Professional Perspective

Factors influencing team working and strategies to facilitate

successful collborative teamwork
Antoinette McCallin, PhD, MA (Hons), BA, RGON
Faculty of Health and Environmental Sciences, AUT University

Mike McCallin, BHSc (Physio), MA (Hons), MNZSP

Senior Physiotherapist, Physiotherapy Department, Middlemore Hospital, Auckland

ABSTRACT
Collaborative teamwork is more and more important for effective health service
delivery. Collaborative teamwork occurs when health professionals focus on
patient-centred care, problem solving, coordinating care, learning together,
and networking across communities, in order to optimise quality care for patients
and families. Collaborative teamwork is now a World Health Organisation priority
for action. Collaborative teamwork is potentially problematic because some
physiotherapists will collaborate easily whereas others need to learn how to
collaborate with colleagues from different professions. Many will learn the full
nature of collaboration once they graduate and are in practice. The complexity of
practice though means that learning on the job may be too slow in a context where
the need is for a practice-ready workforce. The focus of this paper is to outline the
factors influencing team working and suggest strategies that facilitate successful
collaborative teamwork. The emphasis is practical. Some of the challenges that
physiotherapists face will be discussed from the perspective of making a specialist
team work better. McCallin A, McCallin M (2009): Factors influencing team working
and strategies to facilitate successful collaborative teamwork. New Zealand Journal
of Physiotherapy 37(2): 61-67.
Key Words: Teamwork, collaborative practice, collaborative teamwork,
interprofessional practice

INTRODUCTION whereas others need to learn how to collaborate

Team working is increasingly vital for the delivery
of effective health and social care services (Forte
and Fowler, 2009, p. 58). The current expectation
in Canada and Europe, at least, is that health
professionals will engage in collaborative practice
that supports patient-centred care (Suter, Arndt,
Arthur, Parboosungh, Taylor and Deutschlander,
2009). The drive for collaborative practice is
reinforced further in the World Health Organisation
Annual Report (2008) that notes the importance of
collaborative teamwork. Collaborative teamwork
occurs when multiple health workers from different
professional backgrounds work together in a
team, problem solving, coordinating care, learning
together, and networking with communities, as they
deliver quality care to patients and families (Barr
and Ross, 2009). However, research suggests that
professionals will not collaborate if the effort is only
based on the notion that it will be good for clients
(DAmour, Ferrada-Videla, San Martin Rodirguez and
Beaulieu, 2005, p. 128). In other words, collaborative
teamwork may be a political ideal but whether it is
supported by individual professionals is another
matter. Part of the problem is that modern-day
collaborative teamwork is a sophisticated skill and
some professions are better at it than others. It
requires effective interactions and the sharing of
knowledge and expertise in a team, in a way that
optimises partnership working with both clients and
colleagues (DAmour and Oandsan, 2005).
Collaborative teamwork is potentially problematic
because some physiotherapists will collaborate easily
with colleagues from different professions. Many
will learn the full nature of collaboration once
they graduate and are in practice. The complexity
of practice though means that learning on the
job is too slow in a context where the need is for
a collaborative practice-ready health workforce
(World Health Organisation, 2009). While student
physiotherapists are likely to be exposed to
interprofessional education strategies, professionals
already in practice may need to look at their
collaborative team working skills and consider if
they are up to speed for the modern environment.
Today collaborative teamwork is no longer
an option: it is a basic pre-requisite for effective
practice and quality care. So what are some of
the skills that are important? The focus of this
paper is to outline the factors influencing team
working and suggest strategies that facilitate
successful collaborative teamwork. The emphasis
is practical. We discuss some practical challenges
that physiotherapists face competence, different
worldviews, shared leadership and team travellers
drawing attention to the issues that might
make a specialist team work better. The topic is
important because interprofessional collaboration
and teamwork are priority areas for a pending
World Health Organisation Framework for Action
on Interprofessional Education and Collaborative
Practice (Barr and Ross, 2009). This framework
emphasises the need for new strategies for action,
strategies that reduce the long-standing health
service fragmentation and the more recent global

NZ Journal of Physiotherapy July 2009, Vol. 37 (2) 61

 health workforce shortages. The paper will be of
interest to readers who are District Health Board
clinical managers, to practice owners or team
leaders, senior members of hospital departments
and senior clinicians who are responsible for
supervising team travellers that move around the
organisation on rotation.
