Multi-Disciplinary Teamwork in the Healthcare Setting

Abstract

The term “team” comes from the Proto-Germanic word “taumaz,” meaning to pull and was originally used to refer to a group of yoked animals. Teams are social constructs that require a high level of interdependence in individual tasks and ongoing communication among members to achieve common goals. Different types of teams are classified based on their level of performance, with high-performing teams meeting specific criteria and demonstrating extraordinary performance and highly committed members. Various theories and approaches have been developed to understand the inner workings of effective teams, including social psychological, sociotechnical, ecological, human resources, technological, team lifecycle, task-oriented, and integrative approaches. Specific teamwork skills, such as adaptability, leadership, and effective communication, are essential for the success of a team. Assessing these skills can be challenging, as they are impacted by the specific task and team goals, leading to the need for careful and objective measurement. Developing reliable assessment tools and understanding the evolving nature of teams is crucial for accurately evaluating and improving teamwork skills. Addressing teamwork challenges requires attention to trust, clarity, conflicts, communication, and competition, with strong leadership playing a crucial role.

1. Introduction

Throughout the entire history of mankind, we have resorted to working together in a team whenever the burdens of individual tasks have seemed overwhelming or the prospects of success slim. After all, Homo sapiens is considered a social animal in regard with their way of life [1]. However, Cohen and Levesque argue in their 1991 paper that for a collective effort to be truly effective and hence worthy of the name ‘teamwork’ and the members recognized as a team, more is required than a number of individuals who simply follow the same set of rules and instructions even if working towards the same shared goals [2]. Contrasting between a group of cars in traffic and a convoy, they argue that while the former may follow identical traffic rules and even act coordinated and with the same goal of avoiding accidents and reaching their destination, their efforts do not constitute as true ‘teamwork’. The latter on the other hand, consists of a number of cars that act as one in all their actions and show a certain level of shared conventions and mental state that Cohen et al. argue is necessary for a group effort to become teamwork and is in itself only achievable through effective communication, and ultimately leads towards all involved parties to achieve a sense of joint intention among themselves. The remainder of this chapter aims to dive deeper into the concept of team and teamwork and how it affects healthcare.

1.1 Definition of a team

The term team is derived from the Proto-Germanic taumaz, which means to pull. In Old English it was used to refer to a set of animals yoked together, and it was as recent as the 16th century that it first became used for humans and ultimately found the general meaning of a group of people that are working together [3].

Dyer defines teams as social constructs with a high degree of interdependency in individual tasks and the need for effective and continues communication among members that also poses common and valued goals [4]. Salas and others further expand on that definition by recognizing a distinction between teamwork that they define as the collective efforts in which involvement of more than one member of the team is required and the intermediary goals are not achievable without properly coordinated efforts of interdependent agents part of the team; and taskwork, which is defined in their work as all the components of the team members’ actions that do not require such aforementioned interactions and are performed independent of other members [5]. Furthermore, the terms team performance and team cognition are described in their work respectively as the sum of team members’ teamwork and taskwork through the entire process during which the team is active, and the collective understanding that results from the interconnected interactions of the individuals within the team. Finally, team effectiveness is resulted upon evaluation of the team performance based on a particular set of criteria [5].

Smith and others take a somewhat different approach and while initially provide a similar overall definition of the team, further define different types of teams based on their level of performance:

• Pseudo teams are a group of individuals that while working together actually underperform compared to their individual average.

• Potential teams are defined as groups that poses substantial problems in their communications and believes but non the less are able to perform slightly above individual averages.

• Real teams are those who achieve their expected goals and perform quite well.

• High-performing teams meet all the conditions of real teams and in addition have highly committed members and are able to perform extraordinarily and higher than expected.

It goes without saying that the goal should be for all teams to achieve the status of a high-performing team through effective communication and other constructive measures [6].

1.2 Teamwork theories and models

During the years, there have been numerous attempts at trying to systematically define and model the inner workings of an effective team and as Salas puts it “how to turn a team of experts into an expert team”. Earlier approaches usually focused on the role of different inputs received by a team, e.g., the defined tasks, expected output, individual member characteristics, etc. [7, 8]. While such an approach provided valuable insight into the inner workings of a team, it seemed to overlook dynamic aspects of teamwork, i.e., how each decision and action by a team member might affect the final output of the team.

