Challenges of Inter-Professional Teamwork in Nigerian Healthcare

Inter-professional teamwork in government owned hospitals and various healthcare institutions involving various Professionals such as Doctors, Pharmacists, Medical Laboratory Scientists, Medical Laboratory Technicians, Medical Laboratory Assistants, Nurses, Physiotherapists, Radiographers, Health Information Officers, Human Resources Managers, etc. is becoming a challenge leading to various strikes and labour protests in Nigeria. The patients and family relatives and host communities of such health institutions are becoming uncomfortable with quality of care due to inter-professional discord. This needs a critical discussion towards solving/looking into the challenges such as Personality differences, Health Leadership and Hierarchy, Disruptive behaviors, Culture and ethnicity, Generational differences, Gender, Historical inter-professional and intraprofessional education, Fears of diluted professional identification, Differences in accountability, payment and rewards, Concerns regarding clinical roles and responsibilities, Complexity of care, Emphasis of rapid decision making, Service timing, with Associations and Unions. The exploration would provide solutions for better teamwork practice and improved patients care.


Introduction
Inter-professional teamwork is where various professionals such as doctors, pharmacists, medical laboratory scientists, medical laboratory technicians, medical laboratory assistants, nurses, physiotherapists, radiographers, health information officers, human resources managers and others who work in the healthcare institutions, work together with patients, care givers, families and communities to deliver the highest quality of care [1].
The World Health Organization (WHO) [2] defined inter professional teamwork or collaboration as a situation where multiple healthcare workers from different professional background work together with patients, care givers, families and host communities to deliver the highest quality of care. This is essential in a situation where health care professionals assume complementary roles and cooperatively work together, sharing responsibilities for a problem solving, and decision to formulate and carryout plans for adequate patient's care.
Available evidence however suggest that unlike in the developed world, health care professionals do not collaborate well in Nigeria because of the claim of superiority of a particular health professional like physicians who always claim healthcare leadership and owners of patients which creates more conflict among other healthcare professions that is threatening to tear the health care sector apart, to the detriment of the patients [3].
Most of the challenges faced in the health care sector are due to; several month salaries owed, poor welfare, lack of appropriate healthcare facilities and other emerging factors among health workers.
Researchers have found out that working together reduces the number of medical errors and increases patient's safety [4]. Teamwork also reduces issues that lead to burnout, no longer is one person responsible for the patient health. Today, an entire team of health workers come together to coordinate patients' well-being and it reduces both surgical and diagnostic errors [5].
Teamwork is based on solid communication among healthcare workers with the patients and their families sometimes to feel more at ease. They accept treatments and feel more satisfied with the health care [6] when there is good communication backed up by team spirit.
The teamwork significantly reduces workloads, increases job satisfaction and retention, improves patients' satisfaction and reduces morbidity [7].
This chapter shall examine the Nigerian situation on teamwork and the challenges/hindrances which affect the positive outcomes of quality health delivery. Notably, Nigerian Health workers are knowledgeable on the teamwork and the possible positive outcomes [8][9][10], but the challenging factors have contributed to the less concerns on the teamwork practice and if well addressed, Nigeria shall improve on the next level of positive outcome of healthcare laced with teamwork.

Hindrances of teamwork in healthcare sector in Nigeria
Teamwork has been advocated across the globe. The Nigerian healthcare shows interest in teamwork across healthcare institutions, however some mitigating factors hinder the teamwork spirit and the expected positive outcomes.

Personal values and expectations
Knowing that teamwork requires collaboration and understanding within the health care sector, personal values and expectations of team members counts. Personal values have to be well maintained in other to understand each other. Guiding principles and understanding the core mission of work without letting in expectations and one's personal interest to outweigh the team interest is essential.
In Nigeria, personal values and interest, depending on the exposure and family financial base challenges professionals on how well to work as a good team member or not. Poverty and stress attached to financial crisis may limit expected outcome of services or team outcome.

