Team Effectiveness in General Practice: Insights from the Norwegian Primary Healthcare Team Pilot

Abstract

This chapter provides insights into team effectiveness in general practice. It is based on a qualitative case study from five purposively recruited Norwegian general practices participating in a pilot for implementing primary healthcare teams. To assess team effectiveness, 41 individual and group interviews were performed in the practices. The data production and the analysis were guided by Hackman’s team effectiveness model. Five overarching themes were identified: teamwork nature, buy-in, macro-team leadership, individual satisfaction, and performance outcome. Despite variation in the organizational context, the informants at four of five of the practices agreed that functional teamwork produced good and relevant results—primarily for the patients, as well as largely for themselves as it increased job satisfaction. The study shows that becoming real and effective micro- or macro-teams involves extensive, targeted, and time-consuming change work. Actual change requires leadership, buy-in, and a significant effort linked to structuring the teamwork. The results raise the question of whether it is a sensible use of resources to scale up and spread primary healthcare teams to all general practices in Norway. Management training as part of specialist training for all general practitioners to acquire the competence to lead effective micro-teams could be beneficial for teamwork development.

1. Introduction

Interprofessional primary healthcare teams (PHTs) are promoted as necessary for handling the complexity of contemporary and future healthcare provision and as essential for the ability to provide high-quality and safe healthcare [1, 2, 3]. Schmutz et al. [4] found that teamwork has a positive relationship to performance, regardless of the characteristics of the team or task, and concluded that healthcare organizations should recognize the value of teamwork and emphasize approaches that maintain and improve teamwork for the benefit of patients.

While the assumption that complex health issues are managed better by teams is widely endorsed, the implementation of such teamwork can be challenging [5, 6, 7, 8, 9, 10]. An overview of reviews of interprofessional collaboration in primary healthcare highlighted that most barriers and facilitators were reported at the organizational and inter-individual levels [11]. In general practice, the most frequently reported barriers to well-functioning teamwork between general practitioners (GPs) and nurses were at the system level (e.g., inadequate reimbursement policies for nurses’ services) and at the inter-individual level (e.g., traditional hierarchies, ideological differences in practice and cultural perception of care leading to power struggles, and difficulties regarding professional identity). The most frequently reported facilitators at the organizational level included tools for team communication (e.g., regular meetings, open channels of communication, and use of technologies) and close physical proximity between professionals. At the inter-individual level, the definition of roles and responsibilities and the acceptance of other professionals’ views, competences and practices, and shared leadership were reported. At the individual level, a positive attitude and interest in interprofessional collaboration was identified [12, 13].

The effectiveness of teamwork may vary according to the context [14, 15]. The importance of studying the effectiveness of a team in the specific context in which the teamwork is taking place is emphasized, because of the effect of the context on team processes, psychosocial traits (e.g., cohesion and norms), and task design [16]. A review of interventions to improve team effectiveness found that most studies researched different acute hospital settings and pointed out that less evidence is available about team effectiveness in primary care settings, including general practice [17].

Our study aimed to investigate team effectiveness in interprofessional primary healthcare teams in general practice. The study was carried out in connection with a pilot project introducing interprofessional PHTs in Norwegian general practice. The pilot is part of an international teamwork trend in general practice. The descriptions and evaluations of international initiatives show a diversity of organizational methods and results [18, 19, 20, 21]. The heterogeneity in health systems justify national pilots and associated evaluations in individual countries ahead of eventual whole-system changes.

This study provides contextual insights into team effectiveness. The fact that we are studying a change process that seeks to establish teamwork means that the study probably uncovers aspects that are different from those that would be found in a study of team effectiveness in an established teamwork structure. The study finds that effective teamwork is not necessarily achieved even when both effort and interest are present. Based on the findings, this chapter recommends strategies that can facilitate the implementation of interprofessional teamwork in general practice.

2. Theoretical framework

Health services research has focused on identifying the characteristics of effective teams and developing instruments for measuring team effectiveness [16, 22]. Team effectiveness can be measured by looking at objective outcomes (e.g., quality of care) or subjective outcomes (e.g., effectiveness as perceived by team members) [23]. The theoretical framework guiding the current study is Hackman’s model for assessing team effectiveness [24, 25]. The underpinning idea is that team effectiveness depends on three main outcomes: acceptable performance output, the growth and well-being of the team members, and the viability of the team. Performance outputs may include factors such as patient satisfaction, quality of care, adherence to clinical guidelines, and efficient utilization of resources. Performance output assessments are subjective and are carried out either by the team members themselves (as in this study) or by patients experiencing the teamwork. To achieve the outcomes, the model identifies six conditions: the performing unit is a real team; the team has a compelling direction or purpose; there is a strong and supportive structure; there is a conducive and supportive context; there is the right mix of competent and committed members; and there is competent coaching. Further, team effectiveness is seen as a function of three overarching processes: collective effort, use of knowledge and skills, and a strategy for carrying out the teamwork. The model acknowledges that the outputs of the team, in turn, become inputs for the next cycle of team performance. The outputs provide feedback to the team and influence future inputs, shaping the team’s ongoing effectiveness.

