tasks are
not only undertaken at the same time but the members of the team
swap tasks and cover for each other unhampered by prestige. The
members of the team focus not only on their own tasks but they
© 2008 The Authors. Journal compilation © 2008 Blackwell Publishing Ltd
Parallel
• Intermediate form
• Simultaneous but
individual
Synchronous
• Team
• Exchange
unaffected by prestige
identify needs and weaknesses in the teamwork as a whole by
displaying mobility and by rapidly reallocating resources. Savage
[37] uses the expression ‘multiplexing’ to describe how the
members of a team continually shift focus from one task to
another. Similarly, Drucker [38] describes how team cooperation
takes place synchronously when the team cuts across traditional
demarcation lines. To achieve this, a team needs to coordinate its
tasks and at the same time not be bound to comply with a predetermined workflow. In the words of Drucker [38] the music is then
created ‘as it is played’. Like Drucker [38], Davis [39] believes
that focus is shifting from traditional sequential procedures to the
implementation of multiple functions simultaneously. Davis [39]
uses the metaphor of holism, which means that a team relates all
the elements of a totality to each other in exchanges that are shorn
of concerns about prestige.
The links and differences between sequential, parallel and synchronous forms of cooperation can be summarized in the diagram
below (see Fig. 1).
The levels of cooperation described above are important constituents of the empirical systematization in this study and in the
ensuing analysis.
Methods
To provide an answer to the question posed in this article, a case
study has been undertaken of a trauma team at a Swedish university hospital. In view of its aim, a trauma team was considered to
offer a highly suitable case for study [40]. There are three reasons
for the choice of a trauma team as the subject of this study. The
first is that the study involved recording how teams are formed on
a repeated number of occasions. For this reason, the trauma team,
which is convened and disbanded several times each day, could be
considered very suitable and appropriate, particularly as the team
goes through the procedure (from group to team) every time it is
reconvened. Second, it is unusual for a trauma team to consist of
the same individuals. The different on-call arrangements in different units mean that the staff involved will vary. As a result the
predetermined roles ascribed to the members of the team assume a
particularly prominent and controlling function. And third, the
trauma team can be seen as one way in which a hospital can break
down long-standing patterns of action in order to save time.
In this study we have used two methods to collect data. The first
of these has consisted of personal interviews. During a 5-year
period (2002–2006) we followed and interviewed a number of key
figures in the trauma team. The professional categories interviewed belonged to various vocational groups and have comprised
assistant nurses, nurses, doctors, team leaders and the team coordinator. Interviewing different categories of staff enabled different
points of departure and perspectives to be taken into account.
Altogether 30 personal interviews were made during the entire
data-collection period (2002–2006) [41–44].
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The second data-collection method consisted of direct observation [45]. In practice, data collection comprised following the
trauma team in action in the university hospital’s emergency ward.
We have watched the team at work both where emergency treatment
was involved and during practice sessions. During the five observation sessions we followed the progress of 10 cases: six genuine
patients and four simulated practice situations. These observations
were made during a 2-year period, the years 2005–2006.
One advantage of the use of direct observation as a method
of collecting data is that it is not exposed to the interpretations
of intermediaries. As observers, we could ourselves see, hear,
appraise and select the relevant data. The two methods, personal
interviews and direct observation were considered to supplement
each other and these approaches were regarded as highly appropriate for attainment of the purposes of the study. Another argument is that similar approaches have been used in similar studies of
surgical teams [34,46]. A thorough description of the initiation,
development and maturation of the trauma team is provided below.
Results, team work in
emergency nursing
The trauma team
Trauma teams are based on an organizational concept for emergency treatment that has gained widespread international acceptance [7,47]. This method of working began to be implemented at
the university hospital in the mid-1990s. The staff who work in the
team undergo special training, which is based on a coherent treatment concept according to standardized routines. The trauma team
consists of 11–13 individuals who come from different units and
represent different professions/specialities. They are activated by
an incoming ambulance or alternatively when specific vital criteria
for a patient in the hospital drop below a minimum level. If there
is an alarm, the team assembles in the emergency unit’s special
trauma room. The aim of the team is to identify and remedy as
quickly as possible all of the injuries that threaten the life of a
patient. A patient’s stay in the emergency unit should be brief [48].
