The literature in perspective

Understanding how teams and groups interact across their boundaries, through formal and informal members operating at the edges and relating to each other to a greater or lesser extent collaboratively or competitively, is a crucial phenomenon to understand. Organisational gaps and boundaries underpin the mechanisms by which behaviours, practices, attitudes and values spread; how innovation diffuses and cultural characteristics permeate into systems; and how ideas, knowledge and messages translate and migrate across systems and subsystems.62–65 Barriers and obstacles to creating joined-up teams and groups are omnipresent.31 ,32 ,34 ,56 In one study, obstacles manifested as three types—psychological, situational and social—and women perceived more barriers to networking across teams and groups than did men.66 ,67

Taken together the results show that, as a general rule, teams and groups tend to promote an inwardly-focused identity. Strong in-group norms and behaviours operate within teams and groups. People not only identify with the group to which they belong, but their psychological well-being is often bolstered by their membership, particularly if their group is perceived to be prestigious or beneficial to them.68 Members will collectively draw mental or physical boundaries around themselves, circumscribing their group. People also perennially favour their group: the manifestation of in-group bias is strong and seemingly ubiquitous.69 Professions and organisational units, for example, almost always support and favour internal members over their counterparts in external professions or units. Indeed, who is in or eligible for membership, and who is not is in large part what defines a team or group. The phenomenon does not stop there. Teams and groups seem to be characterised by tacit or explicit knowledge about their membership or who is eligible for membership, and can readily identify those who are not members.69 This poses considerable problems for those seeking to encourage networked behaviours and collaborative structures.

People then align themselves, and identify closely with their own team or group.70 Teams and groups often demand or uphold loyalty from members. Deviants or those who are antigroup or antisocial can be subject to various forms of punishment71 such as being frowned on, gossiped about, left out, shunned or treated as being disloyal. These, among other determinants signifying identity, can lead to strong ‘us and them’ perspectives vis à vis other groups. Outgroups are often treated indifferently, unsympathetically or suspiciously.68 ,72 ,73 There can be prejudice, enmity or even hostility between groups.69 ,74 All told, this state-of-affairs calls for active strategies to promote collaboratively-oriented systems. However, can disparate teams and groups actually be joined-up by active agency into more expansive networks?

A four-factor framework for collaboration across teams and groups

From the literature assessment and content analysis, a framework synthesising and integrating the current state of knowledge was derived. Figure 2 provides four core factors for appreciating networked efforts: understanding the nature of gaps, using the leverage of boundary spanners, stimulating interactive relationships and exerting power via external influences. These were frequently occurring common factors embedded implicitly or accounted for explicitly in the included literature. Within each factor, various strategies with utility for sponsoring networked collaboration across teams and groups are evident.

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Figure 2

A conceptual framework for networked behaviours.

The figure depicts two social entities interfacing each other across an organisational divide. These could be, for example, two wards or two organisational units; or a group of doctors interfacing with another group of doctors; or a group of nurses or allied health professionals, working adjacent to each other. They are bounded, and will have greater or lesser levels of communication, connectivity or interactivity between themselves across the social space delineating them as separate groupings. The question is how to bridge the gap and thereby, help to promote networked connectivity. With that in mind, we turn to a brief description of the four factors and how these operate according to the synthesised studies in the non-health literature. This provides us with lessons about networking and how it operates elsewhere.

The nature of gaps (social or physical spaces, structural holes, disconnected ties) between teams and groups can be characterised and this information used to help join-up those who are unduly divided. Gaps can clearly act as barriers to knowledge and information exchange.63 ,75–77 However, gaps can also be useful: structural holes in networks,78 ,79 for example, offer opportunities for bridging behaviours. Once these gaps are recognised, people can begin to act to close gaps between teams and groups. All in all, a moderate level of spacing between teams and groups in complex social systems seems optimal in promoting interaction.80 ,81 Too many gaps or too wide the spacings between groups can indicate disunity or disintegration, which makes it hard to enhance linkages. Too few gaps, and narrowness increases the risk of poorly formed localised identities or the system being overconstrained, with no breathing space between the team or group. Building effective relationships across gaps or structural holes looms78 ,79 ,82 as an important activity in joining-up teams and groups. Collaboration and partnerships can be encouraged by understanding the nature of the outgroup and intergroup behaviours,68 and the unwritten rules between groups such as those that inform each potential partners’ views on their own and the others’ strengths, limitations and capabilities.83 ,84 Wenger's work on communities of practice85 ,86 and its application87 ,88 is a case in point.

