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skill mix, setting of care, service organisation, individual A wide range of terms are used to describe collaborative

Nancarrow et al. Human Resources for Health 2013, 11:19http://www.human-resources-health.com/content/11/1/19The terms inter/multi-professional are generally narrowerthan the terms inter/multi-disciplinary [13-16] and refer to

1Southern Cross University, Military Road, East Lismore 2480, AustraliaFull list of author information is available at the end of the articlerelationships and management structures.Most existing research explores the impact of one or a

few of these aspects, rather than examining the relation-ships among several of these components on a rangeof staff and patient outcomes. Similarly, interventions

working arrangements between professionals [11]. Termssuch as interdisciplinary, interprofessional, multiprofessional,and multidisciplinary are often used interchangeably in theliterature to refer to both different types of teams and differ-ent processes within them [12]. They are also often used inconjunction with the term team work. However, there aresome consistent distinctions that are useful to understand.

* Correspondence: susan.nancarrow@scu.edu.aumultifactorial nature of team work, which comprises thethat support effective interdisciplinary team work.

Results: Ten characteristics underpinning effective interdisciplinary team work were identified: positive leadership andmanagement attributes; communication strategies and structures; personal rewards, training and development;appropriate resources and procedures; appropriate skill mix; supportive team climate; individual characteristics that supportinterdisciplinary team work; clarity of vision; quality and outcomes of care; and respecting and understanding roles.

Conclusions: We propose competency statements that an effective interdisciplinary team functioning at a high levelshould demonstrate.

Keywords: Interdisciplinary team work, Competencies, Intermediate care, Transitional care, Allied health, Systematic review,Evidence synthesis, Qualitative research

BackgroundInterdisciplinary team work is a complex process inwhich different types of staff work together to share ex-pertise, knowledge, and skills to impact on patient care.Despite increasing emphasis on interdisciplinary teamwork over the past decade, in particular the growth ofinterdisciplinary education [1], there is little evidence asto the most effective way of delivering interdisciplinaryteam work [2]. This difficulty is compounded by the

designed to improve interdisciplinary team work tend tofocus on specifics of team work activities such as: shar-ing of patient files [3], case-conferencing approaches[4,5], or meeting style or frequency [6-10]. To date,there is not a systematic framework around which theseactivities, or characteristics, of interdisciplinary workingcan be structured.

TerminologyTen principles of good inworkSusan A Nancarrow1*, Andrew Booth2, Steven Ariss2, Ton

Abstract

Background: Interdisciplinary team work is increasingly pcare closer to the patient and challenge traditional profesemphasis on the processes of team work, and in some ca

Method: This study draws on two sources of knowledgea published systematic review of the literature on interdisfrom 11 community rehabilitation and intermediate carequalitative content analysis to arrive at a framework that 2013 Nancarrow et al.; licensee BioMed CenCreative Commons Attribution License (http:/distribution, and reproduction in any mediumvalent, supported by policies and practices that bringnal boundaries. To date, there has been a great deal ofs, outcomes.

identify the attributes of a good interdisciplinary team;linary team work, and the perceptions of over 253 staffms in the UK. These data sources were merged usingntifies characteristics and proposes ten competenciesOpen Access

erdisciplinary team

Smith3, Pam Enderby2 and Alison Roots4tral Ltd. This is an Open Access article distributed under the terms of the/creativecommons.org/licenses/by/2.0), which permits unrestricted use,, provided the original work is properly cited.

Nancarrow et al. Human Resources for Health 2013, 11:19 Page 2 of 11http://www.human-resources-health.com/content/11/1/19teams consisting exclusively of professionals from differentprofessions or disciplines, or at least to the relationshipsbetween professionals in teams that may also include othernon-professional staff. The terms inter/multi-disciplinaryare broader and include all members of healthcare teams,professional and non-professional. Other authors havesuggested use of the prefixes multi-, inter- and trans- toreflect differing intensities of integration [17].The focus of this paper is on inter/multi-disciplinary

teams: the research, interventions, and data-gathering ac-tivities underpinning the study included all members ofthe respective healthcare teams. The term interdisciplinaryteam is used as a generic term of reference for thesehealthcare teams which included a range of health serviceworkers, both professionals and non-professionals, withthe majority being from professional groups. However,where authors have used the terms inter/multi/trans-professional or inter/multi-disciplinary the authors originalterms will be used.

