http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(3): 239–245 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2014.901938
THEMED ARTICLE
Transactive memory system as a measure of collaborative practice in a geriatrics team: implications for continuing interprofessional education 1
Department of Pharmacy, Tan Tock Seng Hospital, Singapore, 2Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore, and National Healthcare Group, Health Outcomes and Medical Education Research (HOMER) Unit, Singapore
3
Abstract
Keywords
The interprofessional team meeting is a model of care in which members of the interprofessional team come together with their individual expertise to provide holistic care for the patient. Additionally, interprofessional team meetings serve as a platform for continuing interprofessional education as healthcare professionals come together to learn with, from, and about each other to enhance collaboration and patient care. Utilizing the transactive memory system (TMS) framework, this paper aims to demonstrate the utility of TMS as a measure of interprofessional collaborative practice based on a pilot study in an interprofessional geriatrics team. Questionnaires were administered to 78 members who regularly participated in the interprofessional team meetings. The quality of perceived TMS was measured by the cumulative scores on two previously validated scales. Logistic regression analyses revealed that TMS was a significant predictor of satisfaction with interprofessional team meeting experience and clinical work, whereas TMS scores significantly increased with greater number of interprofessional team meetings attended. Reliability analysis indicated high internal consistency while in factor analysis, each scale was predicated on a dual factor structure instead of the original tri-dimensional structure. Our results indicate the novel use of TMS as a valid and reliable measure of interprofessional collaborative practice. Implications for the role of TMS in continuous interprofessional education, collaborative practice, and patient care are also presented.
Continuing interprofessional education, geriatrics, interprofessional collaboration, interprofessional rounds, survey, transactive memory system
Introduction The rapidly ageing population worldwide underscores an increasing need for greater interprofessional collaborative practice among healthcare professionals to meet the complex medical, functional, and social needs of hospitalized elderly patients (Frenk et al., 2010; Reeves, Lewin, Espin, & Zwarenstein, 2010; World Health Organization, 2010; World Health Professions Alliance, 2013). There is growing evidence that interprofessional team care is beneficial in geriatric patient care and outcomes (Inouye, Bogardus, Baker, Leo-Summers, & Cooney, 2000; O’Mahony, Mazur, Charney, Wang, & Fine, 2007). The interprofessional team meeting, also commonly referred to as the ‘‘multidisciplinary round’’ or ‘‘interdisciplinary round’’ in the geriatrics literature (Landefeld, Palmer, Kresevic, Fortinsky, & Kowal, 1995; Leclerc et al., 2013; O’Mahony et al., 2007), is one such model of care in which members from different professional groups come together with their individual expertise to coordinate patient care, determine care priorities, establish daily goals, and plan for potential transfer or discharge (Spuhler, 2009). Studies
Correspondence: Keng Teng Tan, BS (Pharmacy), Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore; Department of Geriatric Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, 308433 Singapore. E-mail: [email protected]
History Received 18 January 2013 Revised 23 February 2014 Accepted 4 March 2014 Published online 1 April 2014
have demonstrated that interprofessional team meetings simultaneously improve quality outcomes and shorten length of stay while enhancing resident knowledge and attitudes about interprofessional processes and interactions (O’Mahony et al., 2007). Interprofessional team meetings thus provide an attractive platform for continuing interprofessional education where healthcare professionals come together to learn with, from, and about each other to improve collaboration and enhance the quality of care for patients (Kowitlawakul et al., 2014; Nagelkerk et al., 2014; Reeves, 2009). However, barriers exist towards learning and collaboration in interprofessional teams due to contesting professional identities (Kvarnstro¨m, 2008; Reeves, Lewin, et al., 2010), differences in patient problems and priorities (Rice et al., 2010), and lack of appreciation for the contribution of nurses and allied health professionals by physicians (Atwal & Caldwell, 2002). As noted by Reeves and colleagues (2010), for teamwork to develop, it is essential for teams to have shared identity, clear roles, tasks and goals, interdependency of member of team, integration of work, as well as shared responsibility. In light of these arguments, Thistlethwaite (2012) called for studies to explore why collaboration works better in certain settings than in others and how practitioners can learn to practice collaboratively. Despite studies documenting positive educational, interprofessional, and patient outcomes (Hammick, Freeth, Koppel, Reeves, & Barr, 2007; Reeves, Zwarenstein, et al., 2010; Thistlethwaite, 2012), the mechanisms that underline effective interprofessional teams are
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Keng Teng Tan1,2, Fadzli Bin Baharom Adzhahar3, Issac Lim3, Mark Chan2 and Wee Shiong Lim2
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not well understood (Sargeant, Loney, & Murphy, 2008). The measurement of interprofessional collaborative practice that is embedded within a sound conceptual theoretical frameworks remains elusive (Schmitt, 2001; Reeves, 2009), undermining the inferences and conclusions that can be drawn between measured outcomes with interprofessional collaborative practice and education (Cook & West, 2013).
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two acute-care geriatrics wards, we aim to determine the utility of TMS as a measure of interprofessional collaborative practice by measuring its association with satisfaction and level of experience, as well as determining its factor structure and internal consistency.
Methods TMS assessment
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Transactive memory system (TMS) A TMS ‘‘is a set of individual memory systems in combination with the communication that takes place between individuals’’ (Wegner, 1986, p. 186). Simply put, it can be conceptualized as an external memory system for individuals who are only available when individuals know what information exists, where this information resides, and how to retrieve it. The ‘‘transactive’’ quality of TMS refers to the exchanges that take place between members of a group when they are remembering something collectively. The development of TMS involves a process that needs to be constructed over time, beginning when members of a group interact and learn about the domains of expertise that others possess. Similar to an individual memory system, it requires the processes of encoding, storing, and subsequent retrieval before the memory can be used. How then do groups decide which member of the group encodes and stores what information? The allocation of encoding and storage depends on whether there is a recognized expert in a particular area. For example, the pharmacokinetics of metformin will most naturally be in the domain of the pharmacist, but it may be less clear who should encode information regarding the care preferences of an elderly patient in an interprofessional care setting. In the latter situation, the ‘‘circumstantial knowledge responsibility’’ (Wegner, 1986, p. 192) of the situation will determine who will encode and store the information. An effective TMS is deliberate in allocating responsibility for encoding information and will develop a process to deal with ambiguous situations like the one described. The TMS concept thus provides an approach to understand how individuals within a team can think collectively, effectively, and efficiently. The TMS concept has been applied to a variety of domains, including its original context of collective remembering in intimate couples (Wegner, 1985), small work groups in organizations (Faraj & Sproull, 2000; Lewis, 2003; Ren & Argote, 2011) and healthcare teams (Michinov, Olivier-Chiron, Rusch, & Chiron, 2008; Sarcevic, Marsic, Lesk, & Burd, 2008). Michinov and colleagues surveyed nurse and physician anesthetists in French public hospitals and reported strong correlation between TMS scores with perceptions of team effectiveness, job satisfaction, and team identification. In an ethnographic study of TMS in trauma resuscitation, Sarcevic and colleagues (2008) identified inefficiencies in communication processes that negatively impacted on the functioning of the collective memory system among team members to gather, store, and recall information. These studies provide an impetus for us to explore whether TMS can be similarly applied to enhance understand the implicit team processes and knowledge exchange that affect collaborative practice occurring within interprofessional teams in geriatrics. Because interprofessional team meetings assemble different members of an interprofessional team to come together with their individual expertise to assimilate the complex medical, functional, and social needs of elderly patients into a coherent plan of care, it essentially functions as a TMS in which various members of the interprofessional team rely on collective memory to acquire, store, and retrieve relevant information. Based on an exploratory pilot study of the interprofessional team meetings in
This is a cross-sectional study that aims to study the theoretical utility of TMS via the use of two widely used and validated scales that were relevant to the interprofessional team meeting setting. The first was developed by Lewis (2003) within the context of management consultant and high technology teams. The 15-item scale has three main components, which included specialization of knowledge, perception of credibility, and coordination. Each item was scored on a 5-point Likert scale. The main advantage of the Lewis (2003) scale is that it can be utilized in studies that comprise different groups, such as the different occupational groups in our instance (Ren & Argote, 2011). The second 11-item scale, developed by Faraj and Sproull’s (2000) study of software management teams, is premised on expertise location, needed expertise, and shared expertise. This scale is complementary to the Lewis scale and is highly relevant to the interprofessional team meeting context due to its emphasis on measuring how knowledge resource is interdependently managed by team members (Faraj & Sproull, 2000). For each scale, the individual item scores are summed up to yield a possible total score of 75 and 55. Because the two scales are complementary and measure different dimensions of TMS (Ren & Argote, 2011), we elected to keep the scales separate and not combine to form a single metric. Research setting and participants The study was conducted at two Acute Care of the Elderly (ACE) wards of a tertiary teaching hospital (Tan Tock Seng Hospital) in Singapore. General medical elderly patients aged 65 years and above are admitted to the wards through the Department of Emergency and to a lesser extent the outpatient clinics. Weekly interprofessional team meetings were conducted for selected patients with complex medical, functional, and social issues, to establish treatment goals, coordinate patient care, and facilitate early discharge planning. Besides doctors (including senior physicians, fellows and residents) from the Department of Geriatric Medicine, the interprofessional team composed of nurses, physiotherapists, occupational therapists, speech therapists, dieticians, care coordinators, and medical social workers. Each interprofessional team meeting lasts approximately 1 h and is led by the senior doctor with inputs from members of the interprofessional team. This study was approved by the Institutional Review Board of the National Healthcare Group, Singapore. Data collection Data for the current study were collected from April to May 2012. Questionnaires were distributed to all current members of the ACE team who attended interprofessional team meetings in the preceding year (n ¼ 90). There were no exclusion criteria for study participants. We collected demographic details on age, gender, and clinical role (subsequently analyzed in the four categories of doctors, nurses, therapists, and social worker/care coordinators). We measured the level of experience in three ways: years of clinical experience, years of experience in geriatrics, and number of interprofessional team meetings attended. Data for these variables were collected as ordinal data with a priori-determined categories (as displayed in Table 1) to maintain
Transactive memory system in a geriatrics team
DOI: 10.3109/13561820.2014.901938
Table 1. Baseline characteristics of survey participants (n ¼ 78).