3. Study context

Since 2001, Norway has had a patient list system for general practice. This system gives each of the 5.4 million Norwegian citizens the right to be registered with a regular GP; only a minimal number of people opt out [26]. The primary objective of the patient list system is to secure access and continuity of care. Regular GPs provide consultations with their listed patients and coordinate the care of these patients within the healthcare system while also serving as gatekeepers to secondary care and sickness benefits. The GP service is a municipal service. Most GPs are self-employed and operate under an individual agreement with the municipality. A minority of GPs, particularly in rural areas, are employed and work in general practices owned by the municipality.

Over the years, the general population has been very satisfied with the patient list system [27]. In 2022, a regular GP had, on average, 1040 patients on his or her list [28]. GPs typically work in quite small practices alongside other regular GPs (mean: 5.0, interquartile range: [3–6]) [29], and it is uncommon for practices to include other professionals except medical assistants. Thus, interprofessional teamwork inside general practices is less developed in Norway than in many other European countries [30].

The Norwegian Directorate of Health initiated a primary healthcare team (PHT) pilot in the period April 2018–March 2023. The aim was to explore whether a PHT provided a better service for patients than the usual GP scheme. General practices were expanded with nurses, and PHTs included regular GPs, nurses, and medical assistants. PHTs were expected to offer home visits, quality, availability, continuity, and safe services and to work systematically and proactively with target patient groups such as weak demanders and patients with large and complex needs in four main categories: patients with chronic diseases, patients with mental health problems and/or substance abuse problems, frail elderly, and patients with developmental disorders/disabilities [31]. No further directions were given for how the teamwork was to be carried out.

The PHT pilot included 17 self-recruited general practices, each of which included between three and 17 regular GPs, between one and six nurses, and between two and six medical assistants. Each general practice comprised a macro-team and several micro-teams—a common structure, particularly in US models of primary healthcare teams [32, 33, 34, 35]. The macro-team included all professionals working in the practice and was led by a PHT manager (one of the GPs). The micro-teams were formed based on each individual GP’s listed patients and were led by the respective GPs. Normatively, a micro-team was expected to include the GP, a nurse, and a medical assistant (see Figure 1). As part of the pilot, the PHT managers were offered management training corresponding to 30 study credits.

Figure 1.

The micro-team and macro-team.

The pilot provided funding for the nurse resource in the approximate ratio of one nurse to three regular GPs. Nurses were employed with fixed salaries. The regular GP scheme is funded based on activity with approximately 30 percent capitation, and only the GPs’ work is financed. For the pilot, two funding models were available: the activity-based model and a block funding model. Patient co-payment was the same in both models. Within the activity-based model, the GPs claimed fees and patient co-payments as normal. The nurses claimed fees and patient co-payments for the services they provided, with around 50 percent of their salary funded by a fixed allowance from the state. The block funding model relies on risk-adjusted capitation as the main source of funding for the whole practice. Patient co-payments and payments by result indicators make up a small portion of the funding in this model.

By the end of June 2023, 12 percent of the listed patients in the 17 pilot practices had had contact with the PHT [36].

This case study is part of a greater multi-method evaluation study following the pilot [36, 37]. Author BA is an experienced healthcare researcher. Author AF has been working as a GP for 30 years. We share an interest in general practice and in how it can be developed to meet the population’s increasing and changing needs for healthcare.

4. Research question

We sought to answer the following research question: How do team members subjectively assess the team effectiveness of the micro- and macro-teams implemented in their general practice?

5. Methods

5.1 Sample

Five general practices with different profiles and staffing were purposively included in this interview study. Table 1 sums up some of the relevant characteristics of the selected practices. We aimed for variation in the choice of funding model, ownership, staff size and mixture, whether they had nurses before they joined the pilot, the fee-generation among the nurses, and geographical placement and size. The table also shows the number of interviews conducted for the present study and the proportion of the staff that participated.

