Original Research
Effective Interprofessional Teams:
“Contact Is Not Enough” to Build a Team
JOAN SARGEANT, PHD; ELAINE LONEY, MSC; GERARD MURPHY, BSCHE
Introduction: Teamwork and interprofessional practice and learning are becoming integral to health care. It is
anticipated that these approaches can maximize professional resources and optimize patient care. Current research, however, suggests that primary health care teams may lack the capacity to function at a level that enhances the individual contributions of their members and team effectiveness. This study explores perceptions of
effective primary health care teams to determine the related learning needs of primary health care professionals.
Methods: Primary health care team members with a particular interest in teamwork shared perspectives of effective teamwork and educational needs in interprofessional focus groups. Transcripts from nine focus groups with
a total of 61 participants were analyzed using content analysis and grounded hermeneutic approaches to identify
themes.
Results: Five themes of primary care team effectiveness emerged: (1) understanding and respecting team members’ roles, (2) recognizing that teams require work, (3) understanding primary health care, (4) working together:
practical “know-how” for sharing patient care, and (5) communication. Communication was identified as the essential factor in effective primary health care teams.
Discussion: Several characteristics of effective primary health care teams and the related knowledge and skills
that professionals require as effective team members are identified. Effective teamwork requires specific cognitive,
technical, and affective competence.
Key Words: assessment, teamwork, learning needs, interprofessional, communication, education, primary health
care
Background and Purpose
Teamwork and interprofessional practice and learning are
being recognized as central to improved patient care and
outcomes and enhanced patient safety.1–3 Similarly, assessments of interprofessional education interventions and collaboration at both pre- and post-licensure levels demonstrate
Disclosures: The authors report none.
Dr. Sargeant: Director of Research and Evaluation, Continuing Medical
Education, and Associate Professor and Director, Program of Research in
Health and Medical Education, Division of Medical Education, Dalhousie
University, Halifax, Nova Scotia, Canada; Ms. Loney: Qualitative Research
Consultant, Bedford, Nova Scotia, Canada; Mr. Murphy: Senior Owner,
Barefoot Facilitation and Development, Halifax, Nova Scotia, Canada.
Correspondence: Joan Sargeant, Continuing Medical Education, Clinical
Research Centre, C106 5849 University Avenue, Halifax, NS, B3H 4H7,
Canada; e-mail: [email protected].
© 2008 The Alliance for Continuing Medical Education, the Society for
Academic Continuing Medical Education, and the Council on CME,
Association for Hospital Medical Education. • Published online in Wiley
InterScience ~www.interscience.wiley.com!. DOI: 10.10020chp.189
positive educational outcomes including enhanced learner
knowledge, skills, attitudes, and behaviors, and improved
patient outcomes in specific disease conditions.4,5
In response, the United States and Canada are targeting
primary health care improvement through team development and practice. Why is teamwork considered integral to
primary care? One reason is the increased complexity
of primary health care, which precludes physicians from performing all tasks for their patients; the days of the general
practitioner working as a “lone ranger” are past.3 Another
reason is the renewed emphasis of primary health care upon
the broad determinants of health and the focus upon health
promotion and illness prevention.1,2 Viewed through such a
lens, health care needs of the public and individual patients
often require specialized skills that physicians may not possess and that may be more appropriately provided by other
health care professionals. As an example, consider the dietitians, nurses, and other health care team members required to respond to the current obesity epidemic. Teamwork
is important as effective primary health care requires coordination of services and of diverse clinic, institutional, and
community health and social resources.
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“Contact Is Not Enough”
Historically members of diverse health care professions working together for patient care have considered
themselves a “team,” yet theory and research on teamwork highlight that they may actually only be a group of
individuals working beside each other and not a team.6 A
team is “a group with specific tasks the accomplishment
of which requires the interdependent and collaborative efforts of its members.” 7 Key words are interdependent and
collaborative.
Effective collaborative health care teams share common
goals, understand each other’s roles, demonstrate respect for
each other, use clear communication, resolve conflict effectively, and are flexible.6 Developing these attributes, however, is much easier said than done. Key stumbling blocks
include lack of knowledge of the roles and scopes of practice of fellow team members of other professions, and stereotypical views of other professionals that can lead to lack
of respect and limit opportunities to contribute fully as team
members.8–11
From a theoretical perspective, social psychologists suggest that “contact is not enough” to build respect and change
stereotypes and long-held attitudes: ie, just having members
of different social groups or professions work beside each
other is not enough to effect change. Specific interventions
are needed.12,13 Interprofessional education, defined as “learning with, from, and about each other,” is a social undertaking informed by theories of group interaction and social
learning.4,13 Importantly, knowledge is created through the
social exchange of members of the teams, often occurring
informally through interactions in practice settings. A unique
aspect of interprofessional learning is explicitly becoming
aware of professional perspectives that differ from one’s own.
