Creating high collective team identity in multidisciplinary teams A qualitative study conducted in a healthcare organization

Creating high collective team identity in multidisciplinary teams A qualitative study conducted in a healthcare organization Master thesis Organization studies 2017 Dieke van den Broek ANR: 441327 Academic supervisor 1: Roel Rutten Second reader: Remco Mannak MTO evaluator: Verena Schmittmann Professional supervisor: Coen van der Linden

Abstract Many healthcare organizations work with multidisciplinary teams. It is proposed that a high collective team identity (CTI) is needed in order to achieve higher results (Fay et al., 2006). Communication, cohesiveness, participation, standardization of work procedures and interdependency are proposed to influence both performance in multidisciplinary teams as well as CTI (Lemieux-Charles & McGuire, 2006; Jackson, 1996). Research so far has investigated how each factor influences CTI in multidisciplinary teams, but not how they influence CTI in multidisciplinary teams simultaneously. This has led to the research question: How do communication, cohesiveness, participation, standardization of work procedures and interdependency influence the collective team identity in multidisciplinary teams and why? Data was collected via surveys and group interviews with members of seven multidisciplinary teams in a healthcare organization in The Netherlands. The results show three different ways on how the factors influence CTI. Interdependency is necessary for high CTI. Communication, cohesiveness and participation should minimal be moderate, and at least one of them has to be high. Standardized work procedures does not directly influence CTI, but accommodates the visibility of the four other factors in the team. Based on these results, recommendations for further research have been formulated. 2

Table of content Abstract 2 1. Introduction 5 1.1 Research problem 5 1.2 Scientific relevance 6 1.3 Practical relevance 6 2. Theoretical background 8 2.1 Expert diverse teams and CTI 8 2.2 Independent variables 8 2.2 Theoretical mechanism 11 3. Methodological framework 13 3.1 Research design 13 3.2 Research context 13 3.3 Sample strategy 13 3.4 Step 1: Survey 13 3.4.1 Data collection 13 3.4.1 Data analysis 14 3.5 Step 2: Group interviews 14 3.5.1 Data collection 14 3.5.1 Data analysis 15 3.6 Quality indicators 15 4. Results 17 4.1 Team 1 17 4.1.1 Survey Team 1 17 4.1.2 Group interview Team 1 17 4.1.3 Summary Team 1 19 4.2 Team 2 20 4.2.1 Survey Team 2 20 4.2.2 Group interview Team 2 20 4.2.3 Summary Team 2 22 4.3 Team 3 23 4.3.1 Survey Team 3 23 4.3.2 Group interview Team 3 23 4.3.3 Summary Team 3 24 4.4 Team 4 25 4.4.1 Survey Team 4 25 3

4.4.2 Summary Team 4 25 4.5 Team 5 26 4.5.1 Survey Team 5 26 4.5.2 Group interview Team 5 26 4.5.3 Summary Team 5 28 4.6 Team 6 29 4.6.1 Survey Team 6 29 4.6.2 Group interview Team 6 29 4.6.3 Summary Team 6 31 4.7 Team 7 32 4.7.1 Survey Team 7 32 4.7.2 Group interview Team 7 32 4.7.3 Summary Team 7 33 4.8 General results 34 5. Discussion 37 5.1 General discussion 37 5.2 Limitations, strengths and recommendations for future research 38 5.3 Practical relevance 39 5.4 Theoretical contribution 40 6. Conclusion 41 References 43 Appendix A Operationalization scheme 45 Appendix B Survey 48 Appendix C Tables responses per case and per function 51 Appendix D Overview results 52 Appendix E Results per case 53 Appendix F Interview protocol 56 4

