Factors Related to Interprofessional Collaboration and Teamwork Climate in the Family Health Strategy

Background: Working with an interprofessional focus is increasingly necessary, in view of the growing complexity of the population's health needs. This study aims to assess interprofessional collaboration and the teamwork climate in primary health care and determine whether there is a relationship between these two variables. In addition, the relationship of these two measures with the participants' sociodemographic variables was also analyzed. Methods: The AITCS-II instrument was used to measure interprofessional collaboration, while to diagnose teamwork climate, the ECTE instrument was used, a version adapted to the SUS context of the Teamwork Climate Inventory instrument. These two instruments were applied online together with a questionnaire for the sociodemographic characterization of the 544 participants, who belonged to 97 Family Health Strategy teams in a Brazilian municipality. Results: The study showed a strong correlation between interprofessional collaboration and teamwork climate. The studied sample had an unsatisfactory overall score regarding interprofessional collaboration. In addition, there was no relationship between teamwork climate or interprofessional collaboration and the participants' sociodemographic data; including the time of training and the presence or absence of postgraduate studies in public health or family health in the curriculum. Conclusions: The study corroborates the literature, by indicating a correlation between teamwork and interprofessional collaboration, pointing to ECTE as another way to evaluate interprofessional work and the health work process. As for the sociodemographic variables, the results raise an alert towards the strengthening of interprofessional education actions, both during the training of new professionals and in the work process of professionals who are already working.


Background
Professionals from different centers of knowledge, working from an interprofessional perspective, increase the quality of health services provided to the population. Thus, the skills of team members and the sharing and management of cases optimize health practices and productivity in the work environment, with a consequent improvement in results and in the relationship with patient safety 1 .
The reorganization of the work process at the level of Primary Health Care (PHC) was based on teamwork, with the aim of offering the care that users need. In this sense, the medical-centered health care has been replaced by quali ed multiprofessional care, which consists of different types of knowledge, capable of offering a broad scope of interventions to meet the population's health needs 2 .
Teamwork can be de ned as the joint work of two or more professionals to achieve a common goal. Behavioral aspects such as coordination, communication, accountability and sharing of ideas are included in this work process 3 .
In this context, interprofessional collaboration can be de ned as the partnership between a team of health professionals and their patients in a participatory, collaborative and coordinated approach to achieve shared decision-making regarding health care 4 . This can occur within a small team, between teams from the same service, or in the networking involving users and the community 5 .
There is evidence associating better teamwork climate values with better results in health care quality 6-10 and greater user satisfaction 8,11 in addition to providing strategic subsidies to support the development of collaboration within and between PHC teams 12 . In view of the importance of the theme for Primary Health Care and the scarcity of studies based on the Brazilian reality, the aim of this study was to analyze associated sociodemographic factors, interprofessional collaboration and the working climate in Family Health Strategy teams.

Study design and sample
This is an observational, cross-sectional and analytical study, carried out in Campo Grande, capital of the state of Mato Grosso do Sul (Brazil), from 2019 to 2020.
When de ning the sample, the municipality had 146 Family Health Strategy (FHS) teams. However, only 125 of these teams were complete according to the Ministry of Health de nition of a minimum team, which recommends that the team should consist of a doctor, a nurse and a nursing assistant or technician 13 , which is the inclusion criterion for sample de nition; in addition to the aforementioned professional categories, when available, dental surgeons and dental assistants or technicians were also invited to participate in the study, as Page 3/12 recommended by Agreli, Peduzzi and Bailey (2017) 12 . In view of the singularity of the studied municipality, where most of the FHS units have professional social workers and pharmacists, these were also included in the sample.
For the sample calculation, a 95% con dence interval and a 0.5% margin of error were taken into account, establishing a sample of 97 health teams (N = 97). The participating teams were randomly strati ed, respecting the geographic distribution and representativeness of each of the 7 health districts in this municipality (Anhanduizinho, Prosa, Segredo, Lagoa, Bandeira, Centro and Imbirussu), aiming at portraying a scenario as close as possible to reality.
To assess the team's participation, the criterion of a response rate of at least 40% was adopted in relation to the total number of professionals of the corresponding team. This strategy was also adopted by the authors of the team climate instrument 14 .

