The importance of teamwork climate for preventing burnout in UK general practices.

This short report aims to investigate the association between teamwork and burnout among general practitioners (GPs). A two-stage survey was conducted. In stage one, validated self-report measures of burnout and teamwork were completed by 50 GPs across 12 general practices in Greater Manchester, UK. In stage two, staff members across 3 of the 12 general practices (GPs, nursing staff, managers and admin staff) responded to free text questions about teamwork (n = 20). The results of the stage one survey showed that teamwork in GPs was significantly negatively associated with the emotional exhaustion (r = -0.326, P < 0.05) and depersonalization (r = -0.421, P < 0.01) domains of the burnout measure and significantly positively associated with the personal accomplishment (r = 0.296, P < 0.05) domain. Free text responses in stage two were assigned into three themes: (i) addressing organizational barriers which might threaten teamwork, (ii) promoting the view of teamwork as a shared responsibility among all staff members of the general practice and (iii) implementing improvement strategies which can be embedded in the busy environment of general practices. GPs and other staff members of general practices valued the importance of teamwork for boosting their morale and mitigating burnout. Future research should focus on designing and embedding brief teamwork improvement strategies in general practices.

Introduction

Primary care is an essential part of healthcare systems but growing workforce shortage may create new risks for accessibility of services and quality of care. It is therefore important to improve primary care workforce management and identify problematic work conditions, which may cause job leaves and changes. Studies across Europe and the USA consistently show that over half of general practitioners (GPs) experience at least one symptom of burnout such as emotional and physical exhaustion, depersonalization and a reduced sense of personal accomplishment. Burnout is closely associated with the retention and recruitment crisis of healthcare workers and the excessive workload.,

Organization-directed interventions have showed to be more effective for reducing burnout among physicians and other healthcare workers compared person-directed interventions. Cultivating an effective teamwork climate in general practices could be a major component of a workforce wellness strategy in primary care. The concept of teamwork in the workplace refers to the interaction of co-workers sharing their skills and experience to more effectively reach their common workplace goals. Effective teamwork is linked to less stressed healthcare workers, higher job satisfaction and improvements in service delivery.

This pilot study aimed to better understand how to promote teamwork as a ‘wellness strategy’ for the individual professional, as this may improve retention strategies in primary care. The two main objectives of the study were (i) to examine the association between teamwork and burnout among GPs and (ii) to explore the perspectives of all staff members of general practices (GPs, nursing staff, managers and admin staff) about ways to improve teamwork.

Methods

We conducted a pilot study and applied a mixed methods approach. GPs were invited to complete a two-stage electronic survey. The stage one survey included the Maslach Burnout Inventory (MBI)-version for health professionals, the ‘Teamwork’ subscale of the PC-Safequest and some demographic questions for age, gender and years in practice. The survey was circulated by e-mail among all GPs across a convenience sample of 20 general practices in Greater Manchester, UK. Internal consistency for the three domains of the MBI and the teamwork subscale of PC-SafeQuest was high (Cronbach’s α ≥0.79).

The stage two survey was sent to all staff members (GPs, nursing staff, managers and administrative staff) of a subset of participating practices (3 out of the 12) about 8–9 months later. The survey included the MBI, demographic questions including professional role of the participants and two questions relating to the presence/absence of time to socialize with colleagues at work and the regularity of team meetings. Moreover, two free text boxes were provided to elicit qualitative data in relation to teamwork ‘Please add any comments regarding teamwork at your practice’ and ‘Please add any comments on ways for improve practice teamworking’.

Descriptive statistics are presented and Pearson correlations were calculated to assess the relationship between burnout (emotional exhaustion, depersonalization, personal accomplishment) and teamwork scores in GPs. Free text responses were transferred to an excel spreadsheet and analyzed with an inductive approach using conventional content analysis. The analyses were conducted by two authors with clinical and research experience in the field (H.G. and M.P.).

Results

Twelve (60%) out of 20 general practices participated in the study. Fifty of 61 eligible GPs (82%) across 12 general practices completed the stage one survey, 32 (64%) of whom were female and 18 (36%) male. Their median age range was 40–44 years. They had been practising between 2.5 and 20 years. The average score of teamwork among GPs was 5.3 (SD = 1.2). Their average scores on the tree domains of the MBI (emotional exhaustion: M = 23.61, SD = 9.53; depersonalization: M = 39.82, SD = 5.65; personal accomplishment: M = 8.50, SD = 5.77) suggest that this sample of GPs had moderate levels of burnout. Teamwork was negatively associated with the emotional exhaustion and depersonalization domains of the MBI (r = −0.326, P = 0.021; r = −0.421, P = 0.004; respectively) and positively associated with the personal accomplishment domain of the MBI (r = 0.296, P = 0.033).

Twenty-four participants completed the stage two survey (11 GPs, 7 nursing staff, 2 managers and 4 administrative staff), 17 (71%) of whom were females and 7 males (29%). Their average scores on the three MBI domains (emotional exhaustion: M = 22.82, SD = 11.70; depersonalization: M = 37.36, SD = 6.10; personal accomplishment: M = 8.18, SD = 7.14) suggest that primary care workers also had moderate levels of burnout. Although most participants (n = 19; 79%) attended weekly meetings with other members at the practice, fewer than half (n = 11; 46%) felt that had time to meet and socialize with their colleagues during the working day. A total of 20 valid responses were inserted to the two free text boxes for teamwork, which formed three themes and nine subthemes (see table 1).

