Leadership in interprofessional health and social care teams: a literature review

Background

This paper reports on the results of a critical literature review (Grant and Booth, 2009) that aimed to evaluate the evidence and to present an analysis of leadership in interprofessional teams in health and social care organisations.

Concerns over leadership in the UK National Health Service (NHS) first became an area of focus in the late 1980s when professional management was introduced (Mackie, 1987). When the labour government came to power in 1997, leadership capacity was recognised as a critical factor in the reform agenda; to modernise the NHS (Goodwin, 2000). The Department of Health set up a National Centre for Leadership in 2001 as part of the NHS Modernisation Agency and this led to a plethora of leadership initiatives commissioned by NHS organisations that included public health (McAreavey et al. (2001), a range of leadership frameworks (Bolden et al., 2003) and competency frameworks (Bolden et al., 2006). For nearly two decades, leadership development has been a priority within health care but less attention has been given to the effectiveness of leadership on the outcomes of teams. Reports on health service failures at an organisational level have further regularly identified poor leadership as a contributory factor in criminally negligent care (Keogh, 2013; Francis, 2013; Berwick, 2013).

The Kings Fund (2011) has consistently calls for replacement of heroic leadership models which focus on the development individuals in favour of an increased focus on shared/collective leadership models and extension of leadership development efforts to all levels. The continuing erosion of professional divisions in intermediate care and particularly community services has been driven in part by the ambition to create integrated services has enabled health and social care professions to increasingly work together around discrete stages of patient pathways (Ovretveit, 1997; Pollard et al., 2005, Means et al., 2003).

The formation of interprofessional teams has brought the issue of leadership to the fore with the challenge of enabling sometimes large teams of different professionals and differently skilled workers to coordinate their efforts and work more closely together than was traditionally the case. This integration agenda is not straightforward, however, as it fundamentally contradicts many of the fundamental tenets of professionalism (Reeves et al., 2010), with health-care leaders sharing responsibility across services, for the delivery and outcomes of care.

Thylefors et al. (2005) developed a useful taxonomy to understand the level of integration of work practices in health-care teams consisting of a range of professions/disciplines.

“Multiprofessional” teams have no focus on collective working. Professionals treat the patient independently, without the input of other team members. This model represents the customary form of health-care delivery in which doctors traditionally took responsibility for coordinating independent contributions to the care of patients.

Interprofessional working encapsulates the core notion of teamworking, where outputs are measured and based on the collective effort of team members working with the patient. Effective care is accomplished through the interactive efforts of health-care workers, with some responsibilities shared, requiring collective planning and decision-making (Day, 1981; Sicotte et al., 2002).

A study of the effects of multiprofessional and interprofessional team approaches on teamwork; and team effectiveness for rehabilitation teams, found that interprofessional teams showed significantly better results for nearly all aspects of teamwork and team effectiveness measured (Korner, 2010).

This paper presents a review of leadership in interprofessional health and social care teams, seeking to identify elements that are characteristic of and/or associated with higher performance and achieving better patient outcomes.

Methods

Critical review is undertaken as a method for enabling new conceptual insights by seeking to embody existing or derive new theory from existing literature (Torraco, 2016). A potential difficulty with the approach is that the evaluation of contribution is dependent on the type of evidence. In management literature, publications about the topic may be small in quantity, of poor quality, and/or inconsistent in terms of both the application of methods and epistemology (Tranfield et al., 2003).

In addition, systematic reviews in management literature need to relate directly to the context of health and social care (Easterby-Smith et al., 2008) to be considered the best evidence available, even though these may not be rigorous experimental studies of the type normally conducted within the medical sciences and may even propose theory where no empirical evidence exists.

Results

Searches for Interprofessional Team (working and) Leadership identified a total of 634 texts and after supplementing these searches with relevant papers identified in the interprofessional teamworking literature review and back-chaining through reference lists, 1,419 papers were identified as being of possible interest. All papers contained a combination of the key words used in the search from published literature between 1994 to 2015.

Following full text screening, categorisation by methods to exclude opinion pieces and critical appraisal a total of twenty-eight papers were selected. These were deemed to provide an analysis of outcomes from team leadership and proposed conceptual frameworks of IpTL or discussed elements of IpTL in-depth.

The findings of the analysis of these papers is set out below and summarised in IpTL framework. Further explanation of the relevance of each category is also added below to explain the IpTL Framework:

1. Facilitate shared leadership:

   • consciously involve team members in, decision-making and delegate responsibilities appropriately (Day, 1981; McCallin, 1999; Wilson, 2001; Ovretveit, 1997; Mickan and Rodger, 2000; McCallin, 2003, Institute-for-innovation-and-improvement, 2010, Sicotte et al., 2002; West et al., 2003);

   • empower team members (McCray, 2003);

   • develop and maintain non-hierarchical structures (Ovretveit, 1997; Krueger, 1987);

   • provide information the team requires (Mickan and Rodger, 2000);

   • work to create agreement (Mickan and Rodger, 2000); and

   • coach colleagues in shared leadership (McCallin, 2003; Maister, 1993).