		General practices
		Practice 1	Practice 2	Practice 3	Practice 4	Practice 5
Funding model		Activity-based model	Block funding model	Activity-based model	Block funding model	Activity-based model
Practice ownership		Private	Public	Private	Private	Public
Size of municipality (No. of inhabitants)		[20,000–50,000]	[5000–20,000>	> 0.5 million	> 0.5 million	[5000–20,000>
Municipal centrality		Semirural	Rural	Urban	Urban	Rural
Nurse new with PHT		No	No	Yes	Yes	No
Fee-generating contacts with nurses		60% joint consultations, 17% sole consultations	53% home visits, 33% sole consultations	56% sole consultations, 8% basic contacts	55% sole consultations, 23% basic contacts	58% sole consultations, 36% basic contacts
No. of practice staff	No. of GPs	10	6	4	5	10
	No. of PHT nurses	3	2	2	1	2
	No. of other nurses		4			4
	Medical assistants and other personnel	7	2	4	2	2
No. of indivi-dual interviews	GPs	7	4	4	4	7
	PHT nurses	2	2	1	1	2
No. of group interviews/informants	Nurses, medical assistants and other personnel	1/4	2/4	1/3	1 / 2	1 / 5

Table 1.

Key characteristics of the five selected general practices.

Three of the practices were funded on the activity-based model, and two had block funding. The number of GPs varied from four to ten, and the practices had between two and six medical assistants. Two of the practices had previously had nurses. In the pilot, each of the five practices engaged between one and three PHT nurses. The practices were in different parts of Norway and covered urban and rural areas. The interviewees were PHT managers (5), GPs (21), PHT nurses (8), other nurses (7), and medical assistants (11).

5.2 Qualitative interviews

The data for our study were collected 4 years after the start of the pilot. Based on Hackman’s model for assessing team effectiveness, we designed interview guides with the aim of exploring team effectiveness in the micro-and macro-teams in the five practices. To prepare themselves, the interviewees received a thematic interview guide with key topics in advance (see Table 2). The interviewer used a more detailed, structured interview guide with specific questions, making sure that all interviews followed the same order and covered all the themes.

PHT managers, GPs, and nurses	Medical assistants
PHT in this general practice Results and benefits of PHT The importance of PHT for patients Teamwork skills Teamwork challenges Freedom of action in the teamwork Teamwork effects Losses associated with the teamwork Team size and associated expertise Need and opportunity for skills development PHT management Working methods within the general practice Self-evaluation of the teamwork	PHT in this general practice The medical assistants’ role in the teamwork Results and benefits of PHT The importance of PHT for patients Collaboration with the GPs Collaboration with nurse(s) New challenges with teamwork Losses associated with the teamwork Team size and associated expertise Need and opportunity for skills development PHT management Self-evaluation of the teamwork

Table 2.

Thematic interview guide to interviews with PHT managers, GPs, nurses, and medical assistants.

In May and June 2022, 41 structured interviews were performed, five on videocalls and the rest face-to-face in the practices. The PHT managers, GPs, and PHT nurses were interviewed individually, while the other health professionals were interviewed together in groups of two to five participants. The interviews lasted on average 57 minutes (median: 50, min/max: 16/75). They were audio-recorded and transcribed verbatim.

5.3 Analysis

Data analysis of the transcripts was performed with thematic analysis according to Braun and Clarke [38]. We were inspired by an abductive approach in qualitative research [39] theoretically informed by Hackman’s model for team effectiveness. Both authors read the material thoroughly and worked together to reach consensus in interpretation of themes in the qualitative data. We generated and negotiated initial codes and text extracts representing the participants’ experiences with introducing teamwork in macro- and micro-teams and collated these into potential themes. The analysis was performed stepwise; first with five overarching themes being named (see Table 2) and then with the material within each practice being analyzed considering the five overarching themes. In an iterative process, we reviewed the sub-themes considering the research question and the coded extracts, named them, and finally condensed and synthesized the extracts into analytic text. Our preconceptions were mixed when it came to the PHT pilot, leading to a fruitful balance in our approach to the analysis and discussion. The stepwise analysis of text from each practice made it possible to compare and discuss similarities and differences between the different funding and organizational contexts. The five PHT managers were invited to read through and comment on the text, resulting in minor adjustments.

5.4 Ethics

The Norwegian Agency for Shared Services in Education and Research was notified of the study (#405955) and ensured that the planned data processing was in accordance with data protection legislation. Ahead of the interview, all participants received the interview guide and information about the study. Agreement to take part was implicit through attendance at the interview.

