Creative Nursing, Volume 23, Issue 2, 2017

Competition Versus Collaboration in

Health Care Teams

Orlando R. Chapa, DNP, RN, NE-BC

Sobha M. Fuller, DNP, RN-BC, NEA-BC
Lisa J. Hernandez, DNP, RN, CENP
TaShauna McCray, DNP, RN

Innumerable teams have emerged in health care, spurred by the desire to improve
patient quality and satisfaction, provide better population outcomes, and reduce per
capita cost. Team leaders are faced with many choices in team development, such
as collaboration or competition. Although each approach has unique advantages and
disadvantages, is one approach better suited to building the teams needed in today’s
environment? This review examines these two distinct team-building approaches. A
literature review of these two approaches in light of the theoretical frameworks of social
identity theory and team role theory shows support for both ends of the spectrum; how-
ever, collaboration was linked more often with highly successful and effective teams.
Ultimately, the literature demonstrates that collaboration is better suited to developing
teamwork capable of achieving today’s complex health care goals.

Keywords: competition; collaboration; teamwork; health care; social identity theory;

team role theory Orlando R. Chapa,
DNP, RN, NE-BC,
n comparing collaboration and competition within teams, one might assume that is the assistant vice
I collaboration automatically facilitates teamwork, based merely on its definition.
Collaboration, “to work with another person or group in order to achieve or do some-
president at Cook
Children’s Hospital in
Fort Worth, Texas.
thing” (Collaboration, n.d., p. 1), offers the opportunity to cooperate and lead team
members to interdependent mind mapping. Collaboration tends to make team mem-
bers more accountable to each other when shared goals are established (Kohn, 1986).
The definition of competition is “the act or process of trying to get or win
something that someone else is also trying to get or win” (Competition, n.d., p. 1).
Therefore, someone wins at the expense of someone else’s loss. This article ex-
amines whether a collaborative or a competitive approach to teamwork is better
suited to our evolving health care environment.

Sobha M. Fuller, DNP,

COLLABORATIVE APPROACHES TO TEAMWORK RN-BC, NEA-BC, is an
associate chief nursing
In 1999, the Institute of Medicine (IOM) report, To Err Is Human: Building a Safer officer at CHRISTUS
Health System, discussed problems in health care delivery, including the sobering Trinity Mother Frances
fact that tens of thousands of deaths occur annually as a result of preventable med- Health System in Tyler,
ical errors (IOM, 1999). The Agency for Healthcare Research and Quality (AHRQ) Texas.

