The multidisciplinary team is the second prominent defining feature of rehabilitation. The importance of multidisciplinary teamwork is increasingly recognised across all healthcare settings and is a rational response to the complexity of many healthcare problems. Unfortunately, some people equate teamwork with a group of clinicians involved with a particular patient, which constitutes a ‘pseudo-team’. They fail to appreciate the crucial characteristics that define a team. Moreover, as will be shown here, the team’s multi-professional nature is its defining feature. Although a multidisciplinary team may be a group of specialists from different professions, it can also refer to a group of people from different subspecialties within one profession, usually doctors. Should a team be multidisciplinary, interdisciplinary, or transdisciplinary? This page shows that this categorisation of teams has no evidential basis and is not helpful. At best, it describes their way of working. Some of the themes covered on this page are shown below the table of contents.
Table of Contents
Introduction
The need for a multiprofessional team has been recognised from the beginning, certainly by 1920. I say multiprofessional to emphasise the requirement for different professions. The term multidisciplinary may refer to a team of doctors from different medical specialities. Organisations know that teams are the most effective way to manage complex problems. Many clinical problems faced by rehabilitation services are very complex.
Like all organisations, teams develop a culture and ethos, usually improving their functioning, but poorly functioning teams are also quite common. Sometimes the word is used to describe a group of individuals working on a problem, but without any identity, often a disparate group that happens to be involved with one patient or problem. They are not a team.
This page will work through many of the major issues, starting with what a team is.
What is a team?
The word, team, is derived from the “Old English tēam’ team of draught animals’, of Germanic origin; related to German Zaum’ bridle’, also to teem and tow, from an Indo-European root shared by Latin ducere ‘to lead’.”. (From Oxford Languages). We now use the word to describe two or more people working together towards common goals, each contributing according to their expertise and ability. Team members collaborate on their work.
Collaborative working is one key to success in life. A single ant can achieve nothing, but army ants can destroy swathes of the jungle. A single lioness rarely catches a zebra unaided, but a pack will regularly catch 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 a shared goal and 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 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 share only some of the goals and 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.
Collaboration, not competition, leads to success. Competition is “the activity or condition of striving to gain or win something by defeating or establishing superiority over others.” [OED] In a straightforward system with only a few parties involved and undertaking a relatively simple activity and with only one outcome of any significance, completion may help drive improvement. Rehabilitation is a complex activity set in a complex mixture of many systems. Collaboration, not competition, is the only means to achieve the best outcome.
Lastly, a team is a complex system. The individual team members are its components, and there are complex interrelationships between them. [A complex relationship is non-linear, often bidirectional, and is influenced by all other relationships, such that feedback occurs and the consequences of any change are unpredictable.] An essential feature of any complex system is resilience, the ability to adapt to and compensate for the loss of a part. Teams are resilient and resist degradation. A team’s resilience is a common experience because the team adapts to the absence of a team member without much loss of team effectiveness in the short-term (days or a few weeks).
The complex nature of a team and its ability to adapt are illustrated in two diagrams below. The first shows how a team member contributes to a team’s function. While each team member has a specific area of expertise, they share much of their contribution with other members. The second illustrates how a specific patient’s team might be met by different combinations of members from the overall rehabilitation team.
Teams, collaborative activity, and goals.
Collaborative working, or teamwork, depends on many things. The group must have shared goals. This is the vital defining characteristic of a team. The team must agree on its purpose within the healthcare system and on goals for a particular patient. They must therefore understand how they fit into the larger healthcare system and, for each patient, what the issues are (i.e. an agreed formulation).
The formulation must consider the problems, the factors important to their genesis, the prognosis, and, most importantly, the actions that might resolve or reduce the difficulties. The team must discuss any differences in understanding to ensure a shared, agreed-upon plan. If different team members do not commit to the shared goals, rehabilitation planning and goal setting will fail.
In rehabilitation, as in war and most activities, goals themselves are not simple, simple stand-alone phenomena. The identified goals are all part of a larger goal in all situations. The distinction between strategy and tactics is between overarching long-term goals and short-term goals.
Although there is inevitably an overlap because goals fall on a spectrum between the very long-term and the immediate, the distinction is simple:
- tactical refers to “relating to or constituting actions carefully planned to gain a specific military end“.
- strategic refers to “relating to the identification of long-term or overall aims and interests and the means of achieving them.”
These strategic, longer-term, higher-order, or superordinate goals are vital to rehabilitation planning for several reasons:
- Identifying and setting a small number of high-level goals reduces the risk of overlooking important actions
- High-level goals require a 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 enables the team, both individually and collectively, to adapt their actions in the face of changes or unexpected obstacles.
- High-level goals help engage the patient in activities that, in themselves, may seem unimportant.
- Patient engagement depends on the link between the activity and important outcomes being explained and accepted.
There is one crucial difference between a team of horses pulling a plough, 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. Moreover, rehabilitation actions inevitably involve the patient, and the team must always take their perspective into account.
