Rehabilitation Teams

Original Editors - Naomi O'Reilly and ReLAB-HS

Top Contributors - Naomi O'Reilly, Ashmita Patrao, Kim Jackson, Jess Bell, Oyemi Sillo, Wanda van Niekerk, Ewa Jaraczewska, Admin, Tarina van der Stockt, Vidya Acharya, Lucinda hampton and Stacy Schiurring      

Introduction

Cohen and Mohrman define a team as ”a group of individuals who work together to produce products or deliver services for which they are mutually accountable”.  The shared goals of the team are made manifest by mutual and cordial interaction by team members, and the roles of each professional in the team are mutually interdependent and accountable to enable the achievement of set goals. Similarly, Eduardo Salas defines a team as a “distinguishable set of two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal, objective or mission, who have been each assigned specific roles or functions to perform, and who have a limited life-span of membership.”  Basically a team consists of a group of people with complementary skills who are committed to a common purpose, performance goals, and approach, for which they hold themselves mutually accountable. The nature of teams is varied and complex and include teams that draw from a single professional group or multi-professional; work closely together in one place or are geographically distributed; have constant membership or constantly changing membership.

"The premise underlying team care has always been that assorted professionals, each contributing their own discipline's expertise and closely cooperating through oral (team rounds, informal hallway discussions etc.) and written communication (medical record entries, reports etc.) are able to achieve outcomes that are superior to those of a lone clinician, or of a number of different clinicians each practising independently of all others."  Reliance on multifaceted team-based care enables an evolving health care system to address the changing patient needs with regard to physical, psychological, and social aspects of health. The use of collaborative healthcare teams can be effective when team members understand their roles, responsibilities, competencies, and have respect for other healthcare members; allowing for an atmosphere that promotes assessing, planning, and providing optimal care. Effective teamwork in health-care delivery has been shown to have an immediate and positive impact on patient safety. In healthcare and rehabilitation the importance of effective teams is increasing due to factors such as:

• The increasing complexity and specialization of care;
• Increasing co-morbidities;
• Increasing chronic disease;
• Global workforce shortages; and
• Safe working hours initiatives.

Team Composition

Team composition will vary dramatically depending on the phase of rehabilitation, the rehabilitation setting, the rehabilitation context for rehabilitation with the roles often dependent on the specific health system set up and resources available locally. 

Every team will not necessarily include all team members but rather the team composition and the clinical role of each rehabilitation team member as health providers are hugely diverse across various healthcare settings (primary, secondary and tertiary care) and contexts (low resource, high resource, conflict situations, disaster situations). You can read more about the individual members of the rehabilitation team here.

Nonetheless, awareness of the ideal team and roles they play may provide an understanding of areas for future workforce development in the long term and professionals to reach out to for support/information in your current practice in the short term?

Types of Teams

The terms intradisciplinary", “multidisciplinary,” “interdisciplinary,” and “transdisciplinary” are increasingly being used interchangeably to define teams within healthcare and outline the various degrees of involvement of the multiple disciplines within the team environment, but there are some clear differences between these different approaches to care.

Intradisciplinary

Intradisciplinary or unidisciplinary teams are composed of professionals from one single discipline and from a single background. Within an interdisciplinary team you might have a team where all team members share the same professional skills and training, speak a common language of healthcare, and function in the same role within the group such as a team of public health nurses providing home care. Alternatively you might also have a team that includes team members from different levels of training and skill within the discipline. For example, a geriatric mental health outpatient clinic team might be composed of a licensed psychologist, a post-intern, a pre-licensing psychological assistant, a psychological technician, and two psychology practicum students. In an intra-disciplinary team all professionals belong to the same area of expertise and work towards the achievement of a common goal, individuals can support each other with specific tasks, which may improve the quality of performance.

• Work within a single discipline.
• Work towards a common goal.

Multidisciplinary

According to Jefferies & Chan (2004), multidisciplinary team working is described as the main mechanism to ensure truly holistic care for patients and a seamless service for patients throughout their disease trajectory and across the boundaries of primary, secondary and tertiary care. The Multidisciplinary Team (MDT) is a team of professionals that includes representatives of different disciplines e.g. Physiotherapy, Occupational Therapy etc., who coordinate the contribution of each discipline with little overlap to assess and treat the patient separately with discipline-specific goals. There are different definitions and descriptions which capture important features of multidisciplinary work. Each discipline could function autonomously, working in parallel towards a shared goal; acknowledging one other’s contributions and sharing successes. The patient’s progress within each discipline is communicated through written documentation and regular team meetings and as such does not emphasize an integrated approach to care. This type of team approach is predominantly what we see in an acute hospital setting.

• Each discipline works in parallel with clearly defined roles with the team
• Each discipline sets its own individual, specific goals with the patient and communicates these goals and outcomes with the team through written documentation or within team meetings where appropriate 
• In most cases within an Acute Setting the team is Consultant / Physician-led 

Interdisciplinary

Interdisciplinary teams differ from multidisciplinary teams in that they overlap practice with shared goals coordinated into a unified management plan, rather than working individually, allowing for group decision making and group responsibility, with the patient considered an active member of the team. Each team member in an interdisciplinary team builds on each other’s expertise to achieve the common, shared goals. Patient progress is communicated through written documentation and regular team meetings as in the multidisciplinary approach but reports tend to focus more on the common overall patient goals rather than on discipline-specific goals.  According to Fergusson (2014) an interdisciplinary care plan generally is developed by considering the following questions:

• What are the issues?
• Who will be involved?
• What will the interventions be?
• What are the goals of the intervention?
• When will re-evaluation occur? 