6. Findings

The analysis identified five overarching themes capturing the informants’ team effectiveness assessments: teamwork nature, buy-in, macro-team leadership, individual satisfaction, and performance outcome (see Table 3).

Themes	General practices
	Practice 1	Practice 2	Practice 3	Practice 4	Practice 5
Teamwork nature	Well-structured macro teamwork. Unified way of micro-team working and generally structured patient follow-up procedures. Most of the nurses’ fee generation stems from joint consultations with the GP.	Well-structured macro teamwork. Flexibility but largely a unified and highly coordinated way of working in micro-teams. Most of the nurses’ fee generation stems from home visits.	Some structure in the macro teamwork. No unified way of micro-team working. Most of the nurses’ fee generation stems from their sole consultations with patients.	Some structure in the macro teamwork. No unified way of micro-team working. Most of the nurses’ fee generation stems from her consultations with patients and basic contacts with patients and others. One PHT nurse is partly doing medical assistant work.	No structuring of the macro teamwork. No unified way of micro-team working. Most of the nurses’ fee generation stems from their sole consultations with patients and basic contacts with patients and others.
Buy-In	Strong among all the GPs and nurses. Varied among the medical assistants.	Strong among all the professional groups.	Weak among most of the GPs. Varied among the nurses. Strong among the medical assistants.	Varied among the GPs.	Varied among the GPs. Strong among the nurses. Indifference among the other professionals.
Macro-team leadership	Firm and clear. The PHT manager is referred to as a very good leader by fellow workers.	Present, clear, enthusiastic, and inclusive.	Partly absent. Challenging to conduct consensus management when consensus is lacking among the GPs.	Partly absent.	Completely absent during the Covid-19 pandemic. Distance leadership of the practice is also a negative factor.
Individual satisfaction	High and consistent among the GPs and nurses. Varied among the medical assistants.	High and consistent among all the professional groups.	Varied among both the GPs and the nurses. Strong among the medical assistants.	Varied among the GPs. Strong in the nurse. Low among the medical assistants.	Varied among the GPs. Strong among the PHT nurses. Indifference among the other professionals.
Performance output	Health benefits for patients.; Increased job satisfaction.	Health benefits for patients. Increased job satisfaction.	Increased quality of patient care. Increased job satisfaction.	Increased quality of patient care. PHT has made it possible for the GPs to be salaried and use time on macro-team meetings without economic loss. This is highly valued among the GPs.	Varied opinions.

Table 3.

Overarching themes in team members’ evaluation of PHT effectiveness in the five selected general practices.

6.1 Teamwork nature

The nature of the teamwork varied greatly between the practices. At Practice 1 (P1), the teamwork was based on formalized patient follow-up procedures. It was mainly carried out in joint consultations led by the nurse, with the GP attending the final phase. The informants said that they had worked hard on developing the procedures and on finding a common way of working. The nurse and the GP communicated electronically in real time during the consultation, and the GP had to find time to participate in the final phase. There were no formal meetings between the individual nurse and GP other than these consultations in which the patient also participated. The nurses had a weekly meeting among themselves and a meeting with the PHT manager to discuss PHT-related topics. The PHT manager and the GPs also had regular meetings. The informants spoke of these meetings as being important for the development of procedures and the common way of team working. The working method was continuously evaluated and adjusted. The GPs agreed that they were the ones who controlled the patients’ access to the PHT and that there had to be a clear plan for the team follow-up of individual patients. The use of formalized procedures was seen as an assurance for high-quality and equal services. The GPs agreed that a certain degree of individual difference between them was fine but that this had to be balanced so that the patients received equal services. The nurses reported that they had the same approach to the micro-team working with all the GPs.

The work at Practice 2 (P2) was described as team-based, with several nurses having been on the staff long before the PHT pilot was established. Participation in the pilot had provided a larger nurse resource and a more targeted use of this resource. Previously, a nurse had had largely the same function as a medical assistant. In the PHT, all the nurses took on nursing tasks that demanded more competence. Two nurses (the PHT nurses) mostly worked in the PHT. The other nurses worked in the PHT as a minor part of their jobs. As part of the PHT, the nurses followed up patients, according to agreed procedures, in their own consultations, either in the patient’s home or in the practice. The PHT nurses had weekly meetings with the individual GPs in which current patient follow-up in the micro-teams was discussed. The whole staff participated in daily 10–15-minute morning meetings and often in short informal “debriefs” when the phone lines had closed for the day. The informants agreed that they had developed a clear, common structure and way of micro-team working.