Challenges to Collaborative Practice
There is little argument that quality care
improves when two or more professionals are willing
to learn together and integrate specialist knowledge
in a way that benefits the patient (Soubhi, Colet,
Gilbert, Lebel, Thivierge, Hudon and Fortin, 2009).
The ideals of many health professionals working
together are well documented (Clark, Leinhaas
and Filinson, 2002; Long, Kneafsey and Ryan,
2003; Griffiths, Austin and Luker, 2004; Pullon,
2008; Yagura, Miyai, Suzuki and Takehiko, 2005),
as are the problems (Baxter and Brumfitt, 2008;
Booth and Hewison, 2002; Hall, 2005; Hansson,
Friberg, Segesten, Gedda and Mattsson, 2008;
Kvarnstron, 2008; Leipzig, Hyer, Ek, Wallenstein,
Vezina, Fairchild, Cassel and Howe, 2002;
Reilly, 2002). Consistent challenges relate to
communication, understanding other health
professionals roles, effective team working skills
including understanding group norms, conflict
resolution and the ability to tolerate differences,
the ability to contribute to shared care plans and
goal setting, and a willingness to collaborate
(Suter et al. 2009, p. 42). Although the challenges
are commonly recognised, as the same issues
have reappeared in the literature over and over
again in the last decade, less is written about
the practical problems of everyday teamwork, the
practicalities associated with competence, different
worldviews, shared leadership and team travellers.
These are discussed next. The ideas presented
come from a physiotherapist in practice (MCHM)
and a nurse researcher-
academic (AMM) who
has studied the topic
Today collaborative teamwork is
extensively (McCallin
1999, 2003, 2004, 2005,
no longer an option: it is a basic
2006a, 2006b, 2007; pre-requisite for effective practice
McCallin and Bamford,
2007). and quality care.
Competence
New Zealand research on team working has
suggested that competence can not be assumed
when clinicians from different professions work
together in a team (McCallin, 1999, 2004, 2007).
When a new member joins a specialist team the
team needs to know if the new person has the
clinical competence required by the service and if
they can be trusted professionally. While all team
members have a general professional competence,
which is a legal requirement according to the Health
Practitioners Competence Assurance Act (Ministry
of Health, 2003), the specialist team requires
62
competence in the form of expert knowledge and
skill, which cannot be taken for granted. In other
words, general physiotherapy competence is
the base-line, which might be different from the
expectation of specialist competence, which includes
collaborative competencies as well. For instance,
a physiotherapist moving to a new service,
transferring from acute care to the community, from
public hospital work to private practice, immigrants,
or those simply changing jobs, move into a phase
of what Thomas, Hicks, Martin and Cresey (2008)
call transition competence. Transition competence
is common in a teaching hospital environment
where clinicians join specialist teams for short-term
rotations. Also, when staff shortages are the norm,
clinicians on rotation may find themselves thrust
into a specialist team where they must quickly
develop both clinical competence and collaborative
team competence. As a result, competence is always
checked out. Competence is never assumed for
junior staff, although a certain level of collaborative
capability is expected from more experienced senior
staff that can expect a rapid team orientation.
In the everyday world of practice, competence is
complex in that individual competence influences
team competence, and both forms of competence
impact team effectiveness and quality care (Porter-
OGrady, Alexander, Blaylock, Minkara and
Surel, 2006). While many physiotherapists are
well respected for their rehabilitation competence
(Dalley and Sim, 2001), collaborative competence is
another matter. Initially, the focus is on specialist
competence. Do you have specialist competence?
How do we know? Who has seen you working in
a competent manner? When did you acquire your
knowledge? How has knowledge been updated
since? In many services demonstrations of
competence are evidenced through joint treatment
sessions and active involvement in clinical
meetings. Once physiotherapy knowledge and skill
are confirmed attention
turns to collaborative
competence. Everyday
situations provide
opportunity to work
collaboratively with
colleagues to improve
client care (Hunt, 2006).
