Team functioning in Neurorehabilitation: a mixed methods study

ABSTRACT

The objective of this study was to enhance understanding of team functioning in a neurorehabilitation team by identifying the factors that impede and facilitate effective interprofessional team collaboration. We focused on team identification, psychological safety, and team learning, and conducted the research at a neurorehabilitation center treating young patients with severe acquired brain injury in the Netherlands. A mixed-methods approach was employed, integrating quantitative data from questionnaires (N = 40) with qualitative insights from a focus group (n = 6) and in-depth interviews (n = 5) to provide a comprehensive perspective on team dynamics. Findings revealed strong team identification among participants, denoting a shared sense of belonging and commitment. However, limited psychological safety was observed, which negatively affected constructive conflict and team learning. Qualitative analysis further identified deficiencies in shared mental models, especially in shared decision-making and integrated care. These results highlight the crucial role of psychological safety in team learning and the development of shared mental models in neurorehabilitation settings. Although specific to neurorehabilitation, the insights gained may be applicable to enhancing team collaboration in various healthcare environments. The study forms a basis for future research to investigate the impact of improvements in team functioning on patient outcomes in similar settings.

KEYWORDS:

• Acquired brain injury
• interprofessional teams
• neurorehabilitation
• team functioning

Introduction

Cerebrovascular accidents and traumatic brain injury (TBI) are the most common causes of acquired brain injury (ABI; Feigin et al., 2010), affecting an estimated 85 million people worldwide annually (Dewan et al., 2019; Mukherjee & Patil, 2011). ABI can result in severe long-term impairment across various function domains, including physical, neurocognitive, and behavioral functioning (Turner-Stokes, 2003), in turn adversely affecting participation (van Velzen et al., 2009), and quality of life (Verdugo et al., 2021). Following acute care in a trauma center, comprehensive neurorehabilitation is typically warranted to facilitate recovery and societal reintegration (British Society of Rehabilitation Medicine, Royal College of Physicians, Turner-Stokes, 2003). Treatment by an interprofessional team is generally considered necessary for severe forms of ABI (Turner-Stokes, 2008; Wade, 2015; World Health Organization, 2020). Interprofessional rehabilitation care is the recommended approach to improve outcomes of patients with ABI (Momsen et al., 2012; Neumann et al., 2010). Effective neurorehabilitation requires the input of a diverse team of professionals with expertise in different domains. Simply bringing together a group of professionals does not guarantee an effective team (Singh et al., 2018), highlighting the significance of bringing awareness to team functioning in neurorehabilitation.

Background

In interprofessional neurorehabilitation, a team of healthcare professionals collaborates with team-based goals to provide care (Wade, 2015). This team typically comprises rehabilitation physicians, neuropsychologists, counselors, physiotherapists, occupational therapists, speech therapists, nurses, and social workers. The interventions delivered by team members are generally focused on closely related or similar impairments simultaneously. For example, neuropsychologists, occupational therapists, and speech therapists may all address neurocognitive impairments from within each sphere of expertise (Karol & Jacobs, 2014). The treatments provided by one profession may have an impact on the treatments provided by other professions. Given the combination of team-based goals and interdependency of treatments, effective team functioning is an important factor in the quality of neurorehabilitation (Wade, 2015). However, there is limited understanding of what constitutes a successful team in neurorehabilitation (Nancarrow et al., 2013; Neumann et al., 2010), and healthcare professionals typically lack training in collaborating within interprofessional teams (Montagnini et al., 2014). Researchers in social and organizational psychology have extensively investigated team functioning in other fields of activity (e.g., business management, aviation, military), consistently showing the crucial role of team functioning for professional success (Kozlowski & Ilgen, 2006; Marks et al., 2001; Salas et al., 2008). This existing literature can serve as a framework for understanding team functioning in neurorehabilitation. We focused on three fundamental key factors, known to impact team functioning.

The available body of research on team functioning highlights the critical role of team identification and psychological safety in facilitating team functioning (Duhigg, 2016; A. Edmondson, 1999; Solansky & Hertel, 2011; Van Der Vegt & Bunderson, 2005). Team identification refers to the emotional attachment of team members to the team, which promotes their commitment to team goals over individual goals (Van Der Vegt & Bunderson, 2005). Psychological safety, a shared belief among team members that the team provides a safe space for interpersonal risk-taking, such as asking for help or challenging a colleague’s perspective (A. Edmondson, 1999), is essential for effective team engagement (Newman et al., 2017). Thus, team identification sets the stage for engagement of team members, while psychological safety allows for this engagement to lead to effective interaction between team members. These fundamental elements of team functioning form the basis for team learning, which is critical for groups of professionals to evolve into high-performing teams.