Interdisciplinary team workPrevious research has investigated the fundamental con-cepts and features associated with team work. A conceptanalysis [18] to explore the basic understanding of teamwork in the healthcare context drew on both healthcareand literature from other disciplines such as human re-source management, organisational behaviour, and edu-cation, and proposed the following definition for teamwork in the health care context:

A dynamic process involving two or more healthprofessionals with complementary backgrounds andskills, sharing common health goals and exercisingconcerted physical and mental effort in assessing,planning, or evaluating patient care. This isaccomplished through interdependent collaboration,open communication and shared decision-making.This in turn generates value-added patient,organisational and staff outcomes. (p.238).

This definition may be more optimistic and aspirationalthan realistic as it makes several assumptions about thecharacteristics that a team will possess. Enderby [19] iden-tified these characteristics to include a definable member-ship, group consciousness, shared vision, corporate senseof purpose, clear interdependence and interaction, andco-ordinated action.Xyrichis and Reams [18] literature analysis concludes

that the outcomes from team work could be experiencedat three levels (healthcare professionals, patients, andhealthcare organizations) and that these outcomes havean impact on staff satisfaction, quality of care, control of

costs, well-being and retention. Molyneux [20] identifiedthree indicators for positive team work: personal qualitiesand commitment of staff, communication within the team,and the opportunity to develop creative working methodswithin the team. Further literature reviews [11] haveidentified the importance of two themes on interprofessionalteam work, team structure and team processes within whichspecific categories emerged: team premises, team size andcomposition, organizational support, team meetings, cleargoals and objectives, and audit processes.Collaboration is acknowledged as an important compo-

nent of team processes. A concept analysis undertaken byHenneman et al. [21] identified that collaboration re-quires competence, confidence and commitment on thepart of all parties. Respect and trust, both for oneself andothers, is key to collaboration. As such, patience, nurtur-ance and time are required to build a relationship so thatcollaboration can occur (p.108). Identified factors thatcontribute to successful collaboration were: joint venture,cooperative endeavor, willing participation, shared plan-ning and decision-making, team approach, contributionof expertise, shared responsibility, non-hierarchical rela-tionships and shared power based on knowledge andexpertise [21]. However, further reviews [22] have foundthat the reality of shared planning and decision-making,and shared power is very different from the ideal. Giventhe context of interprofessional teams, members willautomatically come from different professions, thereforein practice shared decision-making is likely to conflateindividual team members making decisions within theirown scope of practice with the ideal of all team memberssharing in all decision-making processes, or in otherwords, appropriate decision making. Shared power andleadership may also be a challenge when complex trad-itional hierarchical relationships, particularly those involv-ing medical practitioners, play a larger role and impacteither implicitly or explicitly on team processes [23,24].McCallin [23] suggests that shared leadership occurs onlyin smaller teams privileged with being free to choose allteam members.When considering the characteristics important for

interprofessional team work within the context of organ-isational development, McCray [25] points out that littleattention appears to have been paid to the actual pro-cesses of interprofessional practice within organisationalstrategy, local workforce development planning, and in-dividual continuing professional development.

Necessity of interdisciplinary team workThe need for interdisciplinary team work is increasing asa result of a number of factors including:

(1)an aging population with frail older people and

larger numbers of patients with more complex needsassociated with chronic diseases;

structured change management approach which marries

that evaluated the process and outcomes of different

Nancarrow et al. Human Resources for Health 2013, 11:19 Page 3 of 11http://www.human-resources-health.com/content/11/1/19(2)the increasing complexity of skills and knowledgerequired to provide comprehensive care topatients;

(3)increasing specialization within health professionsand a corresponding fragmentation of disciplinaryknowledge resulting in no-one health careprofessional being able to meet all the complexneeds of their patients;

(4)the current emphasis in many countries policydocuments on multi-professional team work anddevelopment of shared learning; and,

(5)the pursuit of continuity of care within the movetowards continuous quality improvement [26].

Workforce re-structuring to meet these needs requiresthat interdisciplinary teams must integrate changing or-ganisational values with new modes of service delivery[13]. While these changes impact across healthcare as awhole, there are certain sectors where these organisa-tional challenges have encountered more widespread de-bate, in particular primary care, rehabilitation, and careof the elderly. Of these, primary care is perceived to havethe least likely level of success with interdisciplinaryteam work. Indeed, some commentators suggest that aninterdisciplinary culture may only be possible as newgenerations of healthcare professionals enter the work-force [27].Despite the increasing focus on interdisciplinary team

work over the past two decades, there is still no clearsynthesis of the essence of what makes a good interdis-ciplinary team and a lack of empirical research to definewhat such a team might look like. Similarly, there is alack of data identifying the processes of interdisciplinaryteam work and linking these with outcomes. Studiestend to focus on processes or outcomes, but rarely both;or explore components of what defines an interdisciplin-ary team, without providing a clear guide on the attri-butes of good interdisciplinary team practice.This paper draws on a published systematic review of