1. Introduction 1.1 Research problem Nowadays, many healthcare organizations work with multidisciplinary teams. Multidisciplinary teams consist of employees with different expertise. For such teams higher performance and effectiveness have been reported (Körner, 2010), as well as better recovering results for patients (Yagura, Miyai, Suzuki & Yanagihara, 2005), compared to monodisciplinary teams. A pitfall for multidisciplinary teams is when each profession views itself as separated from the other professions. Professionals will preferably cooperate with people with the same profession instead of cooperating with people from their multidisciplinary team (Fay et al., 2006). According to social identity theory this is logical, because we tend to be attracted to people who are similar to us (Schneider & Northcraft, 1999). However, when professionals only identify themselves with professionals from the same profession, a (positive) collective team identity (CTI) cannot be created. If there is a positive CTI, the whole team can enjoy the benefit of a higher variety of knowledge, skills and ability and higher social network (Fay et al., 2006). Thus, for multidisciplinary teams to perform optimal there should be a positive CTI. Various factors have been proposed that influence CTI in a (multidisciplinary) team. Lemieux-Charles & McGuire (2006) identified several team level characteristics which influence team effectiveness, where CTI is part of. When compared to Jackson s (1996) categorization of team level characteristics which influences the processes and outcomes of multidisciplinary teams, several factors could be selected that are most important for CTI in a multidisciplinary team. The characteristics that both studies emphasized are most relevant for this research. These are communication, cohesiveness, participation, standardization of work procedures and interdependency. Communication refers to all forms of sharing of information within the team (Jackson, 1996). Communication between different professionals can be difficult because they use different ways of communication CTI (Ashforth, Harrison & Corley, 2008; McCallin, 2001). When communication is not clear between team members, this influences CTI negatively. Therefore it is important to investigate how communication can have a positive impact on CTI in a multidisciplinary team. Cohesiveness is the extent to which team members want to be part of the team (Wang, Chou & Jiang, 2005). The focus is on the interpersonal relationships among team members, which in turn has a positive impact on CTI (Van der Vegt & Bunderson, 2005). In multidisciplinary teams it is more difficult to be cohesive because there are fewer similarities between team members (Schneider & Northcraft, 1999). Therefore it is important to investigate how cohesiveness can be increased in order to increase CTI. Participation includes all forms of actions the members of a team take in order to influence the team outcome (Zhang & Begley, 2011). The more team members participate, the more activities are aligned and there is more clarity about norms and standards within the team (Alexander, Lichtenstein, Jinnett, Wells, Zazzali & Liu, 2005) which could positively affect CTI. It is unclear yet how participation in multidisciplinary teams influences CTI positively and therefore this factor is includes in this research. Standardization of work procedures describe how work should be performed in order to minimize differences between professionals and to enhance effectiveness (Gilson, Mathieu, Shalley & Ruddy, 2005). To what extend standardization of work procedures is necessary in multidisciplinary teams to perform optimal is unknown, and how it impacts CTI has not been researched (Gilson et al., 2005; Manser, 2009). In this research this relationship will be further investigated. 5

Interdependency refers to the degree in which a team should work together in order to achieve the common goal (Taplin et al., 2015). Research has shown that homogenous teams perform better because they agree more easily (Jackson, 1996). In this research, the focus will be on how interdependency between team members of a multidisciplinary team can be increased in order to increase CTI. It has been studied at different levels how each of these factors individually influence the CTI in (multidisciplinary) teams. However, no research has combined these factors to deepen the insight in why a factor influences CTI in a multidisciplinary team. It is possible that different factors can achieve positive CTI in multidisciplinary teams due to different mechanisms. This would mean that not all factors have to be present in order to have a high CTI in multidisciplinary teams. To deepen the knowledge about how a positive CTI can be obtained, it is also of importance to investigate why these factors influence CTI in multidisciplinary teams. This leads to the following research question: How do communication, cohesiveness, participation, standardization of work procedures and interdependency influence the collective team identity in multidisciplinary teams and why? 1.2 Scientific relevance This research sheds light into the black box of which factors determine the CTI in multidisciplinary teams and in what way they influence CTI. Previous research has focused on which factors influence the existence of CTI in (multidisciplinary) teams (Jackson, 1996; Lemieux-Charles & McGuire, 2006). These factors are defined, namely communication, cohesiveness, participation, standardization of work procedures and interdependency. However, how and why they influence CTI has not extensively been researched. New insights will be given by investigating the process mechanism on how these factors influence CTI in multidisciplinary teams. Furthermore, in this research their combined influence on CTI will be investigated. It is expected that not all factors necessarily have to be high in order to obtain high CTI. However, no research so far has examined this. While most research has focused on teams in general, the addition of a multidisciplinary team is interesting due to the high expert diversity, which is inherent to this type of team. It has been argued that it is more difficult to have a high CTI when a team is diverse (Jackson, 1996). Since no research yet has found conclusive answers on how CTI in a multidisciplinary team is established, this research contributes to this research gap. Further research can build upon this by investigating this in different situations or exploring the mechanisms which will be suggested here. 1.3 Practical relevance More organizations work with multidisciplinary teams (Tekleab, Karaca, Quigley & Tsang, 2016). Especially healthcare organizations are working with multidisciplinary teams to treat their patients (Mullins, Balderson, Sanders, Chaney & Whatley, 1997). It has been shown that when professionals in multidisciplinary teams work together, this increases their team performance and it helps the patient to recover better (Solansky, 2011; Yagura, Miyai, Suzuki & Yanagihara, 2005). If there is a positive CTI, team members have more incentive to cooperate and to share information (Luan, Rico, Xie & Zhang, 2016). Organizations, employees and patients will benefit when the multidisciplinary teams have a positive CTI. However, at this point it is unclear which factors, and how, influence CTI in multidisciplinary teams. There are multiple factors to change, and management and teams themselves 6

need more specific research in order to implement new ways of working in their daily routine. Therefore this research has a valuable contribution by giving more insight in how multidisciplinary teams can obtain a higher CTI. 7