Boundary spanners depending on the circumstances can bridge two or more groupings, and enable exchange and communication. Such roles are often highly regarded and those occupying them can make a valuable contribution in promoting connections between people and groups.89 Useful initiatives to promote boundary crossing include: identifying those with facilitation skills,90 or encouraging potential bridge-builders (those who span or straddle otherwise isolated teams and groups), connectors (people actively linking two or more teams and groups), liaisons (people who shuttle between teams and groups, enabling relations and communication), mavens (folks with a wide circle of contacts), opinion leaders (influential individuals to whom others turn to for advice or information) or cosmopolites (persons with wide-ranging interests and interactions). However, boundary spanners, in the process of fulfilling their role by bridging gaps inevitably alter relationships, and by their efforts to join-up two previously divided groups can create different boundaries and gaps elsewhere. Interestingly, liberal-leaning rather than conservative-leaning individuals are more likely to bridge gaps or boundary span, and advance collaborative activities.91 Gatekeepers play an important protective role in healthcare. For example, in some countries, general practitioners prevent patients from unnecessarily entering specialised healthcare and being over-serviced. However gatekeepers,92 blockers and manipulators can inhibit boundary-spanning behaviours. They need to be identified and their negative influences negated or minimised if networked, collaborative behaviours are to be realised.

This leads to the challenge of how to stimulate interactive relationships. Recurring ideas in the literature include: building joint social capital by emphasising mutual goodwill across teams and groups;74 ,93 formally linking otherwise disparate groupings together;92 providing informal opportunities to inter-relate,77 ,94 including creating commonly-available public space in which to intermingle;25 ,95 promoting dialogue and shared meaning between groups;96 agreeing on joint agendas;97 striving for inclusivity;98 ,99 supporting social diversity100 and generally encouraging, over time, connections and exchanges between teams and groups. These strategies can, depending on the circumstances, strengthen communication and information exchange. Leaders who support informal social activities and promote social ties, for example, after-work activities, can improve productivity and particularly, intergroup functioning and performance.101 People who have strong relationships across teams and groups, and are embedded in the larger organisational culture are less likely to signal an intention to leave their organisation,102 and this can be important in building long-term connectivity. Trust is an important commodity in linking teams and groups;103–105 so building up of trust is an important endeavour. Taken together, these strategies can help connect teams and groups. The right strategy-mix will need to be determined by formal and informal leaders and members of the teams and groups themselves, and are often defined by the context.

External influences can also play a bridging or dividing role. A tertius iungens agent (‘the third who joins’) who builds bridges can help facilitate group interaction, but a tertius gaudens agent (‘the third who enjoys’) can exacerbate existing divides, exploiting these for his or her own benefit.78 ,79 ,106 While there is some support for the notion that outsiders cannot readily dictate to teams and groups,67 other work suggests that group members who share a common enemy107 ,108 or jointly emphasise their distance from or aversion to other groups, thereby differentiating themselves,109 will be more likely to collaborate with each other. This has been a long held belief: if, as the old Arab proverb states, “the enemy of my enemy is my friend” then it is also likely to be the case that “my friend's enemy is my enemy”. Whether or not this is so, teams or groups sharing a negative attitude about or a perceived threat from a third party will be likely to move closer to each other.107

Some key theoretical perspectives

Various theoretical perspectives can be mobilised to explain these empirical findings and the four-factor model. We have specifically encountered two: Weick's tight-loose coupling helps us to understand the extent to which characteristics, such as rules or discretion, are at work in having greater or lesser effects on connectivity between teams and groups. Granovetter's strong and weak ties asks whether people adjoining each other are in a direct relationship, or more distant from each other, that is, merely acquaintances. Either theory can help to some extent illuminate networked patterns of behaviour, and suggest mechanisms to strengthen interactions.

