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Study skills for master's level students : a reflective approach for health and social care

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Leadership in interprofessional health and social care teams: a literature review

Leadership in Health Services

ISSN : 1751-1879

Article publication date: 15 March 2018

Issue publication date: 20 September 2018

The purpose of this study is to review evidence on the nature of effective leadership in interprofessional health and social care teams.

Design/methodology/approach

A critical review and thematic synthesis of research literature conducted using systematic methods to identify and construct a framework to explain the available evidence about leadership in interprofessional health and social care teams.

Twenty-eight papers were reviewed and contributed to the framework for interprofessional leadership. Twelve themes emerged from the literature, the themes were: facilitate shared leadership; transformation and change; personal qualities; goal alignment; creativity and innovation; communication; team-building; leadership clarity; direction setting; external liaison; skill mix and diversity; clinical and contextual expertise. The discussion includes some comparative analysis with theories and themes in team management and team leadership.

Originality/value

This research identifies some of the characteristics of effective leadership of interprofessional health and social care teams. By capturing and synthesising the literature, it is clear that effective interprofessional health and social care team leadership requires a unique blend of knowledge and skills that support innovation and improvement. Further research is required to deepen the understanding of the degree to which team leadership results in better outcomes for both patients and teams.

• Collaboration
• Health care
• Interprofessional
• Multiprofessional

Smith, T. , Fowler-Davis, S. , Nancarrow, S. , Ariss, S.M.B. and Enderby, P. (2018), "Leadership in interprofessional health and social care teams: a literature review", Leadership in Health Services , Vol. 31 No. 4, pp. 452-467. https://doi.org/10.1108/LHS-06-2016-0026

Emerald Publishing Limited

Copyright © 2018, Tony Smith, Sally Fowler-Davis, Susan Nancarrow, Steven Mark Brian Ariss and Pam Enderby

Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

This paper reports on the results of a critical literature review ( Grant and Booth, 2009 ) that aimed to evaluate the evidence and to present an analysis of leadership in interprofessional teams in health and social care organisations.

Concerns over leadership in the UK National Health Service (NHS) first became an area of focus in the late 1980s when professional management was introduced ( Mackie, 1987 ). When the labour government came to power in 1997, leadership capacity was recognised as a critical factor in the reform agenda; to modernise the NHS ( Goodwin, 2000 ). The Department of Health set up a National Centre for Leadership in 2001 as part of the NHS Modernisation Agency and this led to a plethora of leadership initiatives commissioned by NHS organisations that included public health ( McAreavey et al. (2001) , a range of leadership frameworks ( Bolden et al. , 2003 ) and competency frameworks ( Bolden et al. , 2006 ). For nearly two decades, leadership development has been a priority within health care but less attention has been given to the effectiveness of leadership on the outcomes of teams. Reports on health service failures at an organisational level have further regularly identified poor leadership as a contributory factor in criminally negligent care ( Keogh, 2013 ; Francis, 2013 ; Berwick, 2013 ).

The Kings Fund (2011) has consistently calls for replacement of heroic leadership models which focus on the development individuals in favour of an increased focus on shared/collective leadership models and extension of leadership development efforts to all levels. The continuing erosion of professional divisions in intermediate care and particularly community services has been driven in part by the ambition to create integrated services has enabled health and social care professions to increasingly work together around discrete stages of patient pathways ( Ovretveit, 1997 ; Pollard et al. , 2005 , Means et al. , 2003 ).

The formation of interprofessional teams has brought the issue of leadership to the fore with the challenge of enabling sometimes large teams of different professionals and differently skilled workers to coordinate their efforts and work more closely together than was traditionally the case. This integration agenda is not straightforward, however, as it fundamentally contradicts many of the fundamental tenets of professionalism ( Reeves et al. , 2010 ), with health-care leaders sharing responsibility across services, for the delivery and outcomes of care.

Thylefors et al. (2005) developed a useful taxonomy to understand the level of integration of work practices in health-care teams consisting of a range of professions/disciplines.

“Multiprofessional” teams have no focus on collective working. Professionals treat the patient independently, without the input of other team members. This model represents the customary form of health-care delivery in which doctors traditionally took responsibility for coordinating independent contributions to the care of patients.

Interprofessional working encapsulates the core notion of teamworking, where outputs are measured and based on the collective effort of team members working with the patient. Effective care is accomplished through the interactive efforts of health-care workers, with some responsibilities shared, requiring collective planning and decision-making ( Day, 1981 ; Sicotte et al. , 2002 ).

A study of the effects of multiprofessional and interprofessional team approaches on teamwork; and team effectiveness for rehabilitation teams, found that interprofessional teams showed significantly better results for nearly all aspects of teamwork and team effectiveness measured ( Korner, 2010 ).

This paper presents a review of leadership in interprofessional health and social care teams, seeking to identify elements that are characteristic of and/or associated with higher performance and achieving better patient outcomes.

Critical review is undertaken as a method for enabling new conceptual insights by seeking to embody existing or derive new theory from existing literature ( Torraco, 2016 ). A potential difficulty with the approach is that the evaluation of contribution is dependent on the type of evidence. In management literature, publications about the topic may be small in quantity, of poor quality, and/or inconsistent in terms of both the application of methods and epistemology ( Tranfield et al. , 2003 ).

In addition, systematic reviews in management literature need to relate directly to the context of health and social care ( Easterby-Smith et al. , 2008 ) to be considered the best evidence available, even though these may not be rigorous experimental studies of the type normally conducted within the medical sciences and may even propose theory where no empirical evidence exists.

Review questions/objectives

The specific aim of the review was to describe facets of leadership within interprofessional health and social care teams and generate a thematic framework that explains and develops conceptual understanding of that role.

research and grey literature on interprofessional team leadership in health and social care, to appraise any key theoretical constructs and tested variables; and

research and grey literature relating to interprofessional health and social care team working, commenting on interprofessional team leadership.

The search strategy was designed to access peer-reviewed, published studies for the period 1994–2015. This time period was determined as significant, based on the policy context i.e. Department of Health had begun to focus increasingly only patient pathways and interprofessional working to improve patient care (NHS Plan 2000 – www.nhshistory.net/nhsplan.pdf ) and at the end of the period, the Five Year Forward View ( NHS England, 2014 ) outlined and consolidated the ambition to commission and provide integrated health care with significant focus on the leadership of new services and ways of working ( Ham and Murray, 2015 ) .

Cochrane database of systematic reviews;

Health management information consortium;

NHS Confederation;

Department of Health;

King’s Fund; and

University of Sheffield, STAR library database.

A search using all identified relevant keywords and index terms (see Table I ) was then undertaken across all included databases. Hand searching included reference lists of all identified reports and articles, which were screened to identify additional studies and relevant texts in the grey literature referring to interprofessional team leadership in health services. The search was then extended to include any identifiable reference to “team-working” and interdisciplinary, which were broader than interprofessional, to identify any mention of team leadership in a health context. An additional reason for the extension was in recognition of unqualified or non-professional staff who are part of the teams caring for and treating patients. Finally, the search terms identified a range of team and service outcome metrics that refer to the process of care and the impact of care typically using outcomes of service/team rather than health status or health outcome.

Table I below outlines the key search terms and Table II provides the terms used for the additional focus on potential outcomes of team leadership within the care context.

Inclusion and exclusion criteria

The critical review aims to develop an evidence-based theoretical understanding of interprofessional team leadership, including conceptual models for practice. It is based on empirical findings or narrative examples from practice, described and/or evaluated. Selection began with an initial screening of the papers by title and abstract using the specific decision rules to identify relevant papers. A set of decision criteria were developed; to identify relevant papers that would distinguish between leadership theories in health care and those particularly referring to interprofessional teams. The initial categories related to main methodology i.e. empirical study, qualitative research, or a narrative study, or systematic review. This method sorted papers and enabled authors to select key papers related to the review objectives and enhanced decisions about which papers to include or exclude ( Paterson et al. , 2001 ). Further selection identified any papers including reference or outcomes achieved through interprofessional team leadership in health and social care. As there were few papers specifically on this topic, the search was extended to include papers on interprofessional teamwork, again allowing leadership to become the emerging narrative within publications on health care team practice. Owing to the dearth of literature on inter* (professional, disciplinary) team leadership publications discussing primary or secondary research on interdisciplinary team leadership, or interdisciplinary team working were included. Papers that had no apparent evidence base were excluded from the review and these included opinion pieces and editorials with particular views of a single author.

A mixed methods quality appraisal tool was then used to evaluate the selected empirical studies and this was also adapted and applied to the descriptions of teams and clinical practice context. Table III includes the quality assessment criteria used for the study. Evaluations of leadership or team outcomes and processes were included and the content re-viewed for satisfactory description and relevant content.