the literature [28], combined with empirical data derivedfrom interdisciplinary teams involved in the delivery ofcommunity rehabilitation and intermediate care services(CRAICs), to develop a set of competencies aroundeffective interdisciplinary team practice. The researchwas contextualised in CRAICs.CRAICs in England are community-based services fre-

quently offering care for the elderly aimed at preventingadmissions and facilitating earlier discharge from acutecare. They exemplify the practice of interdisciplinaryteam work. Typically, CRAICs employ at least four dif-ferent staff types, including nurses, physiotherapists andoccupational therapists [29]. They often exhibit high

levels of joint working and role sharing, and employ alarge proportion of support workers who, when usedinterprofessional staffing models. Reference lists associ-ated with the identified reports and articles were alsosearched for additional studies. Results were limited toEnglish language articles in recognition of the import-ance of cultural factors in team work, and issues relatingto differences in terminology (for example, multi-, inter-,trans- and cross- disciplinary working). A total of 153studies, including 11 systematic reviews or meta-analysis,were reviewed and analysed; however, only 101 wereusable based on the supporting level of contextual detail.published research evidence relating to interdisciplinaryteam work with the tacit knowledge of the particularteam to develop a tailored approach to optimize theirinterdisciplinary team work [33]. Development of thetool involved three systematic reviews, interactions withteam members using an action research methodology,and capturing extensive, detailed qualitative and quanti-tative feedback from teams and service users.The findings presented in this paper draw on a sys-

tematic review of the literature relating to the compo-nents of interdisciplinary team work and the qualitativedata derived from the implementation of the IMT. Thislatter component of the study included the explorationof team members perceptions of the important compo-nents underpinning interdisciplinary team work. Themesfrom these two perspectives were then examined forareas of agreement and dissonance to arrive at a set ofcompetencies for good interdisciplinary team work.

Systematic reviewThe systematic review, reported and published in full inthe main study report [31], first considered quantitativestudies; in particular randomised controlled trials (RCTs)published and unpublished between 1994 and 2009,appropriately, have been shown to facilitate interdisciplinarypractice in this setting [29]. However, previous research byour team found a great deal of variety in the way that teamswork together, and their levels of effectiveness as teams[30]. In response, we developed an Interdisciplinary Man-agement Tool (IMT) which was implemented iteratively,using an action research approach with 11 teams to explorethe impact of the tool on those teams and their patient out-comes [31].

MethodsThis research formed part of a much larger projectdesigned to develop, implement and evaluate an inter-vention to enhance interdisciplinary team work [28]through the development of an IMT [32]. The IMT is aData on team effectiveness was extracted along with de-tails on team processes, coordination, and leadership; all

to a data extraction table. Themes were identified using

Nancarrow et al. Human Resources for Health 2013, 11:19 Page 4 of 11http://www.human-resources-health.com/content/11/1/19a constant comparative method [35] and then eachstudy was coded appropriately. The constant compara-tive method involves the incorporation, collation andcomparison of newly collected data with existing orprevious data collected from earlier studies. Thematicsynthesis was used to look for common patterns acrossstudies [36].

Team perspectivesEleven CRAICs, including 253 staff were recruited toparticipate in an action research study, which examinedthe impact of implementing the IMT on serviceprovision and outcomes for patients and staff. NHS eth-ics approval was obtained on 11 September 2008 (08/H1004/124). All participating team members providedwritten consent for their involvement in this research.The IMT intervention was implemented through a

series of semi-structured workshops with the support ofa trained facilitator. These workshops included an initial,full day Service Evaluation Conference to ascertaineach teams values, needs, and priorities, and then aseries of half day Team Learning Sets designed toallow for reflective evaluation of their team practice. Theactivities undertaken included the identification of issuesand priority actions that each team wanted to pursueand exploration of what they considered to be charac-teristics of a good team. The workshop outcomes weredetailed in reports and action plans that guided the im-plementation of their proposed changes. These reportselements identified as important in the earlier conceptanalysis of the interdisciplinary team [18].This initial review confirmed that a lack of contextual

detail, both in trials in general [33], and interdisciplin-ary studies in particular [34], makes it difficult to isolatethe ingredients of effective interdisciplinary team work.Specifically, the research team identified a lack of thick-ness in the detail on context, team roles, and processesfrom the review of the RCTs. In the absence of mixed-method studies, suggested as a priority for future re-search by a recent review [34], the team designed asupplementary review strategy. This strategy examinedfindings from qualitative research on interprofessionalteam processes, independent from the RCTs. Inclusioncriteria for the supplementary review were studies be-tween 2000 and 2010 involving an interprofessionalteam in CRAICs which included data focused on teamprocesses. This complementary review identified 20studies to supplement previous findings. The findingsof the separate evidence bases from qualitative andquantitative studies were brought together and isolatedand plans provided the basis of the data for the teamperspectives. The data were entered into NVivo version8.0 and coded thematically to explore the characteristicsof a good team.