Colleagues look for
specific collaborative competencies such as the
ability to communicate effectively across the
disciplines, to problem-solve, to resolve conflict,
to tolerate differences, and to plan care (Suter
et al, 2009). In reality, as the new team member
grows in professional confidence and experience,
collaborative team competence increases. Learning
to work collaboratively with others who have
different views of the world though is often
challenging.
NZ Journal of Physiotherapy July 2009, Vol. 37 (2)
 Different Worldviews
Despite different worldviews, the New Zealand
research shows that successful collaborative
teamwork depends on health professionals having
a fundamental respect for disciplinary diversity
(McCallin, 1999, 2004, 2007). Collaborative teams
rely on team diversity to function effectively (McCallin
and Bamford, 2007). Diversity creates some tension
however, as different health professionals examine
their attitudes towards other professionals, grapple
with different ways of looking at the world, and
demonstrate a readiness to talk through their
differences with colleagues (McCallin, 2005). It is
this talking through of the differences, informally,
outside of team meetings
that has the potential the health professional that
to promote learning and
change thinking. As has
has a strong professional
been indicated having a identity is more open to
willing attitude towards
collaboration goes a long different worldviews
way (Suter et al, 2009).
As a team collaborates, the motivation to work with
colleagues who have different histories, differing
philosophical foundations, differing training and
different clinical traditions is crucial (Cooper and
Stoflet, 2004, p. 45). Distinct professional values
and beliefs underpin disciplinary knowledge.
Different worldviews are also contextual, in that
depending on the hospital or community location,
one model of health may drive client care. For
instance, while the medically focused disease
paradigm usually dominates acute care work
(Lindau, Laumann, Levinson and Waite, 2003),
Cooper and Stoflet (2004) argue that different
philosophical approaches to care influence how
team members think and plan care.
Different worldviews influence collaborative
potential. Sawa (2005) suggests that when clinicians
think in a different paradigm, and regard that as the
only way of looking at the world, collaborative teamwork
is compromised. For example, physiotherapists work
within a bio-psycho-social model of health (Roberts,
1994), doctors and pharmacists practice within the
biomedical model of health, nurses favour a bio-
psycho-social-spiritual model of health, occupational
therapists value a holistic approach to their work,
while the psycho-social model is the basis of social
work practice (Burbank, Owens, Stoukides and
Evans, 2002). Each model is underpinned by a
distinct worldview that has value in its own right,
shapes professional identity, and impacts thinking
and collaborative potential.
Interestingly, the health professional that has
a strong professional identity is more open to
different worldviews (McCallin, 1999, 2004, 2007).
Professional identity, more usually acquired in
postgraduate study, affects professional confidence.
This influences collaborative teamwork because the
physiotherapist who has a clear professional identity
is more likely to cross professional boundaries
and communicate readily with those from other
NZ Journal of Physiotherapy July 2009, Vol. 37 (2)
professions (Griffiths et al, 2004). Having a clear
professional identity may reduce role confusion
(Booth and Hewison, 2002). As noted previously,
understanding roles and the roles of colleagues
is a critical collaborative competency (Suter et
al, 2009). Once again the willingness to find out
about anothers role and understand how another
health professional views the world is important, if
collaborative teamwork is the ultimate goal.
There is little doubt that recognising distinct
worldviews challenges most health professionals,
especially if conflicting assumptions are not
discussed at all (Sawa, 2005). It is important that
novice physiotherapists appreciate that it takes
time and experience to
understand disciplinary
roles, specialisation and
function. The realisation
that every worldview has
a time and a place in
client care is undoubtedly
significant. What is critical
is the appreciation that specialist knowledge is
limited when one worldview dominates client care to
the exclusion of others (Lindau et al, 2003). Coming
to that point of understanding is not easy. However,
when a new physiotherapist for example encounters
different ways of thinking an experienced team
mentor often helps to explain the teams value
systems that impact collaborative teamwork (Faull,
Hartley and Kalliath, 2005). Genuinely appreciating
differences is quite difficult though and may cause
conflict.