At Practice 3 (P3), Practice 4 (P4), and Practice 5 (P5), no manifest structures or common teamworking methods had been developed. Most of the nurses’ fee-generation stemmed from their own contact with patients. In P4 and P5, a high proportion was from basic contact (not directly PHT-related) with patients and others, suggesting that the nurses did tasks that the medical assistants could have done just as well. At P3 and P4, there were weekly whole-staff meetings with PHT themes on the agenda. However, although patient follow-up procedures were developed on paper and it was decided that there should also be weekly meetings between each individual GP and the nurse, the micro-teamwork was carried out to a varying degree. The GPs often occupied the meeting time with patient consultations. At P5, there was no established meeting structure or framework whatsoever to support the teamwork. The nurses at all the three general practices spoke of great variation in their micro-teamwork with the individual GPs: with some GPs, it worked very well; with some, it worked less well, and with some, there was no teamwork at all.

6.2 Buy-in

Buy-in also differed between the practices. At P1, the GPs and nurses unanimously expressed great commitment and buy-in to the PHT. They had transformed into the PHT with great desire. The medical assistants did not, however, express the same buy-in. They believed that they should have been more involved in the teamwork. Several of the other informants said that they had tried to bring out the medical assistants’ important macro-team role in ensuring good patient flow, communication, and interaction. The PHT manager said that they had been concerned with creating ownership and team spirit among all the staff. He emphasized that the PHT was a joint assignment:

We are explicit that we must be something more. We must be something extra. And what can you contribute to this extra […] be clear that we work as a team. We need your participation and your commitment to this team, so that the team is not a manager and some workers, it is a shared responsibility. (PHT leader, P1)

At P2, all the informants expressed strong team affiliation. Several said that their sense of ownership had developed over time. Many pointed to the PHT manager’s commitment and targeted work to involve everyone as an important factor for team buy-in.

At P3, the informants talked about many replacements among the GPs and an accompanying challenge in creating team ownership among the new GPs and GP locums. The PHT manager explained the other GPs’ lack of ownership by saying that they did not experience the same degree of quality and relief in workload from the PHT as he did himself and that they paid too much attention to their own earnings. The other GPs largely confirmed this explanation. One GP was explicit that it was out of the question to “pay” nurses for work that she felt she had the capacity to do herself. The situation was nevertheless experienced as a dilemma, as the GP also saw the professional need for team follow-up among vulnerable listed patients. The nurses and medical assistants expressed a clear team commitment. They talked about the difficulties in creating buy-in among new GPs who had more than enough to do with getting to know their listed patients. The new GPs were not sufficiently informed about the PHT and did not know what to do to become part of it.

At P4, the informants described varying degrees of buy-in between the professions. The PHT manager believed that this had to do with several changes. The practice had expanded, with two new GPs, and both the initial PHT manager and the initial nurse had left. The GPs generally expressed satisfaction with the teamwork, but the new nurse said she lacked a plan for how to work. The medical assistants felt they were sidelined and not heard. They had not been given any special team role, and tasks that they enjoyed had been lost to the nurse.

The PHT manager at P5 spoke of a wide range in the GPs’ views of the PHT—from completely passive and uninterested to enthusiastic and committed. This was confirmed in the individual interviews with the GPs. The nurses said that it had been challenging with an experienced GP staff who had no desire to change their way of working. During the PHT pilot, new GPs and younger GP locums had come in, making teamwork easier because the newcomers were more used to working with nurses. The medical assistants felt barely involved in the PHT. When they, and some of the GPs, talked about the PHT, they meant the PHT nurses. When asked why, one of the medical assistants replied:

In other practices it seems like they’re all involved – it is us in the practice who are the PHT. Whereas here we have always perceived [the PHT] as them [the PHT nurses]. […] So, I feel there is something we’ve missed. (Medical assistant, P5)

6.3 Macro-team leadership

At P1 and P2, all the informants spoke very positively about the PHT managers’ leadership. At P1, the PHT manager was referred to as a very capable leader, with great drive and commitment to the PHT. His macro-team leadership was foregrounded as being decisive in what they had achieved. However, several informants added that the leadership had a good foundation, in that some of the other staff members had a similar commitment and buy-in and that the staff had allowed itself to be led. At P2, all the informants highlighted the PHT manager as committed, inclusive, positive, and solution-oriented. Her clear objective was that everyone should take part in the teamwork. At both practices, it was pointed out that there was a big difference between the PHT managers before and after they had attended management training. The management training gave the PHT managers both the competence and the authority to lead.