In an attempt to further investigate the teams and their innerworkings, Paris and colleagues classify eight theories or approaches that affect our understanding of how human groups function [ref-sycara-paris]:

1. Social psychological: Focusing on how team members interact and relate to one another.

2. Sociotechnical: Assessing member relations from a work and task-related standpoint.

3. Ecological: How working environments can influence teamwork.

4. Human Resources: In what way does the team utilizes its members’ abilities and expertise.

5. Technological: Effect of technology on the teamwork

6. Team Lifecycle: How the team’s performance changes during its lifecycle.

7. Task-oriented: How team roles relate to their functions and tasks.

8. Integrative: How a combination of the above approaches may be used together to yield a more complete picture of the team dynamic and function.

While the above-mentioned approaches are interesting and clarifying in order to create a pathway and provide us with tools that may be used to improve our understanding of teams and teamwork, it is in fact the results of such theories and approaches are shed light on the important characteristics of teamwork. To that end, the following seven principles were illustrated by Salas and others:

1. Teamwork is described by a set of dynamic and adoptive beliefs, attitudes, and actions [9].

If defined as the sum of behaviors and actions performed by each team member with the goal of achieving a certain task, teamwork can then be defined as the collection of those behaviors and how they relate to each other and also to the attitudes and beliefs of each member. Such a definition while seemingly straightforward, does little in the way of providing a solid path toward actual determination of each of these characteristics in a particular team. A challenge further complicated by the everchanging nature of the team and teamwork during the entirety of their task [10]. Such complications have led some researchers to conclude that even if a fixed set of core competencies exist that will render a teamwork effective, their significance and importance will probably vary in different teams [11].

1. True teamwork requires all members to monitor other members actions and provide feedback regarding those actions [9, 12, 13].

Such behavior monitoring can benefit teams in two major ways: It can encourage team members to always perform their best by limiting the grounds for loafing and can minimize the chances of mistakes by the very nature of monitoring [14].

1. Teamwork requires members to be able and willing to help other members and provide compensatory behavior [9].

Considering the major advantages of a team to be the fact that they are able to work more effectively than the sum of their members’ abilities, it becomes a necessity for members to be somewhat familiar with other individuals’ responsibilities and areas of expertise as well as those of their own in order to be able to provide support when needed [15].

1. To be effective, teamwork requires clear and concise communication [16].

Canon and Bowers define effective communication as a process by which clear and accurate information is exchanged between members using the proper terminology [17]. Others argue that effective communication is more than simple and free conversation and requires careful management to be effective especially as the size of the team expands [14].

1. Considering the high interdependency of individual actions within a team, teamwork requires careful coordination between members’ actions [18].

Suggested by research to be bolstered via correct implementation of the third principle discussed [13, 19], and also highly dependent on the fourth principle of effective communication, effective coordination is vital between members to avoid accidents and to help with the decision-making in cases of emergency and hardship.

1. A leadership capable of planning, setting the direction, and determination and coordination of actions [20, 21].

Determining each member’s task, coordinating activities, and creating effective communication between the members are crucial leadership responsibilities that greatly affect the efficiency of the teamwork.

1. Exact characteristics of the teamwork are determined by the requirements of the task [17].

While general principles and characteristics are discussed here that are important for the effectiveness of the teamwork, it is once again emphasized that the nature of the task and structure of the team determine the exact qualities expected of the team [17].

2. Significance of teamwork in healthcare

Having found a basic understanding of what is considered true teamwork and how effective teams tend to function, we now turn towards the use and significance of teamwork in healthcare. In the following lines, examples of how real teamwork can improve the patient outcome or even prove lifesaving, are discussed in detail.

The vitality of teamwork can perhaps be best understood in the care of the surgical patient in the operating room (OR). The complex and high stakes conditions command the implementation of a highly efficient team in order to be able to face the challenges and properly respond to emergency situations. With the OR team comprising of anesthesiologists, nurses, surgeons, and sometimes other operation-specific specialists, stablishing effective communication between team members is vital. Watkins et al. state that more than two-thirds of all failures related to the OR occur as a result of errors in communication rather than technical failures [22]. Such results emphasize the role of careful assessment in order for the policymaking bodies to identify and address problems.