Initially, it may be a struggle for the novice
physiotherapist to be assertive and point out
potential areas of conflict or inconsistencies in
client care (McCallin and McCallin, 2007). Tolerance
is required as everyone adjusts to new personalities
and communication styles. Some team members for
example are better than others in explaining clinical
reasoning, or perhaps dealing with personality
conflicts, or differences of opinion. In time, as long
as clinical competence has been confirmed, most
specialist teams encourage individuals from any
profession to stand out and show their special
strengths. This appreciation of individuality is
important because, ultimately, each client is unique
and requires different approaches. Eventually,
as the clinician grows in experience there is a
realisation that all worldviews have a place and
it is how they are communicated that matters
and makes a difference to the client. Effective
communication becomes even more important when
the shared leadership of collaborative teamwork is
considered.
Shared Leadership
Collaborative teamwork also depends on shared
leadership. The research about interdisciplinary
teams in acute care in New Zealand suggests
that how the person at the top encourages or
discourages collaboration is significant (McCallin,
63
 1999, 2004, 2007). In shared leadership all team
members are active leaders, spontaneously taking
the lead in the team as and when specialist input
is required to solve particular client problems
(McCrimmon, 2005). Shared leadership is different
from the traditional, positional leadership in which
the service leader assumes a general responsibility
for client care yet has little control over professional
input from colleagues. Although the team leader is
not directly responsible for individual professional
practice the team is collectively accountable for
client outcomes. Collaborative teamwork seems to
be more successful if everyone understands that
with shared leadership no one person has all the
answers, and everyone is responsible for the nature
and quality of the collaboration.
Shared leadership works better when the
specialist team is coordinated. Usually, the team
leader and the team coordinator are not one and
the same person (McCallin, 1999, 2004, 2007).
The coordination role though is absolutely critical.
The team coordinator not only coordinates team
efforts but coaches and mentors colleagues in the
collaborative competencies. Having the skill to
coach colleagues from other professions in the art
of negotiation, conflict management and change
management, is a challenge.
In practice, few specialist teams have a designated
team coordinator (McCallin and McCallin, 2007).
Because some clinicians, such as dieticians and
social workers, may be members of more than one
team, often one clinician, usually a senior nurse
like a charge nurse manager, may act as a de facto
coordinator, or an informal leader, during team
meetings. In some situations shared leadership is
evident with the use of the
key worker role. A key worker
leads and advises the team,
If quality care is the goal for
improving communication patients and families, clinical
and encouraging mutual
understanding between competence must be balanced
with collaborative competence
services (Hunter, Playle,
Sanchez, Cahill &
McGowan, 2008, p. 670).
The key worker has a central role supporting the
team and the service provider, promoting effective
communication and coordination across services
and boundaries (Middleton, McCormick, Engel,
Rutkowski, Cameron, Harradine, Johnson, and
Andrews, 2008). In rehabilitation in particular
key workers are the point of contact between the
client, family and the team. The key worker role
is a good example of shared leadership, as this
person leads the team, organising referrals to
other services, running meetings, and directing
discharge planning in relation to a particular client.
This means that the medical staff, who have been
traditional team leaders, are expected to stand
back, to assume an equal role with colleagues
during family meetings that are key-worker lead.
This model of shared leadership is not particularly
new, but demonstrates that the medical staff are
64
no longer natural team leaders and neither should
they have the final say in decision making (Leipzig
et al 2002). The way that professionals who are
used to being positional leaders deal with this
change may have a major impact on collaborative
teamwork. Shared leadership is further complicated
in a teaching hospital where various professionals
move in and out of teams as team travellers on
learning rotations.
