Teams use many different words to describe themselves. A team recently asked me to help them decide whether they are a multidisciplinary or an interdisciplinary team. The background information provided perfectly illustrated the difficulty in defining the team, as illustrated in this figure. (here) The question prompted me to write this blog post to show that the adjective (e.g. multidisciplinary) cannot correctly be applied to the team. It applies to the process of teamwork if it is applicable at all. Multidisciplinary, interdisciplinary, and transdisciplinary adjectives describe how the team members work together; whether they are helpful is another question I will discuss. For a more extended discussion of all aspects of teamwork in rehabilitation, read my chapter in the Oxford Textbook on Neurorehabilitation, second edition. (here)
Collaborative working is one key to success in life. A single ant can achieve nothing, but arm ants can destroy swathes of the jungle. A single lioness will rarely catch a zebra unaided, but a pack will regularly catch their prey. Humans have used collaboration to dominate and possibly destroy the living world. Collaboration is “the action of working with someone to produce something” [OED], and to collaborate is “to work jointly on an activity or project” [OED]
Both definitions imply the existence of some shared goal, a shared sense of purpose. It is unlikely, though not impossible that individual ants have any concept of the goal of, for example, constructing a complex termite’s nest. Individual lionesses probably have a clear idea of the goal – a good feed. Human collaborators are likely to have a shared goal, though often they may only share some of the goals, and they may not be aware of the higher-order goal of the whole organisation. For example, in a war, a platoon of soldiers may know their goal is to capture a strong point, but they may be unaware of the battle plan.
Rehabilitation is not a war, but the process is no less complex. Rehabilitation depends on a thorough analysis of the problems, covering many different systems (or domains) such as behaviours, social roles, and disease within the body. This analysis depends upon input from several or many sources. Each source collecting and interpreting information needs to know the goal of data collection, but it is not otherwise a collaborative process.
However, it is the actions that do require collaborative work. The people involved need to:
- agree on the formulation. They must reach a shared and agreed understanding of what the problems are, what factors are important in their genesis, what the prognosis is, and, most importantly, what actions will resolve or reduce the dfficulties. Without this, rehabilitation will fail.
- develop a plan for (and with) the patient, setting out agreed high-level and intermediate goals. If there are no goals that exend beyond an individual person within the team, then rehabilitation will fail.
- undertake actions, jointly and severally (to borrow a legal phrase), and also with other people who are not members of the team.
The existence of super-ordinate (high-level) goals is vital for several reasons:
- identifying and setting a small number of high-level goals reduces the risk of overlooking some important actions
- high-level goals enforce planning, the bridge between goals and actions.
- The saying, “One cannot be sure that any operational plan will survive the first encounter with the main body of the enemy.” (von Moltke) applies as much to rehabilitation as it does to a battle.
- but this does not devalue planning. Eisenhower summarised this: “In preparing for battle, I have always found than plans are useless but planning is indispensible.“
- in other words, the presence of high-level goals allows the team, both individually and collectively, to adapt their actions in the face of changes or unexpected obstacles.
- they help engage the patient in activities that, in themselves, appear unimportant to the patient.
- provided the link between the activity and important outcomes is explained and believed.
The collaborative activity of a group of people towards an agreed goal identifies the group as a team. One description of a team in the Oxford English Dictionary is “two or more animals, especially horses, in harness together to pull a vehicle.” This definition is difficult to beat as an illustration of the critical characteristics of a team.
There is one crucial difference between a team of horses pulling a plough or a team of soldiers fighting to capture a building and a team of humans working towards rehabilitation goals. The horses and the soldiers had no part in identifying and setting the goals. In rehabilitation, the people involved are also necessarily involved in collecting and collating the data needed to identify, select and develop goals and plan how the team will achieve its purpose. To continue the war metaphor, the rehabilitation team members are, at the same time, the politicians, the army high command, the intermediate officers, and the foot soldiers. Multitasking!
In summary, many activities in life require individuals to work collaboratively together towards a common goal, and the word used to describe that group of people with a common destination is a team. To identify the goals, the group members also have several other preparatory goals such as collecting information, analysing, setting outcome goals, and planning. In the process of rehabilitation, as a member moves from collecting data to undertaking actions, the degree of collaborative, joint working increases.
In this context, we can now consider the question posed: “Is our team multidisciplinary, interdisciplinary, or transdisciplinary?”
The first answer – it is a multiprofessional team.
A rehabilitation team is characterised by having members from several, sometimes many different professions. Having different professions is necessary to cover, as far as possible, the broad range of potential difficulties a patient may have and to deliver the intervention likely to be needed. The precise professions will depend upon the nature of the team and its work. For example, a team focused on delivering assistive technology may have electronic engineers, mechanical engineers, and occupational therapists, whereas a team focused on behavioural problems will have clinical psychologists.
I have used the phrase ‘different professions’ because this is generally more accurate for rehabilitation teams. Many interdisciplinary teams within the health service consist of people from one or two professions, often doctors and nurses, each from a different speciality such as oncology, chronic pain management, palliative medicine, and neuroradiology. They are multidisciplinary but uni- or pauci-professional.
