Interprofessional and transdisciplinary teamwork in health care†
This article has been presented as a keynote lecture at the 5th International Symposium on the Diabetic Foot, Noordwijkerhout, The Netherlands, May 2007.
The article focuses on the need for and the characteristics and positive consequences of interdisciplinary teamwork in health care. Interprofessional collaboration is an important element in total quality management. Factors that determine the success of team work are described, such as a management that promotes openness and an administrative organization that promotes interdisciplinary consultation. Other factors have to do with leadership, shared goals and values, meeting management and planning skills, communication, and also the (degree of) knowledge and the (quality of) perception of competences of other health care workers. The shared care plan is stressed as an important tool. In this, the joint planning of goals for intervention and care is essential. Health care workers with different professional knowledge and background have to harmonize their intervention plan according to the competences and goal settings of the other team members. The core of effective interprofessional teamwork is the presence of interprofessional competences such as these. A brief description of the components and performance criteria of the competence of interprofessional collaboration is given. Copyright © 2008 John Wiley & Sons, Ltd.
The need for interprofessional collaboration from the quality perspective
Different needs and stimuli have promoted interprofessional collaboration in the past decades. One of them is the growing belief in the complexity and multidimensionality of health problems, and the increasing specialization of health care workers involved. Diabetes, being a chronic disease involving several possible complications, is, in this respect, a well-known example 1. Interdisciplinary or interprofessional collaboration is thought to provide better service and yield better results. There is a conviction on this, albeit it is hard to find hard evidence on this matter that is based on scientific research. It is easy to conceive that putting together different sorts of specialized knowledge from different health care workers would lead to a better understanding of patient problems. This is certainly the case for complex diseases that require the attention of different specialists, but it is also the case for most diseases and disabilities when one believes that rehabilitation and care involves different medical, social, and psychological aspects. One person may have attention for all these different aspects, but specialization in health care professions supposes also that a certain professional is better trained to handle specific aspects of a complex situation. Bringing different health care workers together to act on the same situation would bring about a better and faster result. It is a matter of effectiveness and efficiency. Whether this interprofessional collaboration is better in terms of cost effectiveness depends on the quality of the persons working together. A lot of mistakes and unnecessary costs in health care are caused by lack of teamwork or by the poor quality of coordination. The assets of a well-functioning interprofessional collaboration have been demonstrated in two ways. It can lead to an improvement in the care effectiveness for persons with a chronic disease 2 and also to a higher degree of work satisfaction in health care workers 3.
Interdisciplinary and interprofessional teamwork is an important focus in models and instruments for quality management in health care. The PROSE-model 4 describes five levels of quality management. In level one, quality is bound to personal aspects and can be variable, according to the persons working in the organization. The relevant questions are as follows: Does the direction of the unit explicitly stimulate interdisciplinary cooperation? Are most colleagues willing to work together across disciplines? Do most colleagues engage spontaneously in consulting and cooperating with other disciplines? In level two, the staff think proactively in terms of processes and agreements are made, albeit on an informal basis. Questions may be asked, such as the following: Are there persons who are especially skilled in coaching multiprofessional teams? Are task descriptions written out in relation to other disciplines? Do the working groups have clear goals in organizing meetings? Level three is the stage of professional work and quality assurance: health care workers work together on a systematic basis. The items considered may be as follows: Is there a specific input of all disciplines that should be involved in projects and in meetings? Do all professionals have the skills to engage and work efficiently in interdisciplinary meetings? Are working documents in the unit structured and filled out in a way that it enhances efficient interprofessional communication? In level four, continuous improvement is the main characteristic. People learn by evaluating their functioning and teamwork provides synergetic surplus value. Level five is the level of excellence: external expertise is used and internal expertise is exploited in an international context. The PROSE questionnaires 4 can be used as a checklist for assessing the functioning of health care teams from an organizational perspective.