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Characteristicsa Gender Male Female Age (years) 21–25 26–30 31–35 435 Interprofessional team meeting roles Doctors Nurses Therapists (includes physiotherapists, occupational therapists, speech therapists and dieticians) Medical social workers/care coordinators Years in clinical practice 0–3 4–5 45 Exposure to GRM care services 56 months 1 year 2–3 years 43 years Number of interprofessional team meetings attended 1–5 6–10 410 Satisfaction with Overall interprofessional team meeting experience, mean (SD) Professional training and education in interprofessional team meeting, mean (SD) Work in Geriatrics, mean (SD)
Resultsb (n ¼ 78) 12 (15.4) 62 (79.5) 15 22 26 13
(19.2) (28.2) (33.3) (16.7)
27 (34.6) 24 (30.8) 14 (17.9) 12 (15.4) 32 (41.0) 12 (15.4) 32 (41.0) 15 18 13 28
(19.2) (23.1) (16.7) (35.9)
23 (29.5) 15 (19.2) 38 (48.7) 3.77 (0.93) 3.68 (0.78) 3.69 (0.76)
SD, standard deviation. Frequencies may not add up to the total number of respondents due to non-response. b Number (percentage) presented unless otherwise mentioned.
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analyses were applied to evaluate the significance of TMS scores and level of experience in predicting satisfaction scores, adjusting for gender, age, and team roles. We opted for logistic regression as opposed to multiple regression because the former was more robust statistically and less susceptible to distribution of scores and other related issues such as the fulfillment of assumptions of normality, linearity, and homoscedasticity of residuals (Tabachnick & Fidell, 2007). As the dependent variable in logistic regression needs to be categorical, we transformed the satisfaction score into a dichotomous variable that comprises ‘‘not satisfied/neutral’’ and ‘‘satisfied’’ categories. Finally, we performed principal component analysis with varimax rotation to identify the underlying factor structure of both scales. The number of factors to be retained was determined by parallel analysis (Horn, 1965), a more robust and accurate method of factor retention that was less likely to overestimate the number of factors (Wetzel, 2012). For each scale, internal consistency was determined via Cronbach’s alpha. Statistical package for Social Sciences (SPSS) version 16.0 (SPSS Inc., Chicago, IL) and Stata I/C 12 were used for data analysis.
Results Baseline characteristics Seventy-eight healthcare workers who participated in interprofessional team meetings completed the survey questionnaire, yielding a response rate of 86.7%. About 83.8% (n ¼ 62) were female and there was a greater representation of doctors and nurses. Respondents’ clinical experience, exposure to geriatric care services, and number of interprofessional team meetings attended were well distributed across the spectrum. The mean satisfaction scores with overall interprofessional team meeting experience, professional training, and education during interprofessional team meeting, or clinical work in geriatrics ranged from 3.68 to 3.77, see Table 1.
a
the anonymity of the participants. Building upon the work of Michinov et al. (2008), we collected data on satisfaction scores to study the predictive validity of TMS as a measure of interprofessional collaborative practice. Participants were asked to rate on a 5-point Likert scale (1 for ‘‘not satisfied at all’’ through 3 for ‘‘neutral’’ to 5 for ‘‘very satisfied’’) their satisfaction with the overall experience of interprofessional team meetings (with reference to the last five meetings attended), professional training and education during interprofessional team meetings, and clinical work in the field of Geriatric Medicine. We omitted measures of teamwork because the reported good correlation between perceived team effectiveness with coordination items of the Lewis scale suggests significant overlap between them (Michinov et al., 2008). Instead, we selected satisfaction scores as outcome measures based on our postulation that better TMS would lead to superior task performance as a group in formulating patient care plan and hence greater satisfaction with interprofessional team meeting experience. Data analysis We performed independent sample t-tests to examine whether there were differences in TMS scores stratified by participants’ work satisfaction and level of experience. Logistic regression
Satisfaction with interprofessional team meeting and level of experience The mean TMS scores were 57.95 (SD ¼ 5.15; total possible score of 75) and 42.23 (SD ¼ 4.78; total possible score of 55) for the Lewis (2003) and Faraj and Sproull (2000) scales, respectively. Team members who were satisfied with their experience in interprofessional team meetings and geriatrics work had significantly higher TMS scores relative to those who reported dissatisfaction (both p50.001, significant after the Bonferroni correction). However, there was no difference in TMS scores with regard to satisfaction with training and education in interprofessional team meetings. When stratified by the level of experience, TMS scores neither differ significantly by years in clinical service nor years of practice in geriatrics care. However, team members who attended more than 10 interprofessional team meetings have a higher TMS score compared to their colleagues who attended fewer interprofessional team meetings (Lewis: p ¼ 0.01, Faraj and Sproull: p ¼ 0.07), see Table 2. Logistic regression In logistic regression analysis adjusting for age, gender, and interprofessional team meeting role, TMS was a significant predictor of satisfaction with interprofessional team meeting experience (Lewis: OR ¼ 1.24, p ¼ 0.004; Faraj and Sproull: OR ¼ 1.25, p ¼ 0.005) and clinical work (Lewis: OR ¼ 1.33, p ¼ 0.001; Faraj and Sproull: OR ¼ 1.23, p ¼ 0.007), whereas years of clinical service and the number of interprofessional team meetings attended were not significant, see Table 3.