The term, a multiprofessional team, is a much better term to use for a rehabilitation team. It emphasises that individual team members may not share much specific knowledge and skills.
Two of the three terms asked about, interdisciplinary and transdisciplinary, describe modes of working or appear to. I assume that multidisciplinary also refers to a method of working in the question.
Therefore the question posed does not ask about the team members, and the question cannot be answered by considering who the team members are or what their sets of knowledge and skills are. It is a question that applies to the team as a whole and how team members work with each other.
Answer two – the service team.
A second difficulty arises when considering this question – which team?
The figure mentioned in the introductory paragraph and the following paragraph shows the problem graphically. There are many teams. The two most important ones to consider are (1) the team of people who work together with many patients, with a service or other organisation and (2) the group of people involved with a patient, who may include some members of the service team but will often include many others.
This answer concerns the service team, termed the ‘lead team’ in the figure. (here)
Six features define a rehabilitation service team (here):
- shared commitment, a psychological attachment to the team;
- shared team identity, the understanding of and meaning given to the team by other (external) healthcare professionals (and, presumably, the public and people in other organisations)
- shared and explicit team goals, giving the team a clear purpose
- agreed roles and responsibilities, delineating the unique and the shared areas of authority within the team
- interdependence between team members, both when making decisions and when undertaking actions
- integration of work, with team members focusing upon the team’s goals generally and specifically
Sharing knowledge and skills, and thus sharing some professional tasks, is not explicitly mentioned. It can and should follow on from feature five. I certainly believe that ‘blurring of professional boundaries’, with consequent sharing and distribution of some tasks between team members, characterised an efficient and effective team.
As with rehabilitation capabilities, (here) it should be possible to determine a capable team through its behaviour or, more accurately, the behaviours of its members. A good team should show the following behavioural characteristics:
- sharing documentation
- the primary patient record is used to record all major information from all team members
- sharing a common language
- use of words and terms understood by all other team members
- sharing tasks relating to a patient
- undertaking activities with a patients that are usually undertaken by someone from another profession
- sharing knowledge and skills
- team members teach other their unique expertise and learn from other professions
- sharing responsibilities
- team members are able to take on any and all team-level roles – initial assessments, running planning meetings etc
- sharing resources
- the team shares and uses common resources such as offices, areas for social activities, and equipment
The behaviours above characterise a well-functioning, effective team. It is not a type of team. It may be better or worse than other teams in the extent of actual teamwork.
Therefore, I cannot answer the question posed above concerning the team’s function as a team. It would be possible to measure the extent to which a team is functioning well. Indeed, there are many such measures of uncertain validity. (here) It may be possible to improve teamwork after team assessment. (here) It is not possible to classify teams in terms of different processes or observed within the group.
Answer three – role of team within network.
The third matter to consider is the place of a specific rehabilitation team within (a) the whole health and social care system and (b) within the complex team constructed around a patient. In both contexts, a rehabilitation team may have different roles concerning different patients.
As I have said elsewhere (here), “No team is an island, entire of itself; every team is a piece of the healthcare system”. I later expanded this to a more accurate but less concise development of Donne’s original: “No rehabilitation team is a network entire of itself; every network is a piece of the web of social networks, a part of the main; any action in one network reverberates across all networks; they influence us too”.
A study on teams in cancer care used data from electronic patient records to highlight how complex patient care is and the large number of people and groups routinely involved with a single patient. (here) The authors suggest that teams should be conceptualised as networks and that networks interact with each other.
Four different types of team were suggested (here):
- one undertaking actual teamwork, as identified by the six features shown above in the second answer
- consultative collaboration, where the team undertakes some work within the rehabilitation process, such as assessing nature and causes of the problems, and gives advice but does not have any further role
- consultative partnership, when the ‘team’ is restricted to two people
- coordinated collaboration, where the team is consulted but also coordinates actions undertaken by other people
- delegative coordination, where most of the coordination is delegated but the team gives overall direction
- consultative coordination, where the team offers advice on coordination when asked for by others
- None of the features of teamwork are present, but a group works together (face-to-face, or virtually) on areas of common interest and/or with individual patients.
There is some, albeit weak empirical evidence to support this. (here) The authors suggested three types of team activity:
- consultative (i.e. asked for information from others, but worked alone),
- inclusive participation (i.e. more sharing and communication, but often working alone), and
- joint performance (i.e. close sharing, agreed joint goals, joint working occurs).
I conclude that it may be possible to describe the role of a team within the healthcare system and the context of a patient’s care. These two roles may differ, and a team may play different roles at different times or in different proportions.
The question asked cannot be answered as there is no sound conceptual basis to answer. People used the words without any framework surrounding them. One can describe teams in terms of the quality of teamwork, their role and mode of working within the healthcare system in general, and their role within the network of teams involved with a specific patient. Furthermore, the term multidisciplinary should be replaced by the more accurate term, multiprofessional, when describing or characterising a rehabilitation team. Further expansion of ideas about teamwork can be found in this Mind-Map here.