Team Travellers
In the New Zealand research about teamwork
it was clear that team travellers those clinicians
who moved around teams on short-term rotations
were in an invidious position (McCallin, 1999,
2004, 2007). This particular challenge is not
confined to New Zealand. Clark, Leinhaas and
Filinson have noted the tension of exposing newer
clinicians to specialist teamwork at a superficial
level and expecting them to develop substantial
teamwork skills honed in real-life practice settings
and with real-life dilemmas and challenges (2002,
p. 495). McCallin (1999, 2004, 2007) reports that
when relatively new practitioners team travellers
entered a team, they were usually given a job
description of task responsibilities, but team
processes, team orientation or staff development,
in other words collaborative expectations, were not
discussed at all.
Some services though the ones that have a
clear team purpose, goals, time frames, specific
roles and responsibilities, and projected outcomes
for the client welcome team travellers (McCallin
and McCallin, 2007). In reality, travelling around
different teams is so much easier when a team
is clear about its common
purpose, can state who
does what, and clarifies
the role responsibilities in
relation to client care. Any
explanation of where the
new person is expected to
fit in goes a long way to
improving collaboration. Not
surprisingly, moving into a large team for a short-
term rotation is more difficult if team roles and
responsibilities are unclear. Similarly, collaboration
is compromised if there is no one person responsible
to orientate the new person to the ways of the team
(Burbank et al, 2002).
Support for the team travellers primarily comes
from senior members of the team. While support
is usually professionally determined (McCallin and
McCallin, 2007), Kneafsey, Long, Reid and Hulme,
(2004) argue that a team management approach
is preferable if it is available. More often than not,
the nurses or therapists assist in the orientation
of the team traveller. In contrast, members of
the medical profession tend to focus solely on
medical staff orientation. The medical leader is
influential however, as he or she facilitates team
acceptance by recognising professional expertise.
NZ Journal of Physiotherapy July 2009, Vol. 37 (2)
 Once competence is confirmed a medical consultant
may expect any team member to speak on behalf
of the team.
In practice, many clinicians are team travellers by
default, and most cover several teams. A consultant
may head a general medical team as well as a
specialist team, and speech therapists will often
interact with every team in a hospital. Rotational
physiotherapists may find moving into a specialist
team intimidating, especially if the therapist is new
to practice (McCallin and McCallin, 2007). It can
take time to grow into the new role and to contribute
effectively. Then, once the rotation is complete, the
therapist moves on to another new team and begins
the learning experience all over again. This certainly
benefits the organisation, and, if team collaboration
has been positive, the physiotherapist may pass
on some of those collaborative competencies to
their colleagues in other areas. It is much more
difficult though for the specialist team as they train
individuals, only to have them move elsewhere.
Additionally, all teams are vulnerable in the era of
economic rationalisation, as no matter how effective
they are, they may still be disbanded and members
re-assigned elsewhere (Clarke et al. 2002). Obviously,
collaborative teamwork is a constant challenge.
Strategies for Action
As has been seen any sort of teamwork is much
more complicated than it seems at first glance.
Research is helpful in some ways but must be
viewed cautiously, as findings are contextual, and
organisationally and geographically located. What
is clear is that effective collaborative teamwork
will not happen without collaboration between
the politicians, health care organisations, and the
professions, which include the education sector.
Politicians set the mandate for the professions,
influence policy and legislation, and provide funding.
So even if collaborative teams are the strategy of
the future, it may not be reasonable that the
actioning of the strategy,
which currently underpins
most government health
...all health care workers must
hit the ground running and be
policies, is left to a clinical
team to learn through trial
and error experience. If able to work as collaborative
the political commitment
to provide integrated
practice-ready workers
collaborative care is
genuine, much wider organisational and educational
investment and actioning are essential to support
an interprofessional culture change.
It is perhaps timely that the World Health
Organisation (2009) has published an action plan
for the future. In this document collaborative
teamwork is seen as an innovative strategy that
will play an important role in mitigating the global
health workforce crisis (p. 5). There is a clear
international mandate providing direction for the
future. Therefore, the health leaders involved in
service provision, whether as professional leaders,
NZ Journal of Physiotherapy July 2009, Vol. 37 (2)
managers, advisors or clinicians, need to consider
strategies to facilitate successful collaborative
teamwork. The strategies are threefold: political,
organisational and professional, which includes
education.
