Diversity
When discussing patients’ cases, the professionals typically presented differing perspectives. This was manifested in at least two ways. First in that the members most competent to speak on an issue said the most (19), what Thylefors (20) have characterised as functional influence.
Second, the data suggests that in these diverse groups there is a risk of professional perspectives and roles co-existing without intersecting, resulting in parallel perspectives or series of perspectives (22). The two following empirical examples illustrate both. The first is an observation from a team meeting:
The team was discussing a case where they were unsure of the exact nature of patient’s problems. A social educator, who had the main responsibility for following up the patient, started the discussion.
Social educator: ‘I had a meeting with [the patient] yesterday. I asked if [the patient] was willing to agree to hospital admission for a mental assessment. [The patient] does not want that. [The patient] only wants to change the medication. (…) I think [the patient] is in a desperate situation with a lot of debt and a lot of anxiety, and the medicine only makes [the patient] worse.’
One psychologist responded: ‘It becomes difficult when we are unsuccessful in making a proper mental assessment (…) The medicine [the patient] is taking is probably not right. [The psychiatrist] should have a look at it [the psychiatrist was not present at the meeting].
The team continued discussing other possible strategies for helping the patient.
Social worker #1: ‘When it comes to [the patient’s] finances, it’s under the administration of social services.’
Social educator: ‘There are a lot of things we do not know. Does [the patient] have problems with substance use?’
Social worker #1: ‘I don’t know. I’ve never observed [the patient] intoxicated.’
Social worker #2: ‘What if we get [the patient] into “supported housing”? Then we can get closer and observe [the patient].’
Although, the discussion ended without members determining concrete solutions or making decisions, the function of diversity is illustrated in the multiple professional perspectives presented. While the psychologist addressed the need for a mental assessment and (by deferring discussion to the psychiatrist) change of medication, the social workers addressed issues such as substance use, finances, and housing. Consequently, different parts of the patient's possibly compound problem were considered by professionals in the relevant fields, leading to a sense of ownership in tasks for each. Furthermore, functional influence can be observed in that with the absence of the psychiatrist, questions of changes to the patient’s medication fell out of the discussion and the social work perspectives were more prominent.
Functional influence was found to be typical in discussion of patient cases in team meetings. In interviewing a team leader about team discussions of new patient cases, such divisions between professionals became even clearer:
We often start by discussing the patient’s need for treatment and follow-up care. Does the patient have any mental health issues? If so, it becomes natural to involve the psychologist. Does the patient have any somatic diseases? Maybe the psychiatrist should have a look at the patient. Substance use? Problems related to housing and economy? Does the patient need other services [outside the team]? Social services, for example. For such topics, the social worker often makes suggestions.
According to the team leader, when discussing patients with compound issues, the patients’ situations were divided into appropriate sub-themes, which were each in turn linked to the corresponding professional’s perspective or role. This can be understood as an efficient distribution of tasks and responsibilities. However, although both the interview statement and the observation note emphasised the diversity of professional perspectives in the interprofessional teams, no instances of intersection between professions were observed. Instead, in these two examples, when different perspectives were advanced by workers from one field, those in the other fields neither directly grasped their suggestions nor contributed with further reflections. When operating as parallel perspectives or as series of perspectives, the whole concept of interprofessional teamwork could not be fully taken advantage of as the potential for generating new insights was reduced. Consequently, the lack of friction posed a risk to the proper function of diversity.
Relatedly, in interviews, several informants highlighted diversity as the base of interprofessional teamwork. One social worker described the interaction between diverse professionals with unique perspectives as a process of ‘synergy’:
The biggest advantage, I think, is that we all have different perspectives, and understand the patients differently. And when we put our minds together, work collectively, we manage to see the whole person and accomplish the provision of better services for the patients.
Similarly, a psychiatrist stated:
As both professionals and individuals, we are sensitive to different things. We are also blind to different things. There is quality in several professionals observing the patients and everyone having an equal opportunity for influence. The opposite gives no space for creative work.
In summary, this section highlights diversity as a natural characteristic of interprofessional teamwork. However, there is an important dynamic between diversity and the other two aspects. As both the social worker and the psychiatrists expressed, without friction, diversity risks not realising its full potential. Furthermore, there is a need for harmonisers such as ‘everyone having an equal opportunity for influence’, to connect diverse perspectives and to balance potential conflict. Correspondingly, the last two excerpts both suggest how the dynamic between diversity in perspectives (friction) promote creativity and synergy effects.