Professional distribution
Distribution of health workforce has been another serious challenge due to inadequacy in the recruitment and number of personnel in various health facilities. Abimbola [11] did not mince words when he puts it that the low and inequitable distributions of healthcare workers remain an elephant challenge in the Nigerian healthcare sector. Bangdiwala and colleagues [12] opined that there is a global crisis in health workforce as a system by acute shortage and uneven distribution of health workers in several settings. In Nigeria, expert have reported that historically, "brain drain in the form of migration of health workers to high income settings as a major setback in the country" [13]. Current statistics show that one in four doctors and one in twenty nurses trained in Africa are currently working in developed countries, with this contributing to the short fall of over 1.5 million healthcare workers in the African region [14]. Healthcare workforce density in Nigeria, is estimated at 1.95 per 1000 population [15]. These figures reveals disparity and shortage of health professional man-power and may contributes to less attention to team work. In order to handle the huge workload, there should be due consideration to team work and collaboration which makes workload better handled with ease.
In the midst of unequal distribution of healthcare staff, there is embargo on employment of medical laboratory scientists in many healthcare institutions as compared with Doctors and Nurses. This situation leads to lopsided approach and heavy workload on a particular profession thereby stampeding teamwork especially in patients care management.

Personality and professional differences
Personality traits exist in addition to professional differences depending on the different roles as legalized in various countries of practice, an instance of Nigeria.
While some see the practice of medicine as an autonomous one-on-one relationship between the clinician and the patient, others see it as a team work towards a better patient outcome. The challenge emerges when a particular profession in a healthcare setting takes ownership of patient and assumes that other healthcare professionals that come in contact with the patients are not important. This relationship remains a core value in Medicine but it is challenged by many concepts of teamwork and shared care thereby, hindering the sharing of information of their patients through medico-legal implications of team-based care.
Many healthcare workers have shown different views and ways of doing certain thinking in this regards. This serves as a barrier to inter professional teamwork where one behavior or attitude differs from the other and sometimes, the attitudes can be traced to professional differences.

Hierarchy and health leadership
Hierarchy among medical professionals in Nigeria is a serious challenge in teamwork practice in Nigeria. Before 1985, the headship of healthcare institutions was not specific but based on the most qualified professional to hold such office. Not until 1985 when Decree 10 was promulgated for the Teaching Hospitals to be headed by Chief Medical Director (CMD) who must be a Physician (Medical Doctor), registered and licensed. This Decree has been replicated in all health institutions without adequate legal backing. This removed the competency in administration and management in Nigerian healthcare to the hands of Doctors who may or may not have the adequate knowledge in practice of administration and management.
Currently, it is difficult to have a health team where the teams' decision would be accepted if the team leader is not a medical doctor. Strong hierarchical nature of medicine graduates rating as number one in Nigerian healthcare sector pushes for only the doctors to be both Ministers as appointed in the Federal Ministry of Health, Health Agencies, State Ministries of Health and all Hospitals. In a typical Nigerian healthcare, most decisions by a team is not accepted if not headed by a Doctor and this has really posed as a challenge to other professions within the sector.
Supremacy/Headship challenge especially in the health institutions leadership has developed an ugly trend of which team works stands better chance to handle. It was Alubo [16] that opined that the health workforce crisis in the country have taken unique and worrying dimension. In reality, other healthcare workers have alleged that the Nigeria health system is designed to favor doctors mainly, especially in management of health sector not minding if there is certificate or experience in management or not. The alleged dominance of doctors over the years have encouraged other health sector unions (JOHESU) to put up resistance.
In the health care system, different positions and categories are allocated to the health care professionals on the basis of levels. The upper echelons of the hierarchy are superior to the ones occupying the lower level, and thus the communication and collaboration might be formed and therefore serve as a hindrance to interprofessional treatment.
Rosanne [17] posits that difference in attitudes in inter-professional healthcare about who is ultimately in charge could be an "Achilles' heel" across the globe. In Nigeria, the Doctors are fully in charge in all medical interdisciplinary teamwork. There is need to give further attention, because agreement with the concept of shared team decision-making is fundamental to effective interdisciplinary work of any kind. The question of who is in charge is a complex issue with complicated legal, ethical, and professional ramifications.

Disruptive behavior
Most health workers want to be given full attention alone. When this occurs, teamwork cannot be enjoyed; because others might feel less valued and would not be listened to. This serves as a barrier in inter-professional team work.
The situation where every health professional in Nigeria threatens for work to rule, strike and industrial actions based on one issue or the other with other disruptive behaviors makes it very impossible to continue team spirit in healthcare in Nigeria.