Elements and tools for effective interprofessional teamwork
The need for highly specialized knowledge and skills can become a problem when it is not paralleled by the knowledge and skills on how to work effectively together. The growing focus on prevention and on continuity in health care delivery requires that a good quality of interprofessional collaboration is not only present in highly specialized hospital settings but also in primary and community-based health care.
A setting can be multiprofessional, with different health care workers working in the same building. Such a setting can enhance the referral between health care workers, but it cannot guarantee it. The element of having the different professions under one roof may be an asset for a multidisciplinary setting (different health care workers acting independently on one client), but the interprofessional collaboration depends largely on other elements, such as the management and the interprofessional competences of the staff. Interprofessional teamwork exists when health care professionals not only make appropriate referrals to each other and consult each other when needed but also jointly contribute in setting up care and treatment plans. In a transdisciplinary approach, the knowledge in team members of working methods and competences of other professions has reached such a high level and the shared care planning runs so smoothly that it is difficult for an outsider to identify immediately which team member has which profession. This may give the wrong impression that professional identities are given up and that team members share most tasks and responsibilities. Transdisciplinarity does not simply refer to a confusion or dissolution of professional identities; rather, it points out the intensity of shared goal setting, the commonality of a shared reference framework, and the swift interplay between the team members. It also implies the release of stereotyped roles and role perceptions, hierarchical relationships, and jargons frequently linked to professions. The social worker and the nurse are not the only health care workers focusing on the social well-being of the patient, and the physician is not the person who always knows best about diagnosis or who uses difficult terms to display depth of knowledge.
To achieve effective interprofessional collaboration, health care workers not only need specific interprofessional competences but also instruments and working methods. Efficient communication and information management are major issues here. Health care professionals are not always together in the same location at the same time. Organizing meetings with all health care workers involved in the care of a patient is a costly enterprise, and is in most cases not possible. Modern communication technology can help a lot in this. Team members not only can communicate with each other more swiftly by mobile phones and digital assistants but they can even work together on electronic group pages and worksheets. The ICT also can support knowledge updating in health care workers with respect to the competences of other professions in a continuously changing society. Health care workers need to be able to consult the internet not only within their field of specialization, but also to stay informed about new working methods in other health care professions. Websites and journals on specific topics in health care, such as diabetes, therefore should be preferably of a multiprofessional kind, and if possible adopt an interprofessional view. It helps professionals not only to stay tuned to important developments within their own discipline, but also to keep an open mind to developments in other disciplines.
Although modern information technology can bring us great steps forwards, it cannot guarantee an efficient collaboration and an open communication. Regular personal contact between team members and team management are essential components to achieve this. Some characteristics of well-functioning teams can be depicted 5, 6. First of all, a team needs effective leadership from persons who have meeting management skills, and stimulate openness and self-reflection. A team should consist of team members who complement each other's discipline and who take up complementary roles in the team. They should have knowledge of, and respect for, the competences, roles and contributions of other professionals in the team, without any prejudice or stereotyped perceptions. Effective teams can be characterized also by their search for and the definition of common and clear goals that everybody can agree upon. They have a common framework and working tools that stimulate the sharing of knowledge. Most likely, the administration is organized in such a way that it promotes interdisciplinary storage and consultation of patient records and data files. And finally, skills in communication and conflict management have to be present in every team member. In the Healthy Teams Model 7, key characteristics are described as purpose, goals, leadership, communication, cohesion, and mutual respect.
When these elements are present, teamwork is well underpinned. The quality of team meetings, a very important aspect of teamwork, can be enhanced by elements such as the preparation of documents, the presence of key persons, the availability of information, and the management of the meeting process. The team coach should structure the meeting in such a way that enough time is devoted to a shared problem definition, with exploration and analysis, before constructing an intervention strategy. Finally, a meeting should end in a clear follow-up of goals and tasks.
For interprofessional or transdisciplinary teamwork, we need a collective code of ethics, a shared complementary responsibility, effective team coaching and coordination of care planning, and instruments that scaffold teamwork, such as shared electronic patient files. One important tool that promotes interprofessional teamwork is the shared care plan (see Table 1). On a matrix, for each goal, the actively contributing health care workers are identified by the team. For each goal, one of the health care workers takes up the responsibility, while another takes up the responsibility for coordinating the shared care. The joint use of this matrix is aimed towards better involvement of team members.