In a review by Slowey and Abernathy, the effect of team and teamwork was assessed in the care of thoracic surgery patients. Classifying the team dynamics present in the thoracic OR into four dyads (namely the surgeon–nurse, surgeon–trainee, anesthesiologist–nurse, and surgeon–anesthesiologist). While reviewing the literature, they found that previous collaboration between within each dyad plays a significantly more important role than individual experience of team members. Furthermore, they identified five main characteristics (the “Big five”), that greatly influence the effectiveness of the team and roots of many failures can be traced back to malfunctions in one or more of these characteristics [23]:

• Team leadership: Ability to coordinate and direct member actions.

• Mutual performance monitoring: Ability to accurately understand and monitor each team member’s performance.

• Backup behavior: Ability to understand team member needs and responsibilities with the goal of providing support or workload shifts among members when needed.

• Adaptability: Ability to adjust strategy based on the current team and task state.

• Team orientation: Believing in the importance of team goals and their precedence over individual goals.

Recognizing the importance of leadership as one of the most important characteristics of an effective team, Rosenman et al. conducted a narrative review in order to further assess the quality of team leadership education in the setting of emergency medicine (EM) and suggest ways in which resident competencies can be evaluated in this regard [24]. Current standard evaluations regarding teamwork in EM residents include a milestone program that assesses individual resident’s team management skills in a five-step manner in which the first milestone corresponds to the level expected of an intern and the fifth to those of an experienced physician. The residents are expected to reach step four during their training. Rosenman and her team devised a similar milestone assessment tool that focused on leadership skills with steps ranging from the individual having the ability to ask for help when needed and being able to treat others with respect in the first step, all the way to having the ability to effectively managing team resources, motivating members, and resolving conflicts [24]. Such innovations need further investigation regarding effective ways of teamwork education in healthcare workers as well as practical tools for assessment of such skills.

Focusing on another branch of medicine, Fernando and Hughes reviewed the importance of teamwork in the palliative care of terminally ill patients. A vast field requiring coordination between many specialists, palliative care is usually a group effort in many corners of the world. However, in the absence of a standardized approach to the management and structure of such a team, they found significant variation between the structure, efficiency, and working principles of the healthcare team around the globe. Contrasting between multi-disciplinary, inter-disciplinary, and trans-disciplinary when applied to a team, they state the best structure for a healthcare team active in the field of palliative medicine is to be inter-disciplinary meaning that there should exist a meaningful amount of overlap in each team member’s responsibilities and their understanding of other members’ role in the team to allow support and synergy between members in the group to take place. Such a team, in conjunction with an effective communication and strong leadership, will be ideal for administration of palliative care to the patients [25].

3. Teamworking skills: from challenges to resolution

So far, we have discussed the general principles and characteristics that make up an effective team. Though somewhat similar in nature to the aforementioned characteristics, we will now focus on the skills that each member of a team should have in order to properly achieve the collective goals of the team, as well as methods available for the assessment of such skills. Next, we shall have a look on the challenges faced by a team and ways for overcoming those challenges and conflicts.

3.1 Teamwork skills

As mentioned previously, researchers believe that defining a set of skills that if available will result in the formation of the ideal team is somewhat problematic as many of the required skill will either completely change or at least vary in their importance depending on the exact task and team goals. Nonetheless, to circumvent this issue to some degree, Salas and others have tried to classify different skills exactly based on their dependence on a particular task or team (whether each skill or its importance is dependent on a specific task or team or can be considered universal) [17, 26]. Skills are summarized in Table 1. Note that many skills may appear more than once as they may be thought of to be required in more than one level.

