Journal of Interprofessional Care,

December 2007; 21(6): 669 – 686

Therapists’ experiences and perceptions of teamwork in

neurological rehabilitation: Critical happenings in effective
and ineffective teamwork

KITTY M. SUDDICK1 & LORRAINE H. DE SOUZA2

1
Senior Lecturer in Physiotherapy, University of Brighton, and 2Director of Centre for Research in
Rehabilitation, Head of School of Health Sciences and Social Care, Brunel University, Uxbridge,
Middlesex, UK

Abstract
This paper reports the second part of an exploratory study into occupational therapists’ and
physiotherapists’ perceptions and experiences of teamwork in neurological rehabilitation: the factors
that were thought to influence effective and ineffective teamwork, and the meaning behind effective
and ineffective teamwork in neurological rehabilitation. The study was undertaken through semi-
structured interviews of 10 therapists from three different neurological rehabilitation teams based in
the United Kingdom, and used the critical incident technique. Through analysis of the data, several
main themes emerged regarding the perceived critical happenings in effective and ineffective
teamwork. These were: team events and characteristics, team members’ characteristics, shared and
collaborative working practices, communication, specific organizational structures, environmental,
external, and patient and family-related factors. Effective and ineffective team-work was perceived to
impact on a number of levels: having implications for the team, the patient, individual team members,
and the neurological rehabilitation service. The study supported the perceived value of team work
within neurological rehabilitation. It also indicated the extensive and variable factors that may
influence the team-working process as well as the complex and diverse nature of the process.

Keywords: Teamwork, neurological rehabilitation, critical incident technique, critical happenings,

effective and ineffective team work

Introduction
Teamwork is a fundamental component of health-care delivery in the United Kingdom, and
is utilized in the management and rehabilitation of neurological patients. Teamwork has
been supported in the National Service Framework for Long-term Conditions (Department
of Health Long-term Conditions NSF Team, 2005), the National clinical guidelines for
stroke (Intercollegiate Stroke Working Party, 2004) and the National Institute for Clinical
Excellence (NICE) guidelines for Multiple Sclerosis (NICE, 2003).
In 1989 the presidential address at the American Congress of Rehabilitation Medicine
(ACRM) described teamwork and the interdisciplinary team as the cornerstone of
rehabilitation (Diller, 1990). Interdisciplinary teamwork and collaborative methods of

Correspondence: Kitty Suddick, MSc, BSc (Hons), MCSP MHPC, Senior Lecturer in Physiotherapy, School of Health
Professions, University of Brighton, Robert Dodd Building, 49 Darley Road, Eastbourne BN20 7UR, UK.
Tel: þ44 (0)1273 643516. Fax: þ44 (0)1273 643652. E-mail: [email protected]

ISSN 1356-1820 print/ISSN 1469-9567 online Ó 2007 Informa UK Ltd.

DOI: 10.1080/13561820701722634
670 K. M. Suddick & L. H. De Souza

working have been reported to have a number of benefits to the organization and the
provision of the service. However, Schmitt (2001), in reviewing the literature concerned
with collaborative health care delivery research in the United States, challenged the generally
held assumption that interdisciplinary working and collaborative models of care would
provide cost effective services and at the same time automatically increase quality of care.
Research has so far been unsuccessful in determining whether the causal relationship
between teamwork and improvements in effectiveness and quality of care that have been
hypothesized in the literature, can be substantiated. The effectiveness, efficiency, and cost of
these specific collaborative methods of working have not yet been established (Barr, 2000).

Evaluating the effectiveness of teamwork in neurological rehabilitation

Opie (1997) has cited Guzzo’s (1986) distinction between the two aspects from which the
effectiveness of teamwork can be measured: ‘‘intermediate’’ effectiveness (the effectiveness
of the team process) and ‘‘ultimate’’ effectiveness (the group output). Studies that have
investigated outcome from an ultimate effectiveness perspective when comparing team and
non-team care for neurological patients (Wood-Dauphinee et al., 1984) are minimal and
have been unable to support the individual benefits of teamwork. Although some research
on Stroke Units has attempted to indirectly support the contribution of teamwork to the
Stroke Unit benefits reported in the literature, (functional ability, survival, and patients
placement on discharge) (Indredavik et al., 1999, Stroke Unit Trialists Collaboration,
1997), they have not provided conclusive supporting evidence.

Determinants of effective and ineffective teamwork

For interdisciplinary teamwork to occur effectively group co-operation is required
(Armitage, 1983; Barr, 1997; Feiger & Schmitt, 1979). Barr (1997) outlined the actions
that may assist in developing interdisciplinary team work processes: development of team
aims and priorities, clear lines of accountability, recognition of the importance of operational
procedures and culture, evaluation of the meeting of team targets, investment in team
training and the provision of time for development, personal commitment to developing new
skills, openness to learn from colleagues and reflect on ones own practice, establishing and
monitoring agreed understandings for vague concepts, and to be prepared to accept the
difficulties as well as the advantages of team work. Factors that may restrict interdisciplinary
working: differences in priorities, aims, and objectives, confusion over accountability, lack of
understanding of the team process and the team members’ role and responsibility within it,
as well as interpersonal skills (Barr, 1997): have also identified. Freeth’s (2001) review
suggested that a large number of studies highlighted the problems teams face over arguably
quite mundane matters (i.e., timing and venues of meeting, and environmental factors).
Other factors cited have included staff turnover, lack of team learning, and time from patient
referral to service access (Gibbon, 1999). The breadth of literature on this topic has covered
health care teams across specialities, but little has been specifically undertaken on teams
working in neurological rehabilitation.
Freeman et al. (2000) found that in a neurological team, the teamwork philosophy held by
the team or individual members had an influence on observed work behaviour. Those
holding an integrative team work philosophy (similar to that of interdisciplinary team work)
undertook behaviours that supported complex communication requirements, including
wide discussion and negotiation, equal status of members and a shared importance
regarding the team and how it functions. Sharing the same working philosophy may assist in
 Teamwork in neurological rehabilitation 671

