Reaching into the district: strengthening the eye care team
From individual patient care to population care
VISION 2020: The Right to Sight has provided a vision and a common goal for eye care programmes. It has provided the paradigm shift, or change in the way of thinking, from individual patient care to population care, a shift from each person doing a job or task, to a group working to eliminate avoidable blindness. Such a common goal needs a team approach.
The VISION 2020 approach proposes that activities should be planned and implemented for a defined population and geographical coverage and promotes the concept of a manageable unit of a population of 500,000 to one million, termed a VISION 2020 delivery unit. Recommendations on targets for services and resources required have been made as unit ratios of the delivery unit, for example two to four ophthalmologists, four to ten ophthalmic nurses per delivery unit. This implies that there is a team responsible for the eye health of the population of a VISION 2020 delivery unit.
The concept of teamwork
The term team is not commonly used by eye care providers who are more familiar with groups of professionals such as ophthalmologists, ophthalmic nurses, optometrists, support staff, management etc. The concept of teams and team building is more familiar to the management culture.
Management has used the team concept and team building whether in the factory or in organisations to achieve efficiency, effectiveness, job satisfaction and a shared vision. Dr Meredith Belbin, one of the world’s leading experts on team building, has conducted research into group interactions and concludes that all members of an organisation have a dual role. The first role, the functional one, is obvious: an eye care provider belongs to the team because s/he is an ophthalmologist, ophthalmic nurse, records officer, anaesthetist, hospital administrator or whatever. The second role, the team role is defined by Dr Belbin as “a tendency to behave, contribute and inter-relate with others in a particular way”. Members of the team vary in their tendencies, some like action-oriented roles, others are best at people-oriented roles, while others perform the thinking roles for the team. Belbin has identified nine Team-Role types. 1,2,3
Belbin’s team roles
|Action-oriented roles||Contributions||Allowable Weaknesses|
|SHAPER||Challenging, dynamic, thrives on pressure. Has the drive and courage to overcome obstacles.||Prone to provocation, offends people’s feelings|
|IMPLEMENTER||Disciplined, reliable, conservative and efficient. Turns ideas into practical actions.||Can be somewhat inflexible. Slow to respond to new possibilities.|
|COMPLETER/FINISHER||Painstaking, conscientious, orderly, anxious, searches out errors and omissions. Can finalise something that has been started with complete thoroughness.||Delivers on time. Inclined to worry unduly. Weak delegator.|
|People-oriented roles||Contributions||Allowable Weaknesses|
|CO-ORDINATOR||Mature, confident, a good chairperson. Clarifies goals, promotes decision making, delegates well.||Can often be seen as manipulative, off loads personal work.|
|TEAMWORKER||Co-operative, mild, perceptive and diplomatic. Listens, builds, averts friction. Very good with awkward people and place the group’s interests before their own.||Can be indecisive in crunch situations.|
|RESOURCE INVESTIGATOR||Curious, communicative, extrovert, innovative, explores new areas and opportunities. Develops contacts. Requires close involvement with people, skilled in the use of resources and fits easily into management teams.||Over-optimistic. Loses interest once initial enthusiasm has passed. Requires challenge, non finisher.|
|Thinking roles||Contributions||Allowable Weaknesses|
|PLANT||Creative, imaginative, unorthodox. Solves difficult problems.||Ignores incidentals. Too preoccupied to communicate effectively.|
|MONITOR/EVALUATOR||Sober, strategic and discerning. Sees all options, judges accurately.||Lacks drive and ability to inspire others.|
|SPECIALIST||Single-minded, self-starting, dedicated. Provides knowledge and skills which are in rare supply.||Contributes only on a narrow field. Dwells on technicalities.|
The team role is due to one’s personality and is not tied to one’s profession. One person might combine the technical role of ophthalmic assistant, with the team role of resource investigator, exploring opportunities for increasing community-based services. Another might have the same technical role, but be more of an ‘implementer’, good at turning ideas for a new service delivery model into practical actions.
Dr Belbin also promotes the concept that nobody is perfect but a team can be. A team is capable of sustained and enduring success as it builds up a store of shared experience, information and judgement.
‘Horizontal’ and ‘vertical’ teams
In eye care programming to achieve VISION 2020 there may be ‘horizontal’ and ‘vertical’ teams. A horizontal team is made up of workers who function within the same health administrative level, e.g. an eye unit, an ophthalmology department. It can be represented by a series of concentric circles with the number of staff increasing in the outer circles.
