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

Purpose – The purpose of this study is to review evidence on the nature of effective leadership in interprofessional health and social care teams. Design/methodology/approach – A critical review and thematic synthesis of research literature conducted using systematic methods to identify and construct a framework to explain the available evidence about leadership in interprofessional health and social care teams. Findings – Twenty-eight papers were reviewed and contributed to the framework for interprofessional leadership. Twelve themes emerged from the literature, the themes were: facilitate shared leadership; transformation and change; personal qualities; goal alignment; creativity and innovation; communication; team-building; leadership clarity; direction setting; external liaison; skill mix and diversity; clinical and contextual expertise. The discussion includes some comparative analysis with theories and themes in team management and team leadership. Originality/value – This research identifies some of the characteristics of effective leadership of interprofessional health and social care teams. By capturing and synthesising the literature, it is clear that effective interprofessional health and social care team leadership requires a unique blend of knowledge and skills that support innovation and improvement. Further research is required to deepen the understanding of the degree to which team leadership results in better outcomes for both patients and teams.


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.

Review questions/objectives
The specific aim of the review was to describe facets of leadership within interprofessional health and social care teams and generate a thematic framework that explains and develops conceptual understanding of that role.
The review addresses the following key objectives: research and grey literature on interprofessional team leadership in health and social care, to appraise any key theoretical constructs and tested variables; and research and grey literature relating to interprofessional health and social care team working, commenting on interprofessional team leadership.
The search strategy was designed to access peer-reviewed, published studies for the period 1994-2015. This time period was determined as significant, based on the policy context i.e. Department of Health had begun to focus increasingly only patient pathways and interprofessional working to improve patient care (NHS Plan 2000www.nhshistory.net/nhsplan.pdf) and at the end of the period, the Five Year Forward View (NHS England, 2014) outlined and consolidated the ambition to commission and provide integrated health care with significant focus on the leadership of new services and ways of working (Ham and Murray, 2015 A search using all identified relevant keywords and index terms (see Table I) was then undertaken across all included databases. Hand searching included reference lists of all identified reports and articles, which were screened to identify additional studies and relevant texts in the grey literature referring to interprofessional team leadership in health services. The search was then extended to include any identifiable reference to "teamworking" and interdisciplinary, which were broader than interprofessional, to identify any mention of team leadership in a health context. An additional reason for the extension was in recognition of unqualified or non-professional staff who are part of the teams caring for and treating patients. Finally, the search terms identified a range of team and service outcome metrics that refer to the process of care and the impact of care typically using outcomes of service/team rather than health status or health outcome. Table I below outlines the key search terms and Table II provides the terms used for the additional focus on potential outcomes of team leadership within the care context.

Inclusion and exclusion criteria
The critical review aims to develop an evidence-based theoretical understanding of interprofessional team leadership, including conceptual models for practice. It is based on empirical findings or narrative examples from practice, described and/or evaluated. Selection began with an initial screening of the papers by title and abstract using the specific decision rules to identify relevant papers. A set of decision criteria were developed; to identify relevant papers that would distinguish between leadership theories in health care and those particularly referring to interprofessional teams. The initial categories related to main methodology i.e. empirical study, qualitative research, or a narrative study, or systematic review. This method sorted papers and enabled authors to select key papers related to the review objectives and enhanced decisions about which papers to include or exclude (Paterson et al., 2001). Further selection identified any papers including reference or outcomes achieved through interprofessional team leadership in health and social care. As there were few papers specifically on this topic, the search was extended to include papers on interprofessional teamwork, again allowing leadership to become the emerging narrative within publications on health care team practice. Owing to the dearth of literature on inter* (professional, disciplinary) team leadership publications discussing primary or secondary research on interdisciplinary team leadership, or interdisciplinary team working were included. Papers that had no apparent evidence base were excluded from the review and these included opinion pieces and editorials with particular views of a single author.
A mixed methods quality appraisal tool was then used to evaluate the selected empirical studies and this was also adapted and applied to the descriptions of teams and clinical practice context. Table III includes the quality assessment criteria used for the study. Evaluations of leadership or team outcomes and processes were included and the content reviewed for satisfactory description and relevant content. Table I.

Key search terms for IpTL
Interdisciplinary or interprofessional or multiprofessional or multidisciplinary or inter-disciplinary or inter-professional or co-operate* or multi-professional or multidisciplinary or "inter disciplinary" or "inter professional" or "multi disciplinary" or "multi professional"

Data extraction and synthesis
Data extraction was undertaken manually using an excel spreadsheet designed for the purpose of categorising findings. Papers were read and re-read as full text and emergent ideas were identified with key ideas and theories recognised and noted. The Ritchie and Spencer (1994) "Framework" approach was adopted to code the data and further analysis was undertaken using the findings from the selected reports (grey literature). This approach was chosen, because it was both rigorous and permitted the analysis of original data but was also open to adaptation and change; allowing methodical treatment of all similar units of analysis and some case comparisons. Principally it was adopted as a means of synthesis that allowed full review of the located data (Ritchie and Spencer, 1994). Following the coding of papers and data extraction into categories a number of preliminary themes were developed. These formed the basis of the framework that could then be used to create some broader, higher order themes and additional data were included, based on agreement with other authors. The framework was continually modified as a deeper understanding of the data was developed, as new data were coded and new themes emerged. The synthesis was completed when all data had been incorporated and items checked to ensure that the framework permitted a robust "container" for the data and permitted a more conceptual analysis of interprofessional leadership.

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, Table II.

Key search terms for outcomes of IpTL
Interdisciplinary or interprofessional or cooperate* or collaborate* or multidisciplinary or interdisciplinary or interprofessional or co-operate* or multi-disciplinary or "inter disciplinary" or "inter professional" or "multi disciplinary" And 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-forinnovation-and-improvement, 2010, Sicotte et al., 2002West 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).