Firstly, politically, legislation may be required
to ensure that this model of practice becomes
the foundation of health care practice. To date
interprofessional working and collaboration have
been widely discussed in the literature for at least
a decade, although change did not happen in the
United Kingdom or Canada until legislation was
passed to support collaborative practice. In the
United Kingdom, the National Health Service Act
of 2006 (Department of Health, 2006) legislates
for partnership arrangements, which emphasise
working together effectively and integrated
arrangements for service delivery. These goals are
realised through collaborative teamwork. While the
World Health Organisation recognises that policy
development is contextual and what works in
one country may not be automatically transferable
to another the physiotherapy profession and
organisational leaders may need to act strategically,
to lobby the government for change to support
collaborative practice, which strengthens health
systems and improves health outcomes (World
Health Organisation, 2009, p. 5).
Secondly, organisations may need to review
practice management in an environment that
is inherently unstable and dominated by fiscal
restraint. The practical reality in teaching hospitals
at least is that teams change, physiotherapists on
rotation come and go frequently, as often as every
four or six months. In some situations in New
Zealand, in smaller hospitals, it is a luxury for a
physiotherapist to belong to just one team. Some
physiotherapists have broad organisational roles and
responsibilities to several teams. Even if an individual
has a special attachment to a team that is called
home, wide ranging responsibilities to several
teams in an organisation
can compromise the most
enthusiastic commitment
to collaborative teamwork.
True collaboration is thus
constrained according
to organisational, fiscal
and structural barriers.
Organisational managers
might reconsider trialling new management
practices. For example, attaching a physiotherapist
to a team for a minimum period of a year would
improve team stability and go a long way to
supporting a specialist team striving to work
collaboratively.
Thirdly, the profession itself may need to re-
evaluate its position on practice development.
Collaborative teamwork is a strategy for action that
supports interprofessional working. Development
and change begin in education and flows across
into practice. Currently, some undergraduate
65
 students in New Zealand are educated in an
interprofessional learning environment, but
many physiotherapists have not had access to
interprofessional learning and development at
all. Therefore the profession may consider a post-
graduate staff development programme that would
address this issue specifically.
Overall, it is essential that any strategies for action
are integrated. One without the other promotes
continuing fragmentation and undermines what is
possible. Health care organisations need political
support and government funding to develop the
organisational resources and policy change that
will support the interprofessional cultural change,
which is the international way of the future. Without
an integrated plan of action collaborative teamwork
is reduced to a vision, a dream about possibilities.
The future challenge politically, organisationally
and professionally is to strive for a place whereby
specialist teams work collaboratively and provide
evidence that successful collaborative teamwork
improves health and social outcomes for patients.
CONCLUSION
Many physiotherapists have had and continue
to have positive experiences of collaborative
teamwork where collaborative effort improves
quality care for the patient and family. This way
of working tends to occur because some people
are better at collaboration than others. So while
physiotherapists joining a specialist team have, or
are well positioned, to develop specialist competency,
they also need to review their collaborative
competencies, if they are to contribute effectively to
collaborative teamwork. It is clear too that political,
organisational and professional leadership will be
necessary if collaborative teamwork is to become an
integral part of health service delivery. The decision
to collaborate is no longer an option. The global
health workforce crisis means that all health care
workers must hit the ground running and be able
to work as collaborative practice-ready workers.
Key Points
! Longstanding fragmentation of health service
delivery and the global health workforce
shortage make collaborative teamwork an
imperative.
! The drive for collaborative teamwork is a World
Health Organisation priority for action.
! Collaborative teamwork is a sophisticated skill
and some individuals are better at it than others;
others may need staff development.
! The main challenges to collaborative teamwork
are understanding others roles, and effective
communication.
! If quality care is the goal for patients and families
clinical competence must be balanced with
collaborative competence.
! Strategies to improve the effectiveness of service
delivery need to be political, organisational and
professional.
66
ADDRESS FOR CORRESPONDENCE
Dr Antoinette McCallin, Faculty of Health and Environmental
Sciences, AUT University, Private Bag 92006, Auckland 0627. Tel:
09 921 9999 7884. Email: amccalli@aut.ac.nz
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