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Factor analysis Factor analysis was appropriate as the Kaiser–Meyer–Olkin measure of sampling adequacy was 0.80 and 0.79, and the Bartlett test of sphericity was 355.39 (p50.001) and 325.72 (p50.001) for the Lewis (2003) and Faraj and Sproull (2000) scales, respectively (p50.0001). For each scale, parallel analysis indicated an optimal two-factor structure as opposed to the conventional tri-dimensional structure which was originally reported (Lewis, 2003; Faraj & Sproull, 2000), see Tables 4 and 5. The Lewis scale comprised the dimensions of teamwork and team functioning that accounted for 44.7% of the total explained variance. The former (30.0% of total variance) reflected interactions among team members in facilitating knowledge, while the latter (14.7% of total variance) described the nature of interaction in the team. We dropped two items (items 2 and 9) due to weak loadings. Cronbach’s alpha increased from 0.81 to 0.84 when the two items were dropped, indicating a more reliable 13-item, twofactor scale. For the Faraj and Sproull (2000) scale, factor 1 (30.2% of the variance) corresponded to team dynamics while factor 2 (24.3%) reflected team knowledge. Cronbach’s alpha of 0.84 indicated high internal reliability and the total explained variance of the two factors was 54.5%.
Discussion There is an increasing recognition of the central role of teamwork and interprofessional practice and learning in improving patient Table 2. Comparison of baseline characteristics and TMS quality scores.
Characteristics
Lewis score p Value
Faraj score
p Value
Years in clinical service 3 years 57.56 0.61 41.81 0.52 43 years 58.19 42.55 Years of practice in geriatrics care 3 years 58.33 0.49 42.52 0.51 43 years 57.44 41.75 No. of interprofessional team meetings attended Attended 10 interprofessional 56.45 0.01 41.24 0.07 team meetings Attended 410 interprofessional 59.53 43.24 team meetings Satisfaction with interprofessional team meeting experience Not satisfied/neutral 55.08 50.001 39.52 50.001 Satisfied 59.38 43.58 Satisfaction with training and education in interprofessional team meeting Not satisfied/neutral 56.65 0.11 41.23 0.19 Satisfied 58.63 42.76 Satisfaction with work in geriatrics Not satisfied/neutral 54.62 50.001 39.77 0.001 Satisfied 59.71 43.53
care and outcomes and enhancing patient safety (Frenk et al., 2010; Reeves et al., 2010; Salas, King, & Rosen, 2012; World Health Organization, 2010; World Health Professions Alliance, 2013). Earlier studies that investigated the effectiveness of interprofessional education interventions and collaboration have focused largely on justifying whether these interventions work as opposed to having a clarification purpose that seeks to also determine how and why it works and under what circumstances (Cook, Bordage, & Schmidt, 2008; Thistlethwaite, 2012). In line with the broader movement to reconsider the focus on outcomes research in health professions education, there have been calls to develop effective tools to measure interprofessional collaborative practice that can help delineate mechanisms and serve as an intermediary outcome to bridge the causal chain between interprofessional education interventions and higher-order Kirkpatrick’s outcomes (Cook & West, 2013; Schmitt, 2001; Thistlethwaite, 2012). Our exploratory pilot study contributes to an important gap in the literature of workplace learning in continuing interprofessional education in two important ways. First, our paper attempted to delineate the process involved in continuing interprofessional education using the theoretical lens of TMS. Our understanding of how teamwork actually develops and specifically how different professional groups actually learn about and from each other in the workplace, has been severely hindered because the field of continuing interprofessional education has been largely atheoretical (Reeves, 2009). The use of theories is important as it allows not only systematic investigations but also the accumulation of knowledge when scholars build on the work of each other. Although the field is making progress in the use of theories (e.g., Kitto, Gruen, & Smith, 2009; Sargeant, 2009; Reeves et al., 2010), much remains to be done. TMS is a highly useful theoretical frame for scholars in continuing interprofessional education as it mirrors actual team processes with high levels of verisimilitude. Second, our paper provided an avenue for researchers in the field of continuing interprofessional education to evaluate the extent of interprofessional collaborative practice. In our paper, we demonstrated the novel use of TMS as a valid and reliable measure of interprofessional collaborative practice in the context of an interprofessional geriatrics team. In particular, both the adapted Lewis and Faraj, and Sproull scales have good reliability and demonstrated content validity by the dual-factor structure predicated on the key concepts of team roles and team processes; concurrent validity by distinguishing between groups with different satisfaction scores and number of interprofessional team meetings attended; and construct validity by significantly predicting satisfaction with the interprofessional team meeting experience and with their clinical work in geriatrics. The strengths of our study include the use of a sound theoretical framework that has been well studied and validated for more than two decades in different team groups and organizational contexts (Ren & Argote,
Table 3. Logistic regression for satisfaction with interprofessional team meeting and work in geriatrics. Adjusted odd ratioa (95% Confidence interval) Satisfaction with interprofessional team meeting experience Characteristics TMS Score Years of clinical service Number of interprofessional team meetings attended a
Lewis scale 1.23 (1.07–1.42) 0.83 (0.21–3.36) 1.61 (0.38–6.80)
Satisfaction with work in geriatrics
Faraj scale b
1.25 (1.07–1.47) 0.96 (0.23–4.00) 1.34 (0.32–5.33)
Lewis Scale b
1.33 (1.12–1.58) 0.82 (0.18–3.72) 1.41 (0.36–5.55)
Odds ratio (95% confidence interval) displayed, adjusted for age, gender, and interprofessional team meeting role. p50.01.
b
Faraj scale b
1.23 (1.06–1.43)b 0.97 (0.24–4.03) 1.02 (0.28–3.74)
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Table 4. Principal component analysis on the 15 items of the Lewis (2003) scale (varimax rotation).
Specialization 1. Each team member has specialized knowledge of some aspect of the interprofessional team meeting 2. I have knowledge about an aspect of interprofessional team meeting that no other member has 3. Different team members are responsible in different areas 4. The specialized knowledge of several different team members was needed to complete the discussion 5. I know which team members have expertise in specific areas Credibility 6. I am comfortable accepting suggestions for my field of work from other team members during interprofessional team meeting 7. I trust that other team members’ knowledge of geriatric care is credible 8. I am confident relying on the information that other team members bring to the discussion 9. When other members give information, I want to double-check myself 10. I do not have much faith in other members’ ‘‘expertise’’ Coordination 11. Our team works together in a well-coordinated fashion 12. Our team has very few misunderstandings about what to do 13. Our team needs to backtrack a lot 14. We accomplish the task smoothly and efficiently 15. There is much confusion about how we accomplish the task Eigenvalue Percentage of variance explained
Factor 1
Factor 2
0.58 0.49 0.62 0.69 0.72
0.04 0.49 0.18 0.09 0.05
0.67
0.27
0.61 0.61 0.17 0.41
0.28 0.03 0.28 0.70
0.64 0.64 0.17 0.56 0.06 5.02 30.0%
0.30 0.23 0.53 0.40 0.71 1.69 14.7%
Adapted from Lewis (2003)/significant loadings in bold highlights.
Table 5. Principal component analysis on the 11 items of the Faraj and Sproull (2000) scale (varimax rotation).
Expertise location 1. The team has a good understanding of each other’s talents and skills 2. During the meeting, I am assigned tasks/asked questions relevant to my knowledge and skills 3. Team members know what task-related skills and knowledge they each possess 4. Team members know who in the team has specialized knowledge and skill that are relevant to their work Expertise needed 5. Some team members lack specialized knowledge that is necessary to do their task 6. Some team members do not have the necessary knowledge and skill to perform well, regardless of how hard they try 7. Some people In our team do not have enough knowledge and skill to do their part of the team task Bring expertise to bear 8. People in our team share their special knowledge and expertise with one another 9. If someone in our team has some special knowledge on how to perform the team task, he/she is not likely to tell the other team member about it 10. There is virtually no exchange of information, knowledge or sharing of skills among team members 11. More knowledgeable team members freely provide other members with hard-to-find knowledge or specialized skills Eigenvalue Percentage of explained variance
Factor 1
Factor 2
0.41 0.69 0.63 0.74
0.59 0.24 0.45 0.33
0.10 0.11 0.16
0.67 0.84 0.86
0.77 0.60
0.07 0.16
0.63 0.60 4.52 30.2%
0.19 0.03 1.48 24.3%
Adapted from Faraj and Sproull (2000)/significant loadings in bold highlights.