The objective is for treatment not to exceed 20 minutes. This is
part of the ‘golden hour’ that should not be exceeded before a
patient can be transferred for surgical treatment [49]. The trauma
team is dissolved when the patient is transferred for further treatment at one of the hospital’s other units.
Initiation
Only a few minutes after the alarm has been given, the members of
the trauma team assemble outside the emergency unit’s trauma
room. They change rapidly into trauma equipment, which hangs in
orderly rows outside one of the entrances to the trauma room.
Dressed completely in green, their faces concealed behind visors,
all that identifies each individual member is their name plate.
When the patient arrives everyone in the team unites in a ‘silent
minute’. During this period the patient’s condition is reported to
the members of the trauma team by the ambulance attendants. Up
until this moment nobody in the trauma team has taken any initiative. What happens next has been described by several respondents as decisive for the continued work of the team. If the team
leader is to have any influence on the rest of the process, some
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indication is required of her or his leadership position. If the team
leader fails initially to take over leadership, there is a risk of
conflict, which can lead to the creation of turbulence in the team.
In the interviews the respondents stated that in principle there
could be two outcomes if the team leader failed to establish initial
control of the team. To begin with there was a risk that a new
competing leader would emerge, who had suggestions about what
the team should do. If the new leader was distinct and took initial
initiatives, certain members of the team could shift leadership
focus and begin to act according to the new leader’s orders.
Second, there was a risk that several new potential leaders would
make suggestions about the future course of action. This led to
confusion and discussion which would result in delay.
The anaesthetics staffs are described by the respondents as the
main competitors to the team leader. They are considered to have
the expertise to take command and direct people in emergency
situations and were therefore prone to assume leadership. This was
made clear during one of our direct observation sessions. On this
occasion the surgeon was examining a badly injured patient. The
surgeon said very little and the anaesthetist felt that he was acting
too slowly and ineptly. The situation also showed that the team
leader did not take the initiative to establish active control but
adopted the role of a passive spectator.
During the surgeon’s examination of the patient, the anaesthetist has been watching impatiently. Now he begins to ask the
patient questions – ‘What’s your name?’ ‘What year were you
born in?’ The patient answers the questions, upon which the
anaesthetist turns to the team leader and says ‘He has said
what his name is, at least’. During this time the surgeon had
moved from the foot of the bed to the patient’s right. Everyone is waiting for the team leader to take the initiative but
instead the anaesthetist shouts ‘Everyone ready, turn him
over?’ ‘OK, let’s turn him over.’ The team turns the patient
over – on the command – and the surgeon examines his back.
The team leader looks on passively.
(Observation trauma alarm)
In the example above, the anaesthetist took over the role of both
the surgeon and the team leader. He anticipated decisions and
directed the actions of the team without either the surgeon or the
team leader protesting. The team smartly followed the anaesthetist’s orders and the work proceeded. From there on the anaesthetist exerted a dominant influence on the team.
The members of the team exchange amused glances. When
the team leader gives the team orders, the team glances
quickly at the anaesthetist, who from now on has an implicit
‘superordinate veto’ and endorses the words of the team
leader with a glance.
(Observation trauma alarm)
In the interviews the respondents described how a team leader
who sets explicit limits can succeed in regaining the initiative from
an anaesthetist who tries to assume responsibility. This helps to
restore the team’s cohesion. Its members, including the member
who challenged the team leader, back down and conform so that
the work around the patient can proceed.
Development and maturity
The ways in which the trauma team cooperated could differ with
different emergencies. In certain emergencies, the members of the
© 2008 The Authors. Journal compilation © 2008 Blackwell Publishing Ltd
J.M. Berlin and E.D. Carlström
trauma team acted as if the others were not there. On other occasions, the team proceeded from caution during an initial stage
while the members got to know each other to the phase in which
they started to assist each other. This did not take place, however,
without the team being held in a ‘tight rein’ by the team leader.
One reason for this was the parallel method of working that characterized their activities. During the interviews the respondents
were given a chance to reflect on how the way in which the team
cooperated developed (sequential, parallel, synchronous). The
respondents claimed with few exceptions that their cooperation
was on the whole parallel.