Two other theoretical accounts stand out in further explaining the model. The phenomenon of ‘us and them’ is a subset of social identity theory,108 ,110–112 which suggests that humans have strong self-concepts tied to needs for belongingness with those in their in-group, and seek to identify with, be part of or embrace the attitudes and behaviours of their fellow group members. Consequences foreshadowed by social identity theory include robust bias in favour of the in-group, and preferential treatment for fellow members. In-group members are often seen to be estranged from, prejudiced about, competing with, scapegoating or even hating those in out-groups. Clearly, there can be strong pressures or motivations to affiliate with one's group and to distrust, treat warily or actively dislike other groups. Antidotes, such as those described in the conceptual framework for networking (figure 2), will likely need concerted, longitudinal effort to tackle ‘us and them’ feelings and behaviours. Even then, gains are not likely to be huge.

Another mechanism underpinning networking is described by reciprocity theory, also known as tit-for-tat,113 ,114 which predicts that teams and groups will retaliate equivalently. Tit-for-tat theory suggests that the way group members treat those in other groupings, whether badly or well, is more than likely to be reciprocated. This is exemplified by many game theory studies100 and much of the literature from the earliest time period, for example, “do unto others as you would have them do unto you” and “an eye for an eye and a tooth for a tooth”. Successive iterations of reciprocity can readily hard-wire into collaboration or hostility. This phenomenon is strongly related to trust.77 ,115 An optimal response pattern for collaboration across teams and groups seems to be: always start relationships cooperatively, do not be the first to defect, and practise forgiveness when wronged.114

Of course, there are other theoretical accounts which could be developed to help understand groups’ relationships. These include explaining how some teams or groups come to be especially good at connecting with nearby teams or groups compared with others who are not; the mechanisms of affiliation across teams and groups when it spontaneously occurs; specifying how one group comes to be dominant and another subservient; and concepts of mutuality versus rivalry, manifesting most frequently as cooperation versus competition. Each of these is likely to be fruitful to a greater or lesser extent in contextualising the relationships between teams and groups, and could be useful gateways to further research.

The nature of gaps and boundaries, and applications in healthcare

The core ideas of gaps, boundary spanners, interactive relationships and external influences found in the literature review are very well suited to the analysis of healthcare. There are concrete implications for healthcare settings.

Gaps interfering with joined-up services, a key feature of health systems, are very hard to bridge. Gaps can be the physical area between one department and another, the silos operating to structurally delineate medicine, nursing and allied health staff or the temporal divides that separate two or more groups working shifts. These can also emerge as the conceptual gulf between the attitudes of people in one part of the healthcare organisation or system and another. Gaps often manifest as the cultural differences demarcating one unit or professional group (‘us’) and the other (‘them’). All organisations create barriers and partitions which inhibit or prohibit collaboration because of specialisation, myopic internal focus or tribalism. Problems arise where this interferes with effective organisational functioning or the delivery of good care.

Boundaries are phenomena of interest if we have to learn to bridge gaps and create better networked systems of care. Boundaries can be sharp and obvious, as between hospitals and nursing homes or amorphous and unclear, as when two or more organisational groupings remain as separate entities, but share resources, leaders, staff or physical space (eg, different specialists; physicians and nurses; or day and night shift staff). In healthcare there are formal organisational gaps, that is, ‘you are department A and we are department E’, and physical or location gaps, that is, ‘we work here and you, behind that partition, across the corridor, on another floor, or in another building, are over there’. There are conceptual gaps, manifesting in differentiable mental models, that is, ‘you think that way, but we don't’. And there are behavioural gaps, as in ‘this is how we dress, speak, and practise, compared with you’. Gaps can be emotional, for example, two teams who have come to detest each other and are poles apart, or conceptually different, as in the gap between achieving a ‘personal best’ in a team developing a new model of care and a rival teams’ normal, everyday performance. However, categorised gaps and boundaries distinguish teams and groups, and define where one ends and another begins. For those seeking to influence the health system to thereby create networked care, these gaps and boundaries should not be ignored. Instead, by identifying the nature of gaps and boundaries, we can begin to focus on the efforts that are needed to join them up, and create more synergistic effort to improve care for the benefit of patients. This is perhaps the major lesson to take home from this review.