Ten principles of good interdisciplinary team work

A wide range of terms are used to describe collaborative working arrangements between professionals [11]. Terms such as interdisciplinary, interprofessional, multiprofessional, and multidisciplinary are often used interchangeably in the literature to refer to both different types of teams and different processes within them [12]. They are also often used in conjunction with the term team work. However, there are some consistent distinctions that are useful to understand. The terms inter/multi-professional are generally narrower than the terms inter/multi-disciplinary [13‐16] and refer to teams consisting exclusively of professionals from different professions or disciplines, or at least to the relationships between professionals in teams that may also include other non-professional staff. The terms inter/multi-disciplinary are broader and include all members of healthcare teams, professional and non-professional. Other authors have suggested use of the prefixes multi-, inter- and trans- to reflect differing intensities of integration [17].

The focus of this paper is on inter/multi-disciplinary teams: the research, interventions, and data-gathering activities underpinning the study included all members of the respective healthcare teams. The term “interdisciplinary team” is used as a generic term of reference for these healthcare teams which included a range of health service workers, both professionals and non-professionals, with the majority being from professional groups. However, where authors have used the terms inter/multi/trans-professional or inter/multi-disciplinary the authors’ original terms will be used.

Previous research has investigated the fundamental concepts and features associated with team work. A concept analysis [18] to explore the basic understanding of team work in the healthcare context drew on both healthcare and literature from other disciplines such as human resource management, organisational behaviour, and education, and proposed the following definition for team work in the health care context:

“A dynamic process involving two or more health professionals with complementary backgrounds and skills, sharing common health goals and exercising concerted physical and mental effort in assessing, planning, or evaluating patient care. This is accomplished through interdependent collaboration, open communication and shared decision-making. This in turn generates value-added patient, organisational and staff outcomes.” (p.238).

This definition may be more optimistic and aspirational than realistic as it makes several assumptions about the characteristics that a team will possess. Enderby [19] identified these characteristics to include a definable membership, group consciousness, shared vision, corporate sense of purpose, clear interdependence and interaction, and co-ordinated action.

Xyrichis and Ream’s [18] literature analysis concludes that the outcomes from team work could be experienced at three levels (healthcare professionals, patients, and healthcare organizations) and that these outcomes have an impact on staff satisfaction, quality of care, control of costs, well-being and retention. Molyneux [20] identified three indicators for positive team work: personal qualities and commitment of staff, communication within the team, and the opportunity to develop creative working methods within the team. Further literature reviews [11] have identified the importance of two themes on interprofessional team work, team structure and team processes within which specific categories emerged: team premises, team size and composition, organizational support, team meetings, clear goals and objectives, and audit processes.

Collaboration is acknowledged as an important component of team processes. A concept analysis undertaken by Henneman et al. [21] identified that collaboration “requires competence, confidence and commitment on the part of all parties. Respect and trust, both for oneself and others, is key to collaboration. As such, patience, nurturance and time are required to build a relationship so that collaboration can occur” (p.108). Identified factors that contribute to successful collaboration were: joint venture, cooperative endeavor, willing participation, shared planning and decision-making, team approach, contribution of expertise, shared responsibility, non-hierarchical relationships and shared power based on knowledge and expertise [21]. However, further reviews [22] have found that the reality of shared planning and decision-making, and shared power is very different from the ideal. Given the context of interprofessional teams, members will automatically come from different professions, therefore in practice “shared decision-making” is likely to conflate individual team members making decisions within their own scope of practice with the ideal of all team members sharing in all decision-making processes, or in other words, “appropriate” decision making. Shared power and leadership may also be a challenge when complex traditional hierarchical relationships, particularly those involving medical practitioners, play a larger role and impact either implicitly or explicitly on team processes [23, 24]. McCallin [23] suggests that shared leadership occurs only in smaller teams privileged with being free to choose all team members.

When considering the characteristics important for interprofessional team work within the context of organisational development, McCray [25] points out that little attention appears to have been paid to the actual processes of interprofessional practice within organisational strategy, local workforce development planning, and individual continuing professional development.

The need for interdisciplinary team work is increasing as a result of a number of factors including:

Workforce re-structuring to meet these needs requires that interdisciplinary teams must integrate changing organisational values with new modes of service delivery [13]. While these changes impact across healthcare as a whole, there are certain sectors where these organisational challenges have encountered more widespread debate, in particular primary care, rehabilitation, and care of the elderly. Of these, primary care is perceived to have the least likely level of success with interdisciplinary team work. Indeed, some commentators suggest that an interdisciplinary culture may only be possible as new generations of healthcare professionals enter the workforce [27].