© 2017 Springer Publishing Company 97

http://dx.doi.org/10.1891/1078-4535.23.2.97
 used the report’s recommendations to spearhead a coordinated effort to identify
system issues contributing to such errors. Both the ARHQ and IOM denote inad-
equate interdisciplinary collaboration as a contributing factor in systemic errors
(Baker, Gustafson, Beaubien, & Salas, 2005; IOM, 1999).
In 2002, the AHRQ partnered with the Centers for Medicare & Medicaid Ser-
vices (CMS) to develop a survey to determine the patient perspective of hospital
care provided, known as the Hospital Consumer Assessment of Healthcare Pro-
viders and Systems (CMS, 2013). Several survey questions examine perceptions
Lisa J. Hernandez,
DNP, RN, CENP, is the around teamwork and communication.
chief nursing officer The Institute for Healthcare Improvement (IHI) further challenged the health
and vice president care system through its Triple Aim initiative, focusing on providing patient-
of Patient Care Con- centered care, improving population health, and controlling costs while providing
tinuum at Sarah Bush safe and quality care through collaborative health care teams (IHI, n.d.). Today’s
Lincoln Health System
health care environment presents challenges for leaders, including building and
in Mattoon, Illinois.
maintaining highly effective teams.
Theories support both competitive and collaborative approaches in building
highly effective teams, including social identity theory and team role theory. Henri
Tajfel’s social identity theory, developed in the 1970s, emphasized the importance of
understanding “the group in the individual” as well as the individual in the group
(Trepte, 2006, p. 255). Tajfel found that individuals who perceived themselves as
being a member of a group displayed a sense of meaning, team favoritism, and
enhanced teamwork. Team members developed a personal connection to the team,
resulting in enhanced self-esteem, improved social identity, and direct competition
TaShauna McCray, with other teams (Trepte, 2006). Belbin’s team role theory explored roles of indi-
DNP, RN, is the chief
viduals comprising a team to determine the impact of an individual’s behavioral
nursing officer at Cy-
press Fairbanks Med- strengths and weaknesses on team performance (Belbin Associates, n.d.). Belbin
ical Center Hospital in concluded that an understanding of team roles plays an essential part in improving
Houston, Texas. work relationships, developing highly effective teams, establishing mutual trust,
and improving team understanding and collaboration (Belbin Associates, n.d.).
Collaborative and competitive approaches are used throughout health care
systems in an effort to reduce errors, obtain higher patient satisfaction scores,
and provide overall patient-centered care. Competition inside organizations is a
generally accepted practice in promotion of “innovation, efficiency, and perfor-
mance” (Siliciano, 2013, p. 2). Research now indicates that an increase in collab-
oration improves patient outcomes and patient and provider satisfaction (Rabb,
Will, Richards, & O’Mara, 2013), and that “cooperative work is more efficient than
purely competitive work” (Wittchen, Krimmel, Kohler, & Hertel, 2013, p. 320).
The IOM report, Keeping Patients Safe: Transforming the Work Environment of
Nurses, discussed the linkage between a healthy work environment (HWE) and
enhanced patient outcomes, identifying organizational leadership, practice, cul-
ture, and work flow as key areas of concern for health care organizations to focus
efforts to optimize the work environment while improving safety and quality of
care delivery (IOM, 2004). Collaboration has been recognized by the American
Association of Critical-Care Nurses (AACN) as one of six standards necessary to
build an HWE (AACN, 2005). The AACN model (Figure 1) conceptualizes how col-
laboration contributes to an HWE and to optimal patient outcomes. Collaboration
requires effective team communication, trust, credibility, team appreciation, and
shared decision making (Blake, 2013; Sawa & Swift, 2013). Moreover, increased
levels of collaboration have been noted to result in higher levels of performance
and improved outcomes among teams (Sawa & Swift, 2013).

98 Chapa et al.
Figure 1. Healthy work environment.
American Association of Critical-Care Nurses. (2005).

The AACN’s HWE model proved to be effective beyond the profession of nursing
through its use in the Core Competencies for Interprofessional Collaborative Practice de-
veloped by the Interprofessional Education Collaborative (IPEC, 2011). The AACN en-
dorses the principle promoted by the IPEC and the World Health Organization (WHO)
that all disciplines should come together to influence agreed changes to address op-
erations of health care systems to improve clinical outcomes (IPEC, 2011; WHO, 2010).
The AACN model also offers in-depth critical elements to be used as a framework for
promoting true collaboration. These elements can be summarized as team members
embracing the concept of collaboration, skilled communication from leaders and team
members, and role modeling of collaborative behaviors (AACN, 2005).
Team members must understand the value of being collaborative, especially if
they have previously functioned in a competitive environment. The IPEC (2011)
describes one approach to convincing staff of the benefit of collaboration by focus- Collaborative
ing on “virtues in common” (p. 17)—core values that many professional health
and competitive
care workers hold, such as caring, respect, and beneficence. In practice, this means
approaches are
capturing team members’ hearts and minds by relaying stories in which success-
ful collaboration yielded positive results for patients and for workers themselves. used throughout
Another way to foster collaborative practice is through modeling of collabora- health care
tive behaviors (Blake, Leach, Robbins, Pike, & Needleman, 2013). One approach for systems in an
modeling can be applied via the shared governance model, allowing nurses to col- effort to reduce
laborate in their own professional practice. Such models use collaborative tools in- errors, obtain
tended to improve nurses’ work environment, satisfaction, and retention (Sanders,
higher patient
Krugman, & Schloffman, 2013)—in turn, affecting quality of work and outcomes.
satisfaction
scores, and
COMPETITIVE APPROACHES TO TEAMWORK
provide overall
As previously stated, competition inside organizations is a generally accepted patient-centered
practice in promotion of “innovation, efficiency, and performance” (Siliciano, care.
2013, p. 2). Competition has been shown to improve team performance, decision