2. Transformation and change (McCray, 2003; Irizarry et al., 1993):

   • create a climate where staff are challenged, supported, motivated and rewarded (West et al., 2003);

   • respond to change flexibly (Suter et al., 2007);

   • facilitate or act as a catalyst for practice change (Willumsen, 2006);

   • act as a role model (Pollard et al., 2005; West et al., 2014); and

   • inspire other team members (West et al., 2003).

3. Personal qualities:

   • enthusiasm (Pollard et al., 2005);

   • commitment (Abreu, 1997);

   • empathy (McCray, 2003); and

   • knowledge of people (Suter et al., 2007).

4. Goal alignment:

   • ensure the team has articulated a clear and inspiring vision of its work (Lyubovnikova et al., 2015);

   • assure productivity and goals are in line with the organisation (Leathard and Cook, 2004);

   • protect regular time for the team to review its performance (Lyubovnikova et al., 2015); and

   • provide feedback about important issues (Mickan and Rodger, 2000; Leathard and Cook, 2004).

5. Creativity and innovation:

   • establish a productive balance of harmony and debate to ensure creativity (Leathard and Cook, 2004);

   • develop innovations and new practice models (Suter et al., 2007); and

   • ensure effective leadership and team work processes (West et al., 2003).

6. Communication:

   • maintain clear communication channels and facilitate interaction processes (Ovretveit, 1997; Suter et al., 2007; Willumsen, 2006; Blewett et al., 2010);

   • listen to, support and trust team members (Mickan and Rodger, 2000; Leathard and Cook, 2004);

   • initiate constructive debates and share their own ideas (Mickan and Rodger, 2000; Lyubovnikova et al., 2015); and

   • manage conflict and maintain a productive balance between harmony and healthy debate (Mickan and Rodger, 2000; McCray, 2003).

7. Team-building:

   • set expectations for working together (Suter et al., 2007);

   • create a climate of mutual respect (Ovretveit, 1997; Leathard and Cook, 2004);

   • ensure cohesion (Willumsen, 2006);

   • develop the interpersonal skills of the team (Ovretveit, 1997);

   • ensure the contextual socialisation of new/inexperienced team members (McCray, 2003);

   • promote interprofessional collaboration (Suter et al., 2007; McCallin, 2003; Branowicki et al., 2001); and

   • facilitate group reflection on practice (McCallin, 1999; Branowicki et al., 2001).

8. Leadership clarity:

   • ensure clarity of leadership (Nancarrow et al., 2009; West et al., 2003); and

   • combine strong leadership and high involvement (Rosen and Callaly, 2005).

9. Direction setting:

   • coordinate tasks (Mickan and Rodger, 2000);

   • manage processes (Maister, 1993);

   • ensure work is allocated work equally (Pollard et al., 2005); and

   • set clear tasks (Ross et al., 2000).

10. External liaison:

    • represent the team externally (Irizarry et al., 1993);

    • ensure necessary resources (Maister, 1993);

    • develop strategies for promoting the work of the team (Irizarry et al., 1993);

    • demonstrate effectiveness through data collection and evaluation (Irizarry et al., 1993);

    • ensure the team understands its customers and can exploit new opportunities (Willumsen, 2006); and

    • develop networks and linkages(Pollard et al., 2005).

11. Skill mix and diversity:

    • recruit externally and develop internally (Ross et al., 2000);

    • ensure regular supervision and PDR (Burton et al., 2009); and

    • assure access to relevant training (Burton et al., 2009).

12. Clinical and contextual expertise:

    • high levels of professional expertise (Maister, 1993; Irizarry et al., 1993; Branowicki et al., 2001);

    • demonstrate in-depth understanding of the organisation (Branowicki et al., 2001) and current development programmes (West et al., 2014);

    • balance focus between the needs of the patient, organisation and team (Branowicki et al., 2001);

    • facilitate understanding of context and ensure all perspectives are taken into account (Abreu, 1997); and

    • knowledge of the professional role of others (MacDonald et al., 2010).

Discussion and conclusions

An IpTL framework in health care has been synthesised from the available published evidence and has been presented as a range of particular competencies that can be compared to the general management literature related to team management and leadership.