Table 1. Schematic presentation of an interdisciplinary shared care plan for a diabetic person with depressive symptoms and suffering from ulceration on the foot. The health care workers are marked for each goal that they actively contribute to. One of the health care workers takes up the responsibility for each goal. One of them takes up the responsibility for coordinating the shared care
|Organization and support of home-based care||X||X|| || || ||X|
|Optimization of insulin regulation||X||X|| || || || |
|Treatment of clinical depression||X||X|| || || || |
|Wound healing and wound care||X||X|| || ||X|| |
|Stimulation of social contacts||X||X|| || || ||X|
Interprofessional competences are the core of interprofessional teamwork. They play key roles in several dimensions of health care work, such as corresponding and reporting, consulting, goal setting and intervention planning, care management, referral, and follow-up. They are important in the daily cooperation in or between units, the interprofessional consultation by phone or e-mail, the correspondence in case of referral, meetings, and discussions about and with clients. A profound assessment of those competences is needed for effective medical and health care education programmes. This assessment can be done according to a framework that systematically analyses components and performance criteria of the competence 8, as used in the competence chart of ENPHE 9. The clear differentiation between the identification of essential components (knowledge, skills, and attitudes) and of criteria to assess the behavioural performance of health care workers is crucial, as in the performance criteria several components are integrated or used in combination.
The umbrella competence of interprofessional collaboration encompasses the communication of ideas from one's own disciplinary framework of reference towards other disciplines, the use of the expertise of other disciplines and health care workers, and active/effective involvement/participation in task-oriented groups/teams. It includes the harmonization of one's own ideas and activities with those of other health care workers, and the ability to cooperate in the planning, follow-up, and evaluation of the interdisciplinary care. The interdisciplinary focus of a health care worker becomes evident in the way he/she analyses situations of health problems, interventions and care provision, and also in the way he/she talks with and about other health care workers.
The underlying skills that are needed for interprofessional competence can be described as follows: A team member has to be able, for example, to present and defend his/her own opinion in a small group, analyse complex patient situations, draw up a plan of care and intervention, give feedback on the opinion and the behaviour of others, handle conflicts and differences in opinion, and plan activities in accordance with those of others. Further, some of the underlying necessary knowledge that is required of a team member are as follows: A team member would, for example, need to be aware of the competences, target groups, and working methods of the different health care professions, the structure of health care facilities, the processes and goals of interdisciplinary meetings, the models of cooperation, and the styles and methods in managing meetings with small groups. Finally, specific underlying attitudes need be accentuated. A team member must have an eye for the possible role and information of other disciplines, show respect for the opinion and role of others, aim for efficiency in group meetings, and be careful not to draw conclusions too soon on the basis of partial data.
The components mentioned above have to be combined in interprofessional competent handling. The assessment of this competence is not based on the profoundness of knowledge, but on the way this knowledge is used. Team members can be assessed on the way they perceive and assess contexts, the way they fine-tune ideas and working methods, the quality of planning and evaluating shared care, their avoidance of conflicts and misunderstandings, and their attention to cost effectiveness. Specific performance criteria can be listed, such as (1) consulting colleagues of other disciplines spontaneously, as needed/required by the situation, (2) clearly formulating his/her own ideas towards other professions, and checking for understanding, (3) assessing which function a colleague from another discipline can assume in an intervention, (4) working constructively with other professionals on drawing up a treatment and care plan, and (5) talking positively with patients, spontaneously mentioning about (possible) intervention of other professions. These are the kinds of assessment criteria that are used in a growing number of interprofessional learning trajectories for health care students, such as the InterDis-course in the Ghent University Association 10.
Conflict of interest
The author has no conflicts of interest. As the paper contains no empirical data, no ethical committee approval has been asked.