Multidisciplinary Team Working

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76 Multidisciplinary Team Working
Karolina Doulougeri
Department of Industrial Engineering & Innovation Sciences, Eindhoven University of Technology
Anthony Montgomery
Department of Education & Social Policy, School of Social Sciences, Humanities and Arts, University of Macedonia
Multidisciplinary team working refers to a group of people with varied
but complimentary experience, qualifications and skills that contribute
to the achievement of an organization’s goals or objectives. There is an
increasing realization in the workplace that productivity and effective-
ness are linked to team-based work, and that focusing only on improving
individuals within an organization is not an optimal strategy (Salas et al.,
2000). This drive toward team-based working is further complicated by
the fact that organizations are increasingly evolving toward a multidisci-
plinary team-based environment. This challenge is most pronounced in
the area of health care. The terms multidisciplinary, interprofessional,
multifunctional and multiprofessional teamwork are used interchange-
ably to describe the collaboration of different health care professionals
(physicians, nurses, technicians, etc.) who work together. While multi-
disciplinary team working is important in fields such as engineering
(Denton, 1997) and information technology (Weinberg et al., 2005), the
present chapter will specifically focus on health care, where the majority
of research and interventions are concentrated.
Multidisciplinary Team Working in Health Care
The Institute of Medicine (IOM) has established the ability to work in
interdisciplinary teams as one of its core competencies for health care
professionals and recommends that all health care team members have a
clear understanding of each other’s roles and responsibilities (IOM, 2003).
Demographic changes and the resultant changes in mortality/morbidity
have increased the need for multidisciplinary team working in modern
health care. Nancarrow et al. (2013) identified several important reasons
that make it important in modern health care. First of all, the aging
population that is associated with an increased number of patients with
chronic diseases, requiring complex care provided by several health care
professionals. Second, health care professionals need to develop complex
skills and knowledge in order to provide adequate care to patients. Third,
the increased specialization within health care professions makes it almost
impossible for one professional to be able to provide a holistic care
approach. Fourth, multidisciplinary teamwork is considered crucial for
the continuity of care and continuous quality improvement.
However, multidisciplinary team working is particularly challenging for
health care organizations. Health care workers perform interdependent
tasks (e.g. a surgeon needs a patient to be anesthetized) while functioning
in specific roles (e.g. surgeon, surgical nurse, anesthesiologist), but most
clinical units continue to function as discrete and separate collections of
professionals (Knox & Simpson, 2004). This is partially due to the fact that
members of these teams are rarely trained together; furthermore, they
often come from separate disciplines and diverse educational programs
(Baker et al., 2006). Challenges aside, multidisciplinary teamwork in health
care has been associated with benefits for the health care system, the
patients and health care professionals. With regard to patient care, it has
been associated with better quality of care (O’Leary et al., 2012), improved
clinical outcomes (Lemieux-Charles & McGuire, 2006; Xyrichis & Ream,
2008), patient safety (Manser, 2009; Salas et al., 2011), continuity of care
and a more holistic approach toward patients’needs (Fleissig et al., 2006).
In the area ofpatient safety there has been a gradual movement towards
a systems approach to medical error, and multidisciplinary approaches
have the potential to dovetail with safety interventions/initiatives where
shared activities, teamwork and effective communication among health
care teams are considered crucial. With regard to health care professionals,
multidisciplinary team working has also been associated with higher levels
of job satisfaction (Körner, 2010), greater wellbeing (Koerner, 2011) and a
lower risk of burnout and better team climate (Deneckere et al., 2011).
Finally, for the health care system, good team functioning can result in cost
savings, workforce retention, reduced length of stay and reduced turnover
(Grumbach & Bodenheimer, 2004; Xyrichis & Ream, 2008).
Definition of Teamwork and Theoretical Models
In order to explore teamwork in the health care context, Xyrichis and
Ream (2008) conducted a concept analysis and combined findings and
knowledge from health care literature as well as other disciplines such as
human resource management, organizational behavior and education.
In this concept analysis they proposed the following definition of team-
work in the health care context:
A dynamic process involving two or more health professionals with comple-
mentary 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 commu-
nication and shared decision-making.
(p. 238)
In their definition, it becomes clear that multidisciplinary team
working is not a simple sum of different health care professionals
working together as a group (Mathieu et al., 2008; Salas et al., 2000).
Professionals need to work together for a common goal and they need to
share common values (Atwal & Caldwell, 2006; Salas et al., 2008). The
interaction between team members creates additional values that are not
simply the sum of individuals’competencies (Sandberg, 2004).