Team learning is a continuous process of reflection and action that involves interaction between team members, such as asking questions, receiving feedback, experimenting, reflecting on results, and evaluating mistakes or unexpected outcomes (A. Edmondson, 1999). Team learning is underpinned by three important processes; (a) construction, (b) co-construction, and (c) constructive conflict (van den Bossche et al., 2011). In the construction process, team members individually assign meaning to new information. For example, interpretation of patient outcome assessments or weighing different treatment options. Co-construction involves sharing of information and ideas among team members to form mutual understanding and agreement (van den Bossche et al., 2011). When team members hold divergent viewpoints, constructive conflict can arise. Despite being the most complex and difficult component of team learning, constructive conflict is essential for driving real progress and innovation, as it encourages discussion and debate based on shared information and ideas in order to reach consensus.

The objective of this observational study was to enhance understanding of team functioning in a neurorehabilitation team by identifying the factors that impede and facilitate effective interprofessional team collaboration, including the key factors team identification, psychological safety, and team learning. The findings from this study may contribute to the identification of targets for improvement of team functioning in neurorehabilitation, ultimately enhancing the quality of interprofessional care. Additionally, these findings may be transferable to other settings, offering valuable insights for optimizing interprofessional collaboration in other healthcare contexts.

Methods

Design

We used a mixed-methods design, combining questionnaires, a focus group, and in-depth interviews to gain a comprehensive understanding of team functioning within a neurorehabilitation team. The data were collected and analyzed using a constructivist approach, based on the experiences and interactions of participants and researchers. The initial phase involved collecting quantitative data on team functioning, including team identification, psychological safety, and team learning. These data were collected using an online questionnaire administered to all members of the neurorehabilitation team.

Building upon the insights derived from the quantitative data, the qualitative phase was initiated. Here, results from the questionnaire guided the formation of topic areas explored during a focus group with the management team and interviews with clinicians from the neurorehabilitation team. An overview of the data sources and research methods employed can be found in Table 1.

Table 1. Sources of information.

Methods	Sources	Contents	Characteristics	N
Quantitative	Questionnaire	Survey comprising validated questionnaires assessed in all participating clinicians.	35 questions from validated questionnaires	40
Qualitative	Focus group	Focus group with management team and case managers (n = 6).	Lasted 90 minutes Audio recorded Transcribed by first author (total of 15.230 words)	1
Qualitative	In-depth interviews	Semi-structured interviews with clinicians from different rehabilitation disciplines.	Lasted 45 minutes on average Audio recorded Transcribed by first author (total of 27.219 words)	5

Participants and setting

This study was conducted in a specialized neurorehabilitation center in the Netherlands that offers intensive and prolonged rehabilitation care for young patients with severe acquired brain injury. The center is staffed by an interprofessional team consisting of case managers, counselors, a healthcare chaplain, neuropsychologists, nurses, occupational therapists, physiotherapists, rehabilitation physicians, social workers, speech therapists and a vocal coach. Participants in this study included all members of the neurorehabilitation team (n = 40) and management team (n = 6) at the center. Characteristics of participants of the neurorehabilitation team are shown in Table 2. Prior to participation, informed consent was obtained from all participants, and the Amsterdam University Medical Centre Medical Ethical Committee (W22_123 # 22.163) approved the study.

Table 2. Participant characteristics.

Response, n (%)	36 (90%)
Sex, n (%)	77.1% female
Age, Mean (SD)	37.1 years (11.5)
Work experience, Mean (SD)	11.4 years (10.8)
Distribution of educational level (%)	Bachelor 60.0%
	Master 37.9%
	PhD 2.9%
Distribution of professions	Physiotherapist, n = 8
	Occupational Therapist, n = 7
	Speech Therapist, n = 6
	Neuropsychologist, n = 6
	Counselor, n = 2
	Social Worker, n = 2
	Case Manager, n = 2
	Rehabilitation physician, n = 2
	Vocal coach, n = 1
	Healthcare chaplain, n = 1

Data collection

Quantitative data

A digital questionnaire was employed to assess the experience and perceptions of the rehabilitation team regarding team functioning. The questionnaire was distributed to all members of the rehabilitation team via e-mail. A reminder e-mail was sent after 2 weeks, and a verbal reminder was given by the first author (RV) one week later. This questionnaire was designed to include four separate, established, and validated questionnaires, specifically targeting different dimensions of team dynamics (Allen & Meyer, 1990; A. Edmondson, 1999; Lencioni, 2005; Van Der Vegt & Bunderson, 2005). Additionally, the questionnaire gathered demographic information such as sex, age, discipline, educational level, and work experience of the team members.