Nature of skill	Skills
Team Generic; Task Generic	Morale building Challenge resolution Effective communication Task motivation Co-operation Consulting Confidence
Team Specific; Task Generic	Challenge resolution Motivation promotion Effective communication Intra-team feedback Backup behavior Confidence Planning Flexibility Morale building Co-operation
Team Generic; Task Specific	Task structuring Mission analysis Task sequencing Mutual performance monitoring Backup behavior Effective communication Intra-team feedback Confidence Flexibility Planning Task interaction Situational awareness
Team Specific; Task Specific	Task organization Mutual performance monitoring Shared problem-model development Flexibility Backup behavior Effective communication Dynamic reallocation of functions Task structuring Task interaction Motivation promotion

Table 1.

Skills required by an ideal team classified based on the task/team specificity/genericity.

3.2 How to assess teamwork skills

The need for careful and objective measurement of teamwork skills within a team are essential for the team to be able to improve their functions and more efficiently move towards their goals. As such, due to the nature of the many necessary skills required by a team, for such an assessment to be objective and not affected by rater bias is no easy task. Indeed, most if not all the measurement tools depend on rater’s decision to score each skill.

Some of the earliest works in this regard were those by Schiflett and colleagues in which core competencies expected in a team were observed in the team’s behavior and rated using checklists [27]. Despite their dependence on examiner decision, their method was shown to have acceptable inter-rater reliability. In another effort, Morgen and others developed the Critical Team Behaviors Form (CTBF) in 1986. The CTBF again used rating team members’ behavior by completing a checklist covering critical team behaviors classified into seven categories [28].

In their review of the teamwork measurement methods, Baker et al. concluded that while actual methods used in the assessment of a team may be greatly varied (and more often than not, rather inaccurate!), by following a series of principles, one may be able to design an effective and reliable means of assessing teamworking skills in a particular team. These principles are as follows [29]:

1. If one is to truly understand the innerworkings of a team, a good and robust theory of how teams’ function is the way to go.

2. As teams evolve in their needs and functions with time, assessments must also be dynamic and repeated through time.

3. There seem to be no way to avoid the need for observation when measuring team skills. Therefore, care must be taken in the development of measurement methods to maximize inter-rater agreement.

4. A main point of focus should be to try and assess wide variations of teams as possible. Only through rigorous assessment attempt can we streamline our assessment tools and find solutions for unanswered questions.

5. Reliability and stability of assessment tools must be investigated both from an inter-rater agreement and also temporally.

6. Care must be taken to ensure validity of the measurement construct. Pursuing a multimodal approach in the design of the assessment tool, as well as factor analysis, may prove rewarding paths to follow.

Focusing more on the teams active in healthcare, an interesting observation regarding team performance assessment was the fact that self-assessments tended to be quite inaccurate and unreliable, with physicians constantly reporting higher scores compared to nurses [22], thus emphasizing the need for more sophisticated measures. Two of the tools designed to measure team performance in multi-disciplinary surgical teams are the Observational Teamwork Assessment for Surgery (OTAS) [30] and Revised Oxford Nontechnical Skills (NOTECHS) scale [31]. While the former assesses team performance in five categories (namely collaboration, coordination, teamwork, communication, and situational awareness), the NOTECHS measures nontechnical skills in four dimensions of cooperation, leadership, decision-making, and situational awareness. As our understanding of how teams function evolves, so does our tools for the measurement of their skills and performance.

3.3 Challenges in the team and how to solve them

Working in a team, especially in healthcare setting, is challenging. Suppose stressful environment of an emergency room with irrefutable role of team working in patients’ management who are struggling for life. Inattention to these challenges causes loss of productivity and inspiring atmosphere in work place. Here, we will discuss some challenges teams face commonly and the ways to untie them.

3.3.1 Trust

If we analogize a relationship to a building, trust is its core block. Lack of trust causes demotivation among team members. Trust is a key component of a relationship and needs enough time to exist and persist. Paying attention to trust formation between team members especially in first days is the most important point in team formation. Trust issues in teamwork can arise when team members doubt each other’s intentions, capabilities, or reliability. These issues can stem from past experiences of being let down or betrayed by team members, leading to a lack of confidence in their ability to contribute effectively to the team. Trust is essential for a team to work cohesively and productively, as it fosters open communication, collaboration, and a sense of accountability among team members. Without trust, team members may struggle to rely on each other, leading to conflicts, misunderstandings, and ultimately hindering the team’s ability to achieve its goals. Building and maintaining trust within a team requires consistent communication, mutual respect, and a commitment to transparency and reliability.