Data extraction and synthesis

Data extraction was undertaken manually using an excel spreadsheet designed for the purpose of categorising findings. Papers were read and re-read as full text and emergent ideas were identified with key ideas and theories recognised and noted. The Ritchie and Spencer (1994) “Framework” approach was adopted to code the data and further analysis was undertaken using the findings from the selected reports (grey literature). This approach was chosen, because it was both rigorous and permitted the analysis of original data but was also open to adaptation and change; allowing methodical treatment of all similar units of analysis and some case comparisons. Principally it was adopted as a means of synthesis that allowed full review of the located data ( Ritchie and Spencer, 1994 ). Following the coding of papers and data extraction into categories a number of preliminary themes were developed. These formed the basis of the framework that could then be used to create some broader, higher order themes and additional data were included, based on agreement with other authors. The framework was continually modified as a deeper understanding of the data was developed, as new data were coded and new themes emerged. The synthesis was completed when all data had been incorporated and items checked to ensure that the framework permitted a robust “container” for the data and permitted a more conceptual analysis of interprofessional leadership.

Searches for Interprofessional Team (working and) Leadership identified a total of 634 texts and after supplementing these searches with relevant papers identified in the interprofessional teamworking literature review and back-chaining through reference lists, 1,419 papers were identified as being of possible interest. All papers contained a combination of the key words used in the search from published literature between 1994 to 2015.

Following full text screening, categorisation by methods to exclude opinion pieces and critical appraisal a total of twenty-eight papers were selected. These were deemed to provide an analysis of outcomes from team leadership and proposed conceptual frameworks of IpTL or discussed elements of IpTL in-depth.

consciously involve team members in, decision-making and delegate responsibilities appropriately ( Day, 1981 ; McCallin, 1999 ; Wilson, 2001 ; Ovretveit, 1997 ; Mickan and Rodger, 2000 ; McCallin, 2003 , Institute-for-innovation-and-improvement, 2010, Sicotte et al ., 2002 ; West et al ., 2003 );

empower team members ( McCray, 2003 );

develop and maintain non-hierarchical structures ( Ovretveit, 1997 ; Krueger, 1987 );

provide information the team requires ( Mickan and Rodger, 2000 );

work to create agreement ( Mickan and Rodger, 2000 ); and

coach colleagues in shared leadership ( McCallin, 2003 ; Maister, 1993 ).

create a climate where staff are challenged, supported, motivated and rewarded ( West et al ., 2003 );

respond to change flexibly ( Suter et al ., 2007 );

facilitate or act as a catalyst for practice change ( Willumsen, 2006 );

act as a role model ( Pollard et al ., 2005 ; West et al ., 2014 ); and

inspire other team members ( West et al ., 2003 ).

enthusiasm ( Pollard et al ., 2005 );

commitment ( Abreu, 1997 );

empathy ( McCray, 2003 ); and

knowledge of people ( Suter et al ., 2007 ).

ensure the team has articulated a clear and inspiring vision of its work ( Lyubovnikova et al ., 2015 );

assure productivity and goals are in line with the organisation ( Leathard and Cook, 2004 );

protect regular time for the team to review its performance ( Lyubovnikova et al ., 2015 ); and

provide feedback about important issues ( Mickan and Rodger, 2000 ; Leathard and Cook, 2004 ).

establish a productive balance of harmony and debate to ensure creativity ( Leathard and Cook, 2004 );

develop innovations and new practice models ( Suter et al ., 2007 ); and

ensure effective leadership and team work processes ( West et al ., 2003 ).

maintain clear communication channels and facilitate interaction processes ( Ovretveit, 1997 ; Suter et al ., 2007 ; Willumsen, 2006 ; Blewett et al ., 2010 );

listen to, support and trust team members ( Mickan and Rodger, 2000 ; Leathard and Cook, 2004 );

initiate constructive debates and share their own ideas ( Mickan and Rodger, 2000 ; Lyubovnikova et al ., 2015 ); and

manage conflict and maintain a productive balance between harmony and healthy debate ( Mickan and Rodger, 2000 ; McCray, 2003 ).

set expectations for working together ( Suter et al ., 2007 );

create a climate of mutual respect ( Ovretveit, 1997 ; Leathard and Cook, 2004 );

ensure cohesion ( Willumsen, 2006 );

develop the interpersonal skills of the team ( Ovretveit, 1997 );

ensure the contextual socialisation of new/inexperienced team members ( McCray, 2003 );

promote interprofessional collaboration ( Suter et al ., 2007 ; McCallin, 2003 ; Branowicki et al ., 2001 ); and

facilitate group reflection on practice ( McCallin, 1999 ; Branowicki et al ., 2001 ).

ensure clarity of leadership ( Nancarrow et al ., 2009 ; West et al ., 2003 ); and

combine strong leadership and high involvement ( Rosen and Callaly, 2005 ).

coordinate tasks ( Mickan and Rodger, 2000 );

manage processes ( Maister, 1993 );

ensure work is allocated work equally ( Pollard et al ., 2005 ); and

set clear tasks ( Ross et al ., 2000 ).

represent the team externally ( Irizarry et al ., 1993 );

ensure necessary resources ( Maister, 1993 );

develop strategies for promoting the work of the team ( Irizarry et al ., 1993 );

demonstrate effectiveness through data collection and evaluation ( Irizarry et al ., 1993 );

ensure the team understands its customers and can exploit new opportunities ( Willumsen, 2006 ); and

develop networks and linkages( Pollard et al ., 2005 ).

recruit externally and develop internally ( Ross et al ., 2000 );

ensure regular supervision and PDR ( Burton et al ., 2009 ); and

assure access to relevant training ( Burton et al ., 2009 ).

high levels of professional expertise ( Maister, 1993 ; Irizarry et al ., 1993 ; Branowicki et al ., 2001 );

demonstrate in-depth understanding of the organisation ( Branowicki et al ., 2001 ) and current development programmes ( West et al ., 2014 );

balance focus between the needs of the patient, organisation and team ( Branowicki et al ., 2001 );

facilitate understanding of context and ensure all perspectives are taken into account ( Abreu, 1997 ); and

knowledge of the professional role of others ( MacDonald et al ., 2010 ).

Facilitate shared leadership

For interprofessional teams to work effectively, each team member must accept responsibility as a member-leader stepping in and out of the leadership role when their professional expertise, particular knowledge of a client, or the situation comes to the fore ( McCallin, 1999 ; Wilson, 2001 ).

This process requires a formal leader who has overall responsibility for the performance of the team, but consciously shares the leadership function facilitating joint decision-making and delegates leadership roles ( Day, 1981 ; Sicotte et al ., 2002 ; Ovretveit, 1997 ; Mickan and Rodger, 2000 ; McCallin, 2003 , Institute-for-innovation-and-improvement 2010, West et al ., 2003 ).

The key mechanism for achieving this is empowerment ( McCray, 2003 ). The leader actively works to develop/maintain non-hierarchical, democratic structures ( Ovretveit, 1997 ; Krueger, 1987 ). They coach team members ( Maister, 1993 ) to develop the skills required ( McCallin, 2003 ) share their ideas, work to create agreement and supply information the team requires ( Mickan and Rodger, 2000 ).

Transformation and change

Transformational leadership is important ( McCray, 2003 ; Irizarry et al ., 1993 ). The IpTL acts as a role model in line with their espoused values ( Pollard et al ., 2005 ; West et al. , 2014 ) to create a climate in which staff are inspired ( West et al. , 2003 ) challenged, supported, motivated and rewarded ( Irizarry et al. , 1993 ); respond to change in a flexible way ( Suter et al. , 2007 ); and facilitate or act as a catalyst for practice change ( Willumsen, 2006 ).

Personal qualities

The IpTL must be able to show enthusiasm ( Pollard et al. , 2005 ), commitment ( Abreu, 1997 ), the ability to empathise ( McCray, 2003 ) and knowledge of people ( Suter et al. , 2007 ).

Goal alignment

The IpTL works to influence the direction and climate of the group to ensure goal alignment with the organisation and productivity ( Leathard and Cook, 2004 ). They do this by ensuring the team has articulated a clear and inspiring vision of its work, creating regular times when it can review it’s performance ( Lyubovnikova et al. , 2015 ) providing feedback to highlight important issues ( Mickan and Rodger, 2000 ; Leathard and Cook, 2004 ).

Creativity and innovation

A productive balance of harmony and debate is vital to ensure creativity ( Leathard and Cook, 2004 ) and development of innovations and new practice models ( Suter et al. , 2007 ). However, teamwork processes and team leadership have been found to consistently predict team innovation ( West et al. , 2003 ).