2011); the adaptation of two widely used and validated scales of TMS which can be readily applied to different healthcare settings (Faraj & Sproull, 2000; Lewis, 2003); and the empirical validation of these scales in a fairly representative interprofessional team. Although further validation work in other settings is required, we argue that the twin pillars of team roles and team processes in both TMS scales provide a potentially viable means of measuring three out of four competency domains which are outlined in the Interprofessional Education Collaborative Expert Panel (2011), namely roles or responsibilities, teams and teamwork, and interprofessional communication. In our study, the Lewis scale was most stable after omission of two items to yield the final 13-item scale. Although this result needs to be verified with further studies, it is possible that the omitted items two and nine are less applicable to our setting. Due to time constraints in a hectic healthcare environment, members are less likely to double-check information that others provide.
Moreover, from a cultural perspective, individuals in the Asian context are less likely to claim to know everything and are less likely to be untrusting of others’ knowledge (Ho, Lin, Chiu, Lingard, & Ginsburg, 2012). Another significant finding was that both adapted scales were predicated on a two-factor structure instead of the original tri-dimensional structure namely teamwork and team functioning for the Lewis (2003) scale, and team dynamics and team knowledge for the Faraj and Sproull (2000) scale. Closer inspection reveals the conceptual alignment of both adapted and original versions that is underpinned by the twin TMS pillars of team roles and team processes (Faraj & Sproull, 2000; Lewis, 2003). This finding explicate earlier observations that contact per se is not enough to build effective interprofessional teams (Sargeant et al., 2008) and highlight the importance of structuring the interprofessional team meeting to facilitate team processes, team interactions, and understanding of team roles, which in turn can impact satisfaction with the
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overall team learning experience during interprofessional team meetings. Although the impetus of this paper is to demonstrate the utility of the TMS framework and not to compare differences in TMS scores among professional groups, it is noteworthy to mention that 1-way ANOVA revealed differences that were statistically significant for both Lewis (doctors, M ¼ 59.48, SD ¼ 4.99; nurses, M ¼ 55.04, SD ¼ 4.34; therapists, M ¼ 59.15, SD ¼ 5.04) and Faraj scales (doctors, M ¼ 43.77, SD ¼ 4.94; nurses, M ¼ 39.78, SD ¼ 3.87; therapists, M ¼ 42.85, SD ¼ 4.64). The importance and implications of these differences are currently explored in another paper. Our results that TMS contributes positively to team performance and satisfaction are consistent with the available literature in both healthcare and non-healthcare contexts (Faraj & Sproull, 2000; Lewis, 2003; Michinov et al., 2008; Ren & Argote, 2011). TMS is not immediately apparent in newly formed teams but develops over time as team members become more familiar with each other, losing previously conceived stereotypes and acquiring greater understanding of the roles and responsibilities of the team members (Kitaygorodskaya, 2006). Additionally, through the building of closer relationships, members will develop respect and trust, thereby leading to improved clinical efficiencies and workplace satisfaction (Suter et al., 2009). Over time, team members are more likely to develop differentiated and specialized knowledge characteristic of TMS and jointly learn a greater volume of task-relevant information. When encountering an elderly patient with complex medical, functional and social issues, individual members are thus able to draw upon the collective expertise and learning resources afforded by the interprofessional team to more efficiently and effectively formulate a common management plan. In this way, TMS provides an important mechanism that facilitates access to learning and encourage knowledge sharing, thereby benefiting team decisionmaking and performance (Moreland & Myaskovsky, 2000). We also examined the relationship between TMS and level of experience. Interestingly, our results showed a trend towards improvement of TMS scores with greater number of interprofessional team meeting sessions, but not with years of clinical service or practice in geriatrics. This suggests that merely increasing a healthcare professional’s clinical work experience or exposure to geriatrics does not necessarily translate into increased levels of teamwork or understanding of another healthcare professional’s role within the interprofessional team meeting team (e.g. Freeman, Miller, & Ross, 2000; Howarth, Warne, & Haigh, 2012). From the perspective of TMS, newcomers to the interprofessional team meeting team would initially be unfamiliar with the inherent team roles and team processes. With greater exposure to interprofessional team meetings, they would acquire increased appreciation and be able to better contribute to the team roles and processes. This suggests that new members with a lower TMS base in terms of prior knowledge and understanding of the respective roles and responsibilities of the interprofessional team may benefit from a more structured learning experience in the initial stages to induct them into the unfamiliar learning environment of the team (Freeth, 2010). Our study has several limitations. First, the small sample size may affect the statistical power of exploratory factor analysis in determining the optimal number of representative factor loadings. In particular, inadequate sample size may lead to under-estimation of factors that are retained in parallel analysis (Hayton, Allen, & Scarpello, 2004). Confirmatory factor analysis with a larger sample is thus required to determine if the dual-factor structure is still valid. Second, the generalizability of our findings beyond the context of the interprofessional team meeting team in a specialized acute geriatrics ward needs to be established.
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Nonetheless, the applicability of the TMS concept in multiple studies involving non-healthcare and healthcare settings is reassuring and corroborates the possibility of using TMS as a measure of interprofessional collaborative practice and learning. Finally, given the cross-sectional nature of our data, it is not possible to establish the temporal sequence for a definitive antecedent-causal effect. Only with a longitudinal study can we confirm the actual impact of learning and its correlation with improved team performance.
Concluding comments In this paper, we have indicated the theoretical utility of TMS in the context of interprofessional team meetings. Through an exploratory pilot study, we demonstrated the viability of the Lewis (2003) and Faraj and Sproull (2000) scales in measuring perceptions of TMS. Our results indicate that TMS, as a measure of the quality of interprofessional collaborative practice, is a possible antecedent of team members’ satisfaction with interprofessional team meetings and professional work in geriatric medicine. We also suggested that team processes are a major operational dimension of TMS in geriatric care. This present study has, therefore, provided us with the impetus for a larger study with intervention in mind, to investigate the role of TMS in continuous interprofessional learning and improved patient outcomes.
Declaration of interest The study was supported by an educational research grant from the National Healthcare Group Health Outcomes and Medical Education Research office. The authors report no conflicts of interest. The authors were responsible for the writing and content of this paper.
