Teamwork in home care nursing: A scoping literature review

Abstract Due to an increased number of complex multi‐ and long‐term ill patients, healthcare and nursing provided in patients' homes are expected to grow. Teamwork is important in order to provide effective and safe care. As care becomes more complex, the need for teamwork in home care nursing increases. However, the literature on teamwork in the patients' home environment is limited. The aim of this study is to describe the scope of the current literature on teamwork in home care nursing and outline needs for future research. Seven electronic databases were systematically searched and 798 articles were identified and screened. Seventy articles remained and were assessed for eligibility by two of the authors. Eight themes were identified among the 32 articles that met the inclusion criteria. Studies concerned with teamwork regarding isolated tasks/problems and specific teamwork characteristics were most common. Methods were predominantly qualitative. Multiple method approaches and ethnographic field studies were rare. Descriptions of the context were often lacking. The terms ‘team’ and ‘teamwork’ were inconsistently used and not always defined. However, it is apparent that teamwork is important and home care nurses play a crucial role in the team, acting as the link between professionals, the patient and their families. Future studies need to pay more attention to the context and be more explicit about how the terms team and teamwork are defined and used. More research is also needed regarding necessary team skills, effects of teamwork on the work environment and technology‐mediated teamwork.

The global population is ageing and the number of people over 65 is projected to more than double by 2050 (United Nations Department of Economic and Social Affairs, Population Division, 2020). As a result, the need for treatment and care in patients' homes is expected to increase. In Sweden, elderly care is expected to grow by 170,000 employees between 2017 and 2035 (Statistics Sweden, 2017), and the expenditure due to shifts from informal to formal care in the EU is expected to more than double between 2013 and 2060 (European Commission, 2015). In the U.S., the need for home health and personal care aides is projected to grow by 34% between 2019 and 2029 (Bureau of Labor Statistics & U.S. Department of Labor, 2021).
Elderly patients are already being treated and cared for in their ordinary accommodations, even during multi-and long-term illnesses (The National Board of Health and Welfare, 2014a, 2014b). As a consequence, care becomes increasingly complex and requires that different health care providers and professions cooperate around the patient (Reeves et al., 2010). For example, in Sweden, the expansion of home care is part of a larger effort to trim hospital organisations and give primary care centres and home care nursing increased responsibilities (Stiernstedt et al., 2016). This is not only because caring for patients at home is considered more cost-effective but also to protect the Western world's prevailing ideals of human autonomy, dignity and identity (Carlander et al., 2009). Making healthcare more mobile and transferring patient treatment and care into the home setting has its advantages and disadvantages. On one hand, elderly people with chronic illnesses have been found to prefer being treated, cared for and even dying at home (Genet et al., 2011;Gomes et al., 2013;Tarricone & Tsouros, 2008). On the other hand, multimorbid patients living at home grade their health lower than those in nursing homes (The National Board of Health and Welfare, 2018). Multimorbid patients are also readmitted more often after being sent home from the hospital (The National Board of Health and Welfare, 2021).
To meet these needs, healthcare must become more effective, and teamwork is perceived to increase effectiveness (Driskell et al., 2018;Reeves et al., 2010). Teamwork in healthcare can be defined as 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' (Xyrichis & Ream, 2008, p. 238). Besides organisational effectiveness, teamwork is associated with the delivery of safe and high-quality care and increased job satisfaction (Kalisch et al., 2010;Lemieux-Charles & McGuire, 2006;Manser, 2009;Markle-Reid et al., 2010;Welp & Manser, 2016). At the same time, confusion and inconsistencies exist about the use of team and teamwork terminologies in healthcare (Flores-Sandoval et al., 2021;Lyubovnikova et al., 2015;Rydenfält, Borell, & Erlingsdottir, 2019).

| Aim
The aim of this study is to explore the available literature regarding teamwork in home care nursing. More specifically, we intend to describe the scope of the current literature from the perspective of its focus and the methodologies being used and to identify needs for future research.