Communication

The leader must facilitate the interaction processes and develop/sustain clear communication channels in the team ( Ovretveit, 1997 ; Suter et al. , 2007 ; Willumsen, 2006 ; Blewett et al. , 2010 ). They do this by initiating constructive debates and modelling their own ideas ( Mickan and Rodger, 2000 ; Lyubovnikova et al. , 2015 ) and supporting, listening to and trusting team members ( Mickan and Rodger, 2000 ; Leathard and Cook, 2004 ).

The leader must also manage conflict, ensuring a productive balance between harmony and healthy debate ( Mickan and Rodger, 2000 ; McCray, 2003 ).

Team-building

Teamwork is not a naturally occurring phenomenon ( Lyubovnikova et al. , 2015 ). The team leader must therefore invest time in team-building, `setting expectations for working together ( Suter et al. , 2007 ) and creating a climate of mutual respect ( Ovretveit, 1997 ; Leathard and Cook, 2004 ). They work to ensure cohesion ( Willumsen, 2006 ), developing the interpersonal skills of the team ( Ovretveit, 1997 ) promoting interprofessional collaboration through group reflection ( McCallin, 1999 ; Branowicki et al. , 2001 ) on practice and ensuring contextual socialisation of new or inexperienced team members ( McCray, 2003 ).

Collaboration is promoted by allowing enough time for discussion and reflection on practice and encouraging staff to interact with those outside their profession ( Suter et al. , 2007 ; McCallin, 2003 ; Branowicki et al. , 2001 ).

Leadership clarity

In spite of growing support for shared/collaborative/collective leadership models there is evidence to suggest that interprofessional teams need an overall team leader to operate effectively ( McCallin, 2003 ).

A 2009 study found that teams with a specific team leader had higher levels of staff satisfaction than teams where the leadership role was split ( Nancarrow et al. , 2009 ). Clarity of leadership is associated with clear team objectives, high levels of participation, commitment to excellence and support for innovation ( West et al. , 2003 ). Primary health-care team members rated their effectiveness more highly when they had strong leadership and high involvement amongst team members ( Rosen and Callaly, 2005 ).

Direction setting

The leader ensures that the team retains a focus on its priorities and goals and that individual team members maintain the correct focus ( Mickan and Rodger, 2000 ). They work to manage team processes ( Maister, 1993 ) including setting clear tasks ( Ross et al. , 2000 ) coordinating work ( Mickan and Rodger, 2000 ) and ensuring equitable allocation ( Pollard et al. , 2005 ).

External liaison

The team leader must exercise external responsibility for the team ( Irizarry et al. , 1993 ) ensuring that it is represented and gains the resources it requires ( Maister, 1993 ). This requires: promoting the work of the team ( Irizarry et al. , 1993 ) the ability to develop networks and linkages ( Pollard et al. , 2005 ) demonstrating effectiveness through data collection and evaluation ( Irizarry et al. , 1993 ) and adopting a marketing orientation to ensure the team understands its clients and can exploit new opportunities ( Willumsen, 2006 ).

Skill mix and diversity

The team leader’s role is to ensure that the team contains the right skill mix and diversity to achieve its goals and tasks. This involves both external recruitment and internal development ( Ross et al. , 2000 ) with regular supervision, annual performance reviews and access to relevant training important factors ( Burton et al. , 2009 ).

Clinical and contextual expertise

Professionals will only be accepted into IpTL roles if they prove their professional expertise ( Maister, 1993 ; Irizarry et al. , 1993 ; Branowicki et al. , 2001 ). Knowledge of the professional role of others is also a key competency ( MacDonald et al. , 2010 ). Within this, it is important that the team leader balances focus between the needs of the patient, organisation and team ( Branowicki et al. , 2001 ). Understanding of the organisation’s mission, structure, economics, politics ( Branowicki et al. , 2001 ) and current development programmes ( West et al. , 2014 ) together with a sound historical perspective, are also important to facilitate understanding of context and ensure all perspectives are taken into account ( Abreu, 1997 ).

Discussion and conclusions

An IpTL framework in health care has been synthesised from the available published evidence and has been presented as a range of particular competencies that can be compared to the general management literature related to team management and leadership.

Many factors associated with better team leadership within management literature can also be seen in the IpTL framework. Both bodies of literature include a focus on: achieving organisational goals, managing performance, managing external relationships (boundary spanning activities) and demonstrating technical expertise ( Larssen and LaFasto, 1989 ; Hackman, 1989 ; Stanniforth and West, 1995 ; LaFasto and Larssen, 2002 ; Hayes, 2002 ; Hackman, 2002 ; Katzenbach and Smith, 2003 ; Shackleton, 1995 ; Stoker, 2008 ; Burke et al. , 2006 ; Stoker, 2008 ).

In contrast, the IpTL framework specifically highlights a leadership function for the team and the review demonstrates that as well as maintaining the managerial function an interprofessional team requires a person who can promote transformation and change and support creativity and innovation as key elements of their role. Significantly, a meta-analysis by Burke et al. (2006) shows that transformational leadership behaviours, (often linked to change and innovation) can have a potent effect within teams. West et al. (2003) also found that teamwork and team leadership processes consistently predict innovation.

Empowerment appears as a primary focus in the generic team leadership literature as a mechanism for collaboration, but the focus in the IpTL literature is more on shared, collaborative or more recently collective ( West et al. , 2014 ) leadership. Conceptually these factors are distinct, but in the ways they are described appear to have more similarities. The IpTL literature talks more about shared, collective and collaborative leadership, particularly in relationship to professionals within the teams. However, there is a paradox in that there is good evidence that clarity of leadership ( West et al. , 2003 ; Nancarrow et al. , 2009 ) also appears to be important. Other commentators clarify, that shared leadership in IpT’s is facilitated by the team leader ( Krueger, 1987 ; Maister, 1993 ). It may be that shared or collective leadership are more palatable concept to professionals than empowerment as they lend more status to professional expertise and accommodate autonomy rather than challenge it.

The IpTL framework overtly mentions team building as a key activity of the team leader and the wider literature on team leadership also refers to the fact that it takes effort to develop a team ( Stanniforth and West, 1995 ; Hackman, 2002 ; Katzenbach and Smith, 2003 ). In the IpT literature, teamwork is still often an ideal that health and social care organisations are working to attain and a level of complexity is apparently which is to do with ensuring the correct mix and level of skills in the team. The IpTL literature focuses on developing the dynamics within the team as a whole and increasing integrated professional practice, with less attention paid to setting priorities and managing performance.

The literature review also raised some general questions about IpT’s. There is consensus in teamwork literature that teams become less effective as they become larger. However, Nancarrow et al. (2009) found that larger interprofessional care teams providing intermediate and community care for older people produced better patient outcomes, in spite of less satisfaction amongst team members and higher intention to leave. It is not clear from these results whether there is a limit to this relationship, where the economies of scale and enhanced workforce flexibility delivered by larger services, becomes offset by the impact on teamworking? In a further study ( Nancarrow et al. , 2013 ) comments on the difference between assumed shared decision-making and shared power across professions and the reality; perhaps alluding to the challenges of working across a large multi-professional context.

A second issue is that whilst many of the services that took part in this particular study were called teams, it is unclear how many operate as teams in practice. As already discussed, “team” is a term almost ubiquitously applied to work groups. Certainly, the size and structure of teams in this study are often outside the parameters put forward in the literature on teams. A final issue is the term interprofessional. There are increasing numbers of none professionally qualified staff in health care IpT’s, however their role and function in the literature on interprofessional teamworking and leadership is totally absent. We would therefore propose that that interdisciplinary is a more suitable term to use as it is broader and inclusive of all team members.

What is different about IpTL in health care appears to be the unique context in which it is applied. The multiprofessional nature of the workforce in health, the public service setting, their function and the contexts that they operate within, make the dynamics in health care IpT’s differ from the dynamics of teams in other settings. This difference seems to be highlighted by West et al. (2014) who advocate collective, distributed leadership practices for the NHS as a whole that resonate closely with the findings of this review.

Further, the literature does indicate that there are some elements of leadership practice, which may be particularly effective in interprofessional team settings. Perhaps the key issue highlighted is the fact that the operational workforce within health and social care is predominantly multi-professional in nature. Increasingly these professionals, together with other disciplines, are working together in a more integrated fashion. The creation of IpT’s has therefore created a unique leadership context. Whereas traditionally professions would be functionally led (i.e. doctors by doctors, nurses by nurses) by a professional with recognised expertise, in IpT’s, this functional leadership divisions are impossible to sustain. The leader can at most be only from one profession or discipline and therefore cannot therefore demonstrate greater professional expertise in other professions. This makes IpT leadership more demanding as the team leader, needs to find a way of leading a diverse professional workforce, without being able rely on professional credibility as a locus of authority. Further, the IpTL needs to be able to find ways to persuade an interprofessional group, to give up some professional autonomy, to integrate their practices and operate as a team.