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Reeves, S., Lewin, S., Espin, S., & Zwarenstein, M. (2010). Interprofessional teamwork for health and social care (1st ed.). Chichester, West Sussex: Wiley-Blackwell. Reeves, S., Zwarenstein, M., Goldman, J., Barr, H., Freeth, D., Koppel, I., & Hammick, M. (2010). The effectiveness of interprofessional education: Key findings from a new systematic review. Journal of Interprofessional Care, 24, 230–241. Ren, Y., & Argote, L. (2011). Transactive memory systems 1985–2010: An integrative framework of key dimensions, antecedents, and consequences. The Academy of Management Annals, 5, 189–229. Rice, K., Zwarenstein, M., Conn, L.G., Kenaszchuk, C., Russell, A., & Reeves, S. (2010). An intervention to improve interprofessional collaboration and communications: A comparative qualitative study. Journal of Interprofessional Care, 24, 350–361. Salas, E., King, H.B., & Rosen, M.A. (2012). Improving teamwork and safety: Toward a practical systems approach, a commentary on Deneckere et al. Social Science and Medicine, 75, 986–989. Sarcevic, A., Marsic, I., Lesk, M.E., & Burd, R.S. (2008). Transactive memory in trauma resuscitation. In Proceedings of the 2008 ACM conference on computer supported cooperative work (pp. 215–224). New York, NY, USA: ACM. Sargeant, J. (2009). Theories to aid understanding and implementation of interprofessional education. The Journal of Continuing Education in the Health Professions, 29, 178–184. Sargeant, J., Loney, E., & Murphy, G. (2008). Effective interprofessional teams: ‘‘Contact is not enough’’ to build a team. The Journal of Continuing Education in the Health Professions, 28, 228–234. Schmitt, M.H. (2001). Collaboration improves the quality of care: Methodological challenges and evidence from US health care research. Journal of Interprofessional Care, 15, 47–66. Spuhler, V. (2009). Presentation for IHI Expedition: Using multidisciplinary rounds to ensure the right care for every patient. Retrieved from http://www.ihi.org/offerings/VirtualPrograms/Expeditions/ MultidisicplinayRounds/Pages/default.aspx. Suter, E., Arndt, J., Arthur, N., Parboosingh, J., Taylor, E., & Deutschlander, S. (2009). Role understanding and effective communication as core competencies for collaborative practice. Journal of Interprofessional Care, 23, 41–51. Tabachnick, B.G., & Fidell, L.S. (2007). Using multivariate statistics (5th ed.). Boston: Pearson/Allyn & Bacon. Thistlethwaite, J. (2012). Interprofessional education: A review of context, learning and the research agenda. Medical Education, 46, 58–70. Wegner, D.M. (1985). Cognitive interdependence in close relationships. In W.J. Ickes (Ed.), Compatible and incompatible relationships (pp. 253–276). New York, NY, USA: Springer. Wegner, D.M. (1986). Transactive memory: A contemporary analysis of the group mind. In B. Mullen & G.R. Goethals (Eds.), Theories of group behaviour (pp. 185–208). New York, NY, USA: Springer-Verlag. Wetzel, A.P. (2012). Factor analysis methods and validity evidence: A review of instrument development across the medical education continuum. Academic Medicine: Journal of the Association of American Medical Colleges, 87, 1060–1069. World Health Organization. (2010). Framework for Action on Interprofessional Education & Collaborative Practice. Retrieved from http://www.who.int/hrh/nursing_midwifery/en/. World Health Professions Alliance. (2013). World’s health professions call for new emphasis on working together. Retrieved from http:// www.whpa.org/WHPA_Statement_collaborative_practice.pdf.
THEMED ARTICLE
Transactive memory system as a measure of collaborative practice in a geriatrics team: implications for continuing interprofessional education 1
Department of Pharmacy, Tan Tock Seng Hospital, Singapore, 2Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore, and National Healthcare Group, Health Outcomes and Medical Education Research (HOMER) Unit, Singapore
3
Abstract
Keywords
The interprofessional team meeting is a model of care in which members of the interprofessional team come together with their individual expertise to provide holistic care for the patient. Additionally, interprofessional team meetings serve as a platform for continuing interprofessional education as healthcare professionals come together to learn with, from, and about each other to enhance collaboration and patient care. Utilizing the transactive memory system (TMS) framework, this paper aims to demonstrate the utility of TMS as a measure of interprofessional collaborative practice based on a pilot study in an interprofessional geriatrics team. Questionnaires were administered to 78 members who regularly participated in the interprofessional team meetings. The quality of perceived TMS was measured by the cumulative scores on two previously validated scales. Logistic regression analyses revealed that TMS was a significant predictor of satisfaction with interprofessional team meeting experience and clinical work, whereas TMS scores significantly increased with greater number of interprofessional team meetings attended. Reliability analysis indicated high internal consistency while in factor analysis, each scale was predicated on a dual factor structure instead of the original tri-dimensional structure. Our results indicate the novel use of TMS as a valid and reliable measure of interprofessional collaborative practice. Implications for the role of TMS in continuous interprofessional education, collaborative practice, and patient care are also presented.
Continuing interprofessional education, geriatrics, interprofessional collaboration, interprofessional rounds, survey, transactive memory system
Introduction The rapidly ageing population worldwide underscores an increasing need for greater interprofessional collaborative practice among healthcare professionals to meet the complex medical, functional, and social needs of hospitalized elderly patients (Frenk et al., 2010; Reeves, Lewin, Espin, & Zwarenstein, 2010; World Health Organization, 2010; World Health Professions Alliance, 2013). There is growing evidence that interprofessional team care is beneficial in geriatric patient care and outcomes (Inouye, Bogardus, Baker, Leo-Summers, & Cooney, 2000; O’Mahony, Mazur, Charney, Wang, & Fine, 2007). The interprofessional team meeting, also commonly referred to as the ‘‘multidisciplinary round’’ or ‘‘interdisciplinary round’’ in the geriatrics literature (Landefeld, Palmer, Kresevic, Fortinsky, & Kowal, 1995; Leclerc et al., 2013; O’Mahony et al., 2007), is one such model of care in which members from different professional groups come together with their individual expertise to coordinate patient care, determine care priorities, establish daily goals, and plan for potential transfer or discharge (Spuhler, 2009). Studies
Correspondence: Keng Teng Tan, BS (Pharmacy), Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore; Department of Geriatric Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, 308433 Singapore. E-mail: [email protected]
History Received 18 January 2013 Revised 23 February 2014 Accepted 4 March 2014 Published online 1 April 2014
have demonstrated that interprofessional team meetings simultaneously improve quality outcomes and shorten length of stay while enhancing resident knowledge and attitudes about interprofessional processes and interactions (O’Mahony et al., 2007). Interprofessional team meetings thus provide an attractive platform for continuing interprofessional education where healthcare professionals come together to learn with, from, and about each other to improve collaboration and enhance the quality of care for patients (Kowitlawakul et al., 2014; Nagelkerk et al., 2014; Reeves, 2009). However, barriers exist towards learning and collaboration in interprofessional teams due to contesting professional identities (Kvarnstro¨m, 2008; Reeves, Lewin, et al., 2010), differences in patient problems and priorities (Rice et al., 2010), and lack of appreciation for the contribution of nurses and allied health professionals by physicians (Atwal & Caldwell, 2002). As noted by Reeves and colleagues (2010), for teamwork to develop, it is essential for teams to have shared identity, clear roles, tasks and goals, interdependency of member of team, integration of work, as well as shared responsibility. In light of these arguments, Thistlethwaite (2012) called for studies to explore why collaboration works better in certain settings than in others and how practitioners can learn to practice collaboratively. Despite studies documenting positive educational, interprofessional, and patient outcomes (Hammick, Freeth, Koppel, Reeves, & Barr, 2007; Reeves, Zwarenstein, et al., 2010; Thistlethwaite, 2012), the mechanisms that underline effective interprofessional teams are
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Keng Teng Tan1,2, Fadzli Bin Baharom Adzhahar3, Issac Lim3, Mark Chan2 and Wee Shiong Lim2
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not well understood (Sargeant, Loney, & Murphy, 2008). The measurement of interprofessional collaborative practice that is embedded within a sound conceptual theoretical frameworks remains elusive (Schmitt, 2001; Reeves, 2009), undermining the inferences and conclusions that can be drawn between measured outcomes with interprofessional collaborative practice and education (Cook & West, 2013).
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two acute-care geriatrics wards, we aim to determine the utility of TMS as a measure of interprofessional collaborative practice by measuring its association with satisfaction and level of experience, as well as determining its factor structure and internal consistency.
