By Assoc Prof Nigel Tan*, Dr Lim Wee Shiong**, Dr Dujeepa D. Samarasekera***

* Academic Vice Chair, Education, Neuroscience ACP, Education Director, National Neuroscience Institute
** Faculty Advisor, National Healthcare Group Health Outcomes Medical Education Research (NHG-HOMER)
*** Director, Centre for Medical Education, Yong Loo Lin School of Medicine

We encounter daily clinical scenarios similar to ones discussed below. 

An elderly patient with atrial fibrillation is admitted for a stroke. During her care, she is seen by a team comprising many health professionals, including the neurologist, the stroke advanced practice nurse, the rehabilitation physician, the occupational therapist, the physiotherapist, the dietician, and the pharmacist. Individually, they are highly competent individuals, but do they do well as a team in providing optimal care for her?

In 2004 the US basketball team, called the “Dream Team”, comprised some of the best players in the world. Yet somehow, this impressive array of individual talents did not translate into a collective threat and they only managed an Olympic bronze team medal. Sometimes, as illustrated by this case, the whole can be less than the sum of its parts.   The dream became a nightmare.

We often think of professional competence as an individual attribute. We then assume that if we bring highly competent health professionals together in a team, then the individual competence of team members translates to collective competence as a whole team. We make this assumption frequently when we deliver care, even though this may not necessarily be true.

So if we do not hew to an individualist perspective, what then is the collectivist viewpoint? Triandis in his seminal 1995 book titled “Individualism & collectivism : New directions in social psychology” defines the construct known as collectivism, which he describes as a phenomena involving “... closely linked individuals who view themselves primarily as part of the whole be it a family, a network of co-workers.  Such people are mainly motivated by the norms and duties imposed by the collective entity.   Individuals (on the other hand) are motivated by their own preferences, needs and rights, giving priority to personal rather than to group goals.”

We often have an individualist perspective in the way we train our health professionals.   We teach and train them as individuals, then assess and grade them as individuals.   Occasionally we get them to work in groups, and score them on ‘teamwork’, but the individualist viewpoint always predominates at the expense of the collectivist viewpoint.

Yet after they graduate, we suddenly expect these learners who are trained on an individualistic model to transform overnight into a paragon of collective competence in their respective teams.   We assume they’ve learned team skills of communication, collaboration, mutual support and performance monitoring, when in fact these skills may not be well emphasised during their training.

It is thus not surprising that our new health professionals often struggle to be effective members of their workplace teams (at least in the initial stages and often beyond), leading to reduced collective competence and potentially poorer patient care.

“Sometimes the whole can be less than the sum of its parts. The dream becomes a nightmare.”

The notion of collective competence in healthcare and our tendency to over-focus on individual competence when we frame the concept of competence has been explored recently in depth by Dr Lorelei Lingard.   It is impossible for us to do justice to Dr Lingard’s work in this short piece but her book, co-authored with Dr Brian Hodges titled “The Question of Competence” is well worth reading, in particular the chapter on collective competence.

In it, she explores how we as health professionals cannot assume that an individualist attitude of “you do your job well, and I’ll do mine well” leads to collective competence. She explains how collective competence is distributed across networks of people, and how it grows and evolves through interconnected behaviours and shared tools.  

For example, for an ICU patient, nurses and dieticians may be discussing how to optimise the patient’s nutrition (interconnected behaviours), while the physician and the respiratory therapist may be adjusting the ventilator together (shared tools).   The performance of the entire team, more so than any single individual member, best predicts the outcome of the ICU patient.

In order for collective competence to develop, individuals within the team should communicate frequently and understand each other’s mental models. In effective teams with good collective competence, team members also monitor one another’s performance and support one another in difficult times, as they believe they have a shared responsibility for patient care.   These skills do not come naturally, but develop at the workplace through experience and socialisation.

The challenge however is assessing collective competence. While we have many tools that assess us as individuals - such as multisource feedback, mini-CEX, written exams - we are still in the process of developing robust tools for collective competence.

Professor Nick Boreham stressed the need to institutionalise the collective knowledge and skills at the workplace in his recent study titled ‘Collective competence as the construction and enactment of work process knowledge’.   This implies that for specific task-oriented work and disease management scenarios, competency certification should be done focusing on inter-professional teams rather than individuals as an essential element of training future healthcare teams. 

Our collective authorship of this short piece reflects small steps towards role modelling collective competence. By drawing together three clinician-educators from three different healthcare groups to write this article, we hope to demonstrate shared mental models and inter-institutional collaboration as building blocks for collective competence.

In summary, we should consider not just individual competence, but collective competence in our workplace. In order for our teams to develop collective competence, we should learn team skills of communication, collaboration, mutual support and performance monitoring, preferably in the interprofessional setting.

The challenge remains as to how best to learn these skills before health professionals graduate to the workplace and also how best to assess collective competence. We relish future discourses as a collective community of practice to meet these challenges of making dream healthcare teams a reality. 

Assoc Prof Nigel Tan	Dr Lim Wee Shiong	Dr Dujeepa D. Samarasekera