Friction
Friction occurs when divergent perspectives and resources intersect during interactions between professionals, as exemplified in a team meeting discussion of a patient who primarily used his voice to scream and used little verbal language:
Discussing the reason behind this, one psychologist suggested: ‘The fact that [the patient] screams so much could indicate that [the patient] lacks the ability to express himself in words’.
A social educator who knew the patient well responded: ‘I think he screams to get his way’.
The phycologist countered: ‘But it could be something cognitive’.
A second social educator argued: ‘Yes, that could be, but I also think [the patient] screams to get his way’.
This discussion too ended with no clear conclusion. Unfortunately, the psychologist was never interviewed for this study, but both social educators were. When asked about the discussion, the first social educator reflected ‘We cannot agree on everything. The most important thing is that different perspectives are raised.’ Correspondingly, the second social educator said:
As a social educator, you tend to have a focus on behaviour. (…) What I hear when the psychologist asks, ‘could it be something cognitive?’ is a question of, ‘could it be a mental disorder?’ (…) It shows how we challenge each other. Had only social educators been discussing the case, maybe there would have been a complete consensus explaining it as behaviour.
Although the explanation proposed by the psychologist and the explanation proposed by the two social educators were not necessarily contradictory (either, neither, or both explanations could explain the patient’s screaming), the friction between diverse professional perspectives is clearly illustrated in the interaction as different perspectives are present. Just as the social educators’ explanation can be traced back to the perspective of ‘behaviour analysis’, which is central in social education, the psychologist’s mental illness perspective reflects the focus of psychology training. Notably, both social educators emphasised the function of friction in that the intersections between professional diversity prevented professional bias and groupthink rather than posing a barrier to collaboration (25, 26).
The following situation from a team meeting suggests that the intersection process promotes productivity, that is, an increase in output compared to a given amount of input. Here, the team was discussing a patient they had been working with for a long time but whose progress had stalled. The discussion quickly turned to the underlying cause of the patient’s problems:
Social worker: ‘[Another social worker] and I had a meeting with [the patient] last week about his financial situation. He was very aggressive. We talked together after the meeting and decided that it may have been symptoms of withdrawal.’
Psychologist: ‘Intoxicated?’
Social worker: ‘Not intoxicated. He was aggressive and kept saying he needed medication. (…) What are your thoughts?’
Psychologist: ‘My notes say symptoms of anxiety and personality disorder. (…) I have not seen any signs of substance use, but you may have noticed something I have not.’
This situation demonstrates two things. First, due to differences in professional roles, the professionals met the patient in different contexts, and each can thus offer different insights into the patient’s life. In this case, the social workers met the patient in the context of the patient’s financial situation, and the psychologist meet the patient primarily in the context of therapy. Second, the social workers and the psychologist had different professional backgrounds for understand the patient’s situation. While the psychologist’s knowledge base was mental health, the social workers’ training emphasised other factors, in this case, the patient’s living conditions. Consequently, when the two perspectives intersected, a new and deeper insight into the patient’s challenges was created.
Although many of the informants highlighted the function of friction positively, friction is not always straightforward. The data also points to the risk of friction becoming a barrier to collaboration, turning into conflict, or inhibiting some professionals from expressing their opinions, resulting in a form of professional self-sacrifice (21). One psychologist, for example, felt that other team members were quicker to propose medication than he felt comfortable with but that he did not always assert his position. Reflecting on this, he said:
Personally, I think we should be restrictive in prescribing certain kinds of medication, but I do not always express that. (...) I do not bother taking on those discussions. Rather, I think, ‘okay, in addition to prescribing medication, can we also take other actions?’ (…) But this is a compromise according to what I think.
Not always wanting to express his opinion, this statement can be read as both a result of friction and a strategy to avoid friction (conflict) and preserve harmonisation. In the light of the previous discussion on diversity and parallel perspectives, it may be that friction occurs when something is at stake. However, disagreements on fundamental principles among team members can be problematic, as exemplified by the following excerpt from a nurse:
If there is a fundamental disagreement within the team concerning how we work, if these fundamental principles are constantly criticised, then that can be very destructive.