Culture and ethnicity
While there has been a growing acknowledgement that teamwork is important in health care, this has not necessarily been translated into changed practices, especially in emerging and developing nations like Nigeria where cultural norms of communication may mitigate against teamwork. Communication gap is huge because of Federal Character and Catchment area policies of government.
In the healthcare sector in Nigeria; culture and ethnicity serves as a gap in team work. When a client and a health professional are from different background; the difficulty in language, communication and understanding occurs. It might be hard to get a translator and this therefore, ends the means of achieving a goal. Different clients come from different background; therefore the means of understanding within the healthcare system is limited.
Some culture or practices maybe due to religion. This may pose a challenge especially where women abhor medical attention from men or vice versa.

Generational differences
Having a varied generation representing a team will create a barrier in interprofessional teamwork, some health workers have a particular age range; and might have some ideas, attitude or values. When these cannot be maintained, it creates so many differences. The generation gaps puts the just graduated health professional who may be probably doing Internship and full of information communication technology (ICT), savvy to have different approaches to case managements as team members with others who have grown from the ranks while working as a team. The ethical issues serves as a bridge but in some cases, the idea of a junior colleague or team member may be logical but not tolerated in terms of respect and ethics from the senior ones and creates some differences as a team.

Gender
Following the medical practice history, women were nurses and men were physicians; but recently, men are becoming nurses and more women are becoming physicians, although men represents only 7% of the nursing population, and medicine is almost equally represented by both men and women. A study by Wear & Keck-McNulty [18] and Lotan [19] supports the concept that female nurses are more collaborative with female physicians, the result from the qualitative survey shows that female nurses reported higher level of collaboration with female physicians than male physicians. Gender has always been a barrier to collaborative healthcare achievements due to issues concerning on whom to be given several position between a man and a woman [20]. Gender equity in any health team is very important [21].
Gender sensitivity is very import in formation of good teams. In cases were professional members are dominated by men or women, such gender differences poses some challenges in the team performance.
In Nigeria, the women are more among the nurses and men are more among other professionals though there is serious improvement towards mixing the gender unconsciously. In some critical cases, women are required especially to attend to women concern on special or personal preference within the team, but where they are lacking it poses more challenge to the teamwork.

Historical inter-professional and intra-professional education
Various healthcare professionals have different educational backgrounds especially in Nigeria where all professions -Physicians, Pharmacists, Medical laboratory scientists, Nurses etc. have their root traced to other countries of the world. In Nigeria, most of the professions started as Certificates, Diploma, and Degrees.
Take for instance, the training of Medical laboratory scientists originated from London [22]. The first categories of the professionals went to London to train as medical laboratory assistants, technicians and technologist. But currently, it is in country training as medical laboratory scientist of which their background of training or professional status should not be a barrier to teamwork with other healthcare professionals. When various professionals look at historical evolution and education rather than harnessing capacities to improve teamwork, it poses a challenge.

Fears of diluted professional identification
There exists fear of one profession thinking that another profession would learn the job and practice the profession without licensure and adequate certification because of collaborative work as noted in teamwork.
While teamwork enthrones collaboration and sharing of ideas based on professional skills and knowledge, the authors believe that it does not take ones professional status away or dilutes professional identification. However, this fear dominates Nigerian healthcare team practice.

Differences in accountability, payment and rewards
Dispute over accountability, salaries, rewards and allowances in the Nigerian healthcare sector have continued to emerge day in day out among other factors.
Poor remuneration and welfare has also been identified with cases of partiality depending on the professionals involved. The increasing cost of goods and services in Nigeria with increased inflation rates has made it possible that no amount paid to health workers will be enough to satisfy them. Oleribe [23], reported that poor remuneration and wages, poor welfare of the healthcare workforce have led health workers to embark in numerous industrial action due to several month salaries owed and poor working conditions. This strikes and threats of strike continues unabated even at the time of writing this chapter.
In a recent survey of senior management staff of health institution in Nigeria, massive discrepancies in remuneration of health workers in the same grade level across federal, state and local government were observed [24].
Payment and reward are determined based on the position and levels of the professional and this therefore can be mistaken and seen as a means of underrating a particular worker.
In Nigeria, various payment and salary structures exist. We have Consolidated Medical Salary Structure (CONMESS), salary scale for medical doctors and Consolidated Health Salary Structure (CONHESS) for other healthcare professionals. The challenge is that CONMESS puts medical doctors more important in healthcare as other professionals lament frequent review of CONMESS and not same for CONHESS. The argument is that the Chief Executives who are all medical doctors prefer to favor their colleagues to the detriment of other professionals. This is a major factor affecting the team spirit as it is evident that a team comprising of Doctor, Pharmacist, Medical laboratory scientist, Nurse, Radiographer, and Physiotherapist who are in the same grade level shall definitely go home with different amount as wages and emolument even though they are in the same team.