2. Theoretical background 2.1 Expert diverse teams and CTI In many organizations expert diverse teams are needed nowadays (Tekleab, Karaca, Quigley & Tsang, 2016). These teams can, amongst others, be found in health care, where a combination of nurses, doctors and paramedics is needed in order to treat the patient. In literature, multiple terms are used to describe teams high in expert diversity, such as multidisciplinary teams, interdisciplinary teams and transdisciplinary teams (Mullins et al., 1997). For this paper, the term multidisciplinary teams will be used to indicate teams that are composed of employees with different professional expertise. These professions have to cooperate to deliver a specific service (Mitchell, Parker & Giles, 2011). The outcome of expert diverse teams can result in higher performance, such as more innovation, higher production and lower hospital days for the patient (Jackson, 1996; Mitchell, Parker & Giles, 2011). However, expert diverse teams can also have negative performance results due to conflict, lack of information sharing, and friction (Jackson, 1996; Mitchell, Parker & Giles, 2011). The foundation on these two different outcomes can be traced back to two theories (Tekleab, Karaca, Quigley & Tsang, 2016). The first theory, the informational diversity-cognitive resource perspective, states that diversity leads to a broader pool of knowledge and resources, and therefore enhances performance. The second theory, social identity theory, states that people tend to be drawn to other people who are similar to them (Schneider & Northcraft, 1999). This means that in a multidisciplinary team it is more difficult to ensure that people have the feeling they belong to the same team. Instead, they might tend to feel more attracted to people from their own profession in other teams. This could hamper the performance of the multidisciplinary team because the benefit of the diversity will not be used (Solansky, 2011). In multidisciplinary teams it is expected that the outcome of the reasoning from the informational diversity-cognitive resource perspective is visible. However, when people do not identify themselves with their team the benefits of a diverse team will not be used (Solansky, 2011). Identification is an ongoing process and identity is constantly shaped by the team. The identity of one person refers to the question Who am I? The identity of a group is the collective of the group (Ashforth, Harrison & Corley, 2008). In order to obtain high team results, a collective team identity (CTI) should be present. CTI refers to the emotional significance that members of a given group attach to their membership in that group (Van der Vegt & Bunderson, 2005, p.533). CTI ranges from positive to negative. So far, research has focused on the effect of CTI on performance. Several studies found a positive relation between CTI and team performance in expert diverse teams (Solansky, 2010; Van der Vegt & Bunderson, 2005; Mitchell, Parker & Giles, 2011). However, research investigating how a positive CTI can be obtained is missing and incomplete (Jackson, 1996). In this research, the focus will be on how and why positive CTI is obtained. 2.2 Independent variables Several factors have been proposed to enhance CTI in a (multidisciplinary) team. CTI is a team-level construct, and therefore influenced by other team-level characteristics. Jackson (1996) identified several types of diversity, and accordingly describes how these affect team behavior, individually as well as collectively. Diversity refers to the social composition of the team. Diversity influences short term problem solving, decision making, status hierarchies, participation, communication, cohesiveness and team performance. On the long term diversity influences stability and ability to learn and develop 8

over time. Jackson concludes that it depends on both complexity of the team and the environment which dynamics are at play. In order to achieve high performance, it is necessary to have some diversity in a team. However, when a team is diverse on multiple aspects, such as demographic as well as expertise, it is more difficult to achieve high performance. A more recent review by Lemieux-Charles & McGuire (2006) compared studies focused on team effectiveness, and used the Integrated team effectiveness model to identify variables which influence team effectiveness. Antecedents influencing team effectiveness are categorized in task design, team processes, team psychosocial trait and organizational context. Task design has three subcategories: task type, task features and team composition. Team composition refers to diversity, indicating that diversity can influence CTI. However, diversity or multidisciplinary teams were not a research context for these researches. These two reviews are complementary. Where Jackson (1996) takes multidisciplinary teams as the base for her review, Lemieux-Charles & McGuire (2006) focus on CTI as outcome. When the integrated team effectiveness model of Lemieux-Charles & McGuire (2006) is compared with the review of Jackson (1996), the following factors can be identified as important for the presence of a CTI in multidisciplinary teams; communication, cohesiveness, participation, standardization of work procedures and interdependency. These factors are chosen because to a certain extent they should be present in multidisciplinary teams. In this research, the focus lays on creating a deeper understanding of the importance of these factors on how and why they influence CTI. Communication Communication contains all forms of sharing of information (Jackson, 1996) and is a team process (Lemieux-Charles & McGuire, 2006). Communication can vary from low communication, were no information is shared within the team, to high communication where all information is shared within the team. Due to expert diversity it is more likely that people have difficulty communicating, both formal and informal (Jackson, 1996). The reason for this is that the use of different language or ways of communicating emphasizes the differences between people. Communication affects the understanding about each other's professions, impacts the feelings of belonging on the same team and the values given to the team (Ashforth, Harrison & Corley, 2008; McCallin, 2001). A study by Sheehan, Robertson & Ormond (2007) revealed that multidisciplinary teams with stricter role division had less informal communication and understanding of each other's work. Understanding every professional's capability, and sharing information regularly via (in) formal channels helps with the bonding of the team. This shows how communication can have an impact on CTI, both negative and positive. Cohesiveness Cohesiveness refers to the extent to which team member want to be part of the team (Wang, Chou & Jiang, 2005), and is important for team performance. The focus is on the interpersonal relationships among team members, whereas CTI focuses on the connection one has to the team in general (Van der Vegt & Bunderson, 2005). In cohesive groups the collective is valued high and team members have more reasons to stay in the team than to leave (West & Wallace, 1991). Aspects such as psychological safety and self-actualization play a role in this. Cohesive groups are easier formed when groups are more homogeneous. Social identity theory emphasizes this as well. When people in a team feel closer to each other because of similarities, it enhances uniformity (Ashforth, Harrison & Corley, 2008). And when people can identify themselves with other members of the team, it becomes easier to identify 9