The abbreviated version of Lencioni team questionnaire, with a reliability coefficient (α = .80), is commonly employed to evaluate team functioning and contains 15 items assessing 5 dysfunctions of a team: Absence of trust, Fear of conflict, Lack of commitment, Avoidance of accountability, and Inattention to results (Lencioni, 2005). The three key factors were evaluated as follows: Team identification was evaluated using the four questions from Allen and Meyer’s (1990) affective commitment scale, following Van Der Vegt and Bunderson (2005), demonstrating high reliability (α = .89). Psychological safety was measured through a seven-item questionnaire developed by A. Edmondson (1999), indicating a reliability coefficient (α = .81). Team learning was evaluated using a nine-item questionnaire by van den Bossche et al. (2011) with a reliability coefficient (α = .83), which includes three subscales representing distinct facets of team learning: Construction, Co-construction, and Constructive conflict. All questions were scored on a five-point Likert-type scale, ranging from completely disagree (1) to completely agree (5).

Qualitative data

Focus group

To map out the management team’s experiences and perceptions regarding the current and desired team functioning, a focus group with the management team was performed. The management team (n = 4) was supplemented by case managers (n = 2), as case managers oversee the care process and coordinate interprofessional team meetings, which are central to the care provided in the center. The in person focus group comprised six participants, spanned a duration of 90 minutes and was and audio-recorded for analysis. The session was facilitated by three researchers (SB, RV, and MK), who aimed at providing a framework for structured discussion while simultaneously fostering an environment conducive to open dialogue among participants.

Interviews

To map out the experiences and perceptions of team functioning by members of the neurorehabilitation team, in person semi-structured interviews were performed with five selected members of the neurorehabilitation team. The participants were selected by purposive sampling, but had to meet at least the following criteria: (a) they had been employed by the center for more than 1 year, to allow the participant to have a clear view on the team’s functioning over an extended period of time; (b) they had previous work experience in other interprofessional team settings, to ensure a referential context, and (c) they represented different disciplines in the team, to obtain the most complete picture possible and to avoid an overemphasis on aspects specific to a certain discipline. The semi-structured interviews were conducted by one or two researchers (RV and MK). All interviews were audio-recorded and after conducting five interviews, sufficiency (LaDonna et al., 2021) for our study and purpose was reached.

Data analysis

Quantitative analysis

In our quantitative analysis, descriptive statistics summarized the responses from the questionnaires focused on team identification, psychological safety, team learning, and team dysfunctions as identified by the Abbreviated Lencioni Team Assessment. This assessment included evaluations of Absence of Trust, Fear of Conflict, Lack of Commitment, Avoidance of Accountability, and Inattention to Results. Additionally, to ensure the reliability of these scales, we calculated Cronbach’s alpha for each, including the Lencioni scale, to assess their internal consistency. All analyses were performed using SPSS (version 28.0; SPSS Inc., Chicago, IL), with Cronbach’s alpha values above .7 indicating acceptable reliability.

Qualitative analysis

Data from the focus group and interviews were transcribed verbatim and coded using Atlas.ti 9.1.3. The transcripts were analyzed using open coding in a constant comparative approach. We used a grounded theory approach to allow for inductive reasoning, whereby themes and sub-themes emerged from the data without the constraint of a pre-defined framework (Charmaz, 2014). To identify themes and possible sub-themes, relevant text fragments were labeled with keywords by two researchers (RV and SB) independently. Coded transcripts and identified themes and sub-themes were discussed until consensus was reached between two researchers (RV and SB). A third researcher (MK) reviewed the coding for coherence and consistency. A second layer of thematic analysis was then conducted, in which two researchers (RV and SB) examined how participants experienced team functioning, guided by the pre-defined sensitizing concepts of team identification, psychological safety, and team learning (Bowen, 2006). This thematic analysis differed from the initial grounded theory analysis in its directive nature; which allowed us to explore both emergent themes and those aligned with our research objectives. The researchers resolved any coding discrepancies through discussion until consensus was reached. The whole research team used iterative discussion to establish agreement on the final themes.

Reflexivity

The research team comprised a diverse group of experts, including a physiotherapist and clinical health scientist (RV), sociologist (SB), two neuroscientists (MK & JO) and a neurosurgeon (SP). All researchers had knowledge or specialization in interprofessional collaboration, with SB and SP having expertise in qualitative research, providing a comprehensive perspective on the data and theoretical lens applied. Regular group discussions were held to ensure findings and interpretations were carefully considered, enhancing the trustworthiness of the findings. The first author (RV) kept logs of all discussions and steps in the analytical process. In addition to a background in clinical health science, the first author has substantial clinical expertise in neurorehabilitation and previously worked as a physiotherapist on various other rehabilitation teams, bringing a clinical viewpoint to the study together with SP. In addition, the first author was mainly responsible for collecting data from all participants. This was done to enhance the richness of the data, as his expertise and background enabled RV to understand and interpret the data and events that participants described. The other authors (SB, MK, JO) provided a perspective with critical distance from day-to-day clinical health care practice, ensuring conclusions were based on data and not prematurely drawn. As outsiders to the clinical workplace, they were able to reveal what insiders may have overlooked as normal. Two of the authors (MK, RV) were affiliated as researchers with the rehabilitation center and had prior knowledge of participants beyond the scope of the study. This familiarity allowed them to contextualize remarks expressed in focus groups and interviews more comprehensively. The research team was mindful of power differentials and worked to mitigate these to encourage participants to speak freely.