Despite the increasing focus on interdisciplinary team work over the past two decades, there is still no clear synthesis of the “essence” of what makes a good interdisciplinary team and a lack of empirical research to define what such a team might look like. Similarly, there is a lack of data identifying the processes of interdisciplinary team work and linking these with outcomes. Studies tend to focus on processes or outcomes, but rarely both; or explore components of what defines an interdisciplinary team, without providing a clear guide on the attributes of good interdisciplinary team practice.

This paper draws on a published systematic review of the literature [28], combined with empirical data derived from interdisciplinary teams involved in the delivery of community rehabilitation and intermediate care services (CRAICs), to develop a set of competencies around effective interdisciplinary team practice. The research was contextualised in CRAICs.

CRAICs in England are community-based services frequently offering care for the elderly aimed at preventing admissions and facilitating earlier discharge from acute care. They exemplify the practice of interdisciplinary team work. Typically, CRAICs employ at least four different staff types, including nurses, physiotherapists and occupational therapists [29]. They often exhibit high levels of joint working and role sharing, and employ a large proportion of support workers who, when used appropriately, have been shown to facilitate interdisciplinary practice in this setting [29]. However, previous research by our team found a great deal of variety in the way that teams work together, and their levels of effectiveness as teams [30]. In response, we developed an Interdisciplinary Management Tool (IMT) which was implemented iteratively, using an action research approach with 11 teams to explore the impact of the tool on those teams and their patient outcomes [31].

The systematic review, reported and published in full in the main study report [31], first considered quantitative studies; in particular randomised controlled trials (RCTs) published and unpublished between 1994 and 2009, that evaluated the process and outcomes of different interprofessional staffing models. Reference lists associated with the identified reports and articles were also searched for additional studies. Results were limited to English language articles in recognition of the importance of cultural factors in team work, and issues relating to differences in terminology (for example, multi-, inter-, trans- and cross- disciplinary working). A total of 153 studies, including 11 systematic reviews or meta-analysis, were reviewed and analysed; however, only 101 were usable based on the supporting level of contextual detail. Data on team effectiveness was extracted along with details on team processes, coordination, and leadership; all elements identified as important in the earlier concept analysis of the interdisciplinary team [18].

This initial review confirmed that a lack of contextual detail, both in trials in general [33], and interdisciplinary studies in particular [34], makes it difficult to isolate the “ingredients” of effective interdisciplinary team work. Specifically, the research team identified a lack of “thickness” in the detail on context, team roles, and processes from the review of the RCTs. In the absence of mixed-method studies, suggested as a priority for future research by a recent review [34], the team designed a supplementary review strategy. This strategy examined findings from qualitative research on interprofessional team processes, independent from the RCTs. Inclusion criteria for the supplementary review were studies between 2000 and 2010 involving an interprofessional team in CRAICs which included data focused on team processes. This complementary review identified 20 studies to supplement previous findings. The findings of the separate evidence bases from qualitative and quantitative studies were brought together and isolated to a data extraction table. Themes were identified using a constant comparative method [35] and then each study was coded appropriately. The constant comparative method involves the incorporation, collation and comparison of newly collected data with existing or previous data collected from earlier studies. Thematic synthesis was used to look for common patterns across studies [36].

Eleven CRAICs, including 253 staff were recruited to participate in an action research study, which examined the impact of implementing the IMT on service provision and outcomes for patients and staff. NHS ethics approval was obtained on 11 September 2008 (08/H1004/124). All participating team members provided written consent for their involvement in this research.

The IMT intervention was implemented through a series of semi-structured workshops with the support of a trained facilitator. These workshops included an initial, full day “Service Evaluation Conference” to ascertain each team’s values, needs, and priorities, and then a series of half day “Team Learning Sets” designed to allow for reflective evaluation of their team practice. The activities undertaken included the identification of issues and priority actions that each team wanted to pursue and exploration of what they considered to be “characteristics of a good team”. The workshop outcomes were detailed in reports and action plans that guided the implementation of their proposed changes. These reports and plans provided the basis of the data for the team perspectives. The data were entered into NVivo version 8.0 and coded thematically to explore the characteristics of a good team.

Through the use of the constant comparative method, the thematic synthesis of the literature identified sixteen analytical themes with up to 12 descriptive characteristics in each theme. The identified themes and their characteristics are presented in Table 1.

These themes highlight the defining characteristics of interdisciplinary team work. They recognize the important role that leadership plays for the complex communication and coordination necessary among different groups of professionals and non-professionals. They also demonstrate the need for both flexibility and clarity of roles when the bodies of knowledge of distinctive professional groups are shared, protected, and preserved.