Clearly defining roles, responsibilities, and goals for each team member to ensure everyone is on the same page can help in trust issues resolution. Establishing clear expectations will help build trust as team members know what is expected of them and how their contributions fit into the larger team goals. Encouraging ownership of tasks and responsibilities is another way to build trust within the team. By holding team members accountable, you show that you value their contributions and trust them to deliver on their commitments. Building relationships and rapport with team members can help create a sense of trust and camaraderie within the team. Consider hosting team-building activities or social events to foster stronger relationships among team members [32].

3.3.2 Clarity

Clarity issues in teamwork can arise when there is a lack of clear communication, goals, and roles within the team. This can lead to confusion, misunderstandings, and disagreements among team members. Without clear direction and expectations, individuals may struggle to understand their responsibilities and how they contribute to the overall team goals. Additionally, ambiguous communication can result in poor decision-making and a lack of alignment within the team. To address clarity issues, it is important for team leaders to provide clear guidance, establish open communication channels, and regularly check in with team members to ensure everyone is on the same page. By promoting transparency and clarity within the team, members can work effectively towards common goals and achieve success.

Clearly defining each team member’s role and responsibilities can help prevent confusion and ensure that everyone knows what is expected of them. Establishing effective communication channels, such as regular team meetings, email updates, and project management tools, can help ensure that team members are on the same page and can easily share information. Open and honest communication within the team can help prevent misunderstandings and promote collaboration. Regularly providing feedback to team members on their performance and contributions can help address any clarity issues and ensure that everyone is aligned with the team’s goals. Using visual aids, such as charts, diagrams, and project timelines, can help clarify complex concepts and make it easier for team members to understand their roles and responsibilities. Encouraging team members to actively listen to each other can help prevent misunderstandings and ensure that everyone is on the same page. Sometimes, we need training. Providing training and development opportunities for team members can help improve their skills and knowledge, leading to better collaboration and clarity within the team.

3.3.3 Conflicts

Conflicts in teamwork arise when team members have differing opinions, personalities, or work styles that clash with one another. These conflicts can be caused by misunderstandings, miscommunication, or simply by the stress of working together towards a shared goal. Conflict can also be indicative of deeper underlying issues within the team, such as lack of trust, poor leadership, or unequal distribution of work. If not addressed, conflicts can lead to decreased productivity, morale, and cohesiveness among team members. However, when managed effectively, conflicts can actually lead to better solutions and stronger teamwork. It is important for team members to openly communicate, listen to each other’s perspectives, and work towards a resolution that benefits the team as a whole.

To identify root causes, we should work together as a team to identify the underlying issues that are causing the conflict. This could involve uncovering miscommunication, misunderstandings, or differing expectations. Once the root cause is identified, working together to come up with a solution that addresses the conflict in a constructive and mutually beneficial way is an effective method. If the conflict persists or escalates, engaging a neutral third party is a wise option to help facilitate a resolution. In addition, setting clear guidelines and norms for communication and conflict resolution within the team is beneficial to help prevent future conflicts from arising.

3.3.4 Communication

When team members do not effectively communicate with each other, it can lead to misunderstandings, delays in project completion, and conflicts within the team. Some common communication issues include unclear communication, lack of active listening, and differences in communication styles. Unclear communication can result in team members not understanding tasks or expectations, leading to confusion and mistakes. Additionally, when team members do not actively listen to each other, important information can be missed or misinterpreted. Furthermore, differences in communication styles, such as one team member preferring face-to-face communication while another prefers emails, can lead to misunderstandings and miscommunication. To overcome communication issues, it is important for teams to establish clear communication channels, actively listen to one another, and be open to understanding and respecting each other’s communication preferences.

Communication issues in teamwork can be resolved by establishing clear and open channels of communication. This involves setting clear expectations and objectives for each team member, encouraging feedback and active listening, and promoting transparency in sharing information. Regular team meetings and updates can also help to ensure that everyone is on the same page and aligned towards common goals. Additionally, fostering a culture of trust and respect within the team can help to address any underlying issues and facilitate effective communication. By addressing these communication barriers proactively and creating a supportive and collaborative environment, teams can work together more efficiently and effectively towards achieving their objectives [33].