Results

In this section, we first provide an overview of the demographic characteristics of the study participants, shown in Table 1. Next, we report our quantitative and qualitative findings on team identification, psychological safety, and team learning, which were the key quantitative factors analyzed together with the themes and sub-themes identified in the qualitative analysis. The results are presented in a narrative form with illustrative quotes from participants and quantitative scores. An overview of the key factors, themes and their corresponding sub-themes is detailed in Table 3.

Table 3. Description of key factors, themes, and subthemes.

Key factors	Themes	Sub-themes	Additional representative quotes
Team identification The degree to which members of a group attach emotional value to their membership of that group.			“..I believe that our commitment to the center, and our desire to excel for our patients and stand out, is very high.” (Focus Group)
Team psychological safety The shared belief by team members that the team is safe to allow risk-taking (e.g., to ask for help or to challenge a colleague’s view on how to reach a team goal)			“I think that there’s often more positive feedback given than negative because the reception really determines how you go forward with cooperation” (Focus Group) “I personally would never hesitate to speak up, but I know some people do.” (Interviews)
	Accountability The willingness to hold each other accountable for poor performance or habits that impede progress, including offering and accepting criticism or feedback.		“Feedback giving remains a challenging cultural issue for the team” (Focus Group) “I also notice that conflict is sometimes avoided for the sake of safety. It can be difficult to give feedback to a more eloquent colleague, as you may not know how they will react.” (Interviews)
	Safety in team meetings The belief by team members that the team meetings are safe to allow personal risk-taking.		“Everyone should feel safe enough in a team meeting to speak up and contribute” (Focus Group) “As a center, we’re still very young, so not everything can go right. When things go wrong, we need to be able to communicate with each other in order to learn from it. However, if people don’t feel comfortable speaking up due to negative reactions or the belief that they shouldn’t say something, it hinders the center’s development.” (Interviews)
Team learning The continuous process of reflection and action that includes asking questions, asking feedback, experimenting, reflecting on results, and discussing errors or unexpected outcomes of actions.			“Experienced and less experienced people – both have qualities that should be embraced for the team to progress” (Focus Group)“There’s not enough conflict between different opinions. You always have the go-getters, people with big mouths who always have an opinion on everything, and then you have the quieter people who often have really good ideas, but for some reason don’t dare to express them.” (Interviews)
	Hierarchy This theme explores the extent to which team members perceive and interact with hierarchical structures and how these structures impact the overall learning and adaptation process within the team.		There is an informal hierarchy… the personal characteristics of people are more decisive than any hierarchy” (Focus Group) “I’m not a fan of that kind of structure (junior/senior), as it can quickly sound hierarchical, which I don’t really like. Instead, I prefer for things to unfold in a more natural way.” (Interviews)
	Shared mental models An individually held, organized, cognitive representation of task-related knowledge and/or team-related knowledge that is held in common among health care providers who must interact as a team in pursuit of common objectives for patient care.	Shared decision making An approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences.	“The main rehabilitation goal is what the patient actually describes” (Focus Group) “One more concern about team meetings is that I often hear from patients and their families that they feel anxious about them. They’re afraid they might have to stop their treatment, and it’s unfortunate that they feel this way. They perceive that the doctor will simply dictate the course of action and determine when their treatment will end.” (Interviews)
		Discontinuation treatment Referring to (lack of) agreement within the team regarding when to discontinue treatment.	“I believe there were several instances when decisions had to be adjusted later because the team disagreed. After the main meeting, there would sometimes be another smaller meeting because someone, or even multiple people, disagreed. This often revolved around whether to stop or continue treatment.” (Focus group) “At some point, it’s just like, ‘No, the patient is staying because that’s what we agreed on.’ Well, okay, but we didn’t all have a chance to discuss that. I understand that at the end of the day, someone has to make a decision, and it’s not me. I’m fine with the physician being ultimately responsible for the care, but I’d prefer to have a more open and inclusive discussion.” (Interviews)
		Integration of care There are three main team models: multi-disciplinary, inter-disciplinary, and trans-disciplinary teams, which can be viewed as a continuum in the degree of integration between disciplines in the rehabilitation team (Karol & Jacobs, 2014)(Karol & Jacobs, 2014)(Karol & Jacobs, 2014)(Karol & Jacobs, 2014)(Karol & Jacobs, 2014).	“If the patients’ goal is to go to the store, then you have the neuropsychologist, the occupational therapist … you have everything involved” (Focus Group) “I recently accompanied the physiotherapist for one of my patients. We had the patient’s family there, and we quickly came up with a joint strategy, which made us incredibly efficient. However, due to double scheduling, this approach costs more money in the short term.” (Interviews)
		Team meeting processes Referring to (lack of) agreement within the team regarding what makes team meetings effective.	“Everyone should be prepared for a team meeting… it shouldn’t be a monologue from one profession… everyone should be aware of what has been written and we can really spar on the content in the meeting” (Focus Group) “In an effective meeting, time is well managed. There’s an agenda, a chairperson who oversees the agenda, and ideally, a consistent structure for each meeting, so you don’t have to rethink what to discuss every time. A team meeting should be a recurring event that follows a fixed pattern. As for a good team meeting, it’s important that everyone doesn’t simply retell the story they’ve already documented, although some clarification may be needed.” (Interviews)