This critical literature review examines how leaders of interprofessional teams are functioning and the synthesis identifies a framework of factors that contribute to good leadership practice. With a continuing paucity of empirical research data on IpTL, there is still much that is unknown about the IpTL process.

Key search terms for IpTL

Key search terms for outcomes of IpTL

Quality assessment criteria

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Further reading

Department-Of-Health ( 2000 ), The NHS Plan: A Plan for Investment, a Plan for Reform , HMSO , London .

Kings Fund ( 2016 ).

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Corresponding author

About the authors.

Dr Tony Smith is a Senior Lecturer, in Leadership and Organisation Development, at the Centre for Leadership in Health and Social Care, Sheffield Hallam University and has conducted research related to leadership in health and social care teams.

Dr Sally Fowler-Davis is a Clinical Academic Researcher in the Centre for Health and Social Care Research, Sheffield Hallam University and Clinical Research Development Officer for the Combined Community and Acute Care Group at Sheffield Teaching Hospitals.

Susan Nancarrow is a Professor of Health Sciences and Chair of Academic Board at Southern Cross University, Australia. Susan is a Health Services Researcher with a particular interest in health workforce development.

Dr Steven Mark Brian Ariss is a Research Fellow at the School of Health and Related Research, University of Sheffield, UK.

Pam Enderby is a Professor Emeritus of Community Rehabilitation in the School of Health and Related Research University of Sheffield. She is a Speech and Language Therapist and has worked clinically and conducted research related to intermediate care.

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Case study: Taking part in arm fracture research: Sally’s story

Taking part in arm fracture research: Sally's story

A Milton Keynes grandmother who broke her arm in 4 places has urged people to consider taking part in research to shape the future of healthcare after seeing a ‘significant improvement’ in her recovery since joining a local study.

Sally Fennemore spoke a head of International Clinical Trials Day on 20 May, a day of awareness-raising about the importance of health research.

She said she was pleased to be allocated physiotherapy instead of surgery after fracturing her humerus, the upper arm bone in a fall at a friend’s house in October last year. 

The Wavendon grandmother-of-two was assessed in A&E, sent home and prescribed morphine.  She was contacted the following day by the fracture clinic at Milton Keynes University Hospital and invited to take part in the PROFHER-2 study.

The study - funded by National Institute of Health and Care Research (NIHR) - is comparing surgery to physiotherapy alone for people aged over 65 with serious breaks.

Sally, who had never broken a bone before, said: “It was a very bad break and I felt very scared. It was incredibly painful to move my arm and I was covered in bruises.

“When I spoke with the study team, I was certainly still in shock from the fall. The nurses and doctors were very good at explaining what could be involved in the trial and they put me at ease.”

Participants on the study are randomly allocated one of three treatment options:

• Surgery to replace the broken ball at the top of the arm bone and physiotherapy
• Surgery to replace both the ball and socket joint in the shoulder and physiotherapy
• Physiotherapy alone to regain the use of the arm without surgery

Physiotherapy avoids the risks of surgery but it is uncertain whether it is as effective. 

Sally, who received an MBE in 2018 for Services to Female Entrepreneurship and is president of her local Women’s Institute, Wavendon Belles, was randomly assigned physiotherapy.

She said: “I was so happy that I didn't have to have an operation. I’m terrified of hospitals anyway so having an operation would have been horrendous.

“The physio I saw as part of the trial was excellent. She gave me a lot of exercises to do which were painful and difficult at first because my arm and shoulder were so stiff, but the more I practised at home, the easier it became.”

Sally, who ran a PR and event management consultancy in Milton Keynes prior to retiring,  said: “I struggled a lot to do everyday things like put my jumper on by myself. After a few weeks of doing the exercises, I could do it by myself again.

“I only had about 6 sessions with the physiotherapist in the end. The trial team were amazed at how quickly I recovered.”

Sally has stopped physiotherapy sessions but continues to do the exercises daily at home. 

“At an assessment, I was told that my 77-year-old bones are doing very well and that the strength in my arm showed significant improvement. 

“I am so grateful for the treatment I received on the study and I’m thrilled with the outcome.” 

Sally has been married for 29 years to Roger,  said: “My husband and I have been very impressed with the communication from the study team. If I had any problems, I could ring the nurses at any time. 

“I’d say that taking part in these types of research trials is a good idea. I was very well looked after and felt a bit more in control of my treatment.” 

The PROFHER-2 study is sponsored by South Tees Hospitals NHS Foundation Trust and is managed by York Trials Unit. It aims to recruit 380 participants from across 66 UK sites. Results have yet to be published.

Participating in health research helps develop new treatments, improve the NHS, public health and social care and save lives.

The NHS, public health and social care supports research by giving patients opportunities to take part in trials. Healthy people can also take part so results can be compared to those with a medical condition.

Patients are also encouraged to ask their doctor or health professional about research opportunities, view trials seeking volunteers and sign up to be contacted about studies at bepartofresearch.uk  

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An Exploratory Multi-Case Study of the Health and Wellbeing Needs, Relationships and Experiences of Health and Social Care Service Users and the People who Support them at Home

Dr louise henderson.

1 Bon Accord Care, Inspire Building, Beach Boulevard, Aberdeen, AB24 5HP, GB

2 Robert Gordon University, School of Nursing & Midwifery, Garthdee Road, Aberdeen, United Kingdom, AB10 7QE, GB

Dr Heather Bain

3 University of Highlands and Islands, Institute of Health Research and Innovation, Centre for Health Science, Old Perth Road, Inverness, United Kingdom, IV2 3JH, GB

Dr Elaine Allan

Catriona kennedy.

4 The Queens Nursing Institute Scotland, 31 Castle Terrance, Edinburgh, Scotland, United Kingdom, AH1 2EL, GB

5 The University of Limerick, Department of Nursing and Midwifery, Limerick, Ireland, V94 T9PX, GB

Introduction:

International policies and legislation set a precedence of person-centred sustainable integrated Health and Social Care (HSC) that meets the health and wellbeing needs of service users through improved experiences. However, current research focuses on service models, with fewer studies investigating experiences and needs.

This qualitative multi-case [n = 7] study was co-designed with key stakeholders and aimed to explore experiences and needs of people who access and provide HSC at home. Data were collected in a regional area of Scotland (UK) via single [n = 10] or dyad [n = 4] semi-structured interviews with service users [n = 6], informal carers [n = 5] and HSC staff [n = 7] and synthesised using Interpretive Thematic Analysis.

Interpersonal connections and supportive relationships were instrumental in helping all participant groups feel able to cope with their changing HSC needs and roles. They promoted reassurance, information sharing and reduced anxiety; when they were lacking, it negatively impacted upon experiences of HSC.

Discussion:

Promoting inter-personal connections that encourage supportive relationships between people who access and provide HSC and their communities, could promote person-centred Relationship-based care and improve HSC experiences.

Conclusions:

This study identifies indicators for improved HSC, advocating co-produced community-driven services to meet the self-defined needs of those who access and provide care.

Introduction

Many populations across the globe are ageing, with growing numbers of people living with multiple long-term conditions, leading to increased complexity of care provision and rising demand for services [ 1 ]. Integrated Health and Social Care (IHSC) services offer a potential solution to support individual citizens across these populations [ 2 ]. Defining integration can be challenging, it can be seen as a design feature of service provision, organisational structures, or as a medium for delivering person-centred care (PCC) in an efficient way [ 3 ]. To add clarity to its context in this paper, IHSC is considered to be care that is delivered jointly between service users (people who use health and/or social care services), informal carers (people who offer non-contractual support to a service user), and health care and social care (HSC) organisations (including third sector and community initiative groups). Integration aims to promote greater simplicity in public services and facilitate timely, stream-lined access to appropriate HSC [ 4 ]. The actuality for some people who access HSC reflects services that do not always work together to provide care in an integrated way [ 5 , 6 , 7 ]. Moreover, despite widespread acknowledgement in the literature that people who use HSC should be involved in making decisions about their own care, they do not always feel as though they are [ 5 ]. Regional and local access to HSC can be variable, unequal and ill-suited to their needs, being disproportionate to the need and demand for services and reducing access to support [ 8 , 9 ]. There is a plethora of literature containing evidence-based accounts of assessing need, planning, implementing and evaluating IHSC models of care. Whilst these can guide HSC services and sectors in providing care, the experiences of service users can help to decipher health and wellbeing outcomes that are important to them [ 10 , 11 ]. However, there appears to be a paucity of evidence on the experiences of those who access and provide such services.

