In 2015, J. Philos. Sport
published an article entitled “The Nature and Meaning of Teamwork” written by Dr. Paul Gaffney [1
]. This article provides a comprehensive review of the teamwork dynamics in sports. Along with Gaffney’s article, the Special Issue of the Journal also included responses by other scholars in the form of commentary articles to Gaffney’s article [2
]. Gaffney then wrote a response to the commentary articles [9
Gaffney recognized the “interpersonal” nature of teamwork as “complex, encompassing many varieties and many dimensions” defining it as “the commitment of individual players to one another and to a common purpose in the context of a shared athletic enterprise” [1
]. He states the when the individual players join their teammates and “accept the terms of something like a social contract; joining their purposes together in pursuit of a common goal, pledging to be ‘equal’ in a moral sense, although with non-identical roles” [1
Cruess and Cruess, when discussing professionalism among health care practitioners, also speak of a “social contract” [10
]. This refers to the mutual obligation and expectations that health professionals have with society, which includes their patients, governmental entities and the population overall. A health provider fulfills the societal roles of the “professional” and the “healer”, which are addressed separately in the professional preparation of health care practitioners, but are evaluated together by society [10
]. A number of authors writing in healthcare have discussed the role that interprofessional education has on teaching professionalism among health providers [11
]. These authors have argued that the traditional notion of professionalism as a singular trait fails to account for the multiple roles a person performs. Thus, it has been recommended that professionalism is better developed in an interprofessional setting as compared to a uniprofessional setting [11
Gaffney also discusses the “extrapersonal” (macro) elements of teamwork and the influence of team structure on the team dynamics and success of the team. These team members consider this “leap of faith an investment strategy according to which individuals forego immediate satisfactions” to gain the greater satisfaction of success in a team effort [1
]. Boxill refers to this as a “social union”,
“We gain respect through our interdependence with each other in a social union, where we recognize we must reciprocate and complement one another, by recognizing differences and how they are essential to a social union, a well-played game, a well-run office, corporation, etc., all displaying teamwork. Athletic teams have coaches who must recognize the roles they are in to make the best decisions. So even if the goal is to give the team the very best chance to win, it is unclear which person you select to join your team, the person you believe is the best athlete or the player who you believe will complement others”.
Teamwork may seem like a new trend in health care, but interprofessional and collaborative models have been emerging over the last 100 years [15
]. Early mentions of these models in 19th century where, in the Boer and Crimean wars, “medicine (and nursing through the influence of (Florence) Nightingale) employed the tactics of their military colleagues, including a chain of command, clear roles and hierarchy of decision making. This approach to organizing care was subsequently transported back to civilian life” [16
]. In 1910, Dr. William J. Mayo stated: “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary” [17
]. The World Health Organization provides a definition: “[teamwork] in health-care occurs when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, careers and communities to deliver the highest quality of care across settings” [18
Effective interprofessional teamwork and collaboration involves the following: (1) optimizes health-services; (2) strengthens health systems; and (3) improves health outcomes [18
]. Research evidence has shown that interprofessional practice can improve: access to and coordination of health-services; appropriate use of specialist clinical resources; health outcomes for people with chronic diseases and; patient care and safety. It can also decrease total patient complications; length of hospital stays; tension and conflict among caregivers; staff turnover; hospital admissions; clinical error rates; and mortality rates [18
Interprofessional Education (IPE) initiatives have been developed to prepare health professionals to be collaborative-ready to work in teams when they enter the workforce [18
]. In turn, many health professions’ accreditation organizations have updated their standards to include IPE [23
]. The National Athletic Trainers’ Association Executive Committee for Education, for example, included IPE as a recommendation its “Future Directions of Athletic Training Education” document in 2012 [24
], also advocating for IPE in a white paper: “Interprofessional Education and Practice in Athletic Training” in 2015 [25
In the effort to provide a foundation for IPE, groups have convened to operationalize collaborative practice using competency-based frameworks. The most prominent of these being the “Core Competencies for Interprofessional Collaborative Practice” introduced by the Interprofessional Education Collaborative (IPEC) in 2010 and revised in 2016 [26
]. These competency domains are:
Competency 1: Work with individuals of other professions to maintain a climate of mutual respect and shared values (Values/Ethics for Interprofessional Practice).
Competency 2: Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of populations (Roles/Responsibilities).
Competency 3: Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease (Interprofessional Communication).
Competency 4: Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable (Teams and Teamwork).