The digital questionnaire was fully completed by 36 of the 40 employees (response rate 90%). In three cases, the reason for not responding was sick leave or pregnancy leave, and in one case, the reason was unknown. Results of the questionnaire are detailed in Table 4. The results show the initial levels of team dysfunction according to Lencioni’s team assessment and the results for the three key factors. The team scored highest on team identification and had the lowest score on Avoidance of accountability. Comparisons between the key factors can be made by evaluating the mean scores and relative differences. Although all factors were measured on a similar measurement scale, the scores may not be directly comparable due to unique aspects each factor represents. Nevertheless, these initial results helped to identify areas where the team’s functioning could be improved.

Table 4. Results.

	Results
	Mean	SD
Abbreviated Lencioni Team Assessment
Dysfunction 1: Absence of trust	3.3	0.5
Dysfunction 2: Fear of conflict	3.4	0.6
Dysfunction 3: Lack of commitment	3.7	0.5
Dysfunction 4: Avoidance of accountability	2.9	0.4
Dysfunction 5: Inattention to results	3.0	0.4
Team identification	4.1	0.7
Team psychological safety	3.6	0.6
Team learning	3.4	0.5
Construction	3.3	0.9
Co-construction	3.6	0.5
Constructive conflict	3.2	0.6

All the scales range from completely disagree (1) to completely agree (5), higher scores indicate better performance in the areas being assessed.

Team identification

Team identification emerged as a notable strength of the center, supported by both quantitative and qualitative findings. The quantitative analysis showed a relatively high score (M = 4.1, SD = 0.7) for team identification, indicating a shared sense of belonging and commitment among team members. This score can be interpreted as between agreement and complete agreement. This result was further supported by the focus group discussion with the management team, where a member stated: “The commitment to the center, the commitment to that we want to do well for our patients and wanting to be distinctive, is very high!” This suggests that team members are invested in the success of the center and are motivated to provide high-quality care to patients. Additionally, during our analysis, it was revealed that participants perceived themselves as part of various teams, reflecting the multidimensional nature of team dynamics within the center. These perceptions ranged from identifying with their own discipline-specific team to considering themselves part of the broader treatment team or even the entire organization, including the management team. No further relevant (sub)themes for team identification were identified.

Team psychological safety

Team psychological safety was assessed through both questionnaire responses and discussions in focus groups and interviews. Although the quantitative results showed relatively favorable ratings for asking team members for help, only 37% of respondents felt safe to take interpersonal risks. In the focus group discussions and interviews, psychological safety was discussed extensively, with the rehabilitation team members focusing on safety and speaking out in the context of trust. Interviews highlighted that perceived safety was considerable within discipline groups but not optimal in interprofessional team meetings and between staff and management. Some respondents acknowledged limitations in a psychologically safe environment and were aware of colleagues who tended to hold back during interprofessional team meetings. Both the focus group and interviews also revealed that giving feedback face-to-face remained a challenging cultural issue for the team. One rehabilitation team member highlighted a potential trust issue between management and staff: ”The feeling is twofold: On one hand, feeling safe enough to speak out, but also an idea that from the people above you, there is not enough trust in you.” Two themes were identified from the focus groups and interviews: a) safety in team meetings and b) accountability. No further subthemes were identified.

Safety in team meetings

Safety in team meetings is a theme identified corresponding to psychological safety, and it refers to the extent to which team members feel safe to express themselves and their ideas during team meetings without fear of retribution or judgment. Both the focus group and the interviews addressed this issue, highlighting the impact of hierarchy and leadership style on team members’ sense of safety during meetings. Some team members reported incidents in the past that had negatively affected their sense of safety, although they acknowledged that things had improved. However, there were still concerns about the existence of a hierarchy in the team that might hinder open communication:

We had incidents in the past that affected our sense of safety during team meetings. It’s much better now, but I think there is still quite a hierarchy in the team that might make some people hesitant to speak up.