Parallel working methods require clear direction, partly to
follow the predetermined flow of the procedures and also to set
priorities for more or less important tasks. The team leader therefore governs the sequence of activities by giving orders to the
members of the team, who were either told to act or wait. The team
leader played a central role in coordinating the different procedures undertaken around the patient.
The team leader’s management of the team contributed to its
development. During this stage, however, it could happen that the
members of the team gradually identified the way in which the
others were working. Gradually awareness evolved in the team and
between different members. A pattern of action emerged with
some of the team spontaneously and without directions from the
team leader ‘holding back’ while other ‘acted’. In addition, others
could recognize requirements and either assisted or allowed themselves to be assisted across professional boundary lines.
The respondents described the establishment of the team as a
state when fundamentally the parallel working methods continued
but there were synchronous elements. This could be perceived
during observation of teams after they had passed the initial stage
of parallel techniques. The following notes made during observation illustrate the situation described.
Both anaesthetists have been assisted by the neurosurgeon. He
has stretched his arm round one of the anaesthetists to grasp
the ventilation balloon and is now ventilating the patient
. . . The trauma nurse inserts her needle, stopping the flow
with a thumb on the patient’s lower arm. She removes the
sleeve and shouts ‘PVC 2.0 set in right arm’, which is noted
by the secretary. Both of her hands are occupied. The anaesthetics nurse has moved around the bed and also at the same
moment rolled forward the sample trolley, and is now squatting together with the trauma nurse passing her test tube after
test tube . . . One of the assistant nurses sees an ambulance
orderly behind her back and asks him to fetch some scissors.
The orderly glances round and the assistant nurse points to a
table behind the secretary where the scissors are lying. He
gives her the scissors and she begins cutting off the patient’s
garments.
(Observation trauma alarm)
The synchronous elements mean that the role of the team leader
changes. Procedures still follow the predetermined flow with the
team leader directing when needed, but the team does not require
the same degree of control as before. As the team established
itself, the need to maintain the order diminished. The rules do not
need to be shouted out. When dividing lines were crossed, this
took place with consideration and in mutual understanding.
Boundary lines that either could not or should not be disregarded
were respected.
© 2008 The Authors. Journal compilation © 2008 Blackwell Publishing Ltd
The 20-minute team
Both waiting time and the risk of conflict were reduced. One
team leader claimed that in this state the group worked like a
‘body’. Those elements of teams that consisted of members who
routinely worked together could already display this kind of
behaviour in the initial stages, while the team as a whole did not
exhibit elements of synchronicity until cooperation had been
taking place for a number of minutes. However, there were occasions when no synchronous elements appeared during the work of
a trauma team. This could be owing to the team leader’s inability
to perceive that the team was developing synchronous cooperation
and therefore was not prepared to ‘let go of the reins’.
The respondent’s description illustrates how a team leader controlled the team even though its members had identified adaptable
forms of cooperation. An inflexible team leader ‘stuck to his guns’
by failing to tone down his role when the team was dealing with its
tasks sequentially.
Discussion
In the empirical description it can clearly be seen that the trauma
team cuts across the traditional forms of cooperation that prevail
in the hospital. Earlier working methods, when one member of
the staff takes over from another, have been replaced by forms
of simultaneous cooperation. The aim is to recast the intraorganizational role allocation that previously characterized
working methods in health care in order to establish an organization that is capable of taking action without delay. The question we
posed initially was How are teams formed? Our empirical description shows that two factors play a central role when teams are
established. One relates to the forms of cooperation in the team and
the other to its leadership. It turns out that these two factors interact.
Parallel forms of cooperation demand clear leadership and the way
in which leadership was provided contributed to the formation of
the team. These factors are important as the aim of the trauma team
is to undertake in a very short space of time procedures that can
save patients’ lives and offer a stable platform for continued treatment. How they are directed turned out to play a decisive role in
reducing friction between the members of the team.
Forms of cooperation and leadership
The logic of sequential action is firmly established in health care.
Although the aim was to abandon sequential logic, this still did not
happen in the teams. The sequential system of working survives in
the individual plans of action of the members of the team. The only
difference is that they carry out their tasks at the same time, which
has been defined here as parallel cooperation and which means that
the members of the team adopt their given positions and follow a
standardized pattern of action that is based on predetermined roles.