Several models of teamwork can be found in the literature. For example,
Berlin et al. (2012) differentiate five models related to teamwork with regard
to; (1) developmental phases of a team; (2) team integration; (3) the way
members organize and coordinate their activities; (4) the way the team roles
are established; and (5) type of team collaboration and goal orientation. 343

Table 76.1 summarizes the different types of teamwork identified in
the systematic review of Berlin et al. (2012). The review indicated that a
synchronous, complementary or mature team is not necessarily optimal.
More specifically, models with regard to the development of a team, the
degree of internal integration, the organization and coordination of
activities, the establishment of team roles and team collaboration and
goal orientation are presented in a way to synthesize knowledge and give
a critical overview on the topic.
What are the Characteristics of a Good
Multidisciplinary team?
Several studies have explored factors that can either enhance or inhibit
team performance in multidisciplinary teams. For example, a literature
review exploring factors that influence interprofessional team working in
community and primary care identified team structures (e.g. size, com-
position) and team processes (e.g. meetings, objectives) as the most
important factors (Xyrichis & Lowton, 2008). Congruently, the non-
technical skills of team members and institutional support are important
predictors of effective multidisciplinary meetings (Lamb et al., 2013).
Nancarrow et al. (2013), combining results from a systematic review
on interdisciplinary team working and data from a qualitative study with
253 health care professionals working in rehabilitation centers, proposed
ten competencies that characterize a good interdisciplinary team. Those
characteristics were: positive leadership and management attributes;
communication strategies and structures; personal rewards, training
and development; appropriate resources and procedures; appropriate
skill mix; supportive team climate; individual characteristics that support
interdisciplinary teamwork; clarity of vision; quality and outcomes of
care; and respecting and understanding roles.
Our discussion of effective team working will benefit from a review of
the obstacles that hinder effective collaboration. The most commonly
cited reasons include: differing perceptions of teamwork, different levels
of skills acquisitions to function as a team member and the dominance of
medical power that influenced interaction in teams (Atwal et al., 2006).
Moreover, Doyle (2008) has identified the following obstacles: separate
documentation, poor working relationships, lack of awareness and
appreciation of the roles and responsibilities of others, limited time
and resources, overlapping of roles and duplication of services, poor
communication, lack of information sharing, lack of collaboration, lack
of trust and confidence in the abilities of other agencies, increased
workload, lack of appropriately trained staff and constant re-
organization. Hierarchical structures and a silo mentality of professional
groups can also inhibit teamwork and collaboration (Angelini, 2011;
Bleakley, 2006). All those barriers can lead to team members experi-
encing low morale, low motivation, decreased levels of planning and
participation in decision-making and therefore reduce the sense of
belonging in the team (Osabiya, 2015).
The aforementioned indicates that an initial taxonomy of enablers and
obstacles exists for researchers. Most recently, Google investigated what
makes its own teams effective via its Project Aristotle (Duhigg, 2016). The
results of their investigation suggested that ‘psychological safety’–
whereby team members have a shared belief that it is safe to take risks
and share a range of ideas without the fear of being humiliated –
emerged as crucial. It’s reassuring for the field that research at the ‘coal
face’of industry is consistent with the considerable academic research
indicating that psychological safety is a crucial factor in effective team
working (Edmondson & Lei, 2014).
Table 76.1 Models of teamwork identified by Berlin et al. (2012)
Development of a team Forming phase. Members of the project team meet each other and learn about the tasks they will need to perform. Team
members will try to see how they fit in with each other and understand what is expected of them.
Storming phase. Conflicts and polarization between team members may arise as team members tend to challenge each other.
Norming phase. Team members come together and focus more effectively on the project tasks and objectives.
Performing phase. Team members are comfortable with each other and accept group norms. Interpersonal and structural issues
have been settled.
Adjourning phase. The team has developed close relationships and many of the team members will feel a sense of loss when the
group project ends.
Degree of internal integration Multiprofessional concept describes when team roles are specialized; low levels of interactions exist between team members.
Interprofessional concept describes teams where roles are specialized but members collaborate to a higher degree compared to
multiprofessional teams.
Transprofessional concept describes teams where team members have specialized roles but they are required not only to
complement, but also to replace each other when necessary.
Organization and coordination of
activities
Sequential processes occur where assignments are divided in an assembly line. Every task is carefully planned; there is not much
room for improvisation.
Parallel processes occur where team members work simultaneously but individually.
Synchronous processes occur where team members share the workload, work simultaneously and overlap in an organic and
intuitive way.
Establishment of team roles Differentiated teams are where each member in the team has a specialized role. Tasks are performed in serial order controlled
and standardized by the management.