ResultsResults from the thematic synthesis of the literatureThrough the use of the constant comparative method,the thematic synthesis of the literature identified sixteenanalytical themes with up to 12 descriptive characteris-tics in each theme. The identified themes and their char-acteristics are presented in Table 1.These themes highlight the defining characteristics

of interdisciplinary team work. They recognize the im-portant role that leadership plays for the complexcommunication and coordination necessary among dif-ferent groups of professionals and non-professionals.They also demonstrate the need for both flexibilityand clarity of roles when the bodies of knowledge ofdistinctive professional groups are shared, protected,and preserved.

Results from the data on team perspectivesTwo activities undertaken as part of the IMT workshopsprovided data representing the teams perceptions of theimportant components of interdisciplinary team work.These activities were (1) the identification of characteris-tics associated with a good team and, (2) the challengeschosen by the teams as issues on which they consideredfocusing their action plans.The characteristics associated with a good team identi-

fied by the 11 teams were grouped into13 themes(Table 2). In addition the 584 identified issues or chal-lenges were grouped to 11 broad topics (Table 3). Thesetwo thematic analyses were then combined with thethemes identified from the systematic review to form asingle theoretical framework to define the characteristicsof a good interdisciplinary team.Table 4 demonstrates the triangulation of these three

data sources to identify ten characteristics that emergedas underpinning a good interdisciplinary team. The highlevel of concordance across the three sources is illus-trated. The only theme not explicitly identified from thethematic synthesis of the literature that was recognizedby the teams was clarity of vision; however, this waspartly covered by the literature review themes of valuesand professional commitment. It is interesting to notethat an audit of intermediate care, published after thisstudy was completed, recognized weaknesses in strategicplanning by commissioners [37], which was highlightedas a reason for the lack of clear vision by team membersin this study.Not surprisingly, the team participants did not raise any

challenges or issues related to individual characteristics.

This illustrates the value of combining data anonymouslyreported in the literature with primary data from the teams

eNancarrow et al. Human Resources for Health 2013, 11:19 Page 5 of 11http://www.human-resources-health.com/content/11/1/19Table 1 Results from the thematic synthesis of the literatur

Themes

Climate Interprofessional atmosphere

Valued contributions

Communication Formal/Informal structures

Intra-team communication

Individual characteristics Knowledge/experiencethemselves. While the interaction of individual charac-teristics is fundamental to the way the team functions, itis unlikely to be directly affected by team actions, withthe exception of changing recruitment criteria. How-ever, one of the outcomes of the larger IMT interven-tion undertaken as the main part of the study was thatsome teams perceived that they were able to develop in-dividual competencies which better prepared them towork as a member of an interdisciplinary team. Furtherresearch is needed to understand the individual charac-teristics of an interdisciplinary team member.

Interpersonal skills

Personal characteristics

Interdependence Mutual support

Reciprocity within team

Leadership Role of physicians

Learning Action based learning

Interprofessional learning

Patient focus Patient centeredness

Holistic care

Perceptions Differing perceptions of own role, othersroles, team work

Power Equality of relationships

Power/Status

Problem solving/decision-making

Proactive approach

Creativity

Professional commitment Professional identity

Role expectations

Roles Autonomy

Role modeling

Skills Core professional competencies, skills, tasks

Structures Organizational factors

Team building

Team characteristics Capacity

Dynamics/Balance

Values Philosophy

Staff commitmentCharacteristics

Team culture Trust

Nurturing consensus Participative safety

Personal qualities

Completion/Reading care plans Use of shared case notes

Regular case conferences

Interpersonal team Common goalsThe ten themes identified as the characteristics of a goodinterdisciplinary team are further described in the followingTable 5.These characteristics can be re-formulated as competency

statements that an effective interdisciplinary team function-ing at a high level might be expected to demonstrate.Competencies of an interdisciplinary team:

1. Identifies a leader who establishes a clear direction andvision for the team, while listening and providingsupport and supervision to the team members.