Research design

Involving stakeholders in this study.

An integrative literature review was conducted as part of the lead authors PhD study. This review identified gaps in current knowledge about the experiences of people who accessed HSC. Findings were discussed with key stakeholders, including people who accessed and provided HSC services and members of the public. Those who accessed and provided HSC offered their verbal and written feedback in a series of three face-to-face roadshow events (April 2018 – Oct. 2019; attendance circa 80 people per event). Members of the public, who had expressed an interest in receiving information about research activity in their local area, also offered their verbal and written feedback in a community network group meeting (Dec. 2019; attendance circa 50 people). Their feedback and findings of the literature review informed the development of a short series of research questions ( Table 1 ), aim and objectives ( Table 2 ) for this PhD study. Their valued engagement, through early fieldwork and wider formal and informal engagement events, continued iteratively throughout this study, later converting to online engagement events under Covid-19 pandemic restrictions.

Research questions.

Key objectives.

Study design and methods

Relationships between stakeholders in HSC, were explored using Yin’s [ 12 ] embedded model of multi-case study design and qualitative methods ( Tables 1 , ​ ,2). 2 ). This design embraced each participant’s unique perspective whilst recognising a need for them to be ‘bound’ to others with whom they had a caregiver-receiver relationship.

Recruitment of contextual study sample

Scotland has an estimated population of 5,479,900, with 32 regional areas that have populations ranging from 626,410 to 22,190 [ 13 ]. Each regional area has one or more Health and Social Care Partnership (HSCP) areas within their geographical boundaries. These HSCPs facilitate operational delivery of an integration strategic plan to meet population health and wellbeing needs in their area [ 14 ].

An invitation to take part was distributed to potential participants in one regional area of Scotland with three HSCP areas, via professional social media accounts and a cascade email to HSCP staff. Service users [n = 6], informal carers [n = 5] and HSC staff members [n = 7] were recruited between September 2019 – February 2020. Participants [n = 18] were grouped in cases [n = 7]. A case was formed when a service user identified one or two people who supported them at home to take part with them.

Five cases had a service user, informal carer and staff member participant. One case contained one staff member participant, after the service user and informal carer withdrew from the study. One further case contained a staff member and a service user, when the informal carer participant withdrew. Cases were labelled A-F and participants were given pseudonyms to protect their identity ( Figure 1 ).

Contextual sample and cases.

Data collection

Data were collected via semi-structured interviews [n = 14] between Dec 2019 – March 2020. Service users chose an individual interview [n = 2] or a dyad interview [n = 4] with their informal carer. All Staff members [n = 7] and an informal carer [n = 1] were also interviewed individually. All interviews were conducted face-to-face, except for two individual telephone interviews [informal carer Esther; staff member Esme].

Data analysis

Simultaneous inter-case and cross-case analysis was conducted to explore the diversity of experiences and HSC needs across cases in the region [ 12 , 15 ]. Interpretive Thematic Analysis facilitated the development of a framework for developing insights, concepts and patterns of meaning across cases [ 12 , 15 , 16 ]. Researcher reflexive field notes, journaling, and ongoing review of the emerging findings promoted transparency and thick-description of methods, analysis and subsequent findings [ 15 , 17 , 18 ]. Analyses were reviewed by supervisors [n = 3] within the research team, and subject to ongoing external review via multiple research forums across both academic and HSC practice. Furthermore, members of the public in a community network group were invited to explore preliminary thematic findings during analysis, to iteratively develop interpretation of the data and subsequent findings [n = 12] (July 2021).

Promoting trustworthiness

Credibility, transferability, dependability and confirmability were promoted by incorporating multiple participant perspectives, pattern matching techniques, ongoing scientific review and involving stakeholders during data analysis, construction of themes and write-up [ 15 , 17 , 18 ]. Ethical approvals were gained in June 2019 at the hosting academic institution (SERP Reference Number: 19-12). Ethical approvals were granted in October 2019 by the UK-wide Integrated Research Application System (IRAS) (IRAS Project ID: 247771; REC reference: 19/NS/0148). They were granted with the IRAS Research Ethics Committee’s recommendation that people with learning disabilities and those with profound mental health issues were excluded (discussed further in the strengths and limitations section below).

Key findings

Context and overview of findings.

To offer context to the experiences participants shared within their case, relevant background information has been included in Table 3 .

Relevant background information for participants and their cases.

Following analysis, making interpersonal connections was identified as an overarching theme central to helping participants meet their health and wellbeing needs and/or those of others. Figure 2 presents five main themes representing the different contexts in which these connections were made, from understanding self, to linking with individuals, communities, services or wider systems. A summary of key factors that enhanced and hindered participants’ connections and experiences of HSC across these contexts is included in Figure 3 .

Overview of themes.

Factors that enhanced and hindered connections and experiences of HSC.

Understanding and coping with changing health and wellbeing needs

Participants across all groups discussed their experiences of understanding and coping with changing health and wellbeing needs or supporting others to do so.

Understanding changing health and wellbeing needs

Service user [n = 6] and informal carer [n = 7] participants’ understanding of their changing health and wellbeing needs, were shaped by their connections with others. They felt their experiences of accessing HSC could be challenging. Some HSC staff had focussed on service users’ medical conditions that were sometimes unrelated to their presenting complaint, suggesting some staff may not be adopting a person-centred approach to care:

[Caitlin, quoting her Gastric Surgeon’s referral letter, gestures air-quotes] ‘Met with Caitlin, slim lady with Multiple Sclerosis, and I recommend that you give her a stoma’ [Catlin pauses, furrows brow and rolls eyes] …that’s when I was an [gestures air-quotes again] ‘MS person’ and nothing else.” Caitlin, service user, HSCP 1 .

All informal carer participants [n = 5] highlighted the impact their caring role had on their health and wellbeing, and their own need for person-centred support in their caring role. However, informal carer Anisha described an encounter with a Social Worker who exhibited a judgemental attitude, questioning her commitment as a wife and her role as an informal carer, when she raised the prospect of becoming unwell herself and the potential that she might not be able to care for Arthur:

“The quote I got thrown back at me was, ‘a good wife would do that for her husband’, and I thought, yeah, if a good wife’s here type of thing but, I didn’t say it, I should’ve said it really or, maybe I should’ve just turned round and said, ‘well, I’m nae a good wife then!’, you know [crosses arms, frowns].” Anisha, informal carer, HSCP 1 .

Informal carers [n = 5] also highlighted the negative impact that increased stress, as a result of their caring responsibilities, had upon their wellbeing. They reported low mood, depression, emotional strain and physical exhaustion. Staff member participants [n = 7] acknowledged their role in supporting service users and informal carers whilst their health and wellbeing needs were changing.

Feeling able to cope with changing health and wellbeing needs

Service user and informal carer participants emphasised a need for support from HSC staff with their changing health and wellbeing needs. They wanted reassurance and support from staff to feel empowered to make decisions about their care, and to access information to help them cope:

“We get an appointment with them, just to go through things… they [HSC staff] don’t make up your mind for you but, they give the necessary information to allow you to come to a sensible decision… you canna make a decision on anything, if you don’t have the facts, you know.” Arthur, service user, HSCP 1 .

For service users and informal carers, coping with changing health and wellbeing needs was also linked to being able to attend to practical tasks, such as managing finances, personal care, eating and drinking, managing continence, housework and shopping tasks. For some, getting ‘out and about’ to meet others [n = 3 informal carers] and contact with HSC staff [n = 4 service users], promoted engagement with communities and social contacts. However, all service user participants [n = 6] reported feeling lonely and isolated, and this was a source of concern for their informal carers [n = 3] and staff members [n = 2].

Fostering connections and supportive relationships with others for health and wellbeing

Participants’ shared their experiences of fostering connections to build supportive relationships, which enhanced their health and wellbeing.

Building supportive relationships between service users, informal carers and HSC Staff

For all participant groups, connecting with others across HSC services, organisations and sectors to build a supportive relationship was facilitated through face-to-face interactions. Staff member [n = 4] and service user [n = 2] participants highlighted co-location of services as a means of promoting this. An interpersonal or ‘friendly’ connection was perceived by all participant groups as a necessary foundation for building supportive relationships. Commonalities between individuals was a key quality of these connections. Service user Donna, who had carers supporting her for a number of years, offers an example of this when she described her experiences of her need to connect with her HSC carer:

“She’s [Donna’s Carer] chatting to me when I’m showering and I, I find out about her family and things, chat about her family and, you know, that sort of thing… … I considered them as friends [her carers] and, I mean, I have a carer now, who’s been coming for over four years, in this company, and, I mean, she’s really efficient and, you know, I’m made to feel really comfortable and all that but, I mean, I said to her one day, do you think of me as a friend, or just another client [hesitates, looks down]… she [the carer] said, ‘well, just another client ’. Donna, service user, HSCP 2 .