Parallel cooperation is a half-way stage between sequential and
synchronous cooperation and in the context of trauma has the
advantage of enabling treatment time to be reduced. The disadvantage is that the members of the team find it difficult to see what
the others are doing and cover for each other [50]. This can be
compensated for by firm direction from the team leader in managing competing interests around the patient. The team leader
forms an important link in directing and coordinating the parallel
procedures. Inadequacy on the part of the team leader will create
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hesitation in the team and instead their actions will be directed by
their professional logic, which will result in uneven and inflexible
treatment of the trauma.
However, on certain occasions the team underwent a further
stage of development by displaying synchronous elements in their
cooperation. This means that they looked around, noticed both
needs and resources that were not being used and communicated
with each other. Synchronous cooperation is characterized by
mobility and the ability to reallocate resources rapidly [51]. This,
however, required two conditions to be fulfilled. One is that the
members of the team could see the totality of needs and resources
in the team and exploit possibilities of making reallocation. The
second is for the team leader to tone down his own role when a
synchronous technique develops. Regulation by a team leader who
did not alter management approach when the team displayed elements of synchronicity could eliminate the spontaneous interactions initiated by members of the team and therefore inhibits
synchronous development. On the other hand the team leader
could not release control completely and stop directing the team as
the influence of sequential logic still survived even after synchronous elements had developed. Teams therefore never became
entirely synchronous. Their members continued to act on the basis
of their own individual plans of action and the team leader was still
needed to regulate their input and the order in which they took
place. The difficulty was at the same time observing and taking
into account the synchronous elements that had been established
in the team. This way of working can be described as semisynchronous cooperation, in that the team displayed a mixture
between parallel and synchronous cooperation. The two factors
that jeopardized the ability of the team to attain a semisynchronous approach were the team leader’s ability to direct the
process and internal competition for leadership. If the team leader
was able to provide direction to eliminate internal competition for
leadership, conditions prevailed to permit the development of
semi-synchronous methods through the reduction of prestige concerns and uncertainties during the trauma treatment process [52].
The theoretical model presented earlier in this paper therefore
needs to be extended by the addition of semi-synchronous cooperation and there is thus a difference in the management of the
team between the two forms of cooperation. Traditional sequential
techniques do not require the presence of leadership as the work
follows routines in which tasks are handed over like the baton in a
relay race. In health care this normally takes the form of referrals
and unwieldy delegation routines. In the opposite, in other words,
synchronous models, the presence of an official manager is not
Sequential
• Group
• Relay-race
division
• Management need
not be present, routines regulate cooperation
Parallel
• Intermediate
form
• Simultaneous
but individual
• Requires active
on-the-spot
regulation and
leadership
Semi-synchronous
• Intermediate
form
• Team under
development
• Requires on-thespot leadership
that can avoid
eliminating synchronic elements
through over direction
required either, as the teams will transfer leadership to the member
best suited to exercise it any moment with no concern about
prestige. However, the two intermediate forms, parallel and semisynchronous cooperation require active management. Parallel
forms demand constant direction by an explicit leader and semisynchronous cooperation makes even greater leadership demands,
as then it is question of a leader with an active directive role who
is also, at the same time, prepared to ‘back down’ to avoid precluding elements of synchronous cooperation. If an ideal team
can be expected to cooperate synchronously and parallel cooperation is an intermediary stage between group and team, semisynchronous cooperation could characterize the development of
a team.
Theoretical development
In conclusion there are grounds for returning to the question posed
in our research: How are teams formed? One stage in responding
to this question is to return to and supplement the theoretical
diagram presented in the introduction. The previous diagram has
been supplemented with the semi-synchronous form of cooperation (see Fig. 2).