Integrated teams are where different roles are specialized but the members of the team have to interact. The interaction is,
however, planned and controlled.
Complementary teams are where team members are not just integrated but also complement each other.
Team collaboration and goal
orientation
Immature teams are where team members are loosely connected, subgroups exist within the wider team and team members
work individually.
Mature teams are where team members share enthusiasm for the mission and the tasks and team is developed through the
challenge entailed by completion of the mission.
Overripe teams are where team members are characterized by a lack of flexibility, rigid basic values and exclusion of new team
members.
Doulougeri and Montgomery
344

Interventions to Promote Multidisciplinary Team
Working in Health Care
Several studies have attempted to encourage and facilitate multidisci-
plinary team working by implementing interventions. Systematic reviews
evaluating the effectiveness of interventions in hospital environments,
either in acute or chronic care, report beneficial effects, but limitations
with regard to study design and generalization of outcomes (Buljac-
Samardzic et al., 2010; Körner et al., 2016; Zwarenstein et al., 2009).
The three aforementioned systematic reviews reveal considerable het-
erogeneity and a lack of high-quality studies.
Körner et al. (2016), in a systematic review of interventions concerning
chronic care settings, found that only one study included a control
group, and the majority of studies were single-group, non-randomized
trials with a pre–post design. In addition, in this review most of the
studies used staff-related (team climate, team or patient satisfaction,
team performance) or organization-related outcome measures (reduced
length of stay and discharge delay, decreased costs or organizational
learning).
Buljac-Samardzic et al. (2010), exploring interventions aimed at
improving team effectiveness, found that 37 out of the 43 intervention
studies had low to medium quality. High-quality studies reported posi-
tive outcomes of teamwork training with regard to team behaviors, team
attitudes, self- efficacy, individual effectiveness, burnout aspects and
quality of provided care. In this review, interventions aimed to improve
multidisciplinary team working used education and training of team
members in interpersonal or technical and functional skills, standardized
tools and checklists. In most types of interventions the outcomes were
related to team effectiveness, teamwork attitudes, team satisfaction and
less objective outcomes. The review concluded that the majority of
studies yield positive outcomes in non-technical outcomes such as team
communication, cooperation or leadership.
Zwarenstein et al. (2009) conducted a Cochrane Review of practice-
based interprofessional collaboration (ICP) interventions. They included
only randomized controlled trials (RCTs) that reported changes in
objectively measured or self-reported (by use of a validated instrument)
patient/client outcomes and/or health status outcomes and/or health
care process outcomes and/or measures of interprofessional collabor-
ation. They were able to identify only five intervention studies fulfilling
these criteria. They categorized the studies into three main types of
interventions: interprofessional rounds, interprofessional meetings and
externally facilitated interprofessional audit. In terms of outcomes the
results were mixed and varied across settings. For example, they found
that daily interdisciplinary rounds in in-patient medical wards had a
positive impact on length of stay in an acute hospital setting, but had
no impact on length of stay in a community hospital ward. They also
found that monthly multidisciplinary team meetings improved prescrib-
ing of psychotropic drugs in nursing homes and that meetings facilitated
by an external facilitator, who used strategies to encourage collaborative
working, was associated with increased audit activity and reported
improvements to care.
The findings of the three systematic reviews indicate that investigating
multidisciplinary team working is quite complex and challenging for
researchers. The great variation in settings where interventions were
implemented, in samples sizes, in context and duration of interventions
as well as the variation of examined outcomes limit representativeness
and generalizability of findings and make it difficult to draw causal
relationships between interventions and outcomes.
Blackwood (2006) identified three key challenges with the evaluation
of complex interventions. First, the relevant research evidence should be
used systematically in developing the components of the intervention;
second, the definition and measurement of complex intervention out-
comes needs to be improved; and third, appropriate research designs
must be used when evaluating complex interventions.
Brown et al. (2008) suggest that interventions aimed at improving
team working can benefit from a mixed methods approach in order to
explain the findings, contextualize the results and build new theories. In
addition, it is important for the outcomes of interventions to be assessed
at several time points by linking the interventions with team structures,
processes and outcome indicators. Even though RCTs are considered the
gold standard of empirical studies, interventions in complex and
dynamic environments that cannot be duplicated could benefit by inter-
vention designs using new methodologies. For example, experience-
based co-design and TeamSTEPPS are promising approaches, which
provide information about processes, social context, patient engage-
ment, equity, and health literacy; such factors that are typically and
explicitly eliminated from RCT designs as sources of bias and confound-
ing. Experience-based co-design combines participatory and user experi-
ence design tools and processes via a ‘co-design’process involving staff,
patients and carers reflecting on their experiences to identify improve-
ment priorities (Donetto et al., 2015). TeamSTEPPS training is intended
to clarify team roles and responsibilities and optimize the use of infor-
mation, people and resources to achieve the best clinical outcomes for
patients. TeamSTEPPS aims to increase team awareness through a
shared mental model (King et al., 2008).