Providing formal and informal opportunities to learn
about and interact with members of other professions and
to increase ease of working with those who are different
can increase awareness of and respect for others’ roles,
change stereotypical views, and thereby enhance team functioning.8,12,14,15 Good communication among team members is critical and requires specific skills and techniques,
while poor interprofessional communication can hinder team
functioning and strengthen unproductive stereotypes and
perceptions.16–19
Within primary health care, as in other specialty care
areas, additional characteristics of effective teams include
having shared understanding of the discipline and a common language.19–22 Another, of a technical or systems nature, is having protocols to make possible caring for a
common patient across professions and organizations.11
These strategies too have implications for education.
Canada, as are many countries, is undergoing health care
reform. We undertook this qualitative study to inform primary health care reform and particularly preparation of interprofessional team members. The purpose was to increase
understanding of the characteristics of effective primary health
care teams and the related learning needs of team members
for more effective teamwork.
Methods
Background
One Canadian primary health care initiative was Building
a Better Tomorrow, a comprehensive interprofessional education program for providers in the four Canadian Atlantic provinces, funded through Health Canada’s Primary
Health Care Transition fund. Partners included the primary health care divisions of each of the provincial Ministries of Health and the professional development offices
of the Faculties of Medicine of Dalhousie and Memorial
Universities. The goals of the educational program were
to foster collaboration and teamwork among primary health
care providers and enhance knowledge and skills for effective primary health care.23
Study Design
To inform the development of the educational program,
we conducted an extensive needs assessment across the
four provinces. This paper describes one needs assessment
component conducted in Nova Scotia, a qualitative study
using focus groups and designed using the principles of
grounded theory. Grounded theory builds understanding
of a phenomenon from “the ground up,” ie, from the
individuals experiencing the phenomenon, through exploring their perceptions and experiences. Focus groups enable participants to describe experiences and perceptions
meaningful to them and, through discussion with others,
reflect and respond to those of others and potentially create new understanding.24 We believed this approach would
enable primary health care professionals to share and compare their perceptions and experiences regarding effective
interprofessional teams and to clarify similarities and
differences.
Participant Recruitment
Using purposive sampling, we recruited focus group participants from the nine Nova Scotia District Health Authorities and one First Nations community. Primary health care
coordinators in each district identified potential volunteers
with particular interest and expertise in primary health care
and representing diverse professions from existing and evolving primary health care teams. We then invited them to
participate.
Procedures
Skilled facilitators conducted 1–1.5 hour focus groups in
November–December 2004 that were audio-recorded and
transcribed. The study was approved by the Dalhousie University Research Ethics Board.
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Sargeant et al.
Interview questions addressed:
•
•
•
Participants’ experiences of interprofessional primary health
care teams,
Perceived characteristics of effective teams, and
Within the context of these characteristics and their own
primary health care team, their learning needs for working
most effectively as members of an interprofessional, collaborative team.
TABLE 1. Focus Group Participants
Number of
Participants
Primary care0program0site managers, team coordinator,
wellness center directors
8
Family physician
7
Public health nurse
7
Nurse: other ~palliative care, geriatric consult, continuing
care, acute outpatient!
6
Analysis
Dietitian
5
One researcher experienced in qualitative approaches led
the analysis using principles of grounded theory and, through
repeated reading of the transcripts and field notes, coded the
data using QSR N6.25 She initially used content analysis
and interpretative approaches to identify themes and developed matrices to compare themes among groups and data
categories.26,27 She met regularly with the second qualitative researcher to discuss and compare themes and findings
and resolve questions and conflicting findings. The third team
member, also the Nova Scotia project manager, participated
in discussions, provided contextual information, and clarified questions and themes arising from the data.
Mental health ~psychologist, therapist, nurse!
4
PHC coordinators
4
Other ~office manager, public health outreach, client rep.!
4
Nurse practitioner
3
Occupational therapist
3
Women’s and family resource center directors
3
Community Health Board reps.
3
Addictions ~therapist, worker!