This diagram illustrates how the team in the study moves from
parallel forms of cooperation to semi-synchronous ones. The team
embodies remnants of sequential logic but never attains the ideal
synchronicity of a team. This also constitutes the answer to the
research question. Another contribution is the observation of the
role of the team leader. Neither sequential nor synchronous techniques require the presence of any official leader, as in the first case
cooperation is regulated by routines and in the latter by the spontaneous allocation of tasks between the members of the team
unhampered by prestige. On the other hand, the two intermediary
forms, ‘parallel’ and ‘semi-synchronous’, require on-the-spot
and active management. Where parallel cooperation is involved,
the team leader’s control is intended to set priorities between
the different courses of action and avoid competition. Semisynchronous cooperation requires the leader to adopt an actively
directive role while remaining at the same time ready to allow the
team to work independently when it develops synchronous features. This gives us reason to propose a definition of a team that has
a broader meaning than the idealized conception; a team is a
limited number of individuals who cooperate above a sequential
level. This definition differs not only from the idealized definition
of a team but also those based on empirical studies. The concepts
of limited and sequential presuppose that a team does not consist
Synchronous
• Team
• Exchange
unhampered by
prestige
• Requires no official manager,
leadership rotates
spontaneously
Figure 2 Forms taken by teamwork.
574
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J.M. Berlin and E.D. Carlström
of totally differentiated organizations or units [2]. The definition
also requires cooperation above a sequential level, which means
that the team works in parallel but not necessarily synchronously
or without needing leadership [53–55]. In effect, the definition has
only one purpose, which is to differentiate a team from a group.
Given any more specifically idealized definition of team, the
concept of group becomes even more evasive and the concept of
team more unattainable. The effect of such a definition will merely
widen the gap between theoretical assumptions about teams and
how the term is viewed pragmatically.
The ideal synchronous cooperation of the kind that occurs in
Katzenbach and Smith’s [18] depiction is probably never attained
for more than brief periods of teamwork. Tasks are not allocated
without friction. This is because it is unrealistic to expect a state of
complete shared internal understanding in a team. Nor does this
imply the opposite, i.e. a team that does not attain a level of
synchronous cooperation is merely implementing traditional
sequential techniques. There are patently a number of intermediate
forms. One reasonable assumption is that intermediary forms can
also be found in teams other than the trauma team.
Conclusion
It can be seen that the members of the team in this study possess
the prerequisites for the development of semi-synchronous forms
of cooperation and that it is dependent on a firm leader. There
is, however, scope for further descriptions of deviations from
the theoretical team ideal. Obviously these deviations can be
described specifically in teams that work against the clock and are
required to make rapid decisions, act quickly and achieve results.
The trauma team has helped to reduce lead times, which can mean
the difference between life and death for individual patients. The
team overcomes obstacles that exist between professional, specialization and clinical domains and does not comply with earlier
sequential working methods and this has turned out to lead to the
elimination of delays [56]. Despite certain dissent, the team succeeds in carrying out its task. However, research needs to be made
on other teams to examine how far the results of this study can be
generalized. The trauma team turned out to be an appropriate
subject of study, as it worked with a well-defined task in a
restricted area for a short time, which enabled observation of its
development minute by minute. It is not, however, self-evident that
a team that operates for a longer period with less dramatic tasks is
not dependent on its leadership or develops frictionless forms of
cooperation [57]. For this reason analyses are required of the
interactions between members of teams that cooperate for longer
periods [58]. One hypothesis for continued studies is that the
findings shown here can also be found in teams that operate in
different settings.
References
1. Gersick, J. G. (1988) Time and transition in work teams: toward a new
model of group development. Academy of Management Journal, 31
(1), 9–41.
2. Mueller, F. (1994) Teams between hierarchy and commitment: change
strategies and the ‘internal environment’. Journal of Management
Studies, 3 (3), 383–403.
3. Berry, A. J., Broadbent, J. & Otley, D. (1995) Management Control.
Theories, Issues and Practises. London: Macmillan Press LTD.
© 2008 The Authors. Journal compilation © 2008 Blackwell Publishing Ltd
The 20-minute team
4. Church, A. H. (1998) From both sides now: the power of teamwork –
fact or fiction? Team Performance Management, 4 (2), 42–52.
5. Berlin, J. & Carlström, E. (2006) Traumateam – förenklat flöde eller
försvårande hinder? I: Hälso- och sjukvårdens ekonomi och logistik.
En sammanställning av forsknings och utvecklingsprojekt vid Göteborg universitet, Chalmers tekniska högskola, Nordiska högskolan för
folkhälsovetenskap och Västra Götalandsregionen. Göteborg: Göteborgs Universitet.
6. Schouteten, R. (2004) Group work in a Dutch home care organization:
does it improve the quality of working life? International Journal of
Health Planning and Management., 19, 179–194.