themselves with the whole team (Wang, Chou & Jiang, 2005). This means that cohesiveness is more difficult to be present in multidisciplinary teams. Cohesiveness influences CTI in multiple ways. First of all it increases identification with other team members by focusing on similarities, and secondly it focuses on team achievements instead of on what the different professions achieve separately. Participation Team participation contains all forms of actions the members of a team take in order to influence the team outcome (Zhang & Begley, 2011). Participation ranges from high participation, meaning that everyone equally participates, to low participation, meaning that some participate more than others. The amount of cooperation, participation and collaboration between team members determines the level of participation within a team (Zhang & Begley, 2011). Participation goes further than being present at work, and refers to participation in decisions and activities which influence team outcomes. An example of this is being present at team meetings and giving your opinion on a certain matter. Research shows that higher participation leads to higher team performance (West et al., 2003). The more team members participate, the more activities are aligned and there is more clarity about norms and standards within the team (Alexander, Lichtenstein, Jinnett, Wells, Zazzali & Liu, 2005). In multidisciplinary teams, there is a strong division of tasks and responsibilities, which could hamper the participation of all team members because no one is involved with the tasks and responsibilities of other team members (Alexander et al., 2005). This could in turn affect CTI, because when everyone is focused on his own business the team as a collective can be forgotten. Standardized work procedures Standardized work procedures describe how work should be performed in order to minimize differences between professionals and to enhance effectiveness (Gilson, Mathieu, Shalley & Ruddy, 2005). The standardization of work procedures are mostly in the form of formalized programs and plans (Grote, Zala-Mezö & Grommes, 2003). A certain degree of standardization is needed, otherwise it would take a lot of time to decide on everything (Gilson et al., 2005). However when there is high standardization of work procedures, this could results in team members feeling that they have to coordinate and cooperate less (Manser, 2009). Next to this, different professions can have different protocols and procedures, which can lead to conflict when they are contradictory. The type of procedures and clarity about procedures can influence CTI in both a positive and negative way. Interdependency Interdependency refers to the degree in which a team should work together in order to achieve the common goal (Taplin et al., 2015). The three different types of interdependency are pooled, sequential and reciprocal interdependency. In pooled interdependency, everyone works separately to achieve the common goal. With sequential interdependency one team member needs to complete his or her task before the next team member can start working. In multidisciplinary teams there is reciprocal interdependence, meaning that the output from team member A influences the input from team member B, and vice versa. During the rehabilitation of a patient all team members interact with the patient and what happens in one session influences the capabilities of the patient in a different session (Taplin et al., 2015). For these tasks expert diversity is needed. However, different research shows that for achieving optimal results team members should be homogeneous on other characteristics such as demographics (Jackson, 1996). This is because it is easier to agree and commit to decisions made in the team when a vision is shared. High interdependency is achieved when everyone works according 10