However, such conflict did not mean that all hope was lost. The same nurse stated:
Such disagreement has two sides. It can be destructive if the principles the team is founded on are constantly questioned. However, such discussions also make us aware of what we are doing and why.
The dynamic between friction and diversity and two sides of its interaction can be clearly observed here. The main point, however, is that while competition between diverse perspectives can be motivating and productive, friction, when not handled correctly (for example, if team harmonisation is missing), can lead to conflict, which can undermine the potential benefits of interprofessional work.
Harmonisation
Harmonisation can bind distinct professionals and potentially opposing forces. Consistent with literature highlighting respect, trust, shared responsibility, and responsiveness (9–13), this study’s findings demonstrate how such harmonising elements function to connect team members. For example, when asked how the team members worked together despite professional differences, several informants emphasised the ability to learn and incorporate the perspectives of other professions as a harmonising factor. A psychologist, who had joined the team quite recently expressed in an interview: ‘I have spent a lot of time learning to understand the other [professionals] in the team and how they work.’ Likewise, one of the nurses stated:
You must be interested in the perspectives of others and be willing to learn and contribute to the discussions. If not, you should not be part of this team.
In addition to the ability to learn and incorporate the perspectives of other professionals, several informants expressed that they worked well together when all opinions and perspectives were equally valued, as a social worker told the researcher in an interview:
In the beginning I dared to say almost nothing. It took some time, but when I realised that the others listened to me and that my perspectives were appreciated, well, that was very reinforcing and gave me confidence. (…) When you feel that you are listened to and that your opinion is valued, you also contribute well as a team member.
The social worker connected feelings of being respected and valued with ‘contributing well as a team member’. This statement was consistent with other informants’ emphasis on the importance of ‘all voices counting equally’. A psychiatrist observed the following:
Everyone [on the team] is allowed to voice their opinion. Even if one of the ‘heavyweights’, me for example, expresses something, there must be room for others to say, ‘you know what? I do not agree. I see it differently’. (…) We have succeeded in this because [the team members] have confidence in each other.
Here, the psychiatrist linked the space for utterance to the team members having confidence in each other. Simultaneously, it is of interest how the psychiatrist expresses awareness of his higher status compared to other team members by characterising himself as one of the ‘heavyweights’, and thus highlighting how it can be difficult for professionals with lower status to contribute with their perspectives (16, 17). By contrast, when questioned about ‘what brought the team together’, a psychologist answered:
My perception is that we are a flexible group of professionals dedicated to helping the patients. (…) We are collectively responsible for finding solutions that correspond to the patients’ needs, and that it what unites us.
In this statement, the psychologist expressed how shared responsibility and a shared goal (responding to the patients’ needs) created a ‘bond of commitment’ between the team members.
The above interview excerpts present the function of harmonisation. Yet, locating similar expression during ‘real-time interaction’, that is, during team meetings, was comparatively difficult. One reason may be that such interpersonal elements are subtle and difficult to observe in actual practice. The team meetings, were, however, often used as forums for professionals seeking support for their approaches to working with patients. In those situations, team members were often observed making brief affirmative comments to each other, such as ‘I agree’, and ‘well spotted’, or nodding their heads affirmatively. Such affirmations appear to be important expressions of support, helping to establish mutual trust, respect, and recognition among the team members.
These findings suggest that relations based on mutual respect and trust, openness, and acknowledgment of each other’s professional roles can function as conflict reducing and promote a balanced composition of individual parts. However, as previously discussed, over-harmonising runs the risk of discouraging disagreement and debate between team members, which may lead to poor decision making and groupthink (26). Harmonisation must not stand alone. Reflecting on the dynamic between diversity, friction, and harmonisation, one team leader said:
That [the team members] involve themselves and share their different views is in many ways praiseworthy. Professional friction creates space for professional growth. However, it is also a source of conflict and a challenge if they have very diverse perspective on an issue. (…) It is an interesting but difficult question. One important factor, I think, is a sense of confidence within the team, that we know that disagreement is okay and that the team can survive a conflict.
Here, the team leader emphasises how all three aspects, seen collectively, support a productive interprofessional teamwork dynamic. Especially the team leader highlights friction and the need for harmonising elements such as trust as productive factors. However, the empirical data also gives the impression of a dominant need to over-promote harmonisation and its positive function. For example, several of the informant's statements seemed to under-communicate differences in professional status and, instead, emphasise how ‘all voices counted equally’. Exactly why this was so, is difficult to answer. One suggestion may be that diversity and friction are, to some extent, perceived as barriers to productive teamwork (14), while the balancing benefits of harmonisation are described as important to accomplish team goals (11). Such an excessive focus on harmonisation can lead to the disappearance of the potentially positive functions of diversity and friction.