| Search strategy
Review articles can be positioned along a scale from exploratory to explanatory. Compared to systematic reviews of the evidence in relation to specific predefined questions, scoping reviews are usually more explorative, with the intent to '…identify and map the available evidence' (Munn et al., 2018, p. 2). The scoping review design was chosen due to the perceived limited number of studies concerned with teamwork in home care nursing. Related to Arksey and O′Malley's suggested reasons for conducting a scoping review, we focused on 'the extent, range and nature of research activity' (Arksey & O'Malley, 2005, p. 21), that is the scope of the current literature, and on 'research gaps in the existing literature' (Arksey & O'Malley, 2005, p. 21). The data were collected through literature searches in seven electronic databases: Scopus, Web of Science, PubMed, ProQuest, EBSCOhost, CINAHL and APA PsycInfo. The literature search and review processes were inspired by the structured search methodology,

Preferred Reporting Items for Systematic reviews and Meta-Analyses
(PRISMA) 2009 (Moher et al., 2009). This approach was used to (1) identify, (2) screen, (3) assess and (4) include scientific studies. An overview of the review process is presented in Figure 1.
The data were retrieved from the databases on June 3, 2020 and targeted empirical studies were published in scientific journals between January 1, 2010 and June 1, 2020. Since home care nursing

What is known about this topic?
• Teamwork is associated with improved care quality and increased patient safety.
• Treatment and care performed at home tend to become more complex due to the ageing population, which in turn puts higher demands on care professionals.
• There is a lack of contemporary overviews of existing research regarding teamwork when treating and caring for patients at home.

What this paper adds?
• Studies of teamwork in patients' home environments tend to pay too little attention to the context.
• Nurses play a crucial role in teamwork when treating and caring for patients at home.
• More research is needed regarding necessary team skills, effects of teamwork on the work environment and technology-mediated teamwork.
is defined, organised and functions differently around the world, a broad search strategy was used. The search strategy was defined in two levels constrained to the title, abstract and keywords fields. The first level was used to identify possible studies concerning healthcare or care at home and used the following title search terms: 'home care', 'home healthcare', 'home healthcare', 'home care nursing', 'home nursing' and 'home health services'. The second level used the search term 'team*' targeted in the title, abstract and keywords to find studies relating to teamwork. The search string in Scopus looked like this: (TITLE (["home care" OR "home healthcare" OR "home health care" OR "home care nursing" OR "home nursing" OR "home health service"]) AND TITLE-ABS-KEY (["team*"])) AND DOCTYPE (ar OR re) AND PUBYEAR >2009 AND PUBYEAR <2021.
The broad first level was used due to the difficulties in capturing home care nursing that was contextually similar to that which exists in Sweden. The term team* in the second level also includes studies related to teamwork and was considerably more accurate and straightforward.
F I G U R E 1 PRISMA flow chart illustrating the data selection process e3312 | LARSSON et al.

| Criteria for inclusion and exclusion
The articles included had to focus on teamwork in home care nursing where a team, or an equivalent group of care professionals considered to be a team, had to be present. Team structures were examined and the results related to the data from these were necessary to be included. Articles also had to be empirical studies, written in English, and published as articles in scientific journals. Studies were excluded if their data or findings did not clearly address teams or teamwork, if registered nurses were not main contributors to knowledge (i.e. not part of the team being studied) or if the studies lacked descriptions of study design or methodology. Furthermore, studies covering nursing home care or in-patient hospital care were excluded as well as studies involving informal home care and basic home care (care provided by aides and assistant nurses).