to the same vision, and there is high willingness to cooperate. When there is high interdependency this should enhance CTI because of the need that everyone is depending on each other and working towards the same goal. However when people in the team differ too much, this could hinder a positive CTI due to conflict about work processes. 2.2 Theoretical mechanism It is expected that these five factors influence CTI in multidisciplinary teams. However, results on how they influence CTI are either contradictory or not available. Especially when the factors are combined, no research shows which combination of factors lead to a positive CTI in multidisciplinary teams (Lemieux-Charles & McGuire, 2006). It is expected that not all factors have to be high in order to achieve a positive CTI. They could complement or even replace each other and still high CTI can be obtained. Communication can hinder CTI when people do not understand each other because they use different types of communication or a different (professional) language (Jackson, 1996). It is expected when there is clear agreement on the way of communicating, this helps creating a positive CTI. Cohesiveness plays a role in this to the extent that when a team member wants to be part of a team, it will be more open to change behavior such as way of communication in order to fit into the team (Wang, Chou & Jiang, 2005). Next to this, research by Alexander et al. (2005) states that the more team members participate, or are able to expresses their view and being involved in decision making, the more activities are aligned and there is more clarity about norms and standards within the team. Communication is necessary to participate in the process, but only when someone participates the way of preferred communication becomes clear. The level of how much effort someone wants to put in the team, will decide how well this works. However, if someone tries to participate and shows their best intention, but sometimes uses wrong communication methods, this could be forgiven because his other actions make up for it. Standardized work processes play a different role in this, in the sense that they are mainly imposed from outside the team. Team members cannot change this by communication or participation within the team, but they can agree on standards with regard to how important it is to work according to the standardized work procedures. By communicating about acceptance of these standards, or showing willingness to work with them, it can change the atmosphere in a team which influences CTI. Next to this, interdependency is important for multidisciplinary teams (Taplin et al., 2015), but it may not always be visible in the team. Low interdependency could result in low cohesiveness or no communication between team members, which could result in a negative CTI (Jackson, 1996). However, when tasks are very well divided it might not be needed to have much communication or cohesiveness. People will still feel like a team because everyone does what they have to do, resulting in a good team outcome. This suggest that a positive CTI can be obtained in many way, and can be defined in many ways. However, no research so far provides insight in how communication, cohesiveness, participation, standardized work procedures and interdependency influence CTI and why. All factors are somehow present in multidisciplinary teams, but it can differ per team to what extent they are present and influence CTI (figure 1). Due to few insights in literature, no hypotheses can be made about expected relations between the factors and CTI. 11

Communication Cohesiveness Participation Collective team identity Standardized work procedures Interdependency Figure 1 Model of the effect of communication, cohesiveness, participation, standardized work procedures and interdependency on collective team identity 12

3. Methodological framework 3.1 Research design An in-depth multiple case study is conducted to deepen the understanding how and why the selected factors influence CTI in multidisciplinary teams. By studying different cases a more elaborate understanding has been created on what influences CTI in multidisciplinary teams. First a survey was distributed to gather data about the cases. Second, group interviews were conducted in order to gain insights in the underlying mechanisms of why certain factors lead to high or low CTI. The analysis is on team-level, but the unit of observation is the individual. 3.2 Research context This study has been conducted in a rehabilitation center for elderly in The Netherlands, because many multidisciplinary teams work in health care organizations (Tekleab, Karaca, Quigley & Tsang, 2016) and research has shown that better teamwork in multidisciplinary teams positively influence team outcomes such as patience recovery (Solansky, 2011; Yagura, Miyai, Suzuki & Yanagihara, 2005). In this rehabilitation center are 7 multidisciplinary teams with their own specific rehabilitation specialization, which ranges from neurological damage to orthopedics. In total 160 out of 322 employees work in one of the multidisciplinary teams. The amount of team members varies from 5 till 30, with an average of 23 per team. In appendix C an overview of how many nurses and paramedics are part of the team is given. Each team consist mainly of nurses, one geriatric specialist, one case manager and several paramedics. It differs per team and client group which paramedics and how many are involved. Each team has one or two floors with clients. The nurses, geriatric specialist and case manager perform their work on the floor, and have their office close to or on the floor. The paramedics have exercise rooms in a hall way on the ground floor. They only come to the floor when they have a consult in the room of the client. 3.3 Sample strategy All seven multidisciplinary teams took part in this study. All 160 employees who are working in one or multiple multidisciplinary teams, received a survey. To be able to generalize the results from individual responses to team level data, a response rate of at least 50% was preferred. For teams with a lower response rate, it has been checked if there was enough variety in the professions who responded to ensure a wide range of opinions. For the group interviews, 3 to 4 employees per team attended the interview. All functions were involved across all interviews and different professions per group interview were invited. This was to have a wide range of perspective and to mirror the diversity in multidisciplinary teams. 3.4 Step 1: Survey 3.4.1 Data collection Based on theory an operationalization scheme has been made (appendix A). For this survey, former validated items have been used and slightly adapted to fit with the organization. The survey has been distributed to receive information about the CTI within the team, as well as how high the team scores on every factor (appendix B). All questions are on a Likert scale, ranging from 1 to 7. The survey has 13