Methods TMS assessment
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Transactive memory system (TMS) A TMS ‘‘is a set of individual memory systems in combination with the communication that takes place between individuals’’ (Wegner, 1986, p. 186). Simply put, it can be conceptualized as an external memory system for individuals who are only available when individuals know what information exists, where this information resides, and how to retrieve it. The ‘‘transactive’’ quality of TMS refers to the exchanges that take place between members of a group when they are remembering something collectively. The development of TMS involves a process that needs to be constructed over time, beginning when members of a group interact and learn about the domains of expertise that others possess. Similar to an individual memory system, it requires the processes of encoding, storing, and subsequent retrieval before the memory can be used. How then do groups decide which member of the group encodes and stores what information? The allocation of encoding and storage depends on whether there is a recognized expert in a particular area. For example, the pharmacokinetics of metformin will most naturally be in the domain of the pharmacist, but it may be less clear who should encode information regarding the care preferences of an elderly patient in an interprofessional care setting. In the latter situation, the ‘‘circumstantial knowledge responsibility’’ (Wegner, 1986, p. 192) of the situation will determine who will encode and store the information. An effective TMS is deliberate in allocating responsibility for encoding information and will develop a process to deal with ambiguous situations like the one described. The TMS concept thus provides an approach to understand how individuals within a team can think collectively, effectively, and efficiently. The TMS concept has been applied to a variety of domains, including its original context of collective remembering in intimate couples (Wegner, 1985), small work groups in organizations (Faraj & Sproull, 2000; Lewis, 2003; Ren & Argote, 2011) and healthcare teams (Michinov, Olivier-Chiron, Rusch, & Chiron, 2008; Sarcevic, Marsic, Lesk, & Burd, 2008). Michinov and colleagues surveyed nurse and physician anesthetists in French public hospitals and reported strong correlation between TMS scores with perceptions of team effectiveness, job satisfaction, and team identification. In an ethnographic study of TMS in trauma resuscitation, Sarcevic and colleagues (2008) identified inefficiencies in communication processes that negatively impacted on the functioning of the collective memory system among team members to gather, store, and recall information. These studies provide an impetus for us to explore whether TMS can be similarly applied to enhance understand the implicit team processes and knowledge exchange that affect collaborative practice occurring within interprofessional teams in geriatrics. Because interprofessional team meetings assemble different members of an interprofessional team to come together with their individual expertise to assimilate the complex medical, functional, and social needs of elderly patients into a coherent plan of care, it essentially functions as a TMS in which various members of the interprofessional team rely on collective memory to acquire, store, and retrieve relevant information. Based on an exploratory pilot study of the interprofessional team meetings in
This is a cross-sectional study that aims to study the theoretical utility of TMS via the use of two widely used and validated scales that were relevant to the interprofessional team meeting setting. The first was developed by Lewis (2003) within the context of management consultant and high technology teams. The 15-item scale has three main components, which included specialization of knowledge, perception of credibility, and coordination. Each item was scored on a 5-point Likert scale. The main advantage of the Lewis (2003) scale is that it can be utilized in studies that comprise different groups, such as the different occupational groups in our instance (Ren & Argote, 2011). The second 11-item scale, developed by Faraj and Sproull’s (2000) study of software management teams, is premised on expertise location, needed expertise, and shared expertise. This scale is complementary to the Lewis scale and is highly relevant to the interprofessional team meeting context due to its emphasis on measuring how knowledge resource is interdependently managed by team members (Faraj & Sproull, 2000). For each scale, the individual item scores are summed up to yield a possible total score of 75 and 55. Because the two scales are complementary and measure different dimensions of TMS (Ren & Argote, 2011), we elected to keep the scales separate and not combine to form a single metric. Research setting and participants The study was conducted at two Acute Care of the Elderly (ACE) wards of a tertiary teaching hospital (Tan Tock Seng Hospital) in Singapore. General medical elderly patients aged 65 years and above are admitted to the wards through the Department of Emergency and to a lesser extent the outpatient clinics. Weekly interprofessional team meetings were conducted for selected patients with complex medical, functional, and social issues, to establish treatment goals, coordinate patient care, and facilitate early discharge planning. Besides doctors (including senior physicians, fellows and residents) from the Department of Geriatric Medicine, the interprofessional team composed of nurses, physiotherapists, occupational therapists, speech therapists, dieticians, care coordinators, and medical social workers. Each interprofessional team meeting lasts approximately 1 h and is led by the senior doctor with inputs from members of the interprofessional team. This study was approved by the Institutional Review Board of the National Healthcare Group, Singapore. Data collection Data for the current study were collected from April to May 2012. Questionnaires were distributed to all current members of the ACE team who attended interprofessional team meetings in the preceding year (n ¼ 90). There were no exclusion criteria for study participants. We collected demographic details on age, gender, and clinical role (subsequently analyzed in the four categories of doctors, nurses, therapists, and social worker/care coordinators). We measured the level of experience in three ways: years of clinical experience, years of experience in geriatrics, and number of interprofessional team meetings attended. Data for these variables were collected as ordinal data with a priori-determined categories (as displayed in Table 1) to maintain
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Table 1. Baseline characteristics of survey participants (n ¼ 78).
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Characteristicsa Gender Male Female Age (years) 21–25 26–30 31–35 435 Interprofessional team meeting roles Doctors Nurses Therapists (includes physiotherapists, occupational therapists, speech therapists and dieticians) Medical social workers/care coordinators Years in clinical practice 0–3 4–5 45 Exposure to GRM care services 56 months 1 year 2–3 years 43 years Number of interprofessional team meetings attended 1–5 6–10 410 Satisfaction with Overall interprofessional team meeting experience, mean (SD) Professional training and education in interprofessional team meeting, mean (SD) Work in Geriatrics, mean (SD)
Resultsb (n ¼ 78) 12 (15.4) 62 (79.5) 15 22 26 13
(19.2) (28.2) (33.3) (16.7)
27 (34.6) 24 (30.8) 14 (17.9) 12 (15.4) 32 (41.0) 12 (15.4) 32 (41.0) 15 18 13 28
(19.2) (23.1) (16.7) (35.9)
23 (29.5) 15 (19.2) 38 (48.7) 3.77 (0.93) 3.68 (0.78) 3.69 (0.76)
SD, standard deviation. Frequencies may not add up to the total number of respondents due to non-response. b Number (percentage) presented unless otherwise mentioned.
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analyses were applied to evaluate the significance of TMS scores and level of experience in predicting satisfaction scores, adjusting for gender, age, and team roles. We opted for logistic regression as opposed to multiple regression because the former was more robust statistically and less susceptible to distribution of scores and other related issues such as the fulfillment of assumptions of normality, linearity, and homoscedasticity of residuals (Tabachnick & Fidell, 2007). As the dependent variable in logistic regression needs to be categorical, we transformed the satisfaction score into a dichotomous variable that comprises ‘‘not satisfied/neutral’’ and ‘‘satisfied’’ categories. Finally, we performed principal component analysis with varimax rotation to identify the underlying factor structure of both scales. The number of factors to be retained was determined by parallel analysis (Horn, 1965), a more robust and accurate method of factor retention that was less likely to overestimate the number of factors (Wetzel, 2012). For each scale, internal consistency was determined via Cronbach’s alpha. Statistical package for Social Sciences (SPSS) version 16.0 (SPSS Inc., Chicago, IL) and Stata I/C 12 were used for data analysis.
Results Baseline characteristics Seventy-eight healthcare workers who participated in interprofessional team meetings completed the survey questionnaire, yielding a response rate of 86.7%. About 83.8% (n ¼ 62) were female and there was a greater representation of doctors and nurses. Respondents’ clinical experience, exposure to geriatric care services, and number of interprofessional team meetings attended were well distributed across the spectrum. The mean satisfaction scores with overall interprofessional team meeting experience, professional training, and education during interprofessional team meeting, or clinical work in geriatrics ranged from 3.68 to 3.77, see Table 1.