The PHT manager at P3 considered himself too old for management training and was unsure of its usefulness in a practice with a flat structure. The PHT manager believed that his management had to be based on consensus, and as consensus was lacking, it was difficult for him to lead. The staff experienced his leadership somewhat differently. The GPs mainly thought that the PHT manager had done a good leadership job. The nurses pointed to a lack of time for leadership in a hectic everyday life.

The PHT manager at P4 had also completed management training. However, he found it challenging to take over the leadership role in addition to handling a full patient list. The GPs were divided in their views of his leadership. The medical assistants and the nurse said that they experienced too little leadership and missed being followed up.

The PHT manager at P5 had also participated in management training. However, his assessment was that there had been a clear deficit in PHT management. For a long period, his resources had been used for the municipality’s handling of the Covid-19 pandemic. The other informants experienced a clear absence of leadership of both the PHT and the practice. Since the municipality had taken over the administration of the practice a few years earlier, a municipal health manager had formally managed the practice on a part-time basis. This person was not regularly present at the practice, was not a GP, and, according to the PHT manager, lacked the legitimacy to lead the GPs. As municipal employees, the nurses found that it was the municipal health manager who controlled their working hours and work content. During the Covid-19 pandemic, it had been more important for the municipality that they did other tasks than PHT work.

6.4 Individual satisfaction

At P1, all the GPs and nurses said that they were satisfied with the teamworking. At P2, all the informants expressed that they enjoyed teamworking and experienced it as meaningful. In both practices, the informants said that teamwork provided a greater professional community than before. Several GPs pointed out that it was nice not to be so alone with the patients as they had previously been. The teamwork made them do a better job, and this brought them great joy. Both PHT managers saw it as a great privilege for the practices and the local community to be part of the pilot.

At the other three practices, individual satisfaction with PHT varied widely both within and between the professional groups. At P4, one nurse had her last day when the interview was done. She had resigned because she felt that her expertise was being misused as a lot of her time had been spent doing medical assistant tasks. At P5, the medical assistants talked about a frustrating work situation with a heavy workload and low job satisfaction. At the time of the interview, one medical assistant was on long-term sick leave, and another had got a new job at a hospital.

6.5 Performance output

At P1, P2, P3, and P4, almost all the informants had concrete stories about individual patients who had greatly benefited from their teamwork. The informants pointed out that the teamwork (when it was functioning) gave higher quality, more of an overview, a more stable patient follow-up process, and time to explore unclear issues. They also talked about patients expressing satisfaction with team follow-up. The systematic approach facilitated by the procedures contributed to reducing errors and improving workflow. At P1, the informants believed that the PHT also gave a larger production than before.

At P1, P2, and P4, the informants were most definite in their judgment that the teamwork not only increased the quality of patient care but also gave patients better health and well-being. At P3, several informants pointed out that team follow-up was particularly useful also for their listed population, where many had an immigrant background, were economically poor, had a low education level, and for various reasons did not follow up their own illness(es) well enough.

In the case of P4, the choice of the block funding model had enabled the GPs to switch from variable income to having a fixed salary. Several of the GPs were satisfied with this. The funding model had given them the opportunity to hold meetings and follow up patients without being worried about finances.

In P5, the results of PHT were assessed differently within and between the professional groups. The nurses and some GPs talked about positive results for the patients in the same way as the informants at the other practices, but there were also informants among the GPs and medical assistants who either thought it was difficult to assess the results because the PHT objective was unclear or believed that the PHT had not brought about any change whatsoever.

Although the quality of patient care and the health-related results for the patients were noted as the most important, many of the informants at P1, P2, P3, and P4 pointed out that the teamwork provided job satisfaction and security for themselves. It also gave them someone to share their joys with—someone who knew the patient and, for example, knew the effort that had been put in to get to the position where they could help someone who was mentally ill. The PHT had changed their attitudes and the respect they had for each other. It had increased their understanding and appreciation of everyone’s contribution. The impact of the PHT on job satisfaction was mentioned to a lesser extent by the informants at P5.