relationships

Listening skills Different opinions/perceptions

Understanding own role/othersroles

Exploring/Acceptance role overlap

Willingness to share Professional synergy

Team relationships

Need for chairperson role

Nurturing a learning culture Training within clinical teams

Outcomes focus Team care planning and discussion

Timely interventions Impacts of reduced contact time

Hierarchical/traditional role ofmedicine

Assertiveness/confidence

Reluctance to voice opinions Scapegoat (Victimization)

Physician role

Professional jargon Tensions/rivalry

Knowledge/skills Jealousy

Role enactment Role boundaries/delineation/decision making

Role clarity

Sharing of knowledge/information/skills

Differing levels of skill acquisition

Goal planning Time

Common location Team meetings/case conferences

Size Accessibility after hours

Membership

Shared goals/objectives Practice context

Positive attitude

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Nancarrow et al. Human Resources for Health 2013, 11:19 Page 6 of 11http://www.human-resources-health.com/content/11/1/19ble 2 Characteristics of a good team as identified by te

Good communication Communication primarily refethough they could listen as wresolve difficulties within the2. Incorporates a set of values that clearly providedirection for the teams service provision; thesevalues should be visible and consistently portrayed.

3. Demonstrates a team culture and interdisciplinaryatmosphere of trust where contributions are valuedand consensus is fostered.

communication by limiting the twupwards.

Respecting/understanding roles Importance of respecting and undboundaries of each role were wellpotential to impact on patients. Prteam, and differs from that of othe

Appropriate skill mix Skill mix refers to the mix and breaexperience. Teams value diversity,complementary experience and atfull complement of staff.

Quality and outcomes of care Ensuring the quality and outcomesand includes several reflective mecimportance both to have systemsand to meet their targets. This inclact on it; have defined outcomes;appropriateness of referrals and timtheir own successes; and clinicians

Appropriate team processes andsources

This theme includes access to suffimake confidential phone calls; appprocesses, policies, and paperworkWorkload management, having enseveral teams. Finally, the pathwayseen as an important procedural is

Clear vision Participants identified the need forthe direction of the team, but alsothe team.

Flexibility (of the team and thedividuals within it)

The need for flexibility was identifiknowing your boundaries. Individuservice environment and patient nwas also identified, for instance, fle

Leadership and management All teams identified the importanceexplored elsewhere.

Team culture: camaraderie and teampport/relationships

The importance of team culture wrespect, reliability, commitment anincluded the importance of inform

. Training and developmentportunities

Opportunities for gaining new knoand education.

. External image of the service The importance of the external imphysical presentation of the staff (tportrayed to outside agencies throdo not work properly); the externaand the workload of the team.

. Personal attributes Several personal attributes were idincluded approachability, appropriaempathy, good organisation skills,acquiring, demonstrating and sharprotective, reflexive practice, tolera

. Individual rewards and opportunity Participants identified the importanfinancial rewards; opportunities foropportunity to think outside the bmembers

to intra-team communication and included team members feeling asspeak out within a team context; and the ability to discuss and

. It was suggested that being part of a large team hinders good4. Ensures appropriate processes and infrastructures are inplace to uphold the vision of the service (for example,referral criteria, communications infrastructure).

5. Provides quality patient-focused services withdocumented outcomes; utilizes feedback to improvethe quality of care.

o-way communication, and that some peoples' views do not travel

erstanding the roles of other team members; that the limitations andunderstood; and to have an understanding of how the roles have theactitioners should also be aware of how their own role fits within ther team members, and that roles and responsibilities are made explicit.

dth of staff, personalities, individual attributes, professions andand clearly need input from a range of staff who bringtributes to the team. Teams also felt that it was important to have the

of care was identified as an important component of a good teamhanisms both within and external to the team. Teams emphasized thefor capturing their effectiveness (such as measuring patient outcomes);uded suggestions that teams are able to reflect; accept criticism andfollow-up patients; provide feedback to other services (for example, oneliness and appropriateness of information provided); and celebratekeeping their skills up to date.

cient physical resources (office space, parking, computers); privacy toropriate and efficient systems and procedures, including inductionthat serves the need of the service whilst avoiding duplication.ough time to do the job, and time management were highlighted byfor patients, and the integration of the team with wider services wassue.

a clear vision, role and purpose of the team. This was both to steerrequired so that teams could establish appropriate referral criteria into

ed as an individual attribute ability to cover each others roles, butals also need to be flexible to respond to the constantly changingeeds (for instance, flexibility of working hours). Flexibility of the servicexibility in referral criteria.

of good leadership, and the characteristics of a good leader are

as the largest theme, with 66 items within this theme. Trust, mutuald support were the most commonly raised themes. But team cultureal relationships, camaraderie, fun, and friendship between colleagues.

wledge, sharing knowledge, continuing professional development,

age of the service was raised by half of the teams and included thehat is, whether or not they wear uniforms); the external imageugh their external points of contact (for instance phone systems thatl marketing of the service, which is important for managing referrals

entified as being important to having an excellent team. Thesete delegation, being able to compromise, confidentiality, decisiveness,initiative; knowing ones strengths and weaknesses; open to learning;ing new skills and knowledge, patience, personal responsibility,nce

ce of the individual returns on team work, which included goodcareer development; autonomy; challenge within the role and theox.

