Stortingsmelding 26 on primary health care (2014-2015) proposed the establishment of interdisciplinary primary health care teams in the municipal health care service. In this connection, the Department of Health Services at the Norwegian Institute of Public Health received a proposal from the municipality of Trondheim and the NORCE Norwegian Research Centre AS in Bergen to conduct a review of studies of interdisciplinary teams in primary health care.
- We prepared a scoping review in which we included 36 different overviews of quantitative and qualitative studies, ten primary studies, four articles with discussion of terminology, and six overviews of measurement tools.
- The patient population in the quantitative studies that we included, was adults with one or more chronic conditions or who were seriously ill. The population selected for qualitative studies was mainly health personnel who worked in teams.
- The research studies had investigated several kinds of interventions to strengthen teamwork, such as continuing education interventions, practice-based interventions and organizational improvement interventions, as well as the effects of interdisciplinary teams. Many had also been concerned with identifying influencing factors and processes in team collaboration from the health personnel's experiences. Others had been concerned about use of terminology and some of how different concepts had been measured.
Stortingsmelding 26 on primary health care (2014-2015) proposed the establishment of interdisciplinary primary health care teams in the municipal health care service. Working in teams is an increasingly common way to organize the health care in many countries, but there are still many unanswered questions related to this organization model.
The objective of this systematic scoping review was to identify and describe research literature on interdisciplinary teams in the primary health care service. A scoping review of the research knowledge shows primarily what kind of research has been done. The mapping may be further used for the development of project plans, planning for the establishment of interdisciplinary teams, evaluations of new and existing teams and for use in further discussions of interdisciplinary primary health teams in Norway.
In the execution of the scoping review we followed the framework drawn up by Arksey and O’Malley and Joanna Briggs Institute. In the reporting of procedures and findings, we followed a recently published guideline for reporting of scoping reviews. Inclusion criteria were overviews with interdisciplinary teams in the primary health care as a theme, such as systematic reviews, realistic syntheses and integrated overviews, regardless of which study design they had included. A further criterion was primary studies with the following design: randomized controlled trials, interrupted time series studies with at least three measurement times before and after the intervention was initiated, non-randomized controlled trials and before-and-after-studies with control. The two latter study designs had to have at least two units each in both the intervention and control groups. We did not search for primary studies with qualitative study designs.
We searched for literature in Cochrane Central, MEDLINE, EMBASE and CINAHL. Two authors independently considered the references from the literature search for inclusion or exclusion. The studies were sorted and classified according to partially predetermined categories. One of the authors extracted descriptive data from included studies and one other controlled correctness of the data extractions. We compiled and described the studies in tables and text.
We included a total of 56 publications published between 2004 and 2019. Of these, 46 were various types of reviews of different themes and 10 studies were primary studies of the effects of interventions. Four of the reviews examined the terminology that had been used in the field. In 19 of the other reviews, the authors investigated the effects of various types of interventions related to team collaboration. In seven of these reviews the authors studied the effects of various types of interventions to strengthen team collaboration. These were continuous education (one overview), practice-based interventions (one overview, one primary study) and organizational improvement interventions (five overviews, two primary studies). Twelve of the 19 reviews tested the effects of interdisciplinary team as an intervention in itself. In this category we also included seven primary studies that had not been included in any of the reviews. Moreover, several review authors were concerned with identifying the influencing factors and processes in team collaboration based on the experiences of health professionals (17 reviews). Among the included reviews were also six reviews of measurement tools for measuring different outcomes.
Three of the twelve reviews that examined the effects of a team intervention for various purposes limited the population to certain diagnoses (primary hypertension, diabetes and stroke), otherwise the population was mainly elderly with one or more chronic diseases. Some reviews reported positive results for some patient and process outcomes. The results, however, often varied from study to study in each review and between reviews, for example when it came to patient satisfaction and use of health services. Five of the total 19 reviews that examined the effects of team interventions for various purposes included studies that had measured costs. These reported that the quality of the evidence for the effects on costs were low and demonstrated heterogeneous results.
Teams were used in the doctor's office for all types of patients, for home visits of the elderly (geriatric teams), in care at the end of life, in wound care, in blood pressure treatment, for the follow-up of stroke and COPD patients, for drug reviews and in the follow-up of patients at risk not to manage their own drug handling. It appeared that most research was done on the team composition of general practitioner and nurse(s) and general practitioner and pharmacist. But there were also teams with several other occupational groups such as nurses, occupational therapists, physiotherapists, social workers and doctors. In several reviews, it was emphasized that the team should be composed with a view to the purpose. No one could give any answer to how many participants a team ought to have. The patient perspective was often absent from the literature and it is unclear how one imagined that the patient should be involved so that the treatment could be called patient centred.
Three reviews of quantitative studies and 14 reviews of qualitative studies examined influencing factors, processes and experiences with team collaboration. There seemed to be a great deal of agreement across studies on which factors were considered important for successful team collaboration. System level factors that were believed to affect team processes were laws / regulations, opportunities for common premises, sufficient funding and remuneration, the learning of teamwork in the various vocational training programs. At the organizational level, the influencing factors were considered to be supportive management, regular meetings, focus on common visions and goals, evaluation of practice with feedback, facilitation of good communication both formally and informally, routines for coordination, thoughtful composition of the team, degree of role clarifications but also opportunities for role development, professional development and adequate training in teamwork. Respect, trust, positive attitudes and communication skills, as well as a climate for good discussions, were reported as important influencing factors at team level. Some pointed to professional boundaries, different professional cultures and the doctor's authority in the traditional hierarchy as barriers to good cooperation.
The six reviews of measurement tools measured the degree of clinical, professional, organizational and functional integration, how health professionals experienced effectiveness, organizational capabilities, team processes, service coordination, and team collaboration.
The literature was characterized by inconsistent use of terminology. The concepts team and teamwork assumed different forms and lacked well-defined boundaries against other concepts, such as interdisciplinary collaboration in general. However, to the extent that team and teamwork were defined, it was generally agreed that one team consists of at least two people who interact and have common goals. Several emphasized that teamwork is dynamic, involves complex relationships and exists in a larger context.
Based on how teams were described, it seems as if the terms interdisciplinary and multidisciplinary were used interchangeably without implying that there was necessarily a difference in ways of collaborating. That is, this was not possible to distinguish from the descriptions of the studies. We therefore included studies whether they had used the terms interdisciplinary, multidisciplinary or interprofessional. The topic was difficult to delineate in the literature search. It was sometimes unclear whether it was distinguished between continuous daily team collaboration and necessary collaboration between professions only in a current situation. There was also a lack of description as to how well the various interventions that were tested, had actually been implemented.
Examples of research gaps are how patients can best be involved, effects and process evaluations of team implementation and research on causes of heterogeneity in results.
Research has been conducted on the effects of several types of interventions to strengthen team collaboration, such as educational and practice-based interventions, and organizational interventions. Also the effects of interdisciplinary teams as an intervention in itself have been investigated. The quantitative reviews usually reported mixed findings for measured outcomes at the process and patient level, as well as costs of such interventions. However, the reviews of qualitative studies of what health personnel perceived as important influencing factors were quite coherent. Impact factors that were reported as important for good team collaboration were sufficient funding, physical co-location, good management, shared information systems and communication routines, good informal communication, adequate training - also in team collaboration -, focus on common visions and goals and the carrying out of process evaluations with feedback.