An evaluation of a large community hospital system identified a posi-
tive relationship between TeamSTEPPS training (for both clinical and
non-clinical staff ) and perceptions of patient safety culture and team-
work among staff, the quantity and quality of presurgical procedure
briefings, and the use of teamwork behaviors during cases (Weaver
et al., 2010). Evaluations of team training in the operating room environ-
ment have produced similar findings. Studies have shown improvement
in error avoidance rates, and an increase in the properly timed adminis-
tration of prophylactic measures (Awad et al., 2005). Team training has
also been shown to enhance communication, increase employee satis-
faction and reduce turnover among nursing staff. Thus, process-oriented
approaches have the potential to yield important data concerning the
implementation success of interventions among team members.
Conclusions
Even though the importance of multidisciplinary team working in health
care has been recognized, implementing strategies to improve it is more
challenging in practice. In terms of selection, health care organizations
invest heavily in selecting the ‘right person’for the job, but pay less
attention to the constitution of teams. This chapter indicates that multi-
disciplinary team working provides benefits at all levels; however, several
barriers exist to its implementation. Several interventions have yielded
mixed results with regard to their effectiveness. The majority of research-
ers identify the following elements as important: positive leadership and
management attributes; effective communication strategies and struc-
tures; training and development in the principles and practices of team-
work; appropriate resources and procedures to ensure good
organization; appropriate skills mix; supportive team climate; individual
characteristics that support interdisciplinary teamwork; clarity of vision;
Multidisciplinary Team Working
345

clarity of what comprises quality and outcomes of care; and respecting
and understanding roles and an overall climate of psychological safety
(Duhigg, 2016; Fleissig et al., 2006; Lamb et al., 2013; Nancarrow et al.,
2013). However, interventions aimed at improving multidisciplinary
team working so far present a highly heterogeneous picture, with the
majority of the research characterized by study quality that ranges from
low to medium. Given that interventions are developed for specific
contexts, and can adopt a wide range of intervention activities that vary
in duration and evaluation rigor, drawing firm conclusions regarding
which is the best way to improve multidisciplinary team working in
health care settings is difficult. New methodologies adopting a participa-
tory approach can raise awareness and information sharing among team
members regarding team processes and can be beneficial for team
functioning as well as patient care.
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77 Service User and Lay involvement in Health Care
Raksha Pandya-Wood
Department of Health Sciences, University of Leicester
Jim Elliott
Health Research Authority, London
Duncan S. Barron
School of Health Sciences, University of Brighton
Introduction
This chapter introduces the reader to service user and lay involvement in
health care services, research and industry. Many of the specific
examples are drawn from the UK, including its National Health Service
(NHS), but the approaches and lessons will apply to involvement glob-
ally. The chapter discusses key initiatives that have helped shape what
service user and lay involvement is today. From here onwards we refer to
service user and lay involvement as the simpler term ‘public involve-
ment’, where ‘public’can mean, depending on the context, people who
use health and social care services, patients, carers, families of patients
or members of the public (who may use services or be a patient in the
future). We refer to ‘the public’or ‘people’rather than service users or
lay people (see more under ‘Who to involve’below). Involvement in
health care services and research refers to professionals and the public
working collaboratively (as equal partners) or to professionals consulting
the public, and then acting on that input. We use the term ‘involvement’
throughout the chapter to distinguish it from research ‘participation’,
which is where people take part in research studies and ‘engagement’,
which is where information about health care or research is communi-
cated to the public.
From Global to National
Internationally, literature on involvement is growing at a rapid pace
(Evans et al., 2014) and is becoming a significant pillar of health care
policy. Many countries began to involve people in following the
World Health Organization (WHO) declaration of Alma-Ata of 1978,
which stated that: ‘people have the rights and the duty to participate
individually and collectively in their health care’(World Health
Organization, 1978: 1). Involvement is also high on the agendas of
governments and health organizations around the world, including in
the UK, Australia (Saunders & Girgis, 2010), North America (Wale
et al., 2010), Canada (Forbat et al., 2009) and Europe (Tritter, 2009).
In the UK, involvement has two overarching principles: to improve
the quality of public services and enhance accountability for public
spending. Additionally it is a way of allowing ‘patients to drive the
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