A vertical team is made up of staff who function at different administrative levels but are responsible for the coverage of a geographical area or a population unit, e.g. eye care providers who work in a health district. These two types of teams will have some members belonging to the vertical as well as a horizontal team (Figure 1). The regional ophthalmologist could belong to the horizontal team in his/her hospital and the district ophthalmic nurse could belong to the district health management team.
Building a team
A team does not happen by chance but needs to be built. The first stage is the sharing of a vision, a common goal. The next is building the team. The following may be the challenges.
With the horizontal team:
- breaking down professional boxes and recognising the complementary nature of the work of each team member
- acknowledging the inter-dependency of each team member to achieve the shared vision
- defining roles, responsibilities, job descriptions and shared information
- recognising the role and function of sub-teams, e.g., operating theatre team, outpatient team
- ensuring representation/feedback of sub teams in the main team
- resolving potential conflicts of interest and promoting co-operation of members on other teams, e.g., ophthalmic nursing matron and the hospital nursing department.
CASE STUDY The Gambia National Eye Care Programme
The vision of The Gambia’s National Eye Care Programme was to reduce blindness due to cataract. There was a lack of trained human resources and people for training. The vertical team concept used paramedics to deliver cataract surgery and other eye services at each divisional health facility.
The team was responsible for the eye health of a population of 150,000-200,000. Roles, responsibilities and limitations of clinical management of the cadre were defined. They were trained in management skills to enable them to take responsibility for the eye health of the defined population and to lead their sub district/division eye care teams.
The supervising ophthalmologist met with the team during quarterly visits to provide service, supervision, support, some supplies and training. Best of all was when a joint visit was possible of the ophthalmologist, the programme manager and the equipment technician. Using this concept of vertical and horizontal teams has resulted in achieving a cataract surgical rate of 2000 and integrated eye care services from community to tertiary level in a sub-Saharan African country.
A vertical team usually has members of the same or similar profession. The main challenge is the long distance team membership. Frequent communication is essential and visits for problem solving, supervision, support, and training are crucial to prevent professional isolation and ensure quality and standards.
Strategies to achieve a team culture in eye care programmes
Training should include the team concept and team building skills, leadership and vision building within a management module.
Training of teams rather than individuals, aiming at achieving a goal rather than transferring knowledge and skills to an individual, e.g. a programme wishing to provide paediatric ophthalmic services would train a team made up of an ophthalmologist, anaesthetist, nurse etc. The teamwork will be reinforced by the shared training experience.
Composition of teams should include a mix of personnel, e.g. a district eye health horizontal team is made up of one ophthalmologist, four ophthalmic nurses, eight general nurses, one driver, one secretary etc. The district vertical eye health team is made up of one district ophthalmologist and four sub-district senior ophthalmic nurses. The sub-district eye health vertical team is made up of a sub-district senior ophthalmic nurse and the sub-district community ophthalmic nurses.
Co-opting members into the team on a short or long-term basis when additional skills are needed. Scheduled and regular team meetings which cover work plans, review targets, successes, failures, unforeseen events, ‘post-mortem’ reviews of shared events, resolve controversies and reach consensus and planning for the next period. The systematic recording of the minutes of the meeting, and rotating the chairing, help the team stay focused and develop each member of the team.
Celebrations of outstanding performance of a particular team member.
Support group which would also respect personal privacy.
Linkage of the horizontal team to the vertical team to help break down the box which isolates institutional care from population coverage as staff have to function within and between levels of health care and between individual care and population care.
In countries where lack of resources is a major problem, the careful management of financial and other material resources can be what keeps a programme alive. A good management structure ensures that human resources are available in quantity, quality and deployment and that they have the infrastructure and technology to deliver services. Belbin’s team roles become particularly pertinent in the management team. VISION 2020 – a shared vision – requires teams whose members have a functional as well as a team role to deliver it.
1 Belbin R M. Team Roles at Work. Oxford: Butterworth-Heinemann; 1993.
2 Belbin R M. Management Teams – Why they Succeed or Fail. 2nd ed. Oxford: Butterworth-Heinemann; 2003.
3 Meredith Belbin. Homepage on the internet (accessed 26 August 2004). www.belbin.com