Many factors associated with better team leadership within management literature can also be seen in the IpTL framework. Both bodies of literature include a focus on: achieving organisational goals, managing performance, managing external relationships (boundary spanning activities) and demonstrating technical expertise (Larssen and LaFasto, 1989; Hackman, 1989; Stanniforth and West, 1995; LaFasto and Larssen, 2002; Hayes, 2002; Hackman, 2002; Katzenbach and Smith, 2003; Shackleton, 1995; Stoker, 2008; Burke et al., 2006; Stoker, 2008).

In contrast, the IpTL framework specifically highlights a leadership function for the team and the review demonstrates that as well as maintaining the managerial function an interprofessional team requires a person who can promote transformation and change and support creativity and innovation as key elements of their role. Significantly, a meta-analysis by Burke et al. (2006) shows that transformational leadership behaviours, (often linked to change and innovation) can have a potent effect within teams. West et al. (2003) also found that teamwork and team leadership processes consistently predict innovation.

Empowerment appears as a primary focus in the generic team leadership literature as a mechanism for collaboration, but the focus in the IpTL literature is more on shared, collaborative or more recently collective (West et al., 2014) leadership. Conceptually these factors are distinct, but in the ways they are described appear to have more similarities. The IpTL literature talks more about shared, collective and collaborative leadership, particularly in relationship to professionals within the teams. However, there is a paradox in that there is good evidence that clarity of leadership (West et al., 2003; Nancarrow et al., 2009) also appears to be important. Other commentators clarify, that shared leadership in IpT’s is facilitated by the team leader (Krueger, 1987; Maister, 1993). It may be that shared or collective leadership are more palatable concept to professionals than empowerment as they lend more status to professional expertise and accommodate autonomy rather than challenge it.

The IpTL framework overtly mentions team building as a key activity of the team leader and the wider literature on team leadership also refers to the fact that it takes effort to develop a team (Stanniforth and West, 1995; Hackman, 2002; Katzenbach and Smith, 2003). In the IpT literature, teamwork is still often an ideal that health and social care organisations are working to attain and a level of complexity is apparently which is to do with ensuring the correct mix and level of skills in the team. The IpTL literature focuses on developing the dynamics within the team as a whole and increasing integrated professional practice, with less attention paid to setting priorities and managing performance.

The literature review also raised some general questions about IpT’s. There is consensus in teamwork literature that teams become less effective as they become larger. However, Nancarrow et al. (2009) found that larger interprofessional care teams providing intermediate and community care for older people produced better patient outcomes, in spite of less satisfaction amongst team members and higher intention to leave. It is not clear from these results whether there is a limit to this relationship, where the economies of scale and enhanced workforce flexibility delivered by larger services, becomes offset by the impact on teamworking? In a further study (Nancarrow et al., 2013) comments on the difference between assumed shared decision-making and shared power across professions and the reality; perhaps alluding to the challenges of working across a large multi-professional context.

A second issue is that whilst many of the services that took part in this particular study were called teams, it is unclear how many operate as teams in practice. As already discussed, “team” is a term almost ubiquitously applied to work groups. Certainly, the size and structure of teams in this study are often outside the parameters put forward in the literature on teams. A final issue is the term interprofessional. There are increasing numbers of none professionally qualified staff in health care IpT’s, however their role and function in the literature on interprofessional teamworking and leadership is totally absent. We would therefore propose that that interdisciplinary is a more suitable term to use as it is broader and inclusive of all team members.

What is different about IpTL in health care appears to be the unique context in which it is applied. The multiprofessional nature of the workforce in health, the public service setting, their function and the contexts that they operate within, make the dynamics in health care IpT’s differ from the dynamics of teams in other settings. This difference seems to be highlighted by West et al. (2014) who advocate collective, distributed leadership practices for the NHS as a whole that resonate closely with the findings of this review.

Further, the literature does indicate that there are some elements of leadership practice, which may be particularly effective in interprofessional team settings. Perhaps the key issue highlighted is the fact that the operational workforce within health and social care is predominantly multi-professional in nature. Increasingly these professionals, together with other disciplines, are working together in a more integrated fashion. The creation of IpT’s has therefore created a unique leadership context. Whereas traditionally professions would be functionally led (i.e. doctors by doctors, nurses by nurses) by a professional with recognised expertise, in IpT’s, this functional leadership divisions are impossible to sustain. The leader can at most be only from one profession or discipline and therefore cannot therefore demonstrate greater professional expertise in other professions. This makes IpT leadership more demanding as the team leader, needs to find a way of leading a diverse professional workforce, without being able rely on professional credibility as a locus of authority. Further, the IpTL needs to be able to find ways to persuade an interprofessional group, to give up some professional autonomy, to integrate their practices and operate as a team.

Conclusion

This critical literature review examines how leaders of interprofessional teams are functioning and the synthesis identifies a framework of factors that contribute to good leadership practice. With a continuing paucity of empirical research data on IpTL, there is still much that is unknown about the IpTL process.