Data collection and Variables
Data collection was performed online using the Google Forms® platform. First, contact was made, via email and telephone, with the administrative managers of each participating health unit, to present the study proposal and request the submission of this information, along with the link to the online form, for the professional members of the selected teams. The participants' doubts related to the study were resolved via telephone contact and e-mail.

Sociodemographic characteristics
For the characterization of health professionals, the following information was collected: age, gender, education, specialization or continuing education course in Primary Health Care, time working in the team and time working in the institution.

AITCS-II
To measure interprofessional collaboration, the instrument ASSESSMENT OF INTERPROFESSIONAL TEAM COLLABORATION SCALE-II (AITCS-II) 15 was used, after being translated, adapted and validated in Brazil by Bispo and Rossitt (2018) 16 .

Teamwork Climate
To assess teamwork climate, the Team Work Climate Scale (ECTE) instrument 17 , an adapted version, translated and validated into Portuguese from the Team Climate Inventory (TCI), was applied. The instrument consists of four factors: participation (frequency of interaction between team members, and how much they share ideas and information), support for new ideas (encouragement and practical support for new ideas), team objectives (information about the clarity and sharing of team objectives), task orientation (team commitment to the achievement of high standards of quality in the offered service) 14 .
Two of these factors use a Likert scale ranging from 1 to 5: participation (12 items) and support for new ideas (8 items). The other two factors use a Likert scale ranging from 1 to 7: team objectives (11 items) and task orientation (7 items).

Data analysis
After data collection, in order to assess teamwork climate and interprofessional collaboration, the total score was calculated using the four factors of ECTE and on the three factors of AITCS-II for each of the interviewees and then the averages of these scores were calculated per team. Subsequently to the calculation of the respective averages of each team, the total sample average was calculated for each factor of both instruments and the overall average per instrument (Teamwork Climate and Interprofessional Collaboration). This analysis used health teams as the study unit.
In the FHS Units in which there was less than one oral health team per health team, the data was replicated to all PHC teams belonging to this same unit, before calculating the team averages, as indicated by Agreli, Peduzzi and Bailey (2017) 12 . The same procedure was carried out in the case of professionals from other categories who were not part of the basic con guration of a FHS team, such as social workers and pharmacists.
To characterize the participants that constitute the sample teams, the mean and standard deviation (SD) were calculated for data such as age, time since graduation, time at the institution or time working in the team; cases such as the numerical representativeness of positions or job functions, gender and the highest level of schooling, were presented as absolute numbers and percentages.

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The evaluation of the linear correlation between the scores in the ECTE and in the AITCS-II domains, as well as their total score between the health teams was performed using Pearson's linear correlation test. The same test was used to assess the linear correlation between the scores in the ECTE or in the AITCS-II domains, as well as their total score, with time in the profession and time in the team, among the professionals participating in this study.
The comparison between genders, in relation to the scores in the ECTE and in the AITCS-II domains was performed using the Student's t test. The same test was used in the comparison between professionals with and without specialization in Family Health or Public Health, in relation to the scores in the ECTE and the AITCS-II domains.
The comparison between different professionals, in relation to the scores in the ECTE and AITCS-II domains, was performed using the oneway ANOVA test, followed by the Tukey post-test, when necessary.
The other study results were presented as descriptive statistics or tables and graphs. Statistical analysis was performed using the SPSS statistical program, version 23.0, considering a signi cance level of 5%.