Concerns regarding clinical roles and responsibilities
Currently in Nigeria, there exists considerable changes and overlapping in the professional roles played by different health professionals. Ordinarily, from the training levels, there are basic inter-professional expositions of what the health professionals do up to practical terms for knowledge sake but all professionals are licensed to practice their profession [20]. For instance, radiographers can read plain film X-rays, Clinicians, Nurses, Pharmacists can perform some simple medical laboratory tests and their various professional license of practice may not cover such areas as prescribed by law regulating their various practices. These changing roles and task shifting leads to some team challenges in terms of role allocation and acknowledgement.

Complexity of care
Complexity of care may involve changing settings based on the fact that "nature of health care is changing including, increased delivery of care for chronic conditions into community care and many surgical procedures to day-care centres. These changes require the development of new teams and the modification of existing teams" [20] thereby causing instability of teams.
Health-care teams can be transitory in nature, as it is when coming together for a specific task or event (such as cardiac arrest teams or molecular testing teams). The transitory nature of these teams places great emphasis on the quality of training for team members. This raises challenges in medical care where education and training is often relegated at the expense of service delivery [25]. This is because, most healthcare managers in Nigeria lay emphasis on doing the job than more training for the healthcare professionals who do the job. The complexity of care is found in intensive care nursing, surgical cases, molecular and advanced techniques in medical practice associated with the severity of illness and the caring intensity which poses threat to teamwork.

Emphasis of rapid decision making
Decision making with regards to teamwork helps the health workers to be open in discussions. When the decisions are made from certain workers without others involved in such discussion, it creates a teamwork challenge and thus can lead to misunderstanding among the healthcare professionals. This could be due to differences in status among the health workers. And others might feel that their ideas are not welcome, and therefore reduces their efforts. This has been the case where decisions are taken for medical laboratory services in Nigeria in absence of medical laboratory scientist in most management decision-makings in various Nigerian hospitals. Such decisions could be challenged or some approvals returned unattended to due to the lacuna or professional errors. The team spirit diminishes leading to job dissatisfaction [26] in cases where some medical laboratory reagents and consumables are approved or even purchased without adequate input by medical laboratory scientist on the validity and certification of such products towards quality outcome.

Time
Lack of time is a barrier to collaboration and achievement of goals. Time must be given to all team members to collaborate including the clients. Due to the shortage in nursing profession; nurses today have larger patients' number to attend to providing for a limited amount of time to spend with each patient. Combined parttime work with increase patient loads and there is a little for health care providers to interact with each other and their patients. Collaboration requires trust and to build trust; people need time for interaction [20]. Due to shortage of health professionals in Nigeria most especially medical laboratory scientists in various hospitals possibly because of increased unemployment created by healthcare managers and Chief Executives who are Physicians, the robust interaction time in teamwork practice is affected because of the crowded patients in need of attention and numerous samples for analysis with reference to the medical laboratories.