Accountability

A second theme corresponding to psychological safety is accountability. A culture of accountability involves team members’ willingness to hold each other accountable for poor performance or habits that impede progress, as well as offering and accepting criticism or feedback. However, members of the rehabilitation team perceived the current accountability as a weakness within their team. Despite a workshop on accountability organized a year before, the management team also acknowledged that being approachable and accepting criticism and feedback was still a concern. The rehabilitation team attributed the lack of progress to the underutilization of the workshop’s outcomes, a lack of safety in offering substantive feedback, and the perception that feedback is a personal reproach rather than in the best interest of the patients. As a result, the current application of accountability hindered the rehabilitation team’s potential for development and learning from each other. One rehabilitation team member noted, ”If you don’t dare to give feedback because the reaction is sometimes not good or because you feel you are not allowed to say that, then that inhibits the development of the center.‘ The lack of a culture of accountability was further evidenced by the failure to implement an assurance strategy following a center-wide culture session that aimed to improve accountability. One rehabilitation team member expressed, ’I believe that when it comes to safety, individuals do not feel safe enough.”

Team learning

One of the most notable findings from the questionnaire on team learning was that just 20% of respondents agreed or completely agreed on the item “This team has a practice of settling differences by addressing them directly,” while over half disagreed or completely disagreed. In interviews, members of the rehabilitation team acknowledged that there is too little disagreement at the center, and that constructive dialogue is frequently avoided, despite the fact that it is necessary to reach new shared insights and knowledge as a team. One member of the rehabilitation team said,

I think we don’t disagree with each other enough. I feel that sometimes discussions are avoided. Engaging in discussions can lead to progress and help us realize when we’re wrong. But if someone takes things personally, there’s never a real discussion, and I find that unfortunate.

Two themes were identified from the focus groups and interviews: (a) hierarchy and (b) shared mental models, with four subsequent sub-themes;

Hierarchy

According to members of the management team, the center avoided a junior and senior construction upon founding to prevent creating a hierarchy. Although employees were informally referred to as experienced or inexperienced during discussions in the focus group, this distinction was not formally established. Some members of the rehabilitation team agreed with this approach, but others found it complicating. Some members of the rehabilitation team believed that expertise, experience, and peer coaching, were particularly important in cognitive rehabilitation and behavioral treatment. For them, seniority did not always imply years of work experience, but rather unique skills and experience with the target population. One rehabilitation team member shared:

I have already coached three colleagues and have found great enjoyment in doing so. I believe there is much to be gained from this experience. Although I do not favor the use of junior and senior titles as they can sound hierarchical, I do believe in allowing mentorship to occur organically.

Hierarchy was crucial for team learning at the center. Participants note the benefits and drawbacks of an informal seniority approach, lacking an official structure. Although it prevented rigid hierarchies, it could lead to confusion and pressure for experienced members in unofficial senior roles. Rehabilitation team members stressed that mentorship and peer coaching positively influenced team learning, fostering knowledge sharing and skill development. Balancing a nonhierarchical environment while supporting and recognizing experienced members was key.

Shared mental models

The discussions went beyond the pre-established key factor team learning and therefore the theme shared mental models was identified. Shared mental models refer to task-related and team-related knowledge that is collectively held by team members to achieve common patient care objectives (Floren et al., 2018). Shared mental models are an outcome of team learning (van den Bossche et al., 2011). A lack of shared mental models led to differing interpretations of the center’s mission and vision. The focus group and interviews centered on the differing opinions in the team on (a) the extent of patient and family involvement in decision-making, (b) when rehabilitation treatment should be discontinued, (c) the level of integration between disciplines in neurorehabilitation and (d) what processes makes team meetings effective. These topics are elaborated in sub-themes below.

Shared decision making

Shared decision making is an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences (Elwyn et al., 2012). According to both the management and rehabilitation teams, patients and families were under-involved in decision-making. However, in the focus group with the management team, shared decision making was approached purely from the perspective of a caregiver. The rehabilitation team advocated for decisions “beginning and ending with the patient,” and routinely prepared team meetings with patients and families, although the quantity and manner varied depending on the therapist. According to the members of the rehabilitation team, patients and families were frequently too concerned about the outcome of team meetings, indicating a perceived lack of involvement in decision-making. As one rehabilitation team member noted, “the family must now wait until after the fact to be informed. Of course, by then, all decisions have already been made. You can’t truly have an influence if you simply learn about it afterward.”

Treatment discontinuation

Discontinuing treatment is a complex, emotional issue for patients, families, and healthcare providers (Span-Sluyter et al., 2018). Decisions sometimes conflicted within the team, balancing hope for full recovery with the reality of limited outcomes. Managing high hopes for recovery was challenging, and discussions highlighted the delicate balance between optimism and acknowledging reality. The focus group stressed the initial importance of hope in rehabilitation but recognized the eventual need to temper optimism with the truth. Although some saw hope and reality as conflicting, others in the rehabilitation team viewed them as complementary, striving to balance both in decisions about treatment discontinuation.