During the interview, Donna’s non-verbal body language suggested she was disappointed with the disparity between the meaning her HSC carer had placed on the relationship and her own perceptions of it. For all participant groups, supportive relationships were fostered over a period of time, from a place of trust between two individuals, services or sectors. The opportunity to build up a trusting bond was afforded through continuity of contact between these groups, leading to a perception of more collaborative supportive relationships and HSC practices.

Key characteristics of supportive relationships

Key characteristics required for fostering a supportive relationship, as perceived by all participant groups, included personal attributes of empathy, trust, discernment and reliability:

“I think Beverley works well because I can, I can count on her… I know that she’ll be there and that, that she won’t, you know, she won’t turn up sometimes and not others, that’s really quite important to me.”   Barney, service user, HSCP 1 .

Furthermore, when service user and informal carer participants were looking to foster a supportive relationship with HSC staff, they also wanted those staff to be knowledgeable about their condition and circumstances. All participant groups looked to share information, offer support and reassurance when communicating within supportive relationships. However, communication was perceived as challenging across HSC organisations and sectors. All participants [n = 14] attributed this to inefficient methods of communicating across organisational boundaries, with some staff members [n = 5] reporting system-wide data protection issues when trying to share information about those whom they were supporting.

Connecting with communities for health and social wellbeing

Service user and informal carer participants’ experiences of connecting with communities helped them with practical tasks and to maintain social contacts, which were perceived to improve their health and wellbeing. Communities were defined by service user and informal carer participants as local geographical areas, meaning people who lived nearby. They also described communities, where people had a common interest or role such as a religious church group or a group of informal carers.

Maintaining and promoting practical tasks with support from the local community

Service users and informal carers reported that members of their communities provided valued reassurance and support. Some informal carers [n = 2] asked members of their communities to ‘check-in’ with their service user, and service users asked them to help with local grocery shopping and putting their rubbish bins out for collection [n = 2]. Connections that service users and informal carers had with people in their communities were often perceived as more cohesive than those they had with people from statutory HSC services. They attributed this to community members’ in-depth knowledge and understanding of their needs:

“People that support me, are often people who are integrated into the local community so, people know them, erm, and they kind of know me so, that’s quite important to me, like… they know what I need and they, they know that I can’t walk too far so if, for example… I’d went and got some very heavy shopping; they would pick it up and put it in the car for me.” Barney, service user, HSCP 1 .

However, for service user Grant, connecting with people in his community had become more challenging as local populations increased and neighbourly knowledge diluted:

“The village is expanded so much, everybody before knew who I was and knew who the kids were but, no… you don’t know all the people now, you see, and there isn’t that contact, village contact, if you like… I don’t think it’s that open, er, neighbourly kind of care that used to be. The people probably are more dependent on, er, trained professional people.” Grant, service user, HSCP 1.

People in his community no longer had knowledge of his circumstances, leading to reduced informal support and to Grant feeling disconnected from his community.

Improved health and wellbeing through social contact with people in the local community

Social contact with others had a positive influence on mental health and wellbeing. Previous knowledge of a service users’ circumstances helped community members to connect with them socially. All informal carers [n = 5] felt their service users’ social contact with others should be encouraged to promote mental wellbeing. Although service users wanted to maintain and make new social contacts [n = 4], when informal carer Esther encouraged service user Eddie to have social contact with others, he reminded her that he also needed time to himself:

“He’ll [Eddie] sort of remind us, ‘I’m in my 70s! I actually quite like just sitting on my own sometimes and, like just having, having a wee [small] rest and taking it easy’.” Esther, informal carer (talking about her father, service user Eddie), HSCP 2.

This highlighted disparity between the expectations of some informal carers and service users, with relation to service users’ desire and need for social contact with others.

Connecting with other service users and informal carers to feel supported

Communities played a vital role in supporting service users, promoting connections and supportive relationships with people who knew and understood their circumstances. Maintaining and making connections with other service user and informal carers offered an opportunity for participants to share their experiences and access information about their condition or caring role, whilst offering peer support and social contact. However, not all service users and informal carers wanted to connect with communities of people who had similar circumstances or conditions [n = 2]. They reported anxieties around their future, and a risk of mis-matched expectations between treatment and progression of their condition:

“My dad [Eddie] was sort of freshly diagnosed, he was sort of advised [by another person who also had Multiple Sclerosis] not to go along [to the support group], that he might find it a bit upsetting because there would be people there further along in the disease, in wheelchairs and really unwell. So, I think he sort of put off going” . Esther, informal carer, HSCP 2.

Service user participants who did attend these groups [n = 3], felt supported because they were able to exchange accounts of treatment options, discuss symptoms and disease progression, and connect with people who knew and understood their circumstances. However, it also presented challenges in other areas as highlighted through an anecdotal account from staff member Catherine:

“I suppose it’s a great charity that patients, erm, get a lot out of [the support group], I’m sure. Sometimes their [the third sector organisation] opinions can be quite forceful, and we have to look at treatment options from an evidence-based practice [point of view] as opposed to perhaps what’s purported by the – [third sector organisation].” Catherine, staff member, HSCP 1.

Connecting with HSC services for help to maintain and promote health and social wellbeing

Participants’ experiences of connecting with HSC services helped them maintain and promote their health and wellbeing, with availability, access, coordination and utility of HSC relevant to their needs.

Availability of and access to services, at a time when they were needed

Service user [n = 4], informal carer [n = 4] and staff member [n = 6] participants described their experiences of accessing HSC services, reporting fragmentation and reduced availability. It was important to all participants that service users and informal carers had timely access to services, such as physiotherapy and General Practitioners (GP). Service users [n = 6], informal carers [n = 5] and staff members [n = 7] reported reduced access to respite services, a need for greater flexibility in the way services were delivered, and reduced access to HSC services because of perceived obstructive ‘gatekeepers’:

“But there’s a woman in [location] who, you have to convince that you’re in need of the services.” Barney, service user, HSCP 1.

Some service users [n = 3] and informal carers [n = 3] attributed reduced access and availability of services to financial constraints, and inflexible ways of working across HSC systems. Service user Barney perceived HSC as a ‘post-code lottery’, where services were available in some areas but not others and where the nature of individual HSC staff members influenced care. However, when participants could gain access to services at a time when they thought they needed them, they felt supported and that their health and wellbeing needs were being met.

“She [GP] gives us [Barney and his wife] such good support. It seems to me to be a bit of a lottery [access to a supportive GP], it depends very much on the nature of the, of the particular GP.” Barney, service user, HSCP 1.

Coordinating and organising services within an HSC system

All participant groups were looking for further clarity on the way HSC was set up and organised across their services. Service users [n = 4] and informal carers [n = 5] perceived that having a named point-of-contact helped them achieve this:

“Having a Care Manager [as a named point-of-contact] that, you know, coordinated things, that would refer you if you needed physio or OT or anything like that, that worked very well.” Donna, service user, HSCP 2.

However, not all service users had a point-of-contact. For some, this led to a perception of reduced levels of access to care and coordination. Service users and informal carers were not always involved in planning their own care, leading to them feeling disempowered. When they were involved in planning their care, they felt it was more efficient and timelier. They sought the support of HSC staff to plan for the future in order to ensure their changing health and wellbeing needs would be met. However, service user Arthur and his informal carer Anisha felt their Social Worker had demonstrated a short-term view and lack of pre-emptive planning of their care. Anisha explained that this made her feel as though she had fraudulently requested potentially unreasonable support; her non-verbal communication during the interview portrayed a sense of anger and distaste:

[crosses arms, purses lips, raises eyebrows and clicks tongue on the roof of her mouth] “It made me feel, almost fraudulent, as though I was asking for something that I shouldn’t have been asking for at that stage, or at this stage.” Anisha, informal carer, HSCP 1.

Utilising HSC services to meet health and wellbeing needs

Participants’ use of HSC services to meet their health and wellbeing needs were varied. Some service users and informal carers were able to meet their needs through regular contact with a GP, specialist or wheelchair service. For some service users and informal carers, use of HSC was more challenging. They encountered lengthy waiting times and thought their care was not always appropriate, resulting in them using similar private sector services at their own expense.

“The waiting list is 15 weeks [for physiotherapy input], which isn’t handy if you can’t walk down the stairs! I couldn’t get away from it being sore… I think 15 weeks of that I would just be round the bend.” Caitlin, service user, HSCP 1 .

In addition, time constraints of support visits exerted negative pressure on service users and staff members relationships. For some staff members [n = 3], the relationships they formed with more experienced colleagues were instrumental in helping them to feel supported and boosting their confidence in their role.