Competition Versus Collaboration 99

 making, cooperation, and collaboration (Cooke, Kavussanu, McIntyre, & Ring,
Team members
2013; Markussen, Reuben, & Tyran, 2013), as well as individual levels of enjoy-
must understand ment and determination (Cooke et al., 2013). However, a few studies also suggest
the value of being that competition could significantly impact team performance by diminishing in-
collaborative, terpersonal connections and group cohesiveness (LeBouc & Pessiglione, 2013).
especially if they High levels of competition within a team tend to drive members to make im-
have previously provements, and they typically meet organizational goals, but characteristics of
highly competitive teams include distrust among members, individuality, and op-
functioned in
portunism (Anik, Aknin, Norton, Dunn, & Quoidbach, 2013). In health care, nega-
a competitive
tive implications of highly competitive teams include decreased patient satisfaction
environment. with staff teamwork and communication, and decreased employee satisfaction,
potentially resulting in lower organizational reimbursement (Wittchen et al., 2013).

CONCLUSION
Ultimately, the future of health care relies on our ability to achieve healthy and
collaborative work environments. Successful organizations and teams will adopt
and deploy methods to foster collaborative and positive teamwork in both clinical
and administrative domains.
Many initiatives, from the IHI Triple Aim to the public reporting of data, are
changing how health care is delivered (IHI, n.d.). Clearly, the focus is shifting to-
ward highly effective teams offering better service, quality, and patient autonomy
in this new paradigm. To achieve these aims, we need health care teams capable
of working within their system walls, as well as across disciplines and societal
spectrums. The literature points toward a more highly collaborative approach in
building these diverse teams for today’s health care environment.
As leaders of teams, we must navigate the direction of the team based on team
needs. If time, demand, and efficiencies are the driving force for the team, a com-
petitive edge should be considered by the leader. If team synergies are nonexistent,
resulting in teams silos, a collaborative edge would be better suited for the team.
Successful health care organizations today recognize that collaborative teams
make a major difference in achieving strategic goals and providing successful
patient outcomes. Team members must communicate effectively, encourage one
another’s creativity, and maintain high team spirit. High-performing collabora-
tive teams that are strong and agile inspire better results in achieving high quality
outcomes for patient populations.

REFERENCES
American Association of Critical-Care Nurses. (2005). AACN standards for establishing and
sustaining healthy work environments. Aliso Viejo, CA: Author.
Anik, L., Aknin, L., Norton, M., Dunn, E., & Quoidbach, J. (2013). Prosocial bonuses in-
crease employee satisfaction and team performance. PLoS One, 8, e75509. http://
dx.doi.org/10.1371%2Fjournal.pone.0075509
Baker, D. P., Gustafson, S., Beaubien, J. M., & Salas, E. (2005). Medical teamwork and pa-
tient safety: The evidence-based relation (AHRQ Publication No. 05-0053). Rockville, MD:
Agency for Healthcare Research and Quality.
Belbin Associates. (n.d.). Belbin team roles. Retrieved from http://www.belbin.com/rte.asp?id=8
Blake, N. (2013). Collaboration: A key component of excellence. AACN Advanced Critical
Care, 1, 30–32. http://dx.doi.org/10.1097/NCI.0b013e31827b7848