2
Physiotherapist
2
Total participants
61
Results
Nine focus groups were conducted representing eight of
the nine health districts and the First Nations community. The ninth district declined the invitation to participate,
explaining that they were in the early stages of implementing their formal primary health care program and did not as
yet have a coordinator. A total of 61 participants took part
with a range of 4 to 11 participants ~average ⫽ 7! per group.
Participants represented about 13 professions ~see TABLE 1!,
the largest numbers representing program managers, family
physicians, public health nurses, and other nursing specialties. Small numbers of other professionals attended. All
groups included nurses from diverse areas of practice and
represented varying combinations of the professional groups.
Five of the nine groups had at least one physician participant, and three groups included representatives of communitybased nonprofit organizations. Notably, participants held
positive views of interprofessional teamwork and its benefits. For example, most participating physicians were leaders in collaborative practice who were working in partnership
with nurse practitioners and0or were transitioning their practice to involve an interprofessional team formally.
Participants represented teams at various stages of development from emerging to established teams. Some participants were not part of an identified primary health care team
per se but had working relationships with others. Participants were involved in a broad range of primary health care
services ~eg, child and youth health, women’s health, general
primary care, First Nations health, mental health, public
health, home care, continuing care!.
230
Through the analysis of participants’ responses to the
interview questions and of discussions arising from these
responses, five main characteristics of effective interprofessional primary health care teams emerged ~FIGURE 1!:
1. Understanding and Respecting Team Members’
Roles
Two interrelated capacities emerged as central to effective
teams. These were understanding roles of others, a cognitive
capacity, and respecting other team members’ roles, an attitudinal capacity. Their interconnectedness was reflected
across all focus groups regardless of team maturity. Participants explained that knowing about and understanding oth-
FIGURE 1. Characteristics of effective PHC teams.
JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—28(4), 2008
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“Contact Is Not Enough”
ers’ roles, competencies, and scopes of practice underpin the
team approach:
interaction, and focused attention, as the following interaction conveys:
Participant J: . . . in my role as a home physiotherapist, I
don’t really feel like I’m working on a primary health care
team. I feel like I have various partners in the community
that I call on when needed, but the main drawback is they
sometimes aren’t aware of my role and I’m not a hundred
percent aware of their role, so there needs to be more education before we can work together as a team.
Participant A: . . . the other thing about the team, it’s sort of
like a relationship at home: it requires a lot of work. It actually doesn’t just happen.
Similarly, the following exchange illustrates the learning
physicians experienced through working with a nurse practitioner ~NP! who joined their practice:
Participant A: I think that’s the most amazing thing, that
even after all these years, it’s still work. You still have to
work at it. You still have to have specific times for meetings,
and . . . it can’t be informal and hope it will happen; it always requires work. Everybody on the team is working very
hard doing what they do best . . . and so there’s this other
whole big commitment that you have to make to the team
and to ensuring that the team is functioning the way it should.
Participant E: . . . I used to just dump problem patients on
her ~the NP! at first, “Listen, you look after this one, I don’t
know what to do with her anymore.” And now it’s much
more collaborative.
Participant F: . . . you’ve learned to share some information
with her, haven’t you?
Participant E: Oh absolutely. She’s learned to recognize that
we have our own skill set, and I’ve learned to utilize her
skills, which are far superior to mine when it comes to counseling patients.
Respect for others’ roles and ability to demonstrate that
respect were equally important and viewed as essential to
good working relationships that recognize equality:
Participant D: . . . everybody had a chance to speak during
meetings, and everybody respected everybody around the
table, and it just seemed to work well.
Some participants suggested that physicians in particular
may hold more traditional roles of inequality among team
members:
Participant H: . . . the difficulty with physicians’ becoming
part of a team is accepting that sense of equality. It’s not so
much respect in that sort of situation but to be equal with
other people in saying, “your opinions are just as important
as mine.” You can say it, but do you actually behave that
way?
In summary, enhancing understanding and respect for each
other’s roles requires, first of all, learning about their roles
and appreciating their scope of practice, and, second, understanding how they are complementary to one’s own. Our
findings suggest that effective teamwork does not happen
without attention to these tasks and education.
2. Recognizing That Teamwork Requires Work
Several focus groups expressed that primary health care teams
are dynamic and require commitment and work to develop
and then maintain. Teams, according to experienced voices,
are the result of active, ongoing effort. This requires time,
Participant B: Yeah, it doesn’t just happen. . . .
Participant C: You have to work at team building. . . .