Associations and unions
In Nigeria, associations and unions are very strong forces that affect team work in Nigerian healthcare. There are numerous associations as each professional body has their association and related ones went ahead to form unions and recently, some unions joined to form common front for strong bargaining power with the government and that lead to formation of the Joint Health Sector Union (JOHESU). On the other hand, the Nigeria Medical Association (NMA) is umbrella association of all Medical Doctors/Physicians in Nigeria. There are other sub group associations of NMA depending on their area of specialization or the level of practice.
The team work becomes a hard nut to crack in Nigerian healthcare sector for the fact that NMA do not believe that anything good can come out of JOHESU and vice versa. Such has grown to its obnoxious apogee to the extent that what government approves for JOHESU professional members are being opposed by NMA not minding how good the package may add to healthcare practice or to the motivation and job satisfaction of the beneficent. In the course of writing this chapter, the authors observed that an approval by government to Pharmacists (Figure 1) was challenged by NMA on the 16th September, 2020 when their National publicity secretary, Dr. Aniekeme Uwa posited that NMA "will find a permanent solution to the unwarranted assault on the integrity of the noble profession" followed by the JOHESU members and leadership while commending the federal government of Nigeria on behalf of Pharmacists the Secretariat released a statement of the 18th September, 2020 and "wonders how the approval of a consultant cadre in Pharmacy practice would amount to an assault on the integrity of medical practice". JOHESU expects the government to extend the Consultant status to other healthcare professionals as the consultant cadre in health systems is not a sole attainment of a particular profession.
NMA 24 Point agenda and JOHESU 15 Point demands has been two major causes of strike and industrial actions in Nigerian Health industry. Most of the time, the need of one is in direct opposition to the other and makes the dispute resolution not in any way near in Nigeria.
JOHESU demands and counter demands by NMA and vice versa has reached its obnoxious apogee that disbanding the Associations and unions may not really be the solution. For example, the NMA and JOHESU strike in 2014 were based on doctors/nurses, doctors/pharmacists, doctors/medical laboratory scientists, doctors/allied health professionals protracted supremacy challenge. Challenges of Inter-Professional Teamwork in Nigerian Healthcare DOI: http://dx.doi.org /10.5772/intechopen.95414 In the last 10 years, there have been calls to address those prevailing issues especially on the provision of better facilities for disease diagnosis and treatment, improved health workforce and remuneration and a health care scheme. On notable response in the National Health Act, which was signed into law by the former president Goodluck Jonathan on October 31, 2014, Albeit generated diverse disagreement and interest among various health professionals and stakeholders in the preceding 5 years [27].
The goal of the health sector is to ensure delivery to affordable, accessible, equitable and safe health services to the population and in achieving this, every health workforce has an important role to play. However, the challenge posed by associations and unions in Nigerian healthcare is a major hindrance to teamwork.