The threefold model
Based on the hypothesis that diversity, friction, and harmonisation have important functions in interprofessional teamwork and can also involve certain risk, this paper examines how, when combined, those aspects may create conditions conducive to productive teamwork. Findings from analysis of the data collected indicate that the three aspects are closely linked, as illustrated in the threefold ideal-type model below:
Table 3
Model of interprofessional team dynamics
| | Function | Risk | Dynamic |
| Diversity | - Expanding access to knowledge and different perspectives - Distributing tasks and responsibility | - Parallel rather than intersecting perspectives | - Promotes friction and calls for harmonisation. |
| Friction | - Advancing innovation and broader, deeper discussions - Generating new insights | - Conflict | - Counteracts risks for parallel perspectives and the risk for group think with over-harmonisation. |
| Harmonisation | - Supporting a balance of professional distinctiveness - Tying team members together. | - Groupthink | - Reduces risks of conflict - Creates a ‘space for friction’ where opposing perspectives are encouraged and accepted. |
New characteristics of these aspects in the context of interprofessional team dynamics have not been discovered here; numerous studies have contributed to knowledge on interprofessionalism and teamwork relations, exploring the effects and characteristics of each aspect in practice (9, 10). What is new, is an emphasis on the dynamics between them, which allows for a more comprehensive discussion and understanding of processes that promote teamwork productivity. For example, compared to previous studies which have highlighted diversity in professional cultures and roles as a challenge to efficient interprofessional teamwork (14, 22), this study points to diversity as the very basis of interprofessional teamwork and that for diversity to reach its full potential, friction must occur. Here, the findings suggest that friction promotes innovation by producing new insights and taking discussions further. Lastly, harmonisation was found to support a balance in professional distinctiveness, as it fosters trust, respect, and ties professionals together.
When functioning ideally, the three aspects present a productive force driving teamwork forward, that is, the dynamic between them indicate increases in output compared to the given amount of input. That process was observed in team meeting discussions, where the intersection of different professional perspectives helped the team members expand understanding of a patient's situation. By considering the three aspects in combination, this ideal-type model suggests risks to productivity if an aspect is missing or collapses. The data suggests that when professionals on a team lack mutual trust or respect (harmonisation), differences between them and resulting frictions can lead to conflict. Conversely, the lack of diversity, disagreement, and debate between team members can result in collective rationalisation, self-censorship, and poor decision-making (25, 26).
Limitations
Though the model presents a simple design, it was useful for examining three important aspects of interprofessional teamwork as expressed in both the professionals' stated motivations and their observed actions in practice. However, as stated earlier, this should only be understood as an ‘ideal-typical model’ of interprofessional team dynamics (5), meaning that it presents the pure features of a phenomenon cleansed of anything that might oppose it. For example, although power structures are clearly present in interprofessional teams, they are not treated at length in this paper (but in a forthcoming one, based on the same study). By considering differences in professional status among team members, future studies may offer deeper understanding of the three aspects and how they are connected. Moreover, this study was developed within the field of mental health and substance use in Norway. As previously mentioned, Norwegian work culture is characterised by informal communication, high degrees of autonomy for workers, and high level of trust (33). This might have moderated professional power and promoted harmonisation. A further limitation is that, when discussing productivity, no objective assessment of results and achievement of goals was included. Instead, an evaluation was made based on the informants' subjective perceptions. This means that the study cannot say anything about what productive teamwork actually is. However, it presents an empirically grounded ideal-type model.
In the field of mental health and substance use, there is a great deal of overlap between the professions involved. Interprofessional teams made up of multiple professionals from different fields with the right to voice their opinions to one another may enable greater levels of friction than other professional environments. It could be of interest to explore the operation of the three aspects within different contexts where there are greater differences between the professionals on the team and greater potential for conflict. Lastly, what this study does not account for is how teamwork develops over time. For example, it is possible to imagine that disruptive friction is most at risk when starting up a team, at the same time as elements of stabilisation and harmonisation take time to develop.