The interdisciplinary team is very common in inpatient rehabilitation centres. Interdisciplinary teams involve: 

• Professionals involved in joint problem solving
• Overlapping, patient focused treatment goals
• Collaboration with other disciplines
• Regular communication between team members
• Active involvement of the patient 

Transdisciplinary

Transdisciplinary teams share roles across disciplinary boundaries so that communication, interaction, and cooperation are maximised among team members with an overlap of responsibilities that allows flexibility in problem-solving and produces closer interdependence of team members. Team members jointly communicate, exchange ideas and work together to come up with solutions to problems from day one of working with the individual. In this approach, there is no hierarchy among the disciplines, and there is a higher level of communication and cooperation among the individual members of the organisation.   Flexible boundaries and interchangeable roles and responsibilities encourage the exchange of information, knowledge and skills. The interwoven nature of transdisciplinary teams broaden the skill sets of each therapist due to their exposure and substantial interaction with others outside their discipline, but it also allows the team of professionals to work together to reinforce and maintain goals not normally monitored. With a truly transdisciplinary team, the typical boundaries of each professional discipline tend to disappear.

The individual and family are central to this type of team and are respected as equal, and valued team members, often the final decision-makers in the team. As such this model is an extension of the interdisciplinary team and seen as a family-friendly approach, operating within a family-centred practice model. This model is frequently used in environments where there are inadequate numbers and/or unavailability of specific disciplines e.g. developing countries and rural or isolated communities, leading to other team members taking on these missing roles. 

• Professionals have an overlap of responsibilities
• Flexibility in problem-solving 
• Closer interdependence of team members
• Active involvement of the patient and family

Characteristics of Successful Teams

While these teams all have slight differences in how they operate, Mickan and Roger highlight six simple characteristics that always underpin effective healthcare teams:

1. Common Purpose
   • Team members generate a common and clearly defined purpose that includes collective interests and demonstrates shared ownership.
2. Measurable Goals
   • Teams set goals that are measurable and focused on the team’s task.
3. Effective Leadership
   • Teams require effective leadership that set and maintain structures, manage conflict, listen to members, and trust and support members. The authors also highlighted the importance of teams to agree and share leadership functions.
4. Effective Communication
   • Good teams share ideas and information quickly and regularly, keep written records as well as allow time for team reflection. Some of the most in-depth analysis of inter-professional team communication has occurred in high stakes teams, such as are found in surgery.
5. Good Cohesion
   • Cohesive teams have a unique and identifiable team spirit, commitment, and greater longevity as teams members want to continue working together.
6. Mutual Respect
   • Effective teams have members who respect the talents and beliefs of each person in addition to their professional contributions. In addition, effective teams accept and encourage a diversity of opinion among members.

Additional requirements for effective teams include: demonstrating individual task proficiency (both in terms of personal technical skills and teamwork skills); having task motivation; being flexible; monitoring their own performance; effectively resolving and learning from conflict; and demonstrating situation monitoring.

Barriers to Effective Teams

As with any team environment, there are always challenges present and healthcare is no different. There are a number of specific barriers that exist in healthcare that may impact both establishing and maintaining effective teams include:

1. Changing Roles
   • Globally there has been considerable change and overlap in the roles played by different healthcare professionals. Examples include radiographers reading plain film X-rays, nurses performing colonoscopies and nurse and physiotherapy practitioners having prescribing rights. These changing roles can present challenges to teams in terms of role allocation and acknowledgement.
2. Changing Settings
   • Health care delivery is slowly changing with increased delivery of care for chronic conditions and basic surgical procedures into the community and primary care centres. These changes require the development of new teams and the modification of existing teams.
3. Medical Hierarchies
   • Medicine continues to be strongly hierarchical in nature, which can be challenging when establishing and effectively running teams where all members' views are accepted and the team leader is not always the doctor. While there has been a growing acknowledgement that teamwork is important in health care this has not necessarily been translated into changed practices, especially in emerging and developing nations where cultural norms of communication may mitigate against teamwork.
4. Individualistic Nature of medicine
   • Traditionally the practice of medicine was based on the autonomous one-on-one relation between the doctor and patient. While this relationship still remains a core value, the introduction of shared care has implications for team-based care.
5. Instability of Teams
   • Change is common within healthcare and healthcare teams are often transitory in nature, coming together for a specific task or event (such as cardiac arrest teams). The transitory nature of these teams places great emphasis on the quality of training for team members, which raises particular challenges in medicine where education and training is often relegated at the expense of service delivery.

Conclusion

According to Kirshblum and Fergusson, the collaborative approach is the fundamental difference between both the interdisciplinary and transdisciplinary teams in comparison to the multidisciplinary team, which does not emphasise an integrated approach to care. In the multidisciplinary approach, each discipline approaches a situation or problem from its own perspective and then shares findings, often presenting problems with the development of a cohesive management plan. This interdependence is also seen with interdisciplinary teams, but efforts are much more collaborative and team members work together towards a resolution, building on each other’s expertise to achieve common, shared goals. While with transdisciplinary teams, the lines are more blurred and the typical boundaries of each professional discipline tend to disappear.  The interdisciplinary approach to patient care has shown better results for team effectiveness in comparison with a multidisciplinary approach. 

It has been suggested that these distinctions between the different types of teams are probably artificial, as the reality is that no team works in isolation, particularly within a healthcare system. Instead, there is a hierarchy of systems that interact at the level of a patient, department, hospital, or a primary care centre and at many levels in between. And as such, all teams are a part of a network of teams with a single patient often involved with several different teams - some that interact with each other and some that operate in isolation. “No team is an island entire of itself; every team is a piece of the healthcare system.”

Resources

World Health Organisation

Patient Safety Curriculum Guide for Medical Schools - Topic 4: Being an Effective Team Player.