Table 1

Themes, subthemes and quotes from free text responses

Themes	Subthemes	Quotes
1. Organizational barriers and enablers	1a. Structure	‘Teamwork on site is brilliant but teamwork between sites is more difficult. Less options to communicate daily and build good rapport, meetings can be cancelled and not re-booked until next month’.
	1b. Workload	‘Sometimes we are so busy that we barely see colleagues for sometimes days or weeks on end. This isn't great for morale.' ‘More time to meet as a team to socialize and also to practice and learn processes required for the bureaucratic heavy GP workload that is the modern reality of primary care. An hour a week is not enough and actually regular whole days or sessions together are required to get a shared, deep understanding of how to accomplish our work effectively and share our knowledge and experiences and develop our teamworking’.
	1c. Facilities	‘The resource room be improved to try to split the working space and break space.’
2. Shared responsibility	2a. Equity	'Favouritism shown by management and some colleagues towards larger sites. Large turnover of staff makes you feel replaceable and not valued.’
	2b. Shared commitment	‘Not everyone gets involved to the same extent. This is frustrating. Most do and we are all rewarded. Unfortunately, it is the same people who do not contribute.’ ‘We all work well as a team and I certainly feel valued and respected. However, the only concern is when others aren't as invested.’ ‘Some people do not feel like they are working as part of a team, they do their job go home and communicate very little with others.’
	2c. Inter-professional communication	‘I believe in a busy GP practice the team works very effectively - although communication between some clinical staff and reception staff could be improved.’
	2d. Mentorship	‘I would prefer more one to one time with line managers and receiving more praise at work.’
3. Implementing feasible improvements	3a. Regular meetings	‘Meeting at the beginning of the day would provide an over view, help to identify issues and work collaboratively to find solutions and plan for the day ahead most importantly would be nice to know who's in the building and say hello!’
	3b. Protected time schemes	Having more dedicated time to meet and get together would be great. Our staff lunches and away days make such a difference, allowing us all to mingle and get to know one and other better. Great for helping new starters integrate and as well as long standing members of staff have a chance to catch up with one and other.

The first theme ‘Organizational barriers and enablers’ describes teamwork challenges stemming from the amount of workload and clinical arrangements. Excessive workload, common clinical arrangements (e.g. GPs practicing into multiple practices) and ineffective allocation of bureaucratic tasks could prevent GPs from building/sustaining relationships with other primary care workers. The availability/lack of facilities and communal spaces are also important determinants of teamwork.

The second theme ‘Shared responsibility’ suggests that teamwork requires solid commitment by all staff members in general practices. Key aspects which were emphasized are better inter-professional communication, equity in decision making, better mentorship and supervision for more junior members. Staff turnover and discrimination against specific staff members/sites are described as threats to effective teamwork.

The third theme ‘Implementing feasible improvements’ emphasises the need to translate theory into agreed actions to improve teamwork in general practices. The starting point could be simple changes which can be easily embedded within the busy clinical practice such as daily coffee breaks, regular all staff meetings and monitoring of progress. Protected-time support by the practice leadership was viewed as prerequisites for the success of any improvement strategies.

Discussion

This study found that GPs who perceived themselves working in general practices with effective teamwork climate had lower levels of burnout. All primary care workers valued the importance of teamwork for boosting their morale/wellness and improving service delivery. Primary care workers primarily suggested implementing low-intensity teamwork activities, such as regular all staff morning huddles and daily lunch/coffee breaks. Such activities could help reduce burnout and improve morale, because they provide staff members the space and time to relax from their stressful work, to develop better social relationships and to access peer-to-peer support and debriefing by senior colleagues. Such low-intensity teamwork activities do not require major time commitments or resources, and therefore have a realistic potential of being embedded within the busy schedules of general practices at long term.

The findings of this small-scale study should pave the way, first, for larger observational studies to better understand whether teamwork could buffer the adverse effects of work pressures on the morale and retention of primary care workforce, secondly, for intervention studies drawing on the principles of improvement science to design and implement effective teamwork strategies in general practices.

Limitations

The quantitative analysis of this pilot study was based on self-report data obtained from a small, convenience-based sample of GPs. Thus, the quantitative findings solely reflect the perspectives GPs rather than all primary care workers. Although the perspectives of other primary care workers were included in the qualitative analyses, these were only based on analyzing 20 text responses.

Conclusion

These preliminary findings show that improving teamwork has the potential to relieve some of the workforce pressures in lieu of the larger, systematic upheavals that are required to solve the workforce crisis in primary care. The success and sustainability of teamwork improvement strategies in general practices could depend on (i) engaging all staff members in co-producing their teamwork improvement strategy, (ii) establishing support and protected-time schemes by the leadership and (iii) ensuring compatibility with the work schedules and facilities in each practice.

Funding

This study was funded by the NIHR School for Primary Care Research (Project 298). The NIHR Greater Manchester Patient Safety Translational Research Centre (GMPSTRC-2012-202) funded the corresponding author’s time spent in this project. The research team members were independent from the funding agencies. The views expressed in this manuscript are those of the authors and not necessarily those of the National Health Service, the NIHR, or the Department of Health. The funders had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; and the preparation, review, or approval of the manuscript.

Conflict of interest: None declared.