Table 3 Challenges to interdisciplinary team work identified by teams

Code name Code description Inclusion Exclusion

Clarity of vision, uncertaintyand changes to service

The extent to which values areshared by team members includinggoals and objectives of the teamand definitions of the service.

Including uncertainty at strategiclevel, external pressure to changeand ways of managing change.

Excluding issues around cleardelineation of individual rolesand better understanding ofothers' roles/professions (5).

Excluding individual goals (6).

Communication andrelationships-external

Communication and relationships withexternal organizations/services andsenior management.

Knowledge of other services.Including external factors whichaffect the team and the influenceof the team on external services andorganizations.

Excluding issues related tochange and uncertainty (3).

Communication andrelationships-internal

General team relationship andcommunication issues.

Including team integration, clearknowledge of others' roles andmeetings.

Excluding joint working, sharingskills & knowledge and reflectivepractices (8).

CPD, rotation and careerprogression

Activities aimed at professionaldevelopment: training, knowledge,skills, rotation, secondment andopportunitiesfor promotion and progression.

Including individual goals andpersonal issues, for example,anxiety and self-worth.

Facilities, resources, proceduresand administration

Issues relating to facilities,resources and working practicesand procedures.

Excluding capacity/team size,workload & time-management (11).

Joint-working Activities related to staff membersworking together and observingeach others work.

Including joint visits and assessmentsand shadowing opportunities.

Management, leadership,decision-making and autonomy

Explicit mentions of managersand management or leadersand leadership and euphemisms(for example. higher level), especiallyregarding decision making andcoordination.

Includes processes of decisionmaking within the team includingdecisions beingmade by superiorsand having autonomy to make owndecisions

Excluding issues covered byother codes for example, workingprocedures (7), staffing levels (11),clarity of goals (3), communication(4 and 5), de-briefing .procedures(13) and so on.

Morale and motivation Issues reported to positively ornegatively affect the morale ofteam members.

Including motivation, job satisfaction,enjoyment, pride and so on.

Patient treatment,communication, capacityand outcomes

Referral procedures/criteria, capacityand demand issues.

Including patient interventionsand outcomes, and measurementsof effectiveness.

Excluding communicationand relationships with externalservices and organizations (4).

Including throughput of patients,care-needs and issues of workloadand time-management.

Including communication andrelationships with patients andfamily members.

Role mix, professional roles andresponsibilities

Issues regarding the variety of rolesand distribution of responsibilitiescurrently within the team.

Including the balance betweenmaintenance of professional rolesand the need for generic working.

Excluding professional development(6) or service developmentactivities (that is, developing/distributing skills and knowledge) (13).

Excluding team size (11), teamwork issues (5). Excluding lack of clarity of roles (5).

Excluding functions ordinarilyperformed by external services (4).

Service development activities Service development andteam building activities.

Including case reviews and otherreflective practices (for example,de-briefing procedures).

Including specific skill developmentacross the team (for example,supporting changing roles).

Including group knowledgetranslation activities, for example,journal clubs and visits to otherservices.

Nancarrow et al. Human Resources for Health 2013, 11:19 Page 7 of 11http://www.human-resources-health.com/content/11/1/19

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Nancarrow et al. Human Resources for Health 2013, 11:19 Page 8 of 11http://www.human-resources-health.com/content/11/1/19Table 4 Triangulation of the data sources to identify the ch

Data synthesis Data sources

Characteristics of a goodinterdisciplinary team

Themes from thematicsynthesis of theliterature

Themes identifof a good teamworkshops

Communication Communication Good communi

Individual characteristics Individual characteristics Personal qualitie

Problem solving/decision-making

Interdependence

Leadership andmanagement

Leadership Leadership and

Personal rewards, trainingand developmentopportunities

Learning Training and deopportunities

Individual rewar

Quality and outcomes ofcare

Patient focus Quality and outc

Appropriate skill mix Skills Appropriate skill

Team characteristics6. Utilizes communication strategies that promoteintra-team communication, collaborative decision-making and effective team processes.