a
the anonymity of the participants. Building upon the work of Michinov et al. (2008), we collected data on satisfaction scores to study the predictive validity of TMS as a measure of interprofessional collaborative practice. Participants were asked to rate on a 5-point Likert scale (1 for ‘‘not satisfied at all’’ through 3 for ‘‘neutral’’ to 5 for ‘‘very satisfied’’) their satisfaction with the overall experience of interprofessional team meetings (with reference to the last five meetings attended), professional training and education during interprofessional team meetings, and clinical work in the field of Geriatric Medicine. We omitted measures of teamwork because the reported good correlation between perceived team effectiveness with coordination items of the Lewis scale suggests significant overlap between them (Michinov et al., 2008). Instead, we selected satisfaction scores as outcome measures based on our postulation that better TMS would lead to superior task performance as a group in formulating patient care plan and hence greater satisfaction with interprofessional team meeting experience. Data analysis We performed independent sample t-tests to examine whether there were differences in TMS scores stratified by participants’ work satisfaction and level of experience. Logistic regression
Satisfaction with interprofessional team meeting and level of experience The mean TMS scores were 57.95 (SD ¼ 5.15; total possible score of 75) and 42.23 (SD ¼ 4.78; total possible score of 55) for the Lewis (2003) and Faraj and Sproull (2000) scales, respectively. Team members who were satisfied with their experience in interprofessional team meetings and geriatrics work had significantly higher TMS scores relative to those who reported dissatisfaction (both p50.001, significant after the Bonferroni correction). However, there was no difference in TMS scores with regard to satisfaction with training and education in interprofessional team meetings. When stratified by the level of experience, TMS scores neither differ significantly by years in clinical service nor years of practice in geriatrics care. However, team members who attended more than 10 interprofessional team meetings have a higher TMS score compared to their colleagues who attended fewer interprofessional team meetings (Lewis: p ¼ 0.01, Faraj and Sproull: p ¼ 0.07), see Table 2. Logistic regression In logistic regression analysis adjusting for age, gender, and interprofessional team meeting role, TMS was a significant predictor of satisfaction with interprofessional team meeting experience (Lewis: OR ¼ 1.24, p ¼ 0.004; Faraj and Sproull: OR ¼ 1.25, p ¼ 0.005) and clinical work (Lewis: OR ¼ 1.33, p ¼ 0.001; Faraj and Sproull: OR ¼ 1.23, p ¼ 0.007), whereas years of clinical service and the number of interprofessional team meetings attended were not significant, see Table 3.
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Factor analysis Factor analysis was appropriate as the Kaiser–Meyer–Olkin measure of sampling adequacy was 0.80 and 0.79, and the Bartlett test of sphericity was 355.39 (p50.001) and 325.72 (p50.001) for the Lewis (2003) and Faraj and Sproull (2000) scales, respectively (p50.0001). For each scale, parallel analysis indicated an optimal two-factor structure as opposed to the conventional tri-dimensional structure which was originally reported (Lewis, 2003; Faraj & Sproull, 2000), see Tables 4 and 5. The Lewis scale comprised the dimensions of teamwork and team functioning that accounted for 44.7% of the total explained variance. The former (30.0% of total variance) reflected interactions among team members in facilitating knowledge, while the latter (14.7% of total variance) described the nature of interaction in the team. We dropped two items (items 2 and 9) due to weak loadings. Cronbach’s alpha increased from 0.81 to 0.84 when the two items were dropped, indicating a more reliable 13-item, twofactor scale. For the Faraj and Sproull (2000) scale, factor 1 (30.2% of the variance) corresponded to team dynamics while factor 2 (24.3%) reflected team knowledge. Cronbach’s alpha of 0.84 indicated high internal reliability and the total explained variance of the two factors was 54.5%.
Discussion There is an increasing recognition of the central role of teamwork and interprofessional practice and learning in improving patient Table 2. Comparison of baseline characteristics and TMS quality scores.
Characteristics
Lewis score p Value
Faraj score
p Value
Years in clinical service 3 years 57.56 0.61 41.81 0.52 43 years 58.19 42.55 Years of practice in geriatrics care 3 years 58.33 0.49 42.52 0.51 43 years 57.44 41.75 No. of interprofessional team meetings attended Attended 10 interprofessional 56.45 0.01 41.24 0.07 team meetings Attended 410 interprofessional 59.53 43.24 team meetings Satisfaction with interprofessional team meeting experience Not satisfied/neutral 55.08 50.001 39.52 50.001 Satisfied 59.38 43.58 Satisfaction with training and education in interprofessional team meeting Not satisfied/neutral 56.65 0.11 41.23 0.19 Satisfied 58.63 42.76 Satisfaction with work in geriatrics Not satisfied/neutral 54.62 50.001 39.77 0.001 Satisfied 59.71 43.53
care and outcomes and enhancing patient safety (Frenk et al., 2010; Reeves et al., 2010; Salas, King, & Rosen, 2012; World Health Organization, 2010; World Health Professions Alliance, 2013). Earlier studies that investigated the effectiveness of interprofessional education interventions and collaboration have focused largely on justifying whether these interventions work as opposed to having a clarification purpose that seeks to also determine how and why it works and under what circumstances (Cook, Bordage, & Schmidt, 2008; Thistlethwaite, 2012). In line with the broader movement to reconsider the focus on outcomes research in health professions education, there have been calls to develop effective tools to measure interprofessional collaborative practice that can help delineate mechanisms and serve as an intermediary outcome to bridge the causal chain between interprofessional education interventions and higher-order Kirkpatrick’s outcomes (Cook & West, 2013; Schmitt, 2001; Thistlethwaite, 2012). Our exploratory pilot study contributes to an important gap in the literature of workplace learning in continuing interprofessional education in two important ways. First, our paper attempted to delineate the process involved in continuing interprofessional education using the theoretical lens of TMS. Our understanding of how teamwork actually develops and specifically how different professional groups actually learn about and from each other in the workplace, has been severely hindered because the field of continuing interprofessional education has been largely atheoretical (Reeves, 2009). The use of theories is important as it allows not only systematic investigations but also the accumulation of knowledge when scholars build on the work of each other. Although the field is making progress in the use of theories (e.g., Kitto, Gruen, & Smith, 2009; Sargeant, 2009; Reeves et al., 2010), much remains to be done. TMS is a highly useful theoretical frame for scholars in continuing interprofessional education as it mirrors actual team processes with high levels of verisimilitude. Second, our paper provided an avenue for researchers in the field of continuing interprofessional education to evaluate the extent of interprofessional collaborative practice. In our paper, we demonstrated the novel use of TMS as a valid and reliable measure of interprofessional collaborative practice in the context of an interprofessional geriatrics team. In particular, both the adapted Lewis and Faraj, and Sproull scales have good reliability and demonstrated content validity by the dual-factor structure predicated on the key concepts of team roles and team processes; concurrent validity by distinguishing between groups with different satisfaction scores and number of interprofessional team meetings attended; and construct validity by significantly predicting satisfaction with the interprofessional team meeting experience and with their clinical work in geriatrics. The strengths of our study include the use of a sound theoretical framework that has been well studied and validated for more than two decades in different team groups and organizational contexts (Ren & Argote,
Table 3. Logistic regression for satisfaction with interprofessional team meeting and work in geriatrics. Adjusted odd ratioa (95% Confidence interval) Satisfaction with interprofessional team meeting experience Characteristics TMS Score Years of clinical service Number of interprofessional team meetings attended a
Lewis scale 1.23 (1.07–1.42) 0.83 (0.21–3.36) 1.61 (0.38–6.80)
Satisfaction with work in geriatrics
Faraj scale b
1.25 (1.07–1.47) 0.96 (0.23–4.00) 1.34 (0.32–5.33)
Lewis Scale b
1.33 (1.12–1.58) 0.82 (0.18–3.72) 1.41 (0.36–5.55)
Odds ratio (95% confidence interval) displayed, adjusted for age, gender, and interprofessional team meeting role. p50.01.
b
Faraj scale b
1.23 (1.06–1.43)b 0.97 (0.24–4.03) 1.02 (0.28–3.74)
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Table 4. Principal component analysis on the 15 items of the Lewis (2003) scale (varimax rotation).
Specialization 1. Each team member has specialized knowledge of some aspect of the interprofessional team meeting 2. I have knowledge about an aspect of interprofessional team meeting that no other member has 3. Different team members are responsible in different areas 4. The specialized knowledge of several different team members was needed to complete the discussion 5. I know which team members have expertise in specific areas Credibility 6. I am comfortable accepting suggestions for my field of work from other team members during interprofessional team meeting 7. I trust that other team members’ knowledge of geriatric care is credible 8. I am confident relying on the information that other team members bring to the discussion 9. When other members give information, I want to double-check myself 10. I do not have much faith in other members’ ‘‘expertise’’ Coordination 11. Our team works together in a well-coordinated fashion 12. Our team has very few misunderstandings about what to do 13. Our team needs to backtrack a lot 14. We accomplish the task smoothly and efficiently 15. There is much confusion about how we accomplish the task Eigenvalue Percentage of variance explained
Factor 1
Factor 2
0.58 0.49 0.62 0.69 0.72
0.04 0.49 0.18 0.09 0.05
0.67
0.27
0.61 0.61 0.17 0.41
0.28 0.03 0.28 0.70
0.64 0.64 0.17 0.56 0.06 5.02 30.0%
0.30 0.23 0.53 0.40 0.71 1.69 14.7%
Adapted from Lewis (2003)/significant loadings in bold highlights.