Results
In total, 1,122 health professionals were invited to participate in the research. Of these, 544 (n) agreed to participate, totaling a nal response rate of 48.4%, related to 97 FHS teams (N). It was necessary to replace 6 health teams that comprised the initial sample, as the response rate was lower than the minimum rate (40%) de ned in the inclusion and exclusion criteria of this study. The data related to the participants' characteristics are shown in Table 1. The results regarding the teamwork climate and interprofessional collaboration, and the respective factors, as well as the general average of each of the two instruments are shown in Table 2. Overall average of the scores for each domain and total score in the Team Climate Inventory (TCI) and Interprofessional Collaboration scale and the respective standard deviation of the mean (SDM) for each item.There was a strong correlation between the results related to teamwork climate and interprofessional collaboration (p < 0.01, Table 3 and Fig. 1), considering the health teams as the study unit. This correlation was observed in all items, both from ECTE and AITCS-II. As for the position or job function in the team, the only signi cant difference (p < 0.05) observed was related to the item task orientation in the team work climate domain, in which the best result was observed for the professionals working as Social Workers and the worst for professionals working as Pharmacists (Table 4). The results are presented as mean ± standard deviation of the mean. p-value in the one-way ANOVA test. Different lowercase letters on the line related to the "Task orientation" domain, indicates a signi cant difference between different professionals (Tukey's post-test, p < 0.05).
As for complementary training, having a specialization or not in public health or family health, did not imply a statistically signi cant difference (p < 0.05) in relation to the ECTE and AITCS-II scores (Table 5). The results are presented as mean ± standard deviation from the mean. P-value in the Student's t test.
As the data related to time in the team or time in the profession varied, there was no signi cant difference (p < 0.05) between the results of teamwork or interprofessional collaboration in any of their respective factors, and it is not possible to say there is a correlation between them (Table 6).

Discussion
The results of this study demonstrate the strong correlation between interprofessional collaboration and teamwork climate in all dimensions of both instruments used, reinforcing the importance of assessing teamwork climate in health services to promote more comprehensive, resolutive and higher-quality health care. This correlation was also observed by Ndibu et al. (2019) 18 and suggested by Agreli, Peduzzi and Bailey (2017) 12 in a study of mixed methods, in which the team climate seemed to be related to some aspects of interprofessional collaboration.
The version of the team work climate assessment instrument validated in the context of Brazilian PHC 17 offers no recommendations on the strati cation of the obtained numerical results. This makes it di cult to categorize the values obtained in the present study, whether they are satisfactory or not, which was also highlighted by Agreli, Peduzzi and Bailey (2017) 12 in the only study carried out on the subject in Brazil to date, using health teams as the health care analysis unit.
As for interprofessional collaboration, considering the AITCS-II instrument, the literature states that values less than or equal to four, as observed in the present study, indicate unsatisfactory results 19 . This demonstrates there is still great di culty working according to the precepts of interprofessional collaboration, even after decades dedicated to strengthening interprofessional work in FHS services. Thus, the complexity of the work processes in this context is emphasized, showing there is an urgent need for a permanent assessment of these issues, since it implies re ections in terms of micro and macropolitics of management and care. From this perspective, the study results demonstrate formative weaknesses both in the most recent training at the undergraduate level, as well as in the lato sensu postgraduate program. Thus, strategic curricular reorientations are suggested in these two levels of training, so that this topic is contemplated in a longitudinal way as the training periods / modules advance.
Regarding the professionals' job function, only one correlation was observed between this domain and the task orientation dimension, demonstrating that, according to their job function in the team, the professionals have a different perception of their commitment to achieve high quality standards regarding the service offered by the team. This study limitation is the use of a cross-sectional design, that is, the variables were measured at a single point of time, which suggests that the data cannot be used to infer cause and effect; in addition, the data cannot be generalized for all PHC contexts, considering that there are different con gurations of it, characterized according to the local health system and the territory demands.
Thus, other studies, preferably with a mixed design, need to be carried out to better understand the possible relationship between work climate, professional collaboration and other factors that may in uence the results of these two dimensions of the health work process.
The ndings of this study are relevant because they provide support for health managers to adopt measures to improve team work climate and, consequently, provide more collaborative health care and, thus, better quality health care with better results. The results, regarding the sociodemographic variables, raise an alert regarding the training of new professionals and the quali cation actions of already trained professionals, showing the need to expand interprofessional education and the adequacy of the training process, aiming to train professionals and students to work increasingly more according to the principles of interprofessional collaboration.

Conclusion
It was concluded there was a correlation between teamwork climate and interprofessional collaboration, so that the better the working climate, the better the interprofessional collaboration in the corresponding team. As for the sociodemographic factors, only one correlation was observed between the professional's job function in the team and the factor participation in the team (related to teamwork climate). No other relationships were found between the sociodemographic characteristics and other teamwork climate factors or those related to interprofessional collaboration. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Funding
This study was nanced in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior -Brasil (CAPES) -Finance Code 001.