There are, however, challenges in translating these educational competencies to health care. First, building interprofessional teams with individuals who work and have been trained in a uniprofessional context makes full adoption of IPCP problematic. Second, translational research in healthcare that shows the connection between IPE and patient outcomes lags behind the progress made in the implementation of IPE and IPCP [15
]. In addition, there are not yet robust ways to evaluate competency frameworks, which often focus more on individual behaviors and skills or attempt to measure complex tasks with multiple attributes in a single competency/outcome statement [27
Recent research is beginning to examine collaboration in sports medicine, and is revealing that providing health care in a sporting context can pose additional challenges. In a scoping review of the literature, key issues were identified which have had an effect on collaboration in sports medicine [28
]. The following six issues were identified. First, professionalization processes were found to have altered, and in many cases compromised, the influence of sports medicine practitioners, who are often met with more resistance than they would be if they remained casual team members. Second, professional dominance was found to create disparities in power and status between different professional groups (i.e. coaches vs. physicians). Third, status imbalances between sports medicine practitioners created difficulties and friction which restricted their ability to collaborate. Fourth, interprofessional negotiation was found to provide a key mechanism for sports medicine practitioners to try to navigate around tensions related to power/status imbalances. Fifth, ethical behaviors linked to the confidentiality of the patient information in traditional healthcare was found to be more absent in an athletic context as a range of interested parties were expected to be kept fully informed about the athletes’ wellbeing. Finally, issues linked to compromise/competition revealed that sports medicine practitioners needed to balance the desire for performance over care which may mean an athlete misses a sports event; alongside this, there was a distinct competition between sports medicine practitioners which often excluded collaborative input.
In this paper, we present the results of a study that brought together a group of experts in collaborative health care to discuss how teamwork principles from sport could be applied to healthcare and sports medicine.
lists the frequency of codes with the first two questions. In Question 1, which focuses on the positive aspects of teamwork in sports and healthcare, more excerpts were coded with the IPEC domains of Teams/Teamwork (n
= 18) and Roles/Responsibilities (n
= 16) than in Question 2. The IPEC domain of Values/Ethics (n
= 20) was coded more frequently in Question 2, which focuses on the barriers to teamwork in sports and healthcare. Few excerpts were coded with Interprofessional Communication on both questions. The majority of the Question 1 excerpts were coded with an Extrapersonal (n
= 32) locus and the majority of the Question 2 excerpts were coded with an Interpersonal (n
= 25) locus.
details the interaction between the IPEC and locus coding. Code co-occurrence analysis was performed to assess interaction between the IPEC domain and locus coding. Teams/Teamwork (n
= 23, 79.31%) and Roles/Responsibilities (n
= 17, 56.67%) were primarily coded with an Extrapersonal locus. Despite a small number (n
= 5), Interprofessional Communication had primarily an Interpersonal locus (n
= 4, 80.00%). The remaining IPEC domain code, Values/Ethics, was nearly equal between the loci.
provides representative quotes on Question 1 for each of the IPEC domains along with the Extrapersonal and Intrapersonal loci. The excerpts highlight the structural components of athletics that are not explicitly addressed many times in healthcare. Many of these are benefits involve defined roles on athletic teams. These roles include a clearly defined leader, who is often not expected to be one of the participants in the activity. Another stated benefit involves the physical space and time allocated for practice and team building. Communication and a mutual understanding of goals, especially when defining success, were identified by the participants in their conversations.
provides representative quotes on Question 2 for each of the IPEC domains along with the Extrapersonal and Intrapersonal loci. The excerpts in Table 5
highlight the challenges that occur with teamwork in both athletics and healthcare. The majority of these barriers involve and interpersonal locus and the IPEC domains of Communication and Values/Ethics for interprofessional practice. Some of the comments made by the participants also referred to commitment and trust between members of team.
The table conversations on Question 3 varied in content and theme. Some of the participants stated they were unsure how to answer based on their understanding of sports medicine and how healthcare is provided in that context. Many of the participants mentioned they had limited knowledge of athletic trainers and related professionals such as athletic therapists, sports therapists and kinesiologists.