Two activities undertaken as part of the IMT workshops provided data representing the teams’ perceptions of the important components of interdisciplinary team work. These activities were (1) the identification of characteristics associated with ‘a good team’ and, (2) the challenges chosen by the teams as issues on which they considered focusing their action plans.

The characteristics associated with a good team identified by the 11 teams were grouped into13 themes (Table 2). In addition the 584 identified issues or challenges were grouped to 11 broad topics (Table 3). These two thematic analyses were then combined with the themes identified from the systematic review to form a single theoretical framework to define the characteristics of a good interdisciplinary team.

Table 4 demonstrates the triangulation of these three data sources to identify ten characteristics that emerged as underpinning a good interdisciplinary team. The high level of concordance across the three sources is illustrated. The only theme not explicitly identified from the thematic synthesis of the literature that was recognized by the teams was “clarity of vision”; however, this was partly covered by the literature review themes of values and professional commitment. It is interesting to note that an audit of intermediate care, published after this study was completed, recognized weaknesses in strategic planning by commissioners [37], which was highlighted as a reason for the lack of clear vision by team members in this study.

Not surprisingly, the team participants did not raise any challenges or issues related to individual characteristics. This illustrates the value of combining data anonymously reported in the literature with primary data from the teams themselves. While the interaction of individual characteristics is fundamental to the way the team functions, it is unlikely to be directly affected by team actions, with the exception of changing recruitment criteria. However, one of the outcomes of the larger IMT intervention undertaken as the main part of the study was that some teams perceived that they were able to develop individual competencies which better prepared them to work as a member of an interdisciplinary team. Further research is needed to understand the individual characteristics of an “interdisciplinary team member”.

The ten themes identified as the characteristics of a good interdisciplinary team are further described in the following Table 5.

These characteristics can be re-formulated as competency statements that an effective interdisciplinary team functioning at a high level might be expected to demonstrate.

Competencies of an interdisciplinary team:

In addition, our study identified the need for teams to regularly invest time in the processes of team development and maintenance of team functioning to ensure that these competencies are entrenched and enacted in their daily practice. Recognition of such time is frequently omitted from randomized controlled trial evidence of interprofessional working and is correspondingly overlooked when performing cost effectiveness evaluations.

The systematic review, which sought to identify quantitative studies detailing the outcomes of different staffing models, proved most amenable to conventional methods of systematic review and did not require significant amendment from its original protocol. However, the review team encountered the now-familiar deficit in contextual richness or “thickness” within the quantitative studies and had to compensate with strategies specifically seeking qualitative research studies or process evaluations [38]. We acknowledge, in association with guidance provided by the Cochrane Collaboration Qualitative Methods Group, that qualitative evidence from studies from the same source as the trials (within study reports or “sibling studies”) would reduce the contextual variation between different configurations of interdisciplinary working. However given the acknowledged absence of such studies [34], the best available solution was to bring together the two evidence bases and then to triangulate them with rich primary qualitative research data.

This study has not examined the interaction between the characteristics of interdisciplinary teams and it is possible that there is some interdependence between some of the characteristics. For instance, previous research suggests that good leadership may be required for the team to have strong clarity of vision [39]. Further exploration and validation is required to examine whether any causal relationships exist between the different components of interdisciplinary team work.

The facilitation process used in the workshops in this study was informed by the available literature, and therefore has the potential to bias the results from the teams. The risk of researcher bias was lessened by having the teams facilitated by six different facilitators. It is notable that the views of the teams, and the issues they faced, were all similar. The high level of concordance between the published literature and the findings from the teams suggests strong face validity for the characteristics described and competencies proposed in this paper.

The results presented in this paper are derived from interdisciplinary teams involved in the delivery of CRAICs. As such, they involve a specific, but broad, range of disciplines. Previous literature has shown that these groups are typified by being non-medically led, non-hierarchical and fairly democratic in their approaches [24]. This research, and previous research [30, 31], also found a great deal of heterogeneity in the structure and organization of these teams. It is therefore not possible to assume that these findings are relevant to all interdisciplinary teams. Further research will be required to examine the generalizability of these characteristics and competencies beyond this paper.

By establishing a broad set of competencies to guide interdisciplinary team work it moves towards the identification of a suite of processes to which teams can adhere, and sets up mechanisms and areas for improvement. As the published literature demonstrates, few existing interventions around interdisciplinary team work focus on these competencies and processes to implement them. Instead such studies tend to examine a single mechanism to support interdisciplinary team work. The characteristics and competencies identified in this study provide a framework for investigating good interdisciplinary team work, how it might be examined in different contexts, and how teams might identify interventions to improve or optimize their interdisciplinary team work.