Integration of care

The integration of care was a major topic discussed by all participants in the study. When shown a continuum of multidisciplinary, interdisciplinary, and transdisciplinary collaboration, according to the team models in neurorehabilitation described by Karol (Karol & Jacobs, 2014), respondents expressed that the preferred state was a combination of interdisciplinary and transdisciplinary collaboration, but that it was situational. At the time of assessment, the team primarily worked in a multidisciplinary manner with occasional interdisciplinary collaboration. Both the management and rehabilitation teams emphasized the importance of specialized disciplines. The rehabilitation team also saw value in seeing patients together as a team to create a joint strategy, but this was hindered by separate therapy schedules. As one team member noted, interdisciplinary collaboration requires proactive organization. Participants highlighted a mutual interest between therapists and nurses in integrating nurses more substantially into therapeutic aspects of patient care, beyond their traditional care roles.

Team meeting processes

Interprofessional team meetings were designed to periodically evaluate and coordinate patient care, a goal that was well understood by all participants. However, a member of the management team questioned whether everyone appreciated the significance of the moment, suggesting that the mandatory nature of the meeting may lead some participants to only think about it while sitting there rather than viewing it as a tool that defines a patient’s treatment process. The effectiveness of interprofessional team meetings depends on certain preconditions. The interviews and focus group discussions revealed that adequate preparation and time management were two preconditions that were the most discussed as bottlenecks.

Preparation for team meetings is considered a crucial precondition, and participants must be adequately prepared to contribute effectively. However, both groups pointed out that this was not always the case. Planning time for preparation into the everyday routine can be challenging, and insufficient preparation was experienced by both physicians and other disciplines. According to a member of the management team, ”I notice that things aren’t thought of or discussed until in the team meeting, which makes the team meeting less effective. Additionally, a rehabilitation team member shared,

The physician always asks “are there any questions regarding the team meeting form?” and then I catch myself that I haven’t actually read it all. While actually I would like to, because when I have read it, I always have a question.

Time management was considered another important precondition for the success of team meetings. Members of the rehabilitation team believed that good time management during the meeting was essential for a successful outcome. However, time was typically stressed in connection with preparation. Most members of the rehabilitation team agreed that enough time was allotted for the team meeting itself, but that the time allotted for preparation was not usually sufficient. Ensuring that these preconditions are met can significantly improve the overall effectiveness of interprofessional team meetings.

Discussion

The aim of this study was to investigate team functioning in a neurorehabilitation team, with an emphasis on factors that impede or facilitate effective collaboration. We focused on the key factors of team identification, psychological safety, and team learning. The findings reveal that despite a strong team identification within this neurorehabilitation team, suboptimal psychological safety hindered the learning process. We will expand on these conclusions in the next paragraphs and contextualize them within existing literature.

Our study indicates that the team’s ability to engage in constructive conflict, which is essential for effective team learning and the development of shared mental models, was negatively impacted by suboptimal psychological safety. This aligns with previous research that underscores the importance of psychological safety in healthcare teams (O’Donovan & McAuliffe, 2020). Concerns about hierarchy, professional norms, and the principle of autonomy, a long-valued characteristic that permits physicians to exercise their expertise independently, may lead such teams to avoid constructive criticism (A. C. Edmondson et al., 2016; O’Donovan & McAuliffe, 2020). In neurorehabilitation teams, where a diverse range of professionals collaborate, this hierarchy can be particularly pronounced. Senior members or those from more traditionally esteemed professions may inadvertently create an environment where other team members feel their contributions are less valued or welcome. Ingrained professional norms can create invisible barriers to team cohesion. Each profession brings its own set of established practices, beliefs, and communication styles, which can lead to misunderstandings or even conflicts when not aligned. Furthermore, the accountability issues that were also identified in this study, have also been recognized in literature as a common source of conflict within healthcare teams (Brown et al., 2011).

Consequently, we discovered a lack of shared mental models in a number of areas, including on shared decision-making and care integration, both of which are essential for patient-centered care. Although patient-centered care has received widespread endorsement across healthcare settings recently (Stiggelbout et al., 2012), adopting these approaches is often found challenging by rehabilitation professionals (Kayes & Papadimitriou, 2023). In our research, we found that team members frequently had divergent perceptions of shared tasks, goals and the desired approach. We know from literature that co-construction and constructive conflict can aid in achieving consensus, as several researchers have shown that teams that engage in these learning processes are more likely to develop shared mental models (McComb & Simpson, 2014; van den Bossche et al., 2011). Therefore, promoting co-construction and constructive conflict can be an effective strategy to improve team learning and performance.

When considering interventions in healthcare to promote team functioning, it is essential to recognize that there is no one-size-fits-all solution, and changing behavior can be a difficult process. Each team is unique, and interventions must be tailored to the team’s context, composition, and goals, taking into account personal motivation and individual preferences (Buljac-Samardzic et al., 2010; Kilpatrick et al., 2020; Shuffler et al., 2011). By recognizing and addressing the specific needs of a team and considering the team’s input in the intervention process, healthcare professionals are likely to enhance team functioning and improve patient outcomes effectively.