7. Saltman, D. C., O’Dea, N. A., Farmer, J., Rosen, G. & Kidd, M. R.
(2007) Groups or teams in health care: finding the best fit. Journal of
Evaluation in Clinical Practice, 13, 55–60.
8. Procter, S. & Mueller, F. (2000) Teamworking. London: MacMillan
Press LTD.
9. Oxford University Press. (2006) The Concise Oxford English
Dictionary. Oxford: Oxford University Press.
10. Desombre, T. & Ingram, H. (1999) Teamwork: comparing academic
and practitioners’ perceptions. Team Performance Management, 5 (1),
16–22.
11. Walton, R. E. (1985) Toward a strategy of eliciting employee commitment based on policies of mutuality. In HRM Trends and Challenges
(eds R. E. Walton & P. R. Lawrence), pp. 30–53. Boston, MA: Harvard
Business School Press.
12. Senge, P. M. (1990) The Fifth Discipline. The Art and Practice of the
Learning Organization. New York: Doubleday/Currency.
13. Drucker, P. F. (1988) The coming of the new organization. Harvard
Business Review, 66 (5), 45–53.
14. Galbraith, J. R. & Lawler, E. E. (eds) (1993) Organizing for the Future.
San Francisco, CA: Jossey-Bass Publishers.
15. Hammer, M. (1995) The Reengineering Revolution. London: Harper
Collins.
16. Partington, D. & Harris, H. (1999) Team role balance and team performance: an empirical study. Journal of Management Development,
18 (8), 694–705.
17. Prichard, J. S. & Stanton, N. A. (1999) Testing Belbin’s team role
theory of effective groups. Journal of Management Development, 18
(8), 652–665.
18. Katzenbach, J. R. & Smith, D. K. (1993) The Wisdom of Teams.
Creating the High-Performance Organization. London: Harvard
Business School Press/The McGraw-Hill Companies.
19. Cyert, R. M. & March, J. G. (1963) A Behavioural Theory of the Firm.
Hemel Hempstead: Prentice Hall.
20. Anthony, R. N. (1988) The Management Control Function. Boston,
MA: Harvard Business School Press.
21. Opie, A. (1997) Effective team work in health care: a review of issues
discussed in recent research literature. Health Care Analysis, 5 (1),
62–73.
22. Antoniadis, A. & Videlock, J. (1991) In search of teamwork: a transactional approach to team functioning. The Transdisciplinary Journal,
1 (2), 157–167.
23. Davison, G. & Hyland, P. (2002) Palliative care teams and organisational capability. Team Performance Management – an International
Journal, 8 (3/4), 60–67.
24. Hackman, J. R. & Wageman, R. (2005) A theory of team coaching.
Academy of Management Review, 30 (2), 269–287.
25. Benders, J. & Van Hootegem, G. (1999) Teams and their contextmoving the team discussion beyond existing dichotomies. Journal of
Management Studies, 36 (5), 609–628.
26. Axelsson, R. (2000) The organizational pendulum: healthcare management in Sweden 1865–1998. Scandinavian Journal of Public
Health, 28, 47–53.
27. Steijn, B. (2001) Work systems, quality of working life and attitudes
of workers: an empirical study towards the effects of team and
575
The 20-minute team
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
576
non-teamwork. New Technology, Work and Employment, 16 (3), 191–
203.
Vallas, P. V. (2003) Why teamwork fails: obstacles to workplace
change in four manufacturing plants. American Sociological Review,
68 (2), 223–250.
Nylén, U. (2005) Coping with Trinity: Human Service Professionals in
Interorganisational Team Work. Unpublished paper presented at
the 18th Scandinavian Academy of Management Meeting 18th-20th
August 2005. Aarhus, Denmark.
Westrin, C.-G. (1996) Juridik och medicin. Några funderingar runt ett
angeläget forskningsfält i 35 års utredande: en vänbok till Erland
Aspelin. Malmö: Departementets utredningsavdelning.
Holmberg, L. (1997) Health-Care Processes. A Study of Medical
Problem-Solving in the Swedish Health-Care Organisation. Lund:
Lund University Press.