Working together across HSC services to promote health and wellbeing

Participants’ experiences of working together across HSC services and systems to promote and maintain health and wellbeing needs highlighted their understanding of ‘integration’. They acknowledged the positive effect that integration could have on HSC services, with pooled information and resources to promote better outcomes for service users and informal carers. However, ‘integration’ appeared to be an abstract concept to many participants (across all groups). Abigail reported a lack of clarity about structural changes, and a lack of communication and preparation for progressing them:

“Integrated HSC started up here maybe a couple of years ago, we were never really given a lot of information about it, naebody [nobody] ever came to speak to us about it and, to be quite honest, we’re nae [not] really sure how it’s supposed to work ‘cause naebody’s ever discussed it with us… I think a lot of our Locality Managers now are HSCP, as opposed to being health board.” Abigail, staff member, HSCP 1.

Services were reported as disjointed, adopting unsafe communication and information sharing practices when bureaucratic processes did not meet the needs of HSC staff, the services or their HSC system. Some staff member participants [n = 6] suggested they needed further information about other HSC services working with people they were supporting. For staff member Debra, personal safety was compromised. She felt she had been placed at risk because of a communication breakdown that left her feeling vulnerable and uncomfortable:

“I had a patient who was very sexually inappropriate towards me, erm, I was just on my own in his house, so I called the Community Nursing staff to let them know [that the person had been inappropriate] but, they’d known about this for a long time and they had already made him double-visits [where two members of staff attend at the same time]. So, I’d been going in for months without knowing this, that was communication breakdown, it wasn’t nice what happened, and that could’ve been prevented had communication been that little bit better or, had we all been on the same system [electronic information system] and that would’ve flagged up for me. That would’ve saved a lot of uncomfortable feeling for myself [looks towards the floor, laughs uncomfortably, hesitates] … so.” Debra, staff member, HSCP 2.

She felt that, had communication in the HSC system been better (through a joined-up electronic information system) this situation could have been avoided, mitigating risk for staff. Promoting trust between people within HSC systems helped to strengthen their supportive relationships and communication, and collaboration was achieved when people were experienced, knowledgeable and flexible in their approach to working with others.

Discussion and theoretical contributions

Findings of this study support the need for significant investment in facilitating and protecting the allocation of HSC staff time to help them develop supportive relationships with service users, informal carers and other staff across HSC systems. This is based on the understanding those in the relationship maintain contact or interaction over a period of time through continuity [ 19 , 20 , 21 ]. Participants highlighted several key characteristics that they perceived as important in interpersonal connections and supportive relationships, which are represented in a typology below ( Figure 4 ).

Typology of interpersonal connection and supportive relationships in HSC.

In addition to the key characteristics of interpersonal connections and supportive relationships, participants across all groups outlined what they perceived as their health and wellbeing needs ( Table 4 ).

Health and wellbeing needs in HSC.

Findings of this study suggest models of HSC should promote the principles of interpersonal connection outlined above, and encourage supportive relationships between service users, informal carers and HSC staff members as a foundational principle of HSC. The concept of connection, through continuity of contact with someone who offers support, has long been acknowledged in relevant models and frameworks as a fundamental principle of PCC for people who access HSC services. Continuity has been advocated across a variety of contexts for many years, to help reduce admissions to hospital, lower HSC costs, and promote Service User and staff satisfaction [ 22 , 23 ]. Findings of this study support a significant investment in facilitating and protecting the allocation of HSC staff time; it can help them to develop supportive relationships with service users, informal carers and other staff across HSC systems.

Many existing frameworks, theories and concepts identify key principles for integrating, improving and delivering HSC and PCC [ 5 , 24 ]. Some key theories were considered when interpreting participants experiences in this study. It is suggested that the findings outlined add to these. When interpreting participants’ experiences of fostering connections and relationships in a care provider-receiver context, behaviours linked to applications of Bowlby’s Attachment theory across the lifespan, were instrumental [ 25 , 26 , 27 ]. To further acknowledge the influence of connection in an HSC environment, a ‘blended’ theoretical lens was adopted. Caring Theory [ 28 ], Person-centred Care [ 29 ], Relationship-Based Care theories [ 30 ] and evidence informed propositions about experiences of people who access HSC [ 5 ] were combined. Figure 5 , blends these key theoretical constructs and contextual influences that were important to study participants.

Theoretical and contextual influences: People-centred Relationship-based Care.

These theories and propositions intersect as People-centred Relationship-based Care, reflecting the key concepts of ‘integrating HSC’, as identified by the study participants: people, services and systems being ‘connected’ through supportive relationships; encouraging knowledge and understanding between people who access and provide HSC; being involved in making decisions about their own care or role, and working together to meet a shared desire for truly individualised care.

Key learning and application to HSC practice

In an online engagement event, members of the public, HSC service users, and informal carers, offered their insights on how this study’s findings might be applied to HSC practice in their local areas [n = 12] (July 2021). They were clear that they wanted their services to provide streamlined and holistic HSC, regardless of organisational or sectorial boundaries. The concepts of People-centred Relationship-based Care have been framed from the viewpoint of participants and entitled ‘My People-centred Relationship-based Health and Social Care’ (PRHSC) ( Figure 6 ).

My People-centred Relationship-based Health and Social Care (PRHSC).

The PRHSC model and its underpinning theories add an original perspective to key concepts of integrating HSC, as perceived explicitly by the people who are at the very centre of accessing and providing it (service users, informal carers and staff members). Furthermore, it could be argued that it could complement existing models of IHSC, for example, the International Foundation for Integrated Care’s nine key conceptual ‘Pillars of Integrated Care’ [ 31 , 32 ]. The PRHSC model’s underpinning blended theories ( Figure 5 ) align closely with fundamental human rights, contributing to social justice by promoting equality and inclusion [ 33 ]. They highlight key insight into participants’ perceptions of integrated care in HSC practice. The application of the PRHSC model should be tested across different groups of people who access HSC in a variety of settings, to establish reliability and the viability of its use. Further exploration of the potential transferability of findings beyond HSC would be warranted across wider communities. For example, industries or public service sectors where elements of caring are incorporated, such as policing or education. It could be argued that these communities may also benefit from a deeper understanding of interpersonal connections and supportive relationships to inform the caring elements of their work.

Strengths and limitations

The active part that members of the public and key stakeholders played in developing ideas, study design and refining interpretations, is key to the credibility of these findings. A further strength is its multi-case embedded design, which allowed multiple perspectives of participants’ reality to be represented in the data within each case. Reflexivity incorporating reflection, curiosity and consultation with key stakeholders and the research team, underpinned the entire research process thereby increasing the trustworthiness and transferability potential of these findings.

A potential limitation to the transferability of these findings is the contextual nature of HSC with the study population being from two HSCPs in one region in Scotland. In line with the ethics panel recommendations (Section 2.2.4), people who have learning disabilities or profound mental health issues were excluded from this study. This is recognised as a limitation and including these communities could have added depth of understanding and promoted relevance to wider practice areas [ 34 , 35 , 36 ].

The overarching purpose of this study was to explore and better understand the health and wellbeing needs, experiences and relationships of people who accessed HSC and the individuals who supported them at home. Interpersonal connections that developed into supportive relationships were perceived by participants in all groups as instrumental in helping them feel able to cope with their changing HSC needs and roles. Supportive relationships promoted reassurance, information sharing and reduced anxiety; when they were lacking, it negatively impacted upon their experiences of HSC. This study highlights that connections, relationships and cross-sectoral working are important and entirely necessary for integrating HSC services. It is important that policy makers and HSC providers recognise the contribution communities can make to HSC; those communities come in many forms, and one model of integrating HSC does not fit all. No one person or service can provide the whole care-package, and all those who access and provide HSC need to have an equal voice. If the integration of HSC is to be improved, we as a society, must be clear on what is expected of HSC services and systems, and how we prioritise the limited resource across all contexts of HSC to meet health and wellbeing needs.

Prof Anne Hendry, Senior Associate, International Foundation for Integrated Care (IFIC), Director, IFIC Scotland , Honorary Secretary, British Geriatrics Society, Honorary Professor, University of the West of Scotland, UK.

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Complex Care in Nursing

• Sally-Anne Wherry - University of Gloucestershire, UK
• Nikki Buck - University of Gloucestershire, UK
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A highly recommended resource for student nurses!  The content from the book gave a broad understanding of how health care professionals can care for individuals living with long term conditions. It highlighted the barriers and challenges they face daily and ways we can support individuals to live a life that is fulfilling for them. The knowledge I have gained from this has been incredibly valuable, which I will take forward into my practice.   