Table 5. Principal component analysis on the 11 items of the Faraj and Sproull (2000) scale (varimax rotation).
Expertise location 1. The team has a good understanding of each other’s talents and skills 2. During the meeting, I am assigned tasks/asked questions relevant to my knowledge and skills 3. Team members know what task-related skills and knowledge they each possess 4. Team members know who in the team has specialized knowledge and skill that are relevant to their work Expertise needed 5. Some team members lack specialized knowledge that is necessary to do their task 6. Some team members do not have the necessary knowledge and skill to perform well, regardless of how hard they try 7. Some people In our team do not have enough knowledge and skill to do their part of the team task Bring expertise to bear 8. People in our team share their special knowledge and expertise with one another 9. If someone in our team has some special knowledge on how to perform the team task, he/she is not likely to tell the other team member about it 10. There is virtually no exchange of information, knowledge or sharing of skills among team members 11. More knowledgeable team members freely provide other members with hard-to-find knowledge or specialized skills Eigenvalue Percentage of explained variance
Factor 1
Factor 2
0.41 0.69 0.63 0.74
0.59 0.24 0.45 0.33
0.10 0.11 0.16
0.67 0.84 0.86
0.77 0.60
0.07 0.16
0.63 0.60 4.52 30.2%
0.19 0.03 1.48 24.3%
Adapted from Faraj and Sproull (2000)/significant loadings in bold highlights.
2011); the adaptation of two widely used and validated scales of TMS which can be readily applied to different healthcare settings (Faraj & Sproull, 2000; Lewis, 2003); and the empirical validation of these scales in a fairly representative interprofessional team. Although further validation work in other settings is required, we argue that the twin pillars of team roles and team processes in both TMS scales provide a potentially viable means of measuring three out of four competency domains which are outlined in the Interprofessional Education Collaborative Expert Panel (2011), namely roles or responsibilities, teams and teamwork, and interprofessional communication. In our study, the Lewis scale was most stable after omission of two items to yield the final 13-item scale. Although this result needs to be verified with further studies, it is possible that the omitted items two and nine are less applicable to our setting. Due to time constraints in a hectic healthcare environment, members are less likely to double-check information that others provide.
Moreover, from a cultural perspective, individuals in the Asian context are less likely to claim to know everything and are less likely to be untrusting of others’ knowledge (Ho, Lin, Chiu, Lingard, & Ginsburg, 2012). Another significant finding was that both adapted scales were predicated on a two-factor structure instead of the original tri-dimensional structure namely teamwork and team functioning for the Lewis (2003) scale, and team dynamics and team knowledge for the Faraj and Sproull (2000) scale. Closer inspection reveals the conceptual alignment of both adapted and original versions that is underpinned by the twin TMS pillars of team roles and team processes (Faraj & Sproull, 2000; Lewis, 2003). This finding explicate earlier observations that contact per se is not enough to build effective interprofessional teams (Sargeant et al., 2008) and highlight the importance of structuring the interprofessional team meeting to facilitate team processes, team interactions, and understanding of team roles, which in turn can impact satisfaction with the
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overall team learning experience during interprofessional team meetings. Although the impetus of this paper is to demonstrate the utility of the TMS framework and not to compare differences in TMS scores among professional groups, it is noteworthy to mention that 1-way ANOVA revealed differences that were statistically significant for both Lewis (doctors, M ¼ 59.48, SD ¼ 4.99; nurses, M ¼ 55.04, SD ¼ 4.34; therapists, M ¼ 59.15, SD ¼ 5.04) and Faraj scales (doctors, M ¼ 43.77, SD ¼ 4.94; nurses, M ¼ 39.78, SD ¼ 3.87; therapists, M ¼ 42.85, SD ¼ 4.64). The importance and implications of these differences are currently explored in another paper. Our results that TMS contributes positively to team performance and satisfaction are consistent with the available literature in both healthcare and non-healthcare contexts (Faraj & Sproull, 2000; Lewis, 2003; Michinov et al., 2008; Ren & Argote, 2011). TMS is not immediately apparent in newly formed teams but develops over time as team members become more familiar with each other, losing previously conceived stereotypes and acquiring greater understanding of the roles and responsibilities of the team members (Kitaygorodskaya, 2006). Additionally, through the building of closer relationships, members will develop respect and trust, thereby leading to improved clinical efficiencies and workplace satisfaction (Suter et al., 2009). Over time, team members are more likely to develop differentiated and specialized knowledge characteristic of TMS and jointly learn a greater volume of task-relevant information. When encountering an elderly patient with complex medical, functional and social issues, individual members are thus able to draw upon the collective expertise and learning resources afforded by the interprofessional team to more efficiently and effectively formulate a common management plan. In this way, TMS provides an important mechanism that facilitates access to learning and encourage knowledge sharing, thereby benefiting team decisionmaking and performance (Moreland & Myaskovsky, 2000). We also examined the relationship between TMS and level of experience. Interestingly, our results showed a trend towards improvement of TMS scores with greater number of interprofessional team meeting sessions, but not with years of clinical service or practice in geriatrics. This suggests that merely increasing a healthcare professional’s clinical work experience or exposure to geriatrics does not necessarily translate into increased levels of teamwork or understanding of another healthcare professional’s role within the interprofessional team meeting team (e.g. Freeman, Miller, & Ross, 2000; Howarth, Warne, & Haigh, 2012). From the perspective of TMS, newcomers to the interprofessional team meeting team would initially be unfamiliar with the inherent team roles and team processes. With greater exposure to interprofessional team meetings, they would acquire increased appreciation and be able to better contribute to the team roles and processes. This suggests that new members with a lower TMS base in terms of prior knowledge and understanding of the respective roles and responsibilities of the interprofessional team may benefit from a more structured learning experience in the initial stages to induct them into the unfamiliar learning environment of the team (Freeth, 2010). Our study has several limitations. First, the small sample size may affect the statistical power of exploratory factor analysis in determining the optimal number of representative factor loadings. In particular, inadequate sample size may lead to under-estimation of factors that are retained in parallel analysis (Hayton, Allen, & Scarpello, 2004). Confirmatory factor analysis with a larger sample is thus required to determine if the dual-factor structure is still valid. Second, the generalizability of our findings beyond the context of the interprofessional team meeting team in a specialized acute geriatrics ward needs to be established.
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Nonetheless, the applicability of the TMS concept in multiple studies involving non-healthcare and healthcare settings is reassuring and corroborates the possibility of using TMS as a measure of interprofessional collaborative practice and learning. Finally, given the cross-sectional nature of our data, it is not possible to establish the temporal sequence for a definitive antecedent-causal effect. Only with a longitudinal study can we confirm the actual impact of learning and its correlation with improved team performance.
Concluding comments In this paper, we have indicated the theoretical utility of TMS in the context of interprofessional team meetings. Through an exploratory pilot study, we demonstrated the viability of the Lewis (2003) and Faraj and Sproull (2000) scales in measuring perceptions of TMS. Our results indicate that TMS, as a measure of the quality of interprofessional collaborative practice, is a possible antecedent of team members’ satisfaction with interprofessional team meetings and professional work in geriatric medicine. We also suggested that team processes are a major operational dimension of TMS in geriatric care. This present study has, therefore, provided us with the impetus for a larger study with intervention in mind, to investigate the role of TMS in continuous interprofessional learning and improved patient outcomes.
Declaration of interest The study was supported by an educational research grant from the National Healthcare Group Health Outcomes and Medical Education Research office. The authors report no conflicts of interest. The authors were responsible for the writing and content of this paper.
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