| Data extraction and analysis
Due to the diverse and inconsistent use of terminologies related to teams and teamwork, a qualitative assessment of each study was conducted to determine if they actually were concerned with teamwork (Flores-Sandoval et al., 2021;Lyubovnikova et al., 2015;Rydenfält et al., 2017;Rydenfält, Borell, & Erlingsdottir, 2019). An inclusive approach to the definition of teams was applied. In practice, this meant that if the identified studies of home care nursing used the terms 'team' or 'teamwork' or were concerned with factors associated with teamwork in healthcare, they were then included.
The articles remaining after the initial identification and screening stages were split between the first and the fourth authors for full-text assessments of eligibility. The two authors went through the articles individually on their own. Then they met and discussed their assessments on what studies should be included or excluded and why. This process continued over several iterations until both authors agreed on which studies to include. After this final assessment, the aim, study design, subject and main results were described for the remaining articles. Here, 'subject' refers to the topic or focus of the assessed study. Then the authors formulated themes based on the subjects identified in each study. The classification of themes was based on the subjects and the overall content of each study.
Depending on the content, it was possible to categorise some studies under multiple themes. After an initial list of themes had been formulated, the second author joined the discussion to further develop the themes. The analysis was then adjusted and verified by the third author.

| RE SULTS
The initial search gave 798 articles. After duplicates were removed, 383 articles remained and were screened. Seventy articles passed the screening. These were then retrieved in full text and assessed for eligibility. The final number of articles left was 32 (see Figure 1). Table 1. The majority of the studies originated from Northern and Western Europe, and North America (see Table 2). The articles were distributed over 21 scientific journals. Eight themes were identified in the literature as shown in Table 3. The study designs and quality of the articles varied considerably, from controlled studies to case studies. Qualitative methods dominated: interviews, questionnaires and focus groups were the most commonly used methods (see Table 4). The studies utilised both stand-alone and multiple methods in their study design; however, the former was most prevalent. When combining methods, the qualitative-qualitative pairing was more common than quantitative-qualitative pairing. Team definitions were not always clearly stated in the literature and sometimes not even present. The studies included did not always clearly describe which professionals constituted the team or which tasks were performed by each professional. However, given the criteria for inclusion, we knew that the teams included had at least one nurse. Descriptions of national and organisational contexts were often given but seldom on a level that provided enough insight into the dynamics of the health care system studied and the organisation of work. The terminology and potential distinction between home healthcare and home care nursing were not always clearly defined either. The results from the included studies across thematic affiliations addressed the need to enhance familiarity and collaboration between team members. The literature also consistently considered teamwork as something good and desirable. We present the eight identified themes in the following sections.

| Teamwork around specific patient groups
This theme consists of studies where teamwork is used to care for specific patient groups including geriatric home care (Larsen et al., 2017;Nasarwanji et al., 2015), paediatric home care (Castor et al., 2017), oncology home care (Dhollander et al., 2019) and dementia home care (Karlsson et al., 2015). Castor et al. (2017) describe the importance of teamwork when caring for sick children at home. Dhollander et al. (2019) show that early involvement of palliative home care efforts can be counteracted in part by ineffective teamwork. The importance of team coherence when conducting pain assessments in dementia patients is highlighted by Karlsson et al. (2015). Larsen et al. (2017) state that professionals in community home care teams need to interact closely, flexibly and collaborate interdependently across organisational boarders to care for multimorbid elderly patients at home. When transferring older patients from hospitals to home health care, Nasarwanji et al. (2015) find that care coordinators play an important role since they assemble collective information from teams and transfer it across healthcare boundaries. This theme highlights the importance of teamwork, often multidisciplinary, when caring for patient groups that suffer from complex multimorbidity.

| Organisational change
This theme includes studies that describe changes in organisations that affect teamwork (Adekpedjou et al., 2020;Josefsson & Peltonen, 2015;Pype et al., 2015;Shaw et al., 2016). According to Adekpedjou et al. (2020), intentions to engage in shared interprofessional decision-making among home care teams decrease during major organisational restructuring events. Josefsson and Peltonen (2015) report on accounts from home care district nurses of better patient conditions after a nationwide care responsibility transfer from county councils to municipalities. The improvements came, however, at the cost of their own work situation. What the studies in this theme have in common is that they are concerned with the improvement of teamwork on a more general level than in relation to specific tasks. However, they also show that this type of organisational change was not always easy to implement or successful (Adekpedjou et al., 2020;Josefsson & Peltonen, 2015).