been tested by two employees to ensure that all questions were clear. Hereafter, the questionnaire was distributed via email. Every employee working in a multidisciplinary team received a questionnaire, and a reminder was sent to the employees after 1, 2 and 4 weeks. A response rate of at least 50% per team is preferred, in order to generate a valid team-based score. To ensure that a 50% response rate was achieved, also attention to the survey was given in team meetings. 3.4.1 Data analysis Before the data was analyzed, the data was checked. First it was checked if all surveys were complete and the questions were mirrored. In appendix C, an overview of the number of received responses per case and per function is given. The response rate is 48,13%. There is one team with 5 employees, other teams are larger with an average of 23 employees. Paramedics work across multiple teams, and therefore the exact amount of employees per team cannot be given. Otherwise people would be counted double or triple. Paramedics were free to choose for which team they filled in the survey. The lowest response rate is 40,82% for Team 2, which is acceptable because there is enough variation in professions who filled in the survey. Team 3 has a high response rate but only has 5 employees. This needs to be treated with caution because it is easy to obtain a very high response rate but not have a representative state of the truth. After analyzing data from the survey and the interviews it can be verified whether these response rates are enough to draw conclusions. Furthermore there are four functions (nurses, personal healthcare assistants, homecare assistants and residential counselor) which have a response rate below 50%. The nurse team has most members within the multidisciplinary team, and when they have a low response rate this can have consequences for analyzing the data. The differences in views between members of the nurse team and other disciplines will be further explored in the interviews. In appendix D the average scores, minimum and maximum score per factor for each team are presented. Appendix E shows an overview of the different scores per team member in order to give insight in the variation among team members. These results will be discussed in order to build a foundation on which the interviews will be based. The results show that most answers are between 4 and 7, and average scores are close to each other. This indicates high agreement and few variance. However, when looked at the difference between the min and max score it shows that team members not always agree highly on all factors. Agreement is low when there is more than 2 points difference between the min and max score on the same factor. 3.5 Step 2: Group interviews 3.5.1 Data collection To elaborate on the results found and to understand why certain interactions between the independent variables can lead to a specific outcome of CTI, 6 group interviews have been held. Due to organizational turbulence it was not possible to conduct a group interview with Team 4. Group interviews are conducted because the interaction between team is visible which can provide valuable information about the factors as well. Each group interview was conducted with a different team, and consisted of 3 or 4 team members. With the amount of 3 to 4 people there is a balance between different views and enough time to express everyone s view. The employees were selected based on their profession, in such a way that per interview different professions and across all groups all professions were involved. The reason for this is that different professions can complement and/or contradict each other s experience on how the team functions together. In table 1 an overview of how 14

many times each profession was involved is given. Homecare assistant and residential counselor were not involved because only 2 teams have them employed. Each group interview took 1,5 hour, of which one hour was used for the actual interview. The rest of the time was used for explaining the purpose of the interview and for wrapping up the interview. The interviews were semi-structured, and starting point was to let the interviewees have a conversation together, guided by the questions asked by the interviewer. In appendix F the interview protocol can be found. This interview protocol is based on information received via the survey. Function Number of times involved in interviews Geriatric specialist 2 Case manager 2 Psychologist 1 Speech therapist 3 Dietician 2 Physiotherapist 1 Occupational therapist 1 Nursing specialist 2 Nurse 5 Personal healthcare assistant 1 Apprentice nurse 1 Homecare assistant 0 Residential counselor 0 Table 1 Overview presence of functions across all group interviews 3.5.1 Data analysis Each interview was recorded, transcribed and coded. The coding of the interview worked as follows. The interview was read, and each time the subject (or factor) changed a new code was added. Sometimes larger pieces of text were selected to give the same code. In this way, the group dynamics would not be lost in too detailed information. When a piece of text was selected, it would be connected to one of the factors. Then a code would be given which would describe the relation between the piece of text and the factor. For example, pieces of text which referred to communication could receive codes as forms of communication, negative/positive communication, formal/informal communication or mono/ multidisciplinary communication. Pieces of text could have multiple codes, as long as the text had one clear point it could be handled together. After coding of the interviews, the results were written down per team. Only information which has a connection with CTI is discussed in the result section. While writing the results section, codes could be slightly changed to fit the situation and to obtain similar coding across interviews. After all individual interviews were discussed, similarities and differences between interviews were searched for and written down. In this way, much in depth information was gained per case, and across all cases information could be compared. 3.6 Quality indicators The validity of this research is assured by using questions from already confirmed questionnaires and by using an operationalization scheme. Next to this, by conducting group interviews the results between the teams can be put into perspective, as well as the information retrieved from the group 15

interview and the survey can be compared to see any inconsistencies. The reliability is assured by pretesting the questionnaire, and by having 6 group interviews consisting of different disciplines. In this way, multiple perspectives are included and enhances the quality of the conclusions drawn from this data. In addition, the use of coding the interviews ensures that it is clear why certain conclusions can be drawn from the group interviews. 16