Approaches to good teamwork in healthcare sector in Nigeria
For a healthcare sector to attain a good team work; health professionals must know how to practice collaboration with improved communication and partnership among all health providers and patients; Clarity on the role of all healthcare providers working within team environment; Better response processes in addressing issues related to healthcare; Effective utilization of health care resources. This leads to team's provision of healthcare services and high level of satisfaction on delivery of services among team members [28][29][30].
All effort should be in place in Nigerian healthcare institutions so as to mind every one's values and assumptions that affect interactions with team members who are definitely other professionals. No matter the strengths and weaknesses of different team members, good teamwork helps to deliver quality and safe care [31][32][33].
Psychosocial factors of team members should not be allowed to affect team interactions. However, the impact of change on team members should be recognized. There is a need for the healthcare leadership to organize workshops and training [34] on teamwork and conflict management with the aid of role plays with small groups and ability of healthcare managers to understand the characters of stress and conflict within the system. Such programmes improves knowledge [35]. Professionals' development among healthcare teams cannot be ignored while encouraging all professionals to show respect for each other [36,37].
Training and practice of emotional intelligence (EI) helps the care givers and healthcare managers in resolving conflicts. It is also imperative to use personality traits and characteristics instrument like crew resources management (CRM) or core self-evaluation (CSE) on conflicts to assess team members who have conflict or less conflict traits.
Also, break the barriers of team communication gaps in healthcare through teaching effective communication strategies, training team members together within undergraduate and postgraduate levels and during team formation stages, stimulate team members together during training or work, redefine healthcare team members to include all healthcare professionals, and make teams democratic in nature in all strata of communication. The healthcare teams should be supported with protocols and procedures such as check lists, IT solutions and briefings and adequate development of organizational culture that support healthcare teams [38].
Patients are the center of every medical team and there is a need to include them as team member in any team function.
The hierarchy of professionals over others should be well considered so that no one profession is exalted over other in healthcare team considering that everyone is very important. It should be however put that the heads of any team should be the most qualified and experienced based on years of service and certifications in management and administration, no matter the professional affiliation. It will not be a Mutual support techniques should be employed in resolving conflicts, using communication techniques [28] while changing and observing behaviors of medical teams. Such support is expected of NMA and JOHESU to each other where the success of one is success of all in the healthcare industry. The NMA is not the government and neither is JOHESU and both should partner in requesting from the government for better healthcare in Nigeria rather than sabotaging each other before the government especially in the aspect of remuneration, promotion and approval of consultant status for other medical and health professionals in the spirit of teamwork.
There should be a close review and consideration by the Nigerian Federal Ministry of Finance and Budget and Planning Office to reconsider review of Salaries of all Medical and Health practitioners in Nigeria. This shall ensure that a team comprising of Doctor, Pharmacist, Medical laboratory scientist, Nurse, Radiographer, and Physiotherapist who are in the same grade level shall definitely go home with same amount as wages and emolument when they are in the same team and same salary grade level. Having considered the length of training during entry points for all professionals in Nigeria, it is germane to pay equally all team members no matter their profession when they are at the same grade level in a team. For example, if all team members are at Chief Level (Grade Level 14) all of them should be paid the same salary. The authors call the attention of Nigerian government as a measure to deal with incessant strike actions among healthcare workers in Nigeria, to work out a uniform salary structure when all health workers can be paid or revert back to normal salary grade level with adequate allowances for all and not necessarily CONHESS and CONMESS. Though entry points of various professionals may differ, when all those in same level are paid equally, the team spirit shall be encouraged and strengthened.
There is an urgent need in the Nigerian health system to build sustainable leadership, through national health system administration policy that allows alignment consideration and coherence of priorities and partnership in the health workforce and among various stakeholders [39,40] towards a formidable team work which would provide an improved outcome of patients who are the customers in the healthcare industry [41,42].
Round table for all health professionals and inter-professional training may help as they may tend to table their challenges, and rub minds on the best approach to teamwork and conflict resolution.
Teamwork involving all professionals is urgently needed as it creates understanding of importance of all professionals involved to operate in harmony [43,44]. Currently, the teams experiences in Nigeria are of one profession with varying levels but the team spirit should cut across all health professionals. The mutual distrust tension and supremacy challenge among the health workforce need to stop as a matter of priority. The focus of health service should be on teamwork rather than factional or individual strength [45].
There is need to design a contextually adaptable framework for inter professional education and collaboration practice in the health sector as recommended by WHO, to further facilitate successful cooperative communication and teamwork in health care service delivery and ensure a healthcare needs and delivery [46].

Conclusion
The inter-professional or interdisciplinary healthcare teams face a set of challenges that are not necessarily encountered by other types of team such as uni-disciplinary or non-health care teams. The importance of inter-professional teamwork is increasingly recognized in healthcare administration and management as possible positive outcomes outweigh the disadvantages. There is improved quality of healthcare for patients, community and healthcare professionals.
Teamwork is difficult to tackle, while making the environment become more complex. But if there is focus on the part of the team, the challenges can be overcomed through workshop and training, joint professional training, improved communication strategies, putting aside professional differences, adequate remuneration of the teams based on their levels and allowing all professionals who are qualified to lead a healthcare team to do so without singling out a particular profession as healthcare leaders.
For teamwork to be updated and applied in the Nigerian healthcare, various healthcare professionals such as Doctors, Pharmacists, Medical Laboratory Scientists, Medical Laboratory Technicians, Medical Laboratory Assistants, Nurses, Physiotherapists, Radiographers, Health Information Officers, and Human Resources Managers should put aside personality and professional differences for the team interest; ensure qualified and certified health leadership and hierarchy; stop disruptive behaviors; neutralize culture and ethnicity interferences; blend the generational differences; ensure gender equity and fair play; work with current status and knowledge without historical inter-professional and intra-professional education; remove fears of diluted professional identification; Ensure accountability, payment and rewards to which ever profession as due without discrepancies and antagonism; Respect all professional roles and responsibilities; carry all along in decision making; provide services with a good turnaround time; and show less interest in Associations and Unions when it comes to team work but adequately manage it with government towards successful teamwork and good healthcare practices.