A thought-provoking read It is refreshing to see so many important issues brought together in an easily read format. […] The book does a great job of introducing concepts before engaging the reader with a scenario or a case study … [I like] the use of ‘Experts by Experience’ throughout the book (as it brings the subject to life), and the friendly and accessible style of writing.  

An excellent read, focusing on the importance of holistic assessments when caring for individuals living with long-term conditions. The book gives a broad understanding of the challenges and barriers people face daily, and the different ways health care professionals can support individuals to live a life that is fulfilling for them. Throughout the book, case studies are shared giving readers an insight into the lived experiences of people living with long-term and complex conditions.

The knowledge I have gained from this book has been thought provoking and incredibly valuable which I will take forward into my future practice.   

We have adopted this book as essential and recommended reading as it aligns with much of the syllabus and learning outcomes of the module.

Some good pointers and models of care to consider when explaining to students the complexity of care delivery

Essential text to support my current field in regards to learning and teaching complex care.

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Sally - James Case Study - Sociology Assignment help

Assignment Task:

Purpose of this assignment

The aim of this assignment is to enable you to develop an understanding of the technologies used to support users of health and social care services in living independently. You will need to develop your knowledge and competency level to understand the benefits of these technologies and the health and safety considerations associated with them in a health and social care environment.  On completion of the unit and assignment, you will have a clear understanding of:

1. The use of technology to support independent living for users of health and social care services ( Learning Outcome 1) 2. The implications of technological developments for use in health and social care (Learning Outcome 2) 3. Specific recommendations of technologies to support independent living for users of health and social care services  (Learning Outcome 3)

Case Study 1: 

Sally is a 42-year-old female who presents to her GP with complaints of tingling and numbness in her left foot, 18 months later she also complained of double vision. Consultation with a neurologist at that time resulted in a diagnosis of multiple sclerosis. She was placed on disease-modulating medication and educated about lifestyle changes to avoid fatigue, which manages her double vision, with the exception of long workdays. The GP refers her to a vision specialist for management of the impairment of double vision that interferes with activities and participation in her job as an account executive. The GP has also requested the assistive technology specialist to provide information and education about other assistive devices that are available should she develop additional impairments. 

A vision specialist recommended an eye patch for use when warranted and suggested she stays in touch with the assistive technology specialist should other problems arise. Two years later, Sally returned to her GP with complaints of weakness and numbness in her right side (upper and lower body). These new impairments interfered with her ability to drive to and from work and chauffeur her children to soccer and other after-school activities. Her function at work has been greatly compromised as well. She was experiencing difficulty with typing, maneuvering around the building, holding her lunch tray, and performing other activities of daily living. She was referred to the Occupation Therapist for an ankle-foot orthosis (AFO) for the right foot and a cane to improve her mobility, and she was also referred to the Assistive Technology Specialist for consideration of alternate input methods for the keyboard. A keyboard was chosen that covered a larger surface with large black letters surrounded by a yellow background. Both specialists worked together to identify other aids to facilitate additional activities, such as Sally's personal care activities using a dressing stick and toothbrush handles; cooking using kitchen aids, including jar openers, recipe cardholders, and large-handled pots and pans; and gardening using adapted gardening tools.  The GP referred her to a driver's trainer specialist to adapt her vehicle with a spinner knob and left foot accelerator and to train her in this new way of driving. At this time, the GP also referred her to a social worker for support and counseling regarding her finances, work, and personal life decisions. Throughout the previous 4 years, Sally's family has noticed changes in her memory function. After the psychologist completes a cognitive evaluation and identifies strengths and weaknesses, Sally was provided a hand-held personal digital assistant (PDA), called the "Pocket Coach," to aid in her memory skills. This device enabled her to push a single button to remember "what to do next." It assisted her to remember to complete task activities and to manage important aspects of her healthcare, such as taking medications and nutritional supplements. 

Case study 2:  James is 59 years of age. He suffers from Learning disability, limited mobility and chronic health problems which include Epilepsy and Diabetes type 2. In Nov. 2012, he fell to the floor with a suspected heart attack and could not reach the alarm/emergency cord in her room for help. He was admitted in the hospital for nearly month. On discharge, he expressed his wishes to go back to his self-contained flat in Sunshine Sheltered Accommodation so that he could continue to live independently. 

Using the case study above, or your own case study: 1. Identify James’s specific needs in order to support him to live independently (3.1).  2. Make your own recommendations on how Technology might support her independent living arrangements. (3.2) 3. Evaluate the usefulness of technology for James and also for other users of health and social care services. (3.3)   LO 1 1.1 Explain how technology can be used to support users of health and social care services in living independently. 1.2 Analyse barriers to the use of technology to support users of health and social care services in living independently.  1.3 Explain the benefits of these technologies to health and social care organizations and their users. 

LO 2     2.1 Explain health and safety considerations in the use of technologies in health and social care 2.2 Discuss ethical considerations in the use of technologies in health and social care 2.3 Explain the impact of recent and emerging technological developments on health and social care services, organizations and care workers

LO 3      3.1  Identify the specific needs of an individual requiring support to live independently 3.2 Make recommendations for how technologies might support the independent living arrangements 3.3 Evaluate the usefulness of technology for users of health and social care services

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Intraurban social risk and mortality patterns during extreme heat events: A case study of Moscow, 2010-2017

Affiliations.

• 1 Russian Presidential Academy of National Economy and Public Administration, 119571, Prospect Vernadskogo, 84, Moscow, Russian Federation; Lomonosov Moscow State University, Faculty of Geography, 119991, Leninskiye gory, 1, Moscow, Russia. Electronic address: [email protected].
• 2 Lomonosov Moscow State University, Faculty of Geography, 119991, Leninskiye gory, 1, Moscow, Russia. Electronic address: [email protected].
• 3 Lomonosov Moscow State University, Faculty of Geography, 119991, Leninskiye gory, 1, Moscow, Russia; Lomonosov Moscow State University, Research Computing Center, 119234, Leninskiye gory, 1c4, Moscow, Russia; A.M. Obukhov Institute of Atmospheric Physics Russian Academy of Science, 119017, Pyzhyovskiy Pereulok, 3, Moscow, Russia; Moscow Center of Fundamental and Applied Mathematics, GSP-1, Leninskie gory, 1, bld.1, 199991, Moscow, Russia. Electronic address: [email protected].
• 4 Lomonosov Moscow State University, Faculty of Geography, 119991, Leninskiye gory, 1, Moscow, Russia. Electronic address: [email protected].
• 5 Russian Presidential Academy of National Economy and Public Administration, 119571, Prospect Vernadskogo, 84, Moscow, Russian Federation; Lomonosov Moscow State University, Faculty of Geography, 119991, Leninskiye gory, 1, Moscow, Russia. Electronic address: [email protected].
• 6 National Research University Higher School of Economics, International Laboratory for Population and Health, 101000, Myasnitskaya st., 20, Moscow, Russia. Electronic address: [email protected].
• 7 National Research University Higher School of Economics, International Laboratory for Population and Health, 101000, Myasnitskaya st., 20, Moscow, Russia. Electronic address: [email protected].
• 8 Lomonosov Moscow State University, Faculty of Geography, 119991, Leninskiye gory, 1, Moscow, Russia; National Research University Higher School of Economics, Faculty of Geography and Geoinformation Technology, 109028, Pokrovsky bvd, 11, Moscow, Russia. Electronic address: [email protected].
• PMID: 32992266
• DOI: 10.1016/j.healthplace.2020.102429

There is currently an increase in the number of heat waves occurring worldwide. Moscow experienced the effects of an extreme heat wave in 2010, which resulted in more than 10,000 extra deaths and significant economic damage. This study conducted a comprehensive assessment of the social risks existing during the occurrence of heat waves and allowed us to identify the spatial heterogeneity of the city in terms of thermal risk and the consequences for public health. Using a detailed simulation of the meteorological regime based on the COSMO-CLM regional climate model and the physiologically equivalent temperature (PET), a spatial assessment of thermal stress in the summer of 2010 was carried out. Based on statistical data, the components of social risk (vulnerabilities and adaptive capacity of the population) were calculated and mapped. We also performed an analysis of their changes in 2010-2017. A significant differentiation of the territory of Moscow has been revealed in terms of the thermal stress and vulnerability of the population to heat waves. The spatial pattern of thermal stress agrees quite well with the excess deaths observed during the period from July to August 2010. The identified negative trend of increasing vulnerability of the population has grown in most districts of Moscow. The adaptive capacity has been reduced in most of Moscow. The growth of adaptive capacity mainly affects the most prosperous areas of the city.

Keywords: Adaptive capacity; Heat wave; Physiologically equivalent temperature (PET); Urban heat island (UHI); Vulnerability.

Copyright © 2020 Elsevier Ltd. All rights reserved.

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