Facilitate shared leadership
For interprofessional teams to work effectively, each team member must accept responsibility as a member-leader stepping in and out of the leadership role when their professional expertise, particular knowledge of a client, or the situation comes to the fore (McCallin, 1999;Wilson, 2001). This process requires a formal leader who has overall responsibility for the performance of the team, but consciously shares the leadership function facilitating joint decision-making and delegates leadership roles (Day, 1981;Sicotte et al., 2002;Ovretveit, 1997;Mickan and Rodger, 2000;McCallin, 2003, Institute-for-innovation-and-improvement 2010, West et al., 2003. The key mechanism for achieving this is empowerment (McCray, 2003). The leader actively works to develop/maintain non-hierarchical, democratic structures (Ovretveit, 1997;Krueger, 1987). They coach team members (Maister, 1993) to develop the skills required (McCallin, 2003) share their ideas, work to create agreement and supply information the team requires (Mickan and Rodger, 2000).

Transformation and change
Transformational leadership is important (McCray, 2003;Irizarry et al., 1993). The IpTL acts as a role model in line with their espoused values (Pollard et al., 2005;West et al., 2014) to create a climate in which staff are inspired (West et al., 2003) challenged, supported, motivated andrewarded (Irizarry et al., 1993); respond to change in a flexible way (Suter et al., 2007); and facilitate or act as a catalyst for practice change (Willumsen, 2006).

Goal alignment
The IpTL works to influence the direction and climate of the group to ensure goal alignment with the organisation and productivity (Leathard and Cook, 2004). They do this by ensuring the team has articulated a clear and inspiring vision of its work, creating regular times when it can review it's performance (Lyubovnikova et al., 2015) providing feedback to highlight important issues (Mickan and Rodger, 2000;Leathard and Cook, 2004).

Creativity and innovation
A productive balance of harmony and debate is vital to ensure creativity (Leathard and Cook, 2004) and development of innovations and new practice models (Suter et al., 2007). However, teamwork processes and team leadership have been found to consistently predict team innovation (West et al., 2003).

Communication
The leader must facilitate the interaction processes and develop/sustain clear communication channels in the team (Ovretveit, 1997;Suter et al., 2007;Willumsen, 2006;Blewett et al., 2010). They do this by initiating constructive debates and modelling their own ideas (Mickan and Rodger, 2000;Lyubovnikova et al., 2015) and supporting, listening to and trusting team members (Mickan and Rodger, 2000;Leathard and Cook, 2004).
The leader must also manage conflict, ensuring a productive balance between harmony and healthy debate (Mickan and Rodger, 2000;McCray, 2003).

Team-building
Teamwork is not a naturally occurring phenomenon (Lyubovnikova et al., 2015). The team leader must therefore invest time in team-building,`setting expectations for working together (Suter et al., 2007) and creating a climate of mutual respect (Ovretveit, 1997;Leathard and Cook, 2004). They work to ensure cohesion (Willumsen, 2006), developing the interpersonal skills of the team (Ovretveit, 1997) promoting interprofessional collaboration through group reflection (McCallin, 1999;Branowicki et al., 2001) on practice and ensuring contextual socialisation of new or inexperienced team members (McCray, 2003).
Collaboration is promoted by allowing enough time for discussion and reflection on practice and encouraging staff to interact with those outside their profession (Suter et al., 2007;McCallin, 2003;Branowicki et al., 2001).

Leadership clarity
In spite of growing support for shared/collaborative/collective leadership models there is evidence to suggest that interprofessional teams need an overall team leader to operate effectively (McCallin, 2003).
A 2009 study found that teams with a specific team leader had higher levels of staff satisfaction than teams where the leadership role was split (Nancarrow et al., 2009). Clarity of leadership is associated with clear team objectives, high levels of participation, commitment to excellence and support for innovation (West et al., 2003). Primary health-care team members rated their effectiveness more highly when they had strong leadership and high involvement amongst team members (Rosen and Callaly, 2005).

Direction setting
The leader ensures that the team retains a focus on its priorities and goals and that individual team members maintain the correct focus (Mickan and Rodger, 2000). They work to manage team processes (Maister, 1993) including setting clear tasks (Ross et al., 2000) coordinating work (Mickan and Rodger, 2000) and ensuring equitable allocation (Pollard et al., 2005).

External liaison
The team leader must exercise external responsibility for the team (Irizarry et al., 1993) ensuring that it is represented and gains the resources it requires (Maister, 1993). This requires: promoting the work of the team (Irizarry et al., 1993) the ability to develop networks and linkages (Pollard et al., 2005) demonstrating effectiveness through data collection and evaluation (Irizarry et al., 1993) and adopting a marketing orientation to ensure the team understands its clients and can exploit new opportunities (Willumsen, 2006).

Skill mix and diversity
The team leader's role is to ensure that the team contains the right skill mix and diversity to achieve its goals and tasks. This involves both external recruitment and internal development (Ross et al., 2000) with regular supervision, annual performance reviews and access to relevant training important factors (Burton et al., 2009).
Clinical and contextual expertise Professionals will only be accepted into IpTL roles if they prove their professional expertise (Maister, 1993;Irizarry et al., 1993;Branowicki et al., 2001). Knowledge of the professional role of others is also a key competency (MacDonald et al., 2010). Within this, it is important that the team leader balances focus between the needs of the patient, organisation and team (Branowicki et al., 2001). Understanding of the organisation's mission, structure, economics, politics (Branowicki et al., 2001) and current development programmes (West et al., 2014) together with a sound historical perspective, are also important to facilitate understanding of context and ensure all perspectives are taken into account (Abreu, 1997).

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.
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.