| Descriptive studies of teamwork characteristics
This theme encompasses studies of assessment of team types ( were single-method studies relying on questionnaires or interviews (see Table 4).

| Team skills
This theme includes studies where skills considered important for

| Teamwork and work environment
The studies on this theme describe the relationship between teamwork and factors associated with the work environment such as job satisfaction (Maurits et al., 2017), staff retention (Tourangeau et al., 2014) and work attractiveness (De Groot et al., 2018).

| Teamwork and digitalisation
This theme consists of one study that examines the attempt to support teamwork through digital means (Gonghom & Tantivitayatan, 2018).
These authors investigate a proposed model for virtual team collaboration in home healthcare where team communication and collaboration are mediated through technology. They conclude that technology can help solve problems related to service accessibility and even be a possible strategy to address medical staff shortages.
However, healthcare workers were found to favour synchronous over asynchronous communication during consultations regarding medical decision-making.

| DISCUSS ION
This study reviews the scope of the existing literature on teamwork in home care nursing. As previous studies have indicated, the terms team and teamwork are not always used in a consistent manner (Lyubovnikova et al., 2015;Rydenfält, Borell, & Erlingsdottir, 2019;West & Lyubovnikova, 2012). In comparison, the included studies did not always give a good indication of which professionals constituted the team (e.g. Adekpedjou et al., 2020;Dhollander, 2019;Larsen et al., 2017) or of the overall organisational context dynamics (e.g. Lee et al., 2019;Nasarwanji et al., 2015;Noguchi-Watanabe et al., 2019). This is problematic since subtle differences in team organisation and conceptualization can have significant implications for how the practice functions. In addition, it is not uncommon for study results to include teamwork as only one aspect while also investigating or even targeting something else (e.g. Castor et al., 2017;De Groot et al., 2018;Lee et al., 2019;Ree & Wiig, 2019;Sun et al., 2019). As in healthcare in general, the included studies frame teamwork as something positive (Reeves et al., 2010), and thus, the utility of teamwork is seldom critically discussed.
In the following sections, we will discuss the implications of the results. In turn, we will address a need for richer descriptions of the

| A need for richer descriptions of the context of teamwork
The emphasis of the literature is manifested through the most common theme: the use of teamwork around a specific task or problem.
This is natural since teams can play an important role in the organisation's ability to manage tasks related to care. However, teamwork constitutes and affects more than the handling of specific isolated tasks or problems, such as patient safety and medication manage- ment. An analysis that is too narrow leaves out much of the context and risks missing aspects that are important in order to understand teamwork. For example, the staff's perspectives, including personal growth and contributions to the work environment, do not come to the fore in the literature, except for the small theme: teamwork and the work environment. These aspects are associated with engagement in efficient and effective teamwork (Hackman, 2002). As with the largest theme (teamwork around a specific task or problem), the studies in the second largest theme, descriptive studies of teamwork characteristics, also tended to give too little attention to the context. This indicates that there is an overall need to provide richer descriptions of contextual settings when studying teamwork in home care nursing.
These descriptions should include a more theoretically driven analysis and the use of methods better suited to capture the nuances and complexity of the studied context. Holistic approaches that apply method triangulation and thick case descriptions (Flyvbjerg, 2006;Geertz, 1973)  Ultimately, this is important to ensure the generalizability and transferability of the results. A thick description helps the reader to relate the study findings to other cases and determine their applicability (Firestone, 1993 These results are consistent with other theories on teamwork in healthcare (Rydenfält et al., 2017). This creates opportunities for organisational learning, which can be further enforced through appropriate organisational change and interpersonal team skills.
However, interventions to improve teamwork need to be carefully considered beforehand and executed in relation to the staff's situation. Otherwise, they may affect teamwork negatively and increase employee turnover.