7. Discussion

This study shows that becoming real and effective micro- or macro-teams in general practice involves extensive, targeted, and time-consuming development and change work. In addition to clear leadership, actual change requires buy-in and a significant effort linked to structuring the teamwork. The organizational context for teamwork, which is most clearly reflected in the informants’ stories about teamwork nature, buy-in, leadership, and individual satisfaction, varied widely between the five practices. P1 and P2 largely fulfilled the criteria, conditions, and processes set by Hackman [24, 25] to create team effectiveness. The other three practices (P3, P4, and P5) had been less successful in this. However, despite variations in the organizational context, the informants at P1, P2, P3, and P4 agreed that functional teamwork produced good and relevant results, primarily for the patients as well as largely for themselves as it increased their job satisfaction. These results are in line with findings in other studies [4, 15, 34, 40]. The stories told by the informants at P1 and P2 indicate an increase over time in their ability to collaborate. Role clarification and a reasonable distribution of labor in both the macro- and the micro-teams ensured that different skills were used well. This teamwork viability was present to a lesser extent in P3, P4, and P5. Important reasons for this seem to be turnover, especially among the GPs, and a lack of both macro- and micro-team leadership. It cannot be ruled out that the reason for turnover was a lack of success in changing to teamwork. Lack of structure, leadership, and support had a negative impact on the assessments of team effectiveness; for example, the team members to a lesser extent had a common perception of the purpose of the teamwork, and the distribution of responsibility and tasks was to varying degrees agreed upon in the macro-teams. The negative impacts of turnover and a lack of leadership are known, from other studies, to hamper teamwork [7, 9, 41, 42].

The patient list system set natural frames for the micro-teams, and the medical assistants seemed to have no function or enhanced role in these teams. This contrasts with the way in which the micro-teams were normatively described as part of the pilot [31] and with findings from other studies [33, 34]. However, the medical assistants had an important role and contribution to the macro-team and the functioning of the practices. Our study shows that a micro-team (i.e., a GP and nurse) can function well even if the practice does not achieve a unified way of micro-teamworking. However, the fact that certain micro-teams function less effectively reduces the overall team effectiveness in the practice. The informants’ descriptions indicate that different aspects determined the micro-team practice. The GP’s buy-in was important, and what seemed to be decisive was whether the GP took the expected leadership and managed the micro-team for the benefit of their listed patients in the target group. The GP’s experience was also important. New GPs needed time to get to know their listed patients and find out who might benefit from team-based follow-up. In addition, it seemed that new GPs were not sufficiently socialized into PHTs and only partly understood the concept, which is related to a lack of macro-team leadership, buy-in, and support at the practice. On the other hand, some young GPs connected more easily to teamwork because they were used to it from hospital settings, while some old GPs wanted to continue in their usual way of working.

Hackman’s normative model for assessing team effectiveness (1987) has been a suitable theoretical starting point for our study. However, the model is not specifically developed for assessing teamwork in general practice. It emphasizes the importance of real teams as a condition for team effectiveness but does not pay particular attention to aspects related to turnover in teams. Turnover was a significant issue at three of the practices (P3-P5) in our study. Turnover, especially among GPs, probably creates some unique challenges in a patient list system. It takes time for new GPs to gain an overview of their listed patients’ needs. At the same time, the Norwegian list system is largely built on self-employment and individual contracts between GPs and the municipalities, which promotes GPs’ autonomy and not teamwork. For studies in general practice, it may be appropriate to add team stability as a condition for creating team effectiveness.

The funding models (activity-based or block funding) did not in general seem to have a decisive impact on teamwork effectiveness. This might relate to self-selection into the funding models. However, the fact that teamwork could give a lower income to self-employed GPs funded on the activity-based model was highlighted as an explanatory factor for the lack of interest in teamwork among informants at P3, while the opportunities that came with the choice of the block funding model were highlighted by the informants at P4 as something that enhanced teamwork. Similar perceptions have been identified in previous studies [42, 43]. The fact that our informants did not place more emphasis on financial aspects may have to do with the fact that Hackman’s model does not include these aspects. This could be a potential weakness with the model when studying team effectiveness in a general practice model based primarily on self-employed GPs.

Tuckman’s [44] sequential stages of development for groups solving tasks together (forming, storming, norming, and performing) is an alternative theoretical framework that can help make sense of team development. In the forming phase, boundaries for work tasks and relationships are tested at the same time as the individuals adjust to management, other team members, and the existing system. The storming phase is characterized by resistance and often conflict, linked to team influence and expected involvement. In the norming phase, resistance is overcome, the content of the collaboration and cohesion develops, and new standards, roles, and trust are established. In the performing phase, the structures are in place and support the tasks to be performed. Our findings suggest that at the time of the interviews, the five practices were in different phases. P1 and P2 had probably reached the performing phase, while it is likely that P3, P4, and P5 were still in the forming phase, mainly due to turnover and an absence of leadership. Awareness of Tuckman’s four stages could be useful for studies on teamwork implementation in GP practices. Our study demonstrates that moving from one stage to the next does not happen automatically.