4. Results In this section the results are presented per team and teams will be compared for general results. Per team first the survey is discussed, than the group interview and lastly a summary is given were the results from the survey and group interview are combined and conclusions are drawn. In this way a deeper understanding of the case can be created, because the information gained from both information sources is not forgotten or confused with other cases. After all cases are discussed, the overall results will be discussed. Data retrieved from the survey are presented in appendix C, D and E. 4.1 Team 1 4.1.1 Survey Team 1 Sixteen employees of Team 1 filled in the survey. This is 68,09% of the team members and a mix of all professions. Respondents vary in their individual averages, which indicates that they are not inclined to give only positive or negative scores (appendix E). On all factors there is wide variation in scores, indicating few agreement between respondents. When a closer look is taken, it shows that two factors have one respondent with an extreme score. For participation there is one low score (3,5 points), otherwise spreading would be below 3. For standardized work procedures scores are low, with exception of one high score. Communication, participation and standardized work procedures fluctuate around the CTI score, indicating no clear relationship. Two respondents score higher on cohesiveness than on CTI. This indicates that in general cohesiveness is less visible in the team than CTI. Lastly, interdependency scores resemblance the CTI scores most, and therefor give the most realistic picture of the height of CTI. This indicates a strong relationship between interdependency and CTI. 4.1.2 Group interview Team 1 In this interview four team members participated. What is different in this team compared to other teams, is the presence of the multidisciplinary working place. Here, nursing and paramedic students conduct their internship for half a year. Together with the professionals they form a multidisciplinary team. These students are expected to take over some clients near the end of their internship. CTI The first thing mentioned when the interviewees were asked about Team 1 were the multidisciplinary consultations. In these meetings, representatives of each profession is present to discuss the clients. It was positive that all disciplines were together, but the drawback of this is that the complete multidisciplinary team was never together. Furthermore Team 1 was described as a diverse team with a good and open atmosphere where everyone is equal. Due to change of team members, expectations and anticipations had to be built again, but due an effective way of working this did not hinder the team processes. Communication The team has multiple forms of communication, namely oral, mail, phone and online client dossier. Oral communication and online client dossier are both positive. Oral communication takes place during formal meetings, such as the multidisciplinary consultations, and on informal occasion. Oral communication is more detailed, and online client dossier is more efficient. Communication via phone was neither very positive nor negative. Some disciplines have only 1 phone with 3 people which makes it ineffective to reach someone. Communication via mail is negative because it is very inefficient and 17

it is not desirable to share client information via mail. Information exchange between the nurses and other disciplines is negative. This has several reasons. First, sharing information within the nurse team is difficult because there are many nurses, they have small contracts and they work different shifts. Especially process related information is not always communicated to all nurses. Secondly, oral communication is difficult because nurses do not always have time when paramedics come onto the floor due to unplanned client care. Lastly, nurses and paramedics have separate breaks. Due to physical distance there is less non-work related conversation between nurses and other disciplines. In Team 1 communication is experienced positive, especially communication with regard to client related information. It would be beneficial for the CTI when there is more communication between nurses and paramedics. Cohesiveness Altogether, Team 1 is described as a cohesive group but cohesiveness is experienced differently by the paramedics. One paramedic works most hours for Team 1 and feels very involved with the team. She guides students from the multidisciplinary working place, which enhances her involvement and cohesiveness with this team. Another paramedic feels evenly involved in Team 1 and other teams and does not feel cohesive with all team members. She sometimes finds it difficult to know who belongs to which team because she mainly sees representatives at the multidisciplinary consultations. The geriatric feels involved, but due to circumstances he was less visible within the team because he had to support another team as well. This negatively affected cohesiveness. Cohesiveness with the students of the multidisciplinary working place depends on the student. They are not necessarily seen as part of the team, but in general cohesiveness with them grows during the semester. It is appreciated by everyone when extra activities are organized, such as having a drink together or attending a sports event. One interviewee would appreciate more informal moments with nurses. So, there is room for improving cohesiveness between all members. When cohesiveness between all members increase, this increases CTI because there is a clearer picture of the team as a whole. Participation Participation depends on intrinsic motivation, priorities someone has and flexibility of a person. Especially multidisciplinary client related participation is high. People bring new initiatives to the table and are aware of clients goals. One paramedic immediately loses feeling with the clients and team when she does not attend meetings. It is therefore important to stay involved all the time. Policy making takes a long time due to organizational causes. Also the view of Team 1 is sometimes different than the view of the rest of the organization. This enhances team spirit within Team 1, because they feel they are together against the rest of the organization. Overall, participation of team members is high. Everyone contributes to ensure goals are achieved. This is valued by all team members. This high participation results in a good and positive team spirit, which ensures a more positive view on the team members and teams as a whole. Therefore, participation seems to explain the already positive CTI. Standardized work procedures The structured way of working is important for effective working and new team members easily get involved. Most work procedures are not (knowingly) documented. This was not negative because the structured way of working gave a clear guideline. Only one interviewee experienced the lack of monodisciplinary guidelines documentation negative. It can be concluded that standardized work procedures are important for a positive CTI because people know what to expect from the team and can easily join team processes. 18