Thus, after successfully formulating the patient’s situation and setting out both long-term and short-term goals, the team should develop a plan for (and with) the patient, including agreed high-level and intermediate goals.
The team will then take action, jointly and severally (to borrow a legal phrase). More importantly, the plans and activities will inevitably involve others who are not members of the multi-professional expert rehabilitation team. Collaboration with other groups and individuals is also essential to multiprofessional rehabilitation teamwork. Indeed, there is often a multiagency team.
The team's structure and characteristics.
We use the term team loosely, without considering who or what the team is. For example, is the patient part of the team? I consider it essential that the patient be involved in all decisions about their care. It is also self-evident that the patient needs to engage with many of the team’s activities, such as practising walking or learning how to cook with one arm.
However, the subject of a team’s efforts cannot also be a truly integrated team member. I would not include the patient as a team member. Usually, a team is acting on something inanimate, or the person or people in focus are not required to participate actively in team actions.
Much more important is whether the team is:
- simply the named individuals from the rehabilitation service who are involved, or
- the wider group of people who constitute the rehabilitation service, or
- the people from the rehabilitation service and other healthcare workers in other services, especially community services, who are involved, or
- also people from other organisations such as Social Services, or
- every person involved – family, friends, solicitors etc?
The figure below illustrates the question. There is no simple answer to the questions posed. Provided one acknowledges the various interpretations, the meaning will usually be evident from the context. I have already discussed the extent to which the structure of an individual patient’s team may vary simply by choosing different combinations of staff from the whole rehabilitation team.
The composition of the rehabilitation service’s team, the mix of professions and levels of expertise, depends entirely on the nature of the service and the clinical problems seen. The range of possible needs among the patients seen in most services will be extensive. There will always be rare problems within any service. For example, severe visual loss from retinal damage or extensive damage to the occipital lobes bilaterally is not common in most neurological rehabilitation services. The service could not employ experts in the rehabilitation of individuals with marked visual acuity loss.
It would be reasonable to expect a team to manage at least 80% of the clinical problems it encounters using its members’ expertise. The team should also identify who is willing and able to support the team with the less common issues encountered. For example, most neurological rehabilitation teams will closely collaborate with one or two orthopaedic surgeons to advise on the surgical management of joint contractures.
The reverse will also apply, with individual rehabilitation team members maintaining close relationships with other local services, providing the expertise they need. For example, a doctor and a physiotherapist might advise a stroke rehabilitation service on managing severe spasticity and on whether to use botulinum toxin and intrathecal baclofen.
Last, I will consider the structures and characteristics needed for effective teamwork. I have reviewed the evidence that teams are effective, as well as the research identifying the essential features.
In essence, the following features are critical determinants in team effectiveness:
- identifying the patient’s need, usually based on the biopsychosocial model of illness
- having shared goals and a common, shared understanding of actions needed
- establishing a particular group (team) for each patient, able to meet his/her specific needs
- having good communication and coordination between all team members, and the patient and family
- having, within the team, the range of knowledge and skills needed for the range of patients seen by the team
- presence of trust and mutual respect between members, being able and willing to share knowledge (this is the only feature that concerns culture)
- evaluating progress, and altering goals or actions as required
- organising for teamwork, making opportunities (e.g. team meetings about the purpose of the team and how they work) to develop team identity and culture
Can teams be classified? Part 1.
I once received an email asking for my opinion on whether a team was multidisciplinary, interdisciplinary, or transdisciplinary. I gave my opinion in a separate post on 5 November 2021.
Some people like to classify things, and rehabilitation teams are no exception. There is an element of being one-up if you have a transdisciplinary team, though I do not know on what basis.
The three types usually referred to, and their usual descriptions are:
- multidisciplinary; work undertaken with other disciplines in parallel or sequentially
- interdisciplinary; work undertaken jointly with other disciplines
- transdisciplinary; work integrated across many disciplines and undertaken collaboratively.
I will now consider the question posed: “Is our team multidisciplinary, interdisciplinary, or transdisciplinary?“
Which team?
The first difficulty that arises when considering this question is: which team? The figures in the introductory and following paragraphs show the problem graphically. There are many teams. The two most important ones to consider are:
- the group of people who work together with many patients within a service or other organisation, the service team, and
- The group of people involved with a patient, the patient team, that will include some members of the service team, but will often include many others from outside the service team.
I will refer to the former as the service team and the latter as the patient team.
The service team, referred to as the ‘lead team’ in the figure earlier, has six defining characteristics:
- shared commitment, a psychological attachment to the group;
- 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 on the team’s goals, both 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. Blurring professional boundaries, with consequent sharing and distribution of some tasks between team members, characterises an efficient and effective team.
Team functioning.