A strength of this study is that we interviewed almost all the health professionals at the practices and that the interviews were structured. Participation in the pilot was based on self-selection of the practices. There is reason to assume that at the participating practices, there was a genuine interest, among at least some of the staff, in bringing about a change to a more team-based way of working. Even though both time and interest have been present, our findings show that effective teamwork has not necessarily been achieved.

In their systematic literature review, Buljac-Samardzic et al. [17] show that studies on improving team functioning in healthcare focus on four types of intervention: training, tools, organizational (re)design, and programs. Programs refer to combinations of different interventions. Although the review mostly covers studies conducted in hospitals, the interventions seem relevant in connection with an eventual scaling-up and spread of PHT in Norwegian general practice. Our study shows that the management training offered to the PHT managers as part of the pilot had a positive impact on the development of teamwork, on both the macro and the micro levels. This could be a selection effect. On the other hand, it suggests that the PHT management training should be maintained. Our findings indicate that there will also be benefits in management training for all GPs so that they can acquire competence to lead effective micro-teams. This can, for example, be part of the specialist training in general practice.

Further, our findings indicate that the practices that participated in the PHT pilot have each spent a lot of time developing procedures for the team-based follow-up of different target patient groups. As part of the scaling-up and spread, such procedures should be standardized at national level with associated instruction manuals, including possibilities for sensible local adjustments [45]. Several of the practices in the PHT pilot have used information technology to carry out efficient, systematic searches of the patient lists to identify residents in the target groups who could benefit from team-based follow-up. This could develop into standard procedures. Both our study and others show that clear structures to ensure communication in the team are extremely important. Coombs et al. [32] find that the use of huddles (structured, brief, routine (multiple times a day), and face to-face communication between all members of a team) is both common and effective.

Organizational (re)design focuses on intervening in structures, which will consequently improve team functioning. Norwegian general practice is largely based on self-employment and individual contracts between each GP and the municipality through the general GP scheme system. Most GPs are organized into group practices. It is currently not an option for the municipality and a group-based practice to establish a contract on broader group services. Structural change that provides opportunities to enter into collective agreements on team-based services could support the development of teamwork to a greater extent. The interventions we have pointed to could form a program to support the further development and eventual scaling-up and spread of structured teamwork in Norwegian general practice.

8. Conclusion

Our findings indicate that well-functioning PHTs will be able to provide patients with good-quality primary care and that those who work in well-functioning teams are likely to experience increased job satisfaction. Well-functioning teams require leadership, buy-in, and a significant effort linked to structuring the teamwork and thus are resource-demanding. At general practices that are unable to create this type of team effectiveness, the positive results for patients and healthcare personnel are less likely. Based on our findings, we assume that on a large scale, there will be practices that will not succeed in becoming effective teams. There is also reason to believe that GPs in some practices will not be interested in teamwork at all. Our findings raise the question of whether it is a sensible use of resources to scale up and spread PHT to all general practices in Norway. The danger of a full-scale implementation of PHT is that the allocation of resources to this kind of teamwork might be a waste and create larger differences in the population’s health service provision and associated health outcomes. On the other hand, knowing the many benefits of effective teamwork, it is important to look for strategies that can facilitate a stepwise full-scale implementation. Our study shows that it is important to have time and expertise for overall management of the macro team at the GP practice. However, it appears that micro-teams can function well regardless of the nature of the macro-team. Specialist training in general practice may be a favorable arena for providing GPs with expertise in the management of micro-teams. A low-threshold facilitation of micro-teams may give an opportunity for individual GPs and other health personnel to experience the benefits and challenges of teamwork.

Acknowledgments

Margrete Gaski participated in the study planning. She died in May 2022 and is therefore not included among the authors. The authors are very grateful to Margrete for her contribution. They would also like to thank the five participating general practices for all their help with arranging the interviews and the interviewees for sharing their views and experiences. The authors are members of the research team that evaluated the primary healthcare team pilot in Norway. The pilot was initiated by the Norwegian Directorate of Health (NDH), and they also funded the evaluation. The NDH had no role in the design of the study, the collection, analysis, and interpretation of data, or the writing of this manuscript. The publication charges for this article have been funded by a grant from the publication fund of UiT the Arctic University of Norway.

Conflict of interest

The authors declare no conflict of interest.