Limitations

There are a number of limitations to this study that should be considered. Initially, there was an intention to include nurses in the quantitative analysis; however, due to their distinct employment conditions and a notably low response rate, they were ultimately not included. Notably, we did incorporate the perspective of a head nurse in the qualitative component of the study. We found that participants perceived themselves as being part of various teams. These disparate team definitions and associated dynamics could have influenced questionnaire responses, despite the fact that the questions only pertained to the entire treatment team. Moreover, our qualitative analysis, was based on a relatively small sample size, which could mean that additional insight may have been missed, although qualitative sufficiency was reached after five interviews. A narrow study aim with a targeted group allows for data sufficiency to be achieved with a leaner sample size (LaDonna et al., 2021).

Despite these limitations, the study also had a number of advantages. The use of mixed methods, which included both qualitative and quantitative data collection, is a notable strength. This enabled a more thorough comprehension of the factors influencing team functioning in neurorehabilitation settings. Also, the inclusion of various stakeholders, such as members of the rehabilitation team and the management team in data collection ensured that a variety of perspectives were considered.

Conclusion

Overall, our study contributes to the growing literature on team functioning in healthcare, and more specifically in neurorehabilitation. The results reflect the perspectives and experiences of those who partake in neurorehabilitation teams. They thus provide a unique and valuable viewpoint on the actions that take place inside such a team. Our findings highlight the potential of identifying potential barriers to effective teamwork, so they can be addressed. By doing so, we can improve the quality of care provided to patients requiring neurorehabilitation.

In terms of practical implications, the study offers several important insights. It highlights the significance of psychological safety for team learning, and the development of shared mental models among neurorehabilitation teams. Leaders and managers should therefore prioritize fostering a safe environment that encourages open communication and constructive conflicts. Team members will feel free to express their opinions and ideas, or ask for help without fear of negative consequences thereby facilitating team learning. These findings may be transferable to other settings, offering valuable insights for optimizing team collaboration in other healthcare contexts.

In future research, longitudinal studies may provide valuable insight into the long-term impact of interventions on team functioning. Also, direct observation of team collaboration in daily work contexts, may be a viable next step (Morgan et al., 2015). Future researchers should aim to determine the impact of improved team functioning on patient outcomes, further highlighting the importance of team effectiveness in neurorehabilitation teams.

Acknowledgments

The authors would like to thank all the participants in this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Daan Theeuwes Fonds and the Daan Theeuwes Center for Intensive Neurorehabilitation.

Notes on contributors

Ruud van der Veen

Ruud van der Veen is a physiotherapist and PhD candidate at Amsterdam UMC with a focus on neurorehabilitation research. He aims to enhance care for young adults with severe acquired brain injuries, specifically through pharmacotherapy to improve cognitive functioning, clinical outcome prediction for precision medicine and data-driven healthcare innovation. Van der Veen is also dedicated to optimizing team dynamics in interprofessional rehabilitation care, reflecting a holistic approach to advancing neurorehabilitation practices.

Stéphanie van der Burgt

Stéphanie van der Burgt is Assistant Professor at the Teaching and Learning Centre, Faculty of Medicine UvA. Her PhD research at VUmc School of Medical Sciences on medical specialists’ motivation featured international collaboration, including work at Harvard Medical School. Van der Burgt’s post-PhD career includes a stint at NWO and ongoing postdoctoral research at Amsterdam UMC, AMC, contributing to the fields of evidence-based medical education, quality of care, and personalized medicine with focus on interprofessional collaboration.

Marsh Königs

Marsh Königs is Assistant Professor in developmental neuroscience at Amsterdam UMC. His research is organized in three research lines: Neuroscientific outcome measurement, clinical outcome prediction for precision medicine and data-driven healthcare innovation. Together with prof. dr. Jaap Oosterlaan he is co-lead of the Emma Neuroscience Group, which aims to determine the effects of disease and treatment on brain structure and function in children and young adults.

Jaap Oosterlaan

Jaap Oosterlaan is professor in Pediatric Neurosciences and primarily based at the Emma Children’s Hospital of the Amsterdam University Medical Center with an ancillary affiliation at the Clinical Neuropsychology section of the Vrije Universiteit Amsterdam. At the Emma Children’s Hospital he acts as director of the hospital’s structured multidisciplinary follow-up program for tertiary care pediatric patients. Oosterlaan’s aims at creating better insight in disease and treatment specific patient outcomes and at establishing personalized prognostic models that may help to facilitate prognosis of individual patients.

Saskia Peerdeman

Saskia Peerdeman is a neurosurgeon and board member at Amsterdam UMC, as well as the Dean of the Faculty of Medicine at VU University. She has made significant contributions to neurosurgery and medical education. Peerdeman has served as a staff neurosurgeon at Amsterdam UMC, and her academic roles include professorships focused on professional development and transformative learning in health care. Her dual commitment to clinical excellence, research and educational innovation is evident in her leadership and contributions across healthcare and academia.