Several of the participants had a better sense of the role of athletic trainers in IPCP. One participant talked about the importance of IPE and recognizing common skill sets in the professional preparation curricula:
“My son is a freshman in athletic training, and I run the simulation center at (a university in the United States), and we have athletic training. So I do simulation with those students. But I’m a nurse and I go in and I teach some of their (nursing) courses, like around wound management, because that’s a common skill. But I also work with physical therapists and I work with occupational therapists, so teaching all those common skills to all of those groups in a way that when I talk about wound care they all go oh, it means the same thing, and we’re all going to look at the same thing. Okay, it’s not special just because I have different credentials after my name. So maybe it’s more about do our skill sets, they overlap, they do. I usually identify as common knowledge or shared knowledge, things that we all know together, but maybe it’s less important about the credential, but more important about do our skill sets cover the patient care needs…”
Another participant talked about the importance of recognizing roles and different viewpoints in collaborative healthcare:
“I think part of the collaboration can improve it by having the sport medicine people and athletic therapists, kinesiologists in our case, working together with the nurse practitioners, or working with OT/PT. I know most of our clinics in Canada, will be a PT clinic, but they’ll also have athletic therapy and PT together in a clinic, and so the athletic therapy often does a more immediate, they’re used to the crisis or the intervention on the field where PT are more long term, like stroke rehab and that kind of thing. So I think what you mentioned is really important in that there’s a real benefit, I think there’s an important piece that athletic therapy and kinesiology and just movement professionals bring to the healthcare table that’s actually been missing sometimes in the past.“
Another participant related the importance of including a wide scope of stakeholders on the interprofessional team:
“I do administer an exercise science and athletic training program in the United States, and we, in trying to promote that interprofessional collaborative practice competencies have had to approach this a little differently than our nursing colleagues or our medicine colleagues, because the people we’re collaborating with are not necessarily members of the acute healthcare team, so as you said, it’s helping our students and our clinicians as they’re doing this role, collaborate with teachers and parents and psychologists, you know, sports or whatever, principals or school administration, coaches, I’m just trying to think of the team that kind of surrounds an athlete, at least at the high school and collegiate level, which is where most of our students do their field or practice work. So we’ve spent a lot of time kind of re-conceptualizing who are the different members of the team and what are their roles and responsibilities and how do we communicate and work with them, what are their usual patterns of being...”
This study provided valuable insight, provided by participants with a high level of interest and experience in IPE and IPCP, into issues that health care providers and organizations can learn from the study of athletic organizations. The use of World Café technique generated a unique method of tapping into the shared expertise that exists at a large international conference. Additionally, using the IPEC competency domains and Gaffney’s comparisons of extrapersonal (macro) and interpersonal (micro) aspects of teamwork in athletics in the coding of the excerpts help illuminate the links in collaborative practice(s) between sports and healthcare.
As presented above, a key finding from this study was that teamwork and collaboration principles from organized athletics can have an influence on interprofessional healthcare practice, and, similarly, healthcare principles can be applied to athletics. Study participants recognized that positive aspects of teamwork in sport that can translate to improvement of care include clarity of purpose/goal, well-defined roles, communication and opportunities for practice and team development. These positive aspects are largely extrapersonal (macro elements) and this may be due to the structure of sport. Many sport organizations have rules and established hierarchies based around teamwork. In many health systems, IPCP developed organically among champions in certain professions and organizations who advocated for a wider adoption of these practices. Additional macro structures such as laws, funding structures and professional jurisdictions can also influence the nature of practice in healthcare.
Participants in the study found that the barriers to collaboration had a higher interpersonal locus. This is understandable because structures are easier to modify than the “hearts and minds” (micro elements) of the persons that contribute to organizational and system culture. They identified interprofessional communication, understanding of role and level of value/commitment/purpose of the stakeholders; in either the athletic or healthcare context. The descriptor “social contract” was also mentioned by Gaffney in sport and Cruess and Cruess in healthcare where team members commit to their role pursuing the common good [1
]. However, an interprofessional team can be weakened through lack of communication and incongruence of values and ethics toward IPCP and teamwork.
A number of the results presented above support the wider literature related to interprofessional collaboration in sports medicine [28
]. The overriding team ethos, which competitive and elite sport engenders, broadly integrates each member of the extended athletic family. There is also evidence to suggest that sports medicine providers can benefit from adopting interprofessional behaviors from conventional healthcare contexts [28
]. To fully benefit from the adoption of an athletic teamwork model to encourage collaboration in healthcare; in depth insight into the tensions which sporting networks create; and how professionals respond and adapt to these; will allow a more well-rounded application. Difficulties can arise when applying knowledge from one domain (athletes) to another (healthcare) when there is a lack of understanding of the different contextual factors involved. Therefore, issues such as professionalization, professional dominance, status imbalances, interprofessional negotiation, confidentiality, and compromise and competition [28
] need to be paid close attention to when engaging in such translational work.
This study has a number of limitations: (1) the pool of subjects was limited by those who volunteered to participate while attending an international conference; (2) the lack of tables at the study location did not allow for graphic representations on the “tablecloths”; (3) there were user-related technical challenges with the audio recorders in some of the groups rendering those conversations unusable; (4) athletic trainers were not represented among the participants; and (5) the participants in the study may have had limited background in sport. However, despite these limitations the ATBH conference provided an outstanding opportunity to access an international group of health professionals with interest and expertise in interprofessional collaborative practice. Moving forward, in future studies of this type, it would be important to work with the conference organizers to obtain space that includes tables and provide monitors at the tables to give technical assistance to the participants.