3.3.5 Competition

Competition issues in teamwork can arise when team members are more focused on outperforming each other than collaborating towards a common goal. This can lead to a lack of communication, trust, and cooperation within the team, ultimately hindering the overall productivity and success of the group. Competition can also create tension and conflict among team members, leading to a toxic work environment and decreased morale. It is important for team leaders to foster a culture of collaboration, mutual respect, and shared goals to mitigate competition issues and ensure the team’s effectiveness and cohesion [34]. Encouraging open communication, promoting teamwork, and acknowledging and rewarding collective achievements are key strategies to address competition issues in teamwork.

Competition issues in teamwork can often arise due to conflicting interests, lack of communication, and differing personal goals. In order to address these issues, it is important for team members to establish clear expectations and goals from the outset. Communication also plays a crucial role in resolving competition issues, as it allows team members to openly discuss their concerns and work towards finding a mutually beneficial solution. Additionally, fostering a sense of trust and collaboration within the team can help to minimize the negative effects of competition and promote a more harmonious working environment. Ultimately, by fostering a strong sense of unity and common purpose, team members can overcome competition issues and work together towards achieving shared goals.

As conclusion, all challenges influence each other and to control each one, focusing on all challenges is necessary. Strong leadership is essential in effectively resolving teamwork challenges and promoting a culture of teamwork and collaboration within an organization. Good leaders not only provide support and empowerment for team members but also help in conflict resolution and decision makings.

4. Significance of inter-disciplinary teams in rehabilitation medicine

In this part, we will explain a successful teamwork experience in managing patients in the form of a multidisciplinary team. This team consists of an orthopedic surgeon, a neurologist, a physical medicine and rehabilitation specialist, an orthotic and prosthesis specialist, and a neurosurgeon. Complex patients who require multidisciplinary care are referred to this interdisciplinary clinic. Patients are visited simultaneously by doctors from the mentioned specialized fields. Then, each specialist presents his opinion about the management of the patient from the point of view of his specialized field, and the final treatment plan of the patient is decided by team consensus. Each doctor has the opportunity to examine the patient, and other doctors also can see important points in the history and examination of the patient from the view of each specialty. During the 3 years since the establishment of this weekly clinic, more than 800 patients have been treated and rehabilitated in this setting.

One of the important points in the success of this clinic is the strong leadership of this program in such a way that all team members follow the group leader and have enough trust in him. The goals of this clinic are clear to all team members and participants know exactly what they will achieve from this program. The roles and responsibilities of each person are clearly defined. For example, if a patient needs Botox injections to manage spasticity, this work is done by a neurologist and all members know and accept this work allocation. Leader’s expectations are clear and explained to all members at the beginning of the program. Each team member is trusted and have responsibilities, and no one is ignored. The members of this team have a virtual group for coordination and follow-up of patients and discussion about patients, in which they exchange opinions during the week in addition to the day they attend the clinic. The team leader gives regular feedback to the team members about their contribution and function. For example, if any of the members do not participate in several sessions or do not provide the results of the follow-up of the patient, they will be questioned, while if there is a personal problem that is preventing them from performing responsibilities related to the clinic, they will be supported by other team members. Active listening to team members is one of the characteristics of the team leader and team members that causes effective relationships among people. Conflicts among team members have been resolved by talking and expressing expectations, and if the problem persists, the team leader and sometimes a person from outside the team are invited to judge. The culture of teamwork and collective decision-making caused lack of toxic competitive atmosphere in this team and everyone does their best towards achieving common goals.

5. Conclusion

Working in a team, especially in a healthcare setting, can be challenging. It is important to address these challenges in order to maintain productivity and a positive work environment. Trust is a key component in team dynamics and should be established early on. Clearly defining roles and expectations, as well as promoting transparency and effective communication, can help ensure that everyone is on the same page and working towards common goals. Strong leadership is key to effectively resolving these challenges and promoting a culture of teamwork and collaboration.