The multidisciplinary team

The multidisciplinary team is the second prominent defining feature of rehabilitation. The importance of multidisciplinary teamwork is increasingly recognised in all healthcare and is a rational response to the complexity of many healthcare problems. Unfortunately, some people equate teamwork to 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 multi-professional nature of the team is its defining feature; a multidisciplinary team also describes a group of different specialists from within a single profession. Should a team be multidisciplinary, interdisciplinary, or transdisciplinary? This page will show that this categorisation of teams has no evidential base, nor is it helpful. At best, it describes their way of working. Last, a MindMap here shows some of the many aspects of teamwork discussed on this page.

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 OxfordLanguages). 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 in 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 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.

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.

Last, a team is a complex system. The individual team members are its components, and there are complex interrelationships between the members. [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 can 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 is illustrated in two diagrams. The first demonstrates the contribution made by a team member to a team’s function. While each team member has some unique area of expertise, they share much of their contribution with other members. The second illustrates how the composition of 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, which is teamwork depends upon many things, and the first to discuss is the shared goal, the defining characteristic of a team. Before identifying and agreeing on a team goal, the team must agree on the formulation. They must reach a shared and agreed understanding of the problems, what factors are important in their genesis, the prognosis, and, most importantly, what actions will resolve or reduce the difficulties. Without this, rehabilitation will fail because the team disagree on an appropriate goal.

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 equates to the difference 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 super-ordinate goals are 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.
  • high-level goals 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.

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. Moreover, the actions in rehabilitation 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 shorter-term goals, the team should develop a plan for (and with) the patient, setting out agreed high-level and intermediate goals. If two or more team members share no goals, rehabilitation will fail.

The team will then undertake actions, jointly and severally (to borrow a legal phrase). More importantly, the plans and activities will inevitably involve other people who are not members of the multi-professional expert rehabilitation team. Collaboration with other groups and individuals is also essential for multidisciplinary rehabilitation teamwork.

The team’s structure and characteristics.

We use the term team loosely, without considering who or what is the team. For example, is the patient part of the team? I take it as essential that the patient is 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 member of the team. Usually, a team is acting on something inanimate, or the person or people who are the focus of attention are not required to participate actively with team actions.

Much more important are questions such as:

  • is the team simply the named individuals from the rehabilitation service who are involved?, or
  • is the team the wider group of people who constitue the rehabilitation service? or
  • is the team the people from the rehabilitation service and other healthcare workers in other services, especially community services who are involved? or
  • does the team also include people from other organsations such as Social Services, or
  • is the team every person involved – family, friends, solicitors etc?

This figure illustrates the question. There is no simple answer to the questions posed. One must remember that the word covers several different aspects of a team which will often be evident from contextual information. For example, if one is referring to the patient’s team, it will be a restricted set of people. In contrast, if one is referring to an educational meeting for the rehabilitation team, it will refer to the whole service.

I have already discussed the extent to which the structure of an individual patient’s team may vary simply through 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 of the occipital lobes bilaterally is not common in most neurological rehabilitation services. The service could not employ experts in the rehabilitation of people with marked loss of visual acuity.

There is no rule, but it would be reasonable to expect a team to manage at least 80% of all clinical problems it sees from within its expertise. The team should also identify who is willing and able to support the team with the less common issues seen. For example, most neurological rehabilitation teams will closely link with one or two orthopaedic surgeons to advise on surgical management of joint contractures.

The reverse phenomenon will also apply, with individual rehabilitation team members having a close relationship with another local service. For example, a doctor and physiotherapist might advise a stroke rehabilitation service on managing spasticity and 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 and the research identifying the essential features. (here). In essence, the following features are critical determinants in team effectiveness:

  • identifying the patient’s need, usually on the basis of 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 one.

I once received an email asking for my opinion on whether a team was multidisciplinary, interdisciplinary, or transdisciplinary. 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 tree types usually referred to 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?

A first 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 within 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. I will refer to the former as the service team and the latter as the patient team.

This answer concerns the figure’s service team, termed the ‘lead team’. (here) Six features define a rehabilitation service team (here):

  1. shared commitment, a psychological attachment to the team;
  2. 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)
  3. shared and explicit team goals, giving the team a clear purpose
  4. agreed roles and responsibilities, delineating the unique and the shared areas of authority within the team
  5. interdependence between team members, both when making decisions and when undertaking actions
  6. 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 professional boundaries, with consequent sharing and distribution of some tasks between team members, characterises 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 or the effectiveness and efficiency of its work, but these are measures of the team’s performance.

One can 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 a multiprofessional team.

A rehabilitation team is characterised by having members from several, sometimes many different professions. Having several 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 each have their profession-specific knowledge and skills to contribute to the team.

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. A rehabilitation team may have different roles concerning different patients in both contexts.

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 number of people and groups routinely involved with a single patient. (here) The authors suggest that teams should be conceptualised as networks that interact.

Can teams be classified? Part two.

The discussion above has demonstrated how complex rehabilitation is. The idea that a rehabilitation team is an isolated entity conflicts 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 team (here):

  • Teamwork
    • one undertaking actual teamwork, as identified by the six features shown above in the second answer
  • Collaboration
    • 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
  • 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. (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).

Conclusion.
I conclude that a team cannot be classified on any valid axis or set of axes. It is possible to describe their membership and measure how many of the characteristics associated with better teams they have. It is possible to place a team within a complex and extensive set of networks within which some teams are relatively isolated and others that spread their influence across a large number of teams. One can, therefore, describe the role or roles a team plays within the whole system. A team should spend its time working out how it fits into the greater whole, possibly adapting itself to meet an area of unmet need. The team should aim to have the characteristics associated with better teamwork. It should not agonise about its categorisation.

Summary and conclusion

I have shown that the concept of a multidisciplinary team mentioned by most other people writing about rehabilitation and me 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.

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