In building good interpersonal working relationships and
respect for each other, the role of the individual and his or
her contribution to the team is critical to the effectiveness
of the team. While more experienced team members stressed
the need for work, newer team members expressed some
surprise at the amount of work required. Attending meetings
was identified as one of the ways to work at making teams
effective.
3. Understanding Primary Health Care
All groups indicated that a common understanding of primary health care principles and the ability to use a common
language provide an important basis for building interprofessional primary health care teams. Specific topics included understanding what a primary health care team is, its
philosophy and purpose, roles, responsibilities, services, competencies, and how it works. The immediacy of a particular
learning need appeared dependent on the stage of the team
development. As an immediate need, an increased understanding of primary health care was highly prioritized in
groups where teams were not formalized or were in early
stages of development, shown by this dialogue:
Participant J: . . . need for common understanding is huge,
because if you don’t have a common language, you can have
different meanings for what you are talking about.
Participant K: And because, you’re a multidisciplinary team,
half the team might know what population health is and
what primary health care is, but the other half may not.
Participant J: Well, for a good example, @this# committee
spent almost a whole year of meetings basically around “what
is our job.”
More mature teams seemed to have moved beyond a basic understanding of primary health care and appeared more
interested in how to apply concepts. Participants in these
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groups sought to understand the team approach more fully.
They wanted to learn how to be a team member and how to
work with and collaborate with others. Representatives of a
long-established team highlighted that orienting new members to the team approach is another important aspect of
educational planning easily overlooked in the push to begin
service delivery quickly.
4. Having the Practical “Know-how” for Sharing
Patient Care
Another characteristic of effective primary health care teams
was having the practical “know-how” for managing a common patient and appropriately communicating patient information. Managing a common patient required knowing how
to identify and access the right provider; delegate, share,
and transfer care; and address policy differences among
organizations.
Appropriate communication of patient information included activities like sharing patient records and reports,
attending to patient confidentiality, and communicating between institutions and community agencies, especially when
under different governance structures. Such activities are necessary for interprofessional collaboration and pose questions outside the scope of a single profession that need to be
integrated into the team:
Participant K: I need to know if I’m learning how to work
as a team member, where I share information and where I
don’t. I know it within my practice, but I don’t know it
within a team. And I don’t know to what extent to tell my
patient that I’m going to share that information.
Needs pertaining to sharing confidential patient information and charts were more prominent for evolving teams
working to establish protocols and for teams involved in
collaboration among organizations. Lack of established protocols can be a barrier to teamwork. Participants spoke of
the need to develop appropriate policies and procedures collaboratively to guide these activities, particularly when communicating “between two worlds”; ie, the institution and the
community.
5. Communication
Participants highlighted communication among team members as critical to effective teams. They referred to communication as “the big thing,” “the sine qua non,” the glue that
holds the team together and enables collaborative work:
Participant C: You have to continually be open and communicate on a regular basis, and when you keep that ultimate goal in mind, it’s, well . . . everyone’s working to the
same thing.
232
In order for regular and effective communication to happen, participants described two conditions: accessibility to
the other members and ability to use appropriate communication skills.
Participants generally described having time for formal
and informal communication as characteristic of effective
teams. Established teams commented on the importance of
formal and informal communication among providers and
indicated that both require dedicated time and effort. Formal
meetings were critical to communication and in supporting
team functioning:
Participant W: . . . I was thinking to myself, “My goodness,
they go to a lot of meetings!” @laughter#
Participant X: Like we said before, it’s work. You know
teams just don’t work. You have to work at it, and one of the
major ways you work at it is by meeting.
Participant Y: It’s a commitment on many levels actually.
There’re times where you sit and really listen to others around
that table, and that’s how that works.
Participant X: And I can tell you that the benefits far outweigh the costs.
Additionally, informal opportunities or “corridor consultations” were termed the “backbone” of teamwork as providers exchange patient information, consult each other, and
make referrals.
Appropriate team communication requires using effective skills. Participants described two key ones—listening
to team members and offering one’s perspectives respectfully and assertively, or “listening and speaking up”:
Participant G: Really listening means being not too quick on
the advice; really listen to your teammate when he or she
explains the situation of a particular patient; don’t launch
into advice; and then you have the responsibility to speak
out when something’s going wrong or you don’t agree for
good reasons about the treatment plan.
Others emphasized the need for skills in conflict resolution, and in giving and receiving constructive feedback in a
nonconfrontational manner.