Forsberg, E., Axelsson, R. & Arnets, B. (2001) Effects of
performance-based reimbursement on the professional autonomy and
power of physicians and the quality of care. International Journal of
Health Planning and Management, 16, 297–310.
Lind, J.-I. & Skärvad, P.-H. (1998) Nya Team i Organisationernas
Värld. Malmö: Liber Ekonomi.
Edmondson, A. C. (2003) Speaking up in the operating room: how
team leaders promote learning in interdisciplinary action teams.
Journal of Management Studies, 40 (6), 1419–1452.
Adler, P. S. & Borys, B. (1996) Two types of bureaucracy: enabling
and coercive. Administrative Science Quarterly, 41 (1), 61–89.
Driskell, J. E., Salas, E. & Johnston, J. (1999) Does stress lead to a loss
of team perspective? Group-Dynamics, 3 (4), 291–230.
Savage, C. M. (1996) 5th Generation Management. Oxford:
Butterworth/Heinemann Limited.
Drucker, P. F. (1992) Managing for the Future. Oxford: ButterworthHeinemann.
Davis, S. M. (1982) Futurum Exaktum. Borgå: Werner Söderström.
Yin, R. (1994) Case Study Research: Design and Methods, 2nd edn.
London: Sage.
Eisenhardt, K. M. (1989) Building theories from case study research.
Academy of Management Review, 14 (4), 532–550.
Kvale, S. (1996) Interviews: An Introduction to Qualitative Research
Interviewing. Thousand Oaks, CA: Sage Publications.
Alvesson, M. & Deetz, S. (2000) Doing Critical Management
Research. London: Sage.
J.M. Berlin and E.D. Carlström
44. Rubin, I. S. & Rubin, H. J. (2004) Qualitative Interviewing: the Art of
Hearing Data. Thousand Oaks, CA: Sage Publications.
45. Burgess, R. G. (1991) In The Field – an Introduction to Field
Research. London: Routledge.
46. Edmondson, A. C., Bohmer, R. M. & Pisano, G. S. (2001) Disrupted
routines: team learning and new technology implementation in hospitals. Administrative Science Quarterly, 46 (4), 685–716.
47. Colet, E. & Crichton, N. (2006) The culture of a trauma team
in relation to human factors. Journal of Clinical Nursing, 15, 1257–
1266.
48. Cooke, W. M. (1999) How much to do at the accident scene? Spend
time on the essentials, save lives. British Medical Journal, 319, 1150–
1150.
49. McSwain, N. E., Jr (ed.) (1999) PHTLS. Basic and Advanced Prehospital Trauma Life Support. St. Louis, MO: Mosby.
50. Shabnam, U., Sevdalis, N., Healey, A. N., Darzi, A. & Vincent, C. A.
(2006) Teamwork in the operating theatre: cohesion or confusion?
Journal of Evaluation in Clinical Practice, 12 (2), 182–189.
51. Dyck, B., Starke, F. A., Mischke, G. A. & Mauws, M. (2005) Learning
to build a car: an empirical investigation of organizational learning.
Journal of Management Studies, 42 (2), 387–416.
52. Klein, J. K., Ziegert, J. C., Knight, A. P. & Xiao, Y. (2006) Dynamic
delegation: shared, hierarchical, and deindividualized leadership
in extreme action teams. Administrative Science Quarterly, 51, 590–
621.
53. Buchanan, D. (1987) Job enrichment is dead: long live high performance work design. Personnel Management, May, 40–43.
54. Grayson, D. (1991) Self-regulating work groups – an aspect of
organisational change. International Journal of Manpower, 12 (1),
22–29.
55. Pfeffer, J. (1998) The Human Equation: Building Profits by Putting
People First. Boston, MA: Harvard Business School Press.
56. Ali, J. (1998) Effect of basic prehospital trauma life support program
on cognitive and trauma management skills. World Journal of Surgery,
22, 1192–1196.
57. Brass, D. J. (1984) Being in the right place: a structural analysis of
individual influence in an organization. Administrative Science
Quarterly, 29 (4), 518–539.
58. Aritzeta, A., Swailes, S. & Senior, B. (2007) Belbin’s team role model:
development, validity and applications for team building. Journal of
Management Studies, 44 (1), 96–118.
© 2008 The Authors. Journal compilation © 2008 Blackwell Publishing Ltd