7. Provides sufficient team staffing to integrate anappropriate mix of skills, competencies, andpersonalities to meet the needs of patients andenhance smooth functioning.

8. Facilitates recruitment of staff who demonstrateinterdisciplinary competencies including teamfunctioning, collaborative leadership,communication, and sufficient professionalknowledge and experience.

9. Promotes role interdependence while respectingindividual roles and autonomy.

10.Facilitates personal development throughappropriate training, rewards, recognition, andopportunities for career development.

In addition, our study identified the need for teams toregularly invest time in the processes of team developmentand maintenance of team functioning to ensure that thesecompetencies are entrenched and enacted in their daily

Appropriate process andresources

Structures Appropriate team presources

Team climate Climate Team culture

Respecting andunderstanding roles

Power Respecting and un

Perceptions

Roles

Clarity of vision Values Clear vision

Professional commitment External image of t

Flexibilityacteristics of a good interdisciplinary team

as characteristicsom IMT

Topics identified by participants as challengesto interdisciplinary team work from IMTworkshops

ion Communication and relationships-external

nagement Management, leadership, decision-making andautonomy

opment Continuing professional development, rotation andcareer progression

and opportunity Morale and motivation

es of care Patient treatment, communication, capacity andoutcomes

ix Role mix, professional roles and responsibilitiespractice. Recognition of such time is frequently omitted fromrandomized controlled trial evidence of interprofes-sional working and is correspondingly overlooked whenperforming cost effectiveness evaluations.

DiscussionLimitations of the approachThe systematic review, which sought to identify quanti-tative studies detailing the outcomes of different staffingmodels, proved most amenable to conventional methodsof systematic review and did not require significantamendment from its original protocol. However, the reviewteam encountered the now-familiar deficit in contextualrichness or thickness within the quantitative studies andhad to compensate with strategies specifically seekingqualitative research studies or process evaluations [38]. Weacknowledge, in association with guidance provided by theCochrane Collaboration Qualitative Methods Group, thatqualitative evidence from studies from the same source asthe trials (within study reports or sibling studies) wouldreduce the contextual variation between different configu-rations of interdisciplinary working. However given the

rocesses and Facilities, resources, procedures and administration

Communication and relationships-internal

derstanding roles Joint working

Role mix, professional roles and responsibilities

Clarity of vision, uncertainty and changes to service

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Nancarrow et al. Human Resources for Health 2013, 11:19 Page 9 of 11http://www.human-resources-health.com/content/11/1/19acknowledged absence of such studies [34], the best avail-able solution was to bring together the two evidence basesand then to triangulate them with rich primary qualitativeresearch data.

Table 5 Characteristics of a good interdisciplinary team

Themes Description

1. Leadership and management Having a clear leader of the team, wsupervision; personal development a

2. Communication Individuals with communication skillwithin the team.

3. Personal rewards, training anddevelopment

Learning; training and development;rewards and opportunity, morale and

4. Appropriate resources andprocedures

Structures (for example, team meetinEnsuring that appropriate procedurecommunication systems, appropriate

5. Appropriate skill mix Sufficient/appropriate skills, competeother team members' backgrounds;absent posts.

6. Climate Team culture of trust, valuing contribatmosphere.

7. Individual characteristics Knowledge, experience, initiative, knowork on the same goals.

8. Clarity of vision Having a clear set of values that drivand consistent external image.

9. Quality and outcomes of care Patient-centered focus, outcomes anthe effectiveness of care and using t

10. Respecting and understandingroles

Sharing power, joint working, autonoThis study has not examined the interaction betweenthe characteristics of interdisciplinary teams and it ispossible that there is some interdependence betweensome of the characteristics. For instance, previous researchsuggests that good leadership may be required for the teamto have strong clarity of vision [39]. Further explorationand validation is required to examine whether any causalrelationships exist between the different components ofinterdisciplinary team work.The facilitation process used in the workshops in this

study was informed by the available literature, and there-fore has the potential to bias the results from the teams.The risk of researcher bias was lessened by having theteams facilitated by six different facilitators. It is notablethat the views of the teams, and the issues they faced,were all similar. The high level of concordance betweenthe published literature and the findings from the teamssuggests strong face validity for the characteristicsdescribed and competencies proposed in this paper.The results presented in this paper are derived from

interdisciplinary teams involved in the delivery ofCRAICs. As such, they involve a specific, but broad,range of disciplines. Previous literature has shown thatthese groups are typified by being non-medically led,non-hierarchical and fairly democratic in their ap-proaches [24]. This research, and previous research[30,31], also found a great deal of heterogeneity in thestructure and organization of these teams. It is thereforenot possible to assume that these findings are relevantto all interdisciplinary teams. Further research will be re-

clear direction and management; democratic; shared power; support/ed with line management; leader who acts and listens.

nsuring that there are appropriate systems to promote communication

ining and career development opportunities; incorporates individualotivation.