100 Chapa et al.

Blake, N., Leach, L. S., Robbins, W., Pike, N., & Needleman, J. (2013). Healthy work en-
vironments and staff nurse retention: The relationship between communication, col-
laboration, and leadership in the pediatric intensive care unit. Nursing Administration
Quarterly, 37(4), 356–370. http://dx.doi.org/10.1097/NAQ.0b013e3182a2fa47
Centers for Medicare & Medicaid Services. (2013). HCAHPS: Patients’ perspectives of care
survey. Retrieved from http://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html
Collaboration. (n.d.). In Merriam-Webster’s online dictionary (11th ed.). Retrieved from
http://www.merriam-webster.com/dictionary/collaboration
Competition. (n.d.). In Merriam-Webster’s online dictionary (11th ed.). Retrieved from http://
www.merriam-webster.com/dictionary/competition
Cooke, A., Kavussanu, M., McIntyre, D., & Ring, C. (2013). The effects of individual and
team competitions on performance, emotions, and effort. Journal of Sport and Exercise
Psychology, 35, 132–143.
Institute for Healthcare Improvement. (n.d.). The IHI Triple Aim. Retrieved from http://
www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx
Institute of Medicine. (1999). To err is human: Building a better health system. Retrieved from
http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/
To%20Err%20is%20Human%201999%20%20report%20brief.pdf
Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of
nurses. Washington, DC: National Academies Press.
Interprofessional Education Collaborative. (2011). Core competencies for interprofessional col-
laborative practice. Retrieved from http://www.aacn.nche.edu/education-resources/
ipecreport.pdf
Kohn, A. (1986). No contest: The case against competition. Boston, MA: Houghton Mifflin.
LeBouc, R., & Pessiglione, M. (2013). Imaging social motivation: Distinct brain mechanisms
drive effort production during collaboration versus competition. The Journal of Neuro-
science, 33(40), 15894–15902.
Markussen, T., Reuben, E., & Tyran, J. (2013). Competition, cooperation, and collective
choice. The Economic Journal, 124, F163–F195. http://dx.doi.org/10.1111/ecoj.12096
Rabb, C., Will, S. E., Richards, S., & O’Mara, E. (2013). The effect of collaboration on ob-
stetric patient safety in three academic facilities. Journal of Obstetric, Gynecologic, and
Neonatal Nursing, 42, 606–616. http://dx.doi.org/10.1111/1552-6909.12234
Sanders, C. L., Krugman, M., & Schloffman, D. H. (2013). Leading change to create a healthy
and satisfying work environment. Nursing Administration Quarterly, 37(4), 346–355.
http://dx.doi.org/10.1097/NAQ.0b013e3182a2fa2d
Sawa, B., & Swift, S. (2013). Developing high-performing organizations: Keys to recruiting,
retaining, and developing people who make the difference. Leadership and Management
in Engineering, 13(2), 96–100. http://dx.doi.org/10.1061/(ASCE)LM.1943-5630.0000218
Siliciano, M. (2013). The impact of internal competition on collaboration in public organizations.
Retrieved from http://www.union.wisc.edu/pmra2013/Paper%20Submissions/
Renamed/The%20Impact%20of%20Internal%20Competition%20on%20Collabora-
tion%20in%20Public%20Organizations.pdf
Trepte, S. (2006). Social identity theory. Retrieved from http://www.hamburgmediaschool.
com/fileadmin/user_upload/Dateien/Forschung/Social_Identity_Theory.pdf
Wittchen, M., Krimmel, A., Kohler, M., & Hertel, G. (2013). The two sides of competition: Compe-
tition-induced effort and affect during intergroup versus interindividual competition. Brit-
ish Journal of Psychology, 104, 320–338. http://dx.doi.org/10.1111/j.2044-8295.2012.02123.x
World Health Organization. (2010). Framework for action on interprofessional education &
collaborative practice. Geneva, Switzerland: Author. Retrieved from http://whqlibdoc
.who.int/hq/2010/WHO_HRH_HPN_10.3_eng.pdf?ua=1

Correspondence regarding this article should be directed to Lisa J. Hernandez, DNP, RN, CENP, at
[email protected]

Competition Versus Collaboration 101