| Home care nurses tie the team together
Several studies highlighted that home care nurses fill a critical role in the team when treating and caring for patients at home (Bjornsdottir, 2018;Fløystad et al., 2018;Lee et al., 2019;Sun et al., 2019). On several occasions, the nurses are portrayed as being situated at the core of teamwork, and as the glue that holds care together. Nurses act as a link between the patient and other professionals, thus mantling the role of being responsible for the coordination of care on behalf of the patients and their families.
In contrast, according to the PCMH model used in the U.S. (Hoff & Scott, 2017), primary care physicians are pointed out as being the care coordinators (American College of Physicians, 2021). Several studies include the interaction between nurses and general practitioners in their description of teamwork, either in part or as the main focus (Berggren et al., 2017;Fujita et al., 2017;Mertens et al., 2019;Pype et al., 2014Pype et al., , 2015. This is natural because of the incorporated hierarchical dependence nurses experience with physicians.
However, in home care nursing, nurses are often more independent. Since physicians may be absent or hard to reach for consulta-

| Teamwork as a source of control and support at work
The teamwork and the work environment theme indicate that home care nurses want control over their work situation. This is in line with the Job-Demand-Control-Support model (Karasek, 1990). As

| Digitalisation of home care nursing in relation to teamwork is under-researched
Most striking is the lack of literature on teamwork and digitalisation in home care nursing. There is a strong ongoing trend of digitalization and digitisation in society. This trend is also evident in home care and home care nursing (Frennert, 2021;Rydenfält et al., 2021;Rydenfält, Persson, et al., 2019). But compared with the advanced technological equipment frequently found in hospital settings, home care is often digitalized and digitised with everyday, off-the-shelf technology. When nursing is performed outside institutional settings, assets for communication and documentation of work become essential.
As care becomes more mobile, technology has an immense potential to both mediate and improve teamwork.

| Limitations
As the definitions and organisation of home care and home healthcare vary between countries and contexts, it is possible that we have missed studies because of the variance in terminology even though the search strategy applied was very inclusive. Twenty-one out of the 32 included studies originate from Northern and Western Europe. This could have to do with how the term 'home care nursing' is defined by us as researchers, and how it is contextually manifested in the Scandinavian countries. Scandinavian home care nursing is broadly implemented, thus making it reasonable for countries with less-developed home care nursing and home healthcare to be able to learn from how the Scandinavian ones are organised. Some of the identified themes are closely related, for example Teamwork around a specific patient group and Teamwork around a specific task or problem, as well as Descriptive studies of teamwork characteristics and Team skills. However, these studies have been classified as distinct enough to be placed in separate themes.

| CON CLUS IONS
Teamwork in home care nursing is a limited research field, constituted of studies within a broad scope. The methods used are predominantly qualitative with a single-data collection method. The studies often target teamwork as a means to manage specific tasks or problems. However, many studies lack depth when it comes to the description of the context of teamwork. Thus, future studies need to apply methods better capable of capturing the context, for example ethnographic methods. It is apparent that teamwork in home care nursing is dependent on relationships within the team, and that the home care nurse plays a central role in the management and sustainment of those relationships. Furthermore, teamwork is seldom theorised in the literature, merely described. More research is needed overall, but especially regarding important team skills, how teamwork affects the work environment, and digitalisation in relation to teamwork in home care nursing.

AUTH O R CO NTR I B UTI O N S
The authors conceptualised the review together. RL and CR were mainly responsible for data extraction and analysis. GE and JP assisted with the analysis. RL was main responsible for drafting the manuscript. However, all authors contributed to the writing.

ACK N OWLED G EM ENTS
The authors would like to thank AFA Insurance (Grant DNR: 170278) for financing the research project in which this review has been carried out. We would also like to thank Eileen Deaner for reviewing the language before submission.

CO N FLI C T O F I NTE R E S T
None.

DATA AVA I L A B I L I T Y S TAT E M E N T
Since the article is a review, we have not collected any original data.
However, the references to the articles that the review is based on are provided in the manuscript.