, organizational factors, team members working from the same location).re in place to uphold the vision of the service (for example,ferral criteria and so on).

ies, practitioner mix, balance of personalities; ability to make the most ofing a full complement of staff, timely replacement/cover for empty or

ions, nurturing consensus; need to create an interprofessional

ing strengths and weaknesses, listening skills, reflexive practice; desire to

he direction of the service and the care provided. Portraying a uniform

atisfaction, encouraging feedback, capturing and recording evidence ofas part of a feedback cycle to improve care.

y.quired to examine the generalizability of these character-istics and competencies beyond this paper.By establishing a broad set of competencies to guide

interdisciplinary team work it moves towards the identifi-cation of a suite of processes to which teams can adhere,and sets up mechanisms and areas for improvement. Asthe published literature demonstrates, few existing inter-ventions around interdisciplinary team work focus on thesecompetencies and processes to implement them. Insteadsuch studies tend to examine a single mechanism to sup-port interdisciplinary team work. The characteristics andcompetencies identified in this study provide a frameworkfor investigating good interdisciplinary team work, how itmight be examined in different contexts, and how teamsmight identify interventions to improve or optimize theirinterdisciplinary team work.

ConclusionsInterdisciplinary health care teams face a set of chal-lenges that are not necessarily encountered by othertypes of teams such as unidisciplinary or non-health careteams. These challenges include the contentious natureof sharing professional roles and expertise, planning anddecision-making, while delivering quality patient carewithin complex contexts. This paper combines quantita-tive and qualitative insights from the published literature

Nancarrow et al. Human Resources for Health 2013, 11:19 Page 10 of 11http://www.human-resources-health.com/content/11/1/19with empirical data derived from the experiences and in-sights of interdisciplinary teams working in CRAICs toidentify the characteristics of a good interdisciplinaryteam. Our research has drawn together these sources ofevidence to elicit a theoretical understanding and developa framework to define the characteristics of interdisciplin-ary team work and presented these as competencies foreffective interdisciplinary team work. These outcomes nowneed to be validated with other types of interdisciplinaryteams to determine their level of transferability to otherteams and contexts.

AbbreviationsCRAICs: Community rehabilitation and intermediate care services;IMT: Interdisciplinary Management Tool; UK: United Kingdom.

Competing interestsThe authors declare they have no competing interests.

Authors contributionsSN, PE and AS conceived the original project and obtained the funding,were involved in the data collection, analysis, preparation of the final reportand drafting and amending the final manuscript. SA was involved in allstages of the project implementation, data collection and analysis, draftingthe final report, and contributed to this manuscript. AR performed furtheranalysis, drafting and compilation of the final report. All authors read andapproved the final manuscript.

DisclaimerDepartment of Health disclaimer: The views and opinions expressed thereinare those of the authors and do not necessarily reflect those of the HS&DRprogram, NIHR, NHS or the Department of Health.Target journal: Human Resources for Health

AcknowledgementHS&DR funding acknowledgement: This project was funded by the NationalInstitute for Health Research Health Services and Delivery Research (NIHRHS&DR) program (project number 08/1819/214). Visit the HS&DR website formore information.

Author details1Southern Cross University, Military Road, East Lismore 2480, Australia.2University of Sheffield, Regent Court, 30 Regent Street, Sheffield, SouthYorkshire S1 4DA, UK. 3Sheffield Hallam University, Collegiate Crescent,Sheffield, South Yorkshire S10 2BP, UK. 4University of Victoria, 3800 FinnertyRoad, Victoria, BC V8P5C2, Canada.

Received: 19 November 2012 Accepted: 21 April 2013Published: 10 May 2013

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doi:10.1186/1478-4491-11-19Cite this article as: Nancarrow et al.: Ten principles of goodinterdisciplinary team work. Human Resources for Health 2013 11:19.

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AbstractBackgroundMethodResultsConclusions

BackgroundTerminologyInterdisciplinary team workNecessity of interdisciplinary team work

MethodsSystematic reviewTeam perspectives

ResultsResults from the thematic synthesis of the literatureResults from the data on team perspectives

DiscussionLimitations of the approach

ConclusionsAbbreviationsCompeting interestsAuthors contributionsDisclaimerAcknowledgementAuthor detailsReferences

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