Interdependency In Team 1 high interdependency is a necessary condition for achieving team goals. Not only multiple disciplines have to be involved, but also specific people of that discipline are needed in order to succeed. For example, physiotherapist are assigned to several clients. They do not always attend multidisciplinary consultations of their own client. This hinders the effectiveness of the meeting because the attending physiotherapist does not have the latest information. Some tasks are interchangeable between individuals, such as tasks for the general practitioner in training and geriatric specialist. Team members have to trust that these persons work together and communicate closely. Concluding, interdependency is important. The team is not only dependent on disciplines but also on persons to achieve team goals. Trust between team members is needed for high interdependency. 4.1.3 Summary Team 1 The results from Team 1 are summarized in table 2. CTI has received a high score in the survey, and is experienced positive by the interviewees as well. Team 1 is described as a diverse team with a good and open atmosphere where everyone is equal. A negative point is that all team members are never together. This impacts CTI, because it is unclear who is exactly in the team. Case CTI Communication Cohesiveness Participation Standardized work procedures Interdependency Team 1 Average 5,598 5,286 5,009 5,195 4,698 5,771 + Diverse team, good and open atmosphere, everyone is equal - Whole team never together Table 2 Overview results Team 1 Oral communication, electronic client dossier Communication between nurses and other disciplines Organizing extra activities, many feel part of the team People work for multiple teams, few informal contact between disciplines, not clear who belongs to the team High participation in direct client care More clarity process related issues High standardized way of working +/- Work processes not documented Overall High Moderate to high Moderate to high High High High Everyone is highly visible, dependent on both specific disciplines and people Communication scored high in the survey, but no clear relation between communication and CTI was visible. In the interview it was said that communication in general is positive, especially oral communication and communication via online client dossier. Improvements could be made with regard to informal communication between nurses and other disciplines. When more oral communication is possible, this could enhance CTI because there is a feeling that matters can be discussed and tackled together. Cohesiveness scored low compared to the other factors, and also in the interview it becomes clear that there is no strong cohesiveness. First of all this is due to the fact that paramedics work in multiple teams, and also have obligations, ties and connections there. Secondly, there is little informal contact between disciplines which hinders a strong bond between team members. By arranging more informal contact moments such as having breaks together, cohesiveness would be positively influenced, which in turn influences CTI. Participation scored high, except for one low score. Ambiguity about process related issues could explain this low score, as well as the feeling that nurses not involved. What is interesting, is while management and other parts of the organization disagree with the working view of Team 1, team 19

members are convinced of this way of working. This makes their CTI stronger. Concluding, participation seems to explain why CTI is already high. The low score on standardized work procedures is explained by the fact that documentation of work procedures is not available. It is important that work procedures are being followed, and everyone is doing this. This explains why both participation and CTI are high. Interdependency is high and related to CTI in the survey as well as positively explained in the group interview. Interdependency between both persons and disciplines is needed. Results from both the interview and survey point out that high interdependency is a necessary condition for CTI. It can be concluded that CTI is high, but could be improved when there is a clearer picture of who is part of the team. The factors communication and cohesiveness influence this. Next to this, participation influences CTI in a positive way, because of a strong view on how processes should be done and everyone is participating in these processes. The standardized way of working results in high participation and positive CTI. Documentation of standardized work procedures could play a role in a more positive CTI, however this is not explicitly mentioned nor missed. Lastly, for a positive CTI all team members have to feel the need to work interdependently. 4.2 Team 2 4.2.1 Survey Team 2 Ten team members from Team 2 filled in the survey. Their responses can be seen in Appendix E. The respondents are a diverse mix of professions, therefore a response rate of 40,82% is accepted. Team 2 has the lowest CTI score of all teams. CTI has one low score from a respondent who scores low on other factors as well. Communication scores are close to CTI scores. This indicates a strong relation between both. Cohesiveness, participation and standardized work procedures have wide spreading of scores, which means that there is little agreement on these factors. When cohesiveness is low, CTI is low and when cohesiveness increases, CTI increases. This suggest that cohesiveness positively influences CTI. Next to this, it is interesting to point out that the three respondents who score highest on CTI and the two who score lowest for CTI, score all low for standardized work procedures. This indicates that there is no straightforward link between standardized work procedures and CTI. Respondents score highest on interdependency with an average score of 5,560. What stands out is the high score of respondent 10, who scores low on all other factors. This indicates that interdependency is very important, but it does not contribute to a high CTI alone. Interdependency scores fluctuate around the average CTI score, indicating that it could mean that interdependency determines CTI. 4.2.2 Group interview Team 2 In this interview four team members participated. CTI The interviewees describe Team 2 as a team were every discipline and team member is needed to achieve team goals. However, some nurses do not always feel part of the team, and other disciplines feel that not all nurses positively contribute to team goals. This leads to a negative atmosphere within the multidisciplinary team, and a negative CTI. Communication Different forms of communication take place. The daily round, where in 15 minutes all clients are discussed, is valued most. Nurses often do not attend these meetings due to different reasons. This 20