In summary, from the participants’ perspectives, team communication is an explicitly significant component of effective teamwork. Most groups also identified effective team
communication skills as a continuing education priority. Improving communication would increase understanding, cooperation, and collaboration among team members.
Discussion
In this study we aimed to increase understanding of the
characteristics of effective interprofessional primary health
care teams and related learning needs to make more effective teamwork possible. We learned that members of
effective teams demonstrate five general characteristics: they
understand and respect team members’ professional roles,
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recognize that teams require work, share a common understanding of primary health care, share protocols to guide
patient management across professions, and communicate
well and frequently with each other both formally and informally. These are specific characteristics requiring conscious development.
Results highlight that effective teamwork is not a simple
undertaking. Contact, ie, just working with others, is not
enough to build an effective team. Teamwork is a sophisticated social activity requiring cognitive ~knowledge!, technical ~skills!, and affective ~attitudes! competencies, and
education for developing these. With respect to knowledge,
findings reinforce the need for understanding the roles and
scopes of practice of other team members and the way teams
function within the realm of primary health care. Regarding
technical expertise and skills, acquiring specific communication and team meeting skills is critical. Affective capacities include the ability to convey respect and appreciation of
others, a willingness to learn new ways of interacting and
working, and a giving up of more traditional hierarchal communication practices. Targeted interprofessional educational
interventions can develop such knowledge, skills, and attitudes, although changing entrenched attitudes and styles of
communication is challenging.19,21,22 Effective primary health
care teams also require support by institutional and crossinstitutional systems and protocols to work with shared
patients.23,28
Teamwork as a topic has traditionally not been included
in medical curricula and continuing professional development. Until recently it seems to have been expected that
health professionals intuitively knew how to work together
effectively in teams and the need for specific capacities was
not recognized. The actual “work” of teamwork was not
recognized. This research stresses the need for inclusion of
team skills and the recognition of the work that teams require in professional education.
Implications for education are to integrate content and
opportunities to foster effective interprofessional teamwork
explicitly in prelicensure curricula and continuing education. It means that physicians cannot be educated solely in
isolation from other professions. It means restructuring both
prelicensure and continuing education so that health professionals can learn together, “with, from, and about each
other” 23 and their respective roles. For accrediting bodies,
there is a need to promote teamwork formally and align
such educational interventions with quality improvement efforts.29 Integrating content from other disciplines, eg, social
psychology, to inform topics such as building respect and
changing attitudes, will also prove beneficial. Not taking
these steps can result in maintaining the status quo.
An important limitation of this study was the volunteer
nature of the study population: ie, participants, including
physicians, had an enthusiastic interest in primary care teamwork and in making it work, and their perspectives and
learning needs may not be representative of health professionals less supportive of team-based primary health care.
Lessons for Practice
• Interprofessional education is a social learning activity in which health practitioners in
different professions learn with, from, and
about each other.
• Lack of respect for other health professions
and stereotypical views can interfere with
teamwork and collaboration.
• Effective teamwork actually takes work, a
fact not explicitly recognized in health care.
• Medical education has traditionally not
taught teamwork and interprofessional communication skills.
• Opportunities need to be created for health
professionals to learn together.
However, perspectives of enthusiasts such as these, especially those with experience in developing teams, are valuable for informing the positive characteristics of effective
teams. Alternatively, some participants were from newly
emerging teams, and hence their views may have been less
well developed than those of more mature teams. Some
professions involved in primary health care were underrepresented ~eg, physiotherapists!, and further research
should involve these professions more fully. Finally, this
study was also limited by study funding and schedule. Further and more comprehensive research with both mature
teams and those less enthusiastic about teamwork could
contribute to the rigor of this work, as could observational studies of teams at work.19
Effective primary health care requires teams of diverse
health professionals and institutional and community resources to address patients’ needs and the broader call for
health promotion and illness prevention.1–3 This research increases understanding of the characteristics of effective primary health care teams and educational needs of physicians
and other health professionals. While much of the interprofessional study to date has been funded as individual development projects,30 the challenge for many jurisdictions is to
move from development and research education “projects”
to sustainable education “programs.” 29 Securing funds to
support this work remains a challenge. Implications for research are to conduct increasingly sophisticated studies that
build on the growing body of knowledge in interprofessional education and teamwork to determine, for example,
how the knowledge of other professionals’ roles, respect for
other team members, or specific team communication skills
contributes to improved patient care.
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Acknowledgment
The authors wish to thank Tanya Hill, MSc, Research Associate, Dalhousie Office of CME, for her assistance with
this paper.
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