As with rehabilitation capabilities, one can describe 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 patients that are usually undertaken by someone from another profession
- sharing knowledge and skills
- team members teach others their unique expertise and learn from other professions
- sharing responsibilities
- team members 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. The group may be better or worse than other teams in the extent of actual teamwork or the effectiveness and efficiency of its work, which are measures of the team’s performance.
One can measure team function; there are many such measures of uncertain validity. (here) It may be possible to improve teamwork after a team assessment. (here)
A multiprofessional team
A rehabilitation team is characterised by having members from several, sometimes many different professions. This is necessary to, as far as possible, cover the broad range of potential difficulties a patient may have and to deliver the interventions 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 include electronic engineers, mechanical engineers, and occupational therapists, whereas a team focused on behavioural problems may include clinical psychologists.
I have used the phrase ‘different professions’ because it is generally more accurate for rehabilitation teams. Many multidisciplinary 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 ‘multiprofessional team’ is a better choice for a rehabilitation team. It emphasises that each team member brings their profession-specific knowledge and skills to the team.
Teams and networks.
Ideal rehabilitation services should be part of a larger rehabilitation network to facilitate transfers of primary responsibility and access to expertise not present in the service. Teams should not be considered as complete and self-contained.
As I have said elsewhere, “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”.
That this is how teams work in healthcare was illustrated by a study on teams in cancer care, which used data from electronic patient records. The results highlighted the complexity of patient care and the number of people and groups routinely involved in a single patient’s care. The authors suggest that teams should be conceptualised as networks that interact.
The role of a specific rehabilitation team may vary considerably across contexts, for example, within the whole health and social care system and within the complex team constructed around a patient. Furthermore, a service team may have different roles concerning different patients in both contexts.
Can teams be classified? Part 2.
The discussion above has demonstrated the complexity of rehabilitation. The idea that a rehabilitation team is an isolated entity is at odds with reality. Patients receiving rehabilitation will have their closest links with the individual clinicians seeing them, the patient team.
These patient teams are embedded within a more extensive network of people, the service team. This service team is itself embedded in several other networks: the hospital or community care organisation they are managed by, which will have many other teams, other healthcare rehabilitation teams within other healthcare organisations and networks, many other teams within many other organisations such as Social Services or Employment, and the network of friends and family related to the patient.
Xyrichis and colleagues suggested four different types of teams (here):
- Teamwork
- one undertaking actual teamwork, as identified by the six features shown earlier
- Collaboration
- consultative collaboration, where the team undertakes some work within the rehabilitation process, such as assessing the nature and causes of the problems, and giving advice but does not have any further role
- consultative partnership, when the ‘team’ is restricted to two people
- Coordination
- 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
- Networking
- 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 classification. (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).
They also suggested the three types corresponded “to multidisciplinary, interdisciplinary and transdisciplinary team models.” I do not agree.
These different types of teams are fully consistent with the General Theory of Rehabilitation’s overview of the roles of rehabilitation expertise in facilitating a patient’s adaptation when a malady limits function; the roles are shown in the figure below.
In conclusion, one may describe a team, for example, its membership and the number of characteristics associated with better teams it has. One might also describe the role or roles a team plays within the whole system. A team cannot be classified on any valid axis or set of axes.
Therefore, a team should spend its time working out how it fits into the greater whole, possibly adapting to meet an unmet need. The team should aim to develop the characteristics associated with better teamwork. It should not agonise over its categorisation.
Table of links to other pages/posts.
Teams and teamwork are mentioned on many pages, but a few pages and posts discuss teams and teamwork in more detail. The table below shows them.
| Item/link | Title | Comment |
|---|---|---|
| Page-01 | Rehabilitation team members. | A page introducing one of the categories used for posts. The posts in the category are listed at the end, and teams are discussed on the page too. |
| Page-02 | Capability 3: teamwork | A page in the series on rehabilitation capabilities (as evidence of expertise), focused on the expertise of being a team member, able to contribute, be led, and lead. |
| Page-03 | Rehabilitation in 14 key concepts | A page coverining history and development of rehabilitation; one is teamwork and the links goes to that part |
| Post-01 | Multidisciplinary, Interdisciplinary, or transdisciplinary? | A post responding to advice on whether the team used in a servce wa one of these types. I argue they are invalid and irrelevant. The team should be multiprofessional. |
| Post-02 | Rehabilitation team leadership | A post written after a talk in Genoa discussing who should lead a rehabilitation team. I focus on being a leader, a role that must be earned and is not the right of any person. |
Conclusion
I have shown that the concept of a multidisciplinary team, widely used, is not the simple entity it appears. Instead, a patient with a disability receives care from many individuals who belong to one or more networks. Some networks are sufficiently self-contained to form an identifiable team, and many rehabilitation service groups are well-functioning teams. Nevertheless, even a self-contained group will interact with many other networks. Thus, although a multiprofessional team is vital for effective rehabilitation, it must not be considered an isolated structure; working collaboratively with all other groups is also an essential characteristic of the team.