the team working process. Pound & Ebrahim (2000) demonstrated that physiotherapists
based on an elderly care ward communicated and shared information with members of the
nursing team who held a similar rehabilitation philosophy.
The importance of team communication in the neurological team working process has
been discussed in a number of literary papers and a number of strategies have been reported:
joint treatment areas and treatment sessions (Davis et al., 1992; Pound & Ebrahim, 2000),
team multi-disciplinary note system (Gibbon et al., 2002; Molyneux, 2001), and assessment
forms (Stead & Leonard, 1995), shared offices/team base (Molyneux, 2001), team meetings
and ward rounds (Pound & Ebrahim, 2000), weekly case conferences (Molyneux, 2001),
specific communication systems (Davis et al., 1992; Pound & Ebrahim, 2000), shared
responsibility of the team to inform the key worker (Davis et al., 1992), and the size of the
team (Molyneux, 2001). However, how these factors influence the team working process
and the team working outcome remains unclear due to the complexity of the processes
involved and the limited research undertaken. Gibbon et al. (2002) demonstrated that the
introduction of shared notes and integrated care pathways did not result in changes in
attitude to team working in the four different stroke units studied.
Greater information concerning the teamwork process and its influence on the
collaborative effort is needed. There may be processes and structures used by neurological
teams to promote aspects of team communication, co-ordination, goal setting, joint decision
making, problem solving and team reflection and evaluation that have not been identified
within the literature. There may be specific issues in each team dependent upon their
individual structure and context. Pethybridge (2004) determined that factors perceived to
assist good team working in four different medical and stroke teams, in regards to decision
making and discharge planning were: sharing, consensus and agreement, trust, being in a
learning culture and good leadership. Opie (1997) when presenting a detailed single team
discussion around a complex patient with cognitive and physical impairments; highlighted
the team’s lack of analytical or reflective practice and suggested that this limited the
effectiveness of the team working effort. Molyneux (2001) has reported how open discussion
around the management of individual cases and ongoing reflection in a community-based
stroke rehabilitation team, appeared to assist the team in providing a patient focused model of
care and creative and practical solutions. Structured reflection as a team and the commitment
to problem solving and open communication to provide solutions may be required for teams
to work effectively and adapt alongside the changing face of health care provision.
Joint goal setting is an important process within rehabilitation (Wade, 1998) and a pre-
requisite for adopting the interdisciplinary teamwork model (Schut & Stam, 1994).
Additionally it has been perceived to assist the teams’ ability to work effectively together
(Playford et al., 2000). However the process may not be as effective for some patients, i.e.,
those with communication difficulties; and that issues such as time constraints, and
difficulties in formulating handicap based goals may be additionally restrictive (Davis et al.,
1992). Which methods ensure the optimum team work effort have yet to be determined.
The variations in the research designs and outcomes used within the research literature
have limited the conclusions that can be drawn from the type of team work model adopted,
the teamwork process, and the context and environment in which neurological rehabilitation
teams’ work, on their efficiency and effectiveness. The factors that may influence the
teamworking process may be individual to the neurological team, and also diverse. Studies
that have attempted to evaluate factors such as communication have used a variation of
research methods and outcome measures.
The limited number of studies and the variations in the research designs and outcomes
used within the research literature limit the conclusions that can be drawn regarding the
672 K. M. Suddick & L. H. De Souza

teamwork process in neurological rehabilitation. The aim of this study was to explore the
factors (critical happenings) that were perceived to negatively and positively influence team
work. The critical meaning behind these effective and ineffective happenings would also be
explored. Due to the scope and aim of the research different neurological teams were
selected. This was to ensure that the study explored team working within neurological
rehabilitation as a whole, and did not focus on one individual team or aspect of the process.
The two professions: occupational therapy and physiotherapy were chosen as they were
professions who fulfilled different roles, but who also experienced the blurring of boundaries
and role overlap within the provision of neurological rehabilitation.

The critical incident technique

A critical incident is classified as a clearly defined observation or incident where its
consequences can visibly be related to their effects (Crouch, 1991). Since its development in
1954 by Flanagan to classify and evaluate the training methods of the American Airforce, the
critical incident technique (CIT) has been used within qualitative health care research as an
assessment and evaluation tool (Perry, 1997) and to promote reflective practice (Rich, 1995,
Crouch, 1991). Studies using this approach have also investigated nursing issues such as
indicators for quality care (Norman et al., 1992), and perceptions of the psychological role
in treating rehabilitation patients (Rimon, 1979). The technique is based upon the
supposition that inferences can be made through the classification of reported or observed
specific examples of observed human activity for effective and ineffective or positively and
negatively perceived behaviours (Rich, 1995). Within this approach critical incidents can be
those perceived to be a slight or substantial deviation away from the norm. In this instance
the critical incident technique was utilized to investigate the complex phenomenon of
effective and ineffective team working.
Norman et al. (1992) adapted the approach significantly to investigate indicators for
quality nursing care from patients and their nurses. Rather than focusing on the incident
itself, the analysed information demonstrated ‘‘happenings’’ that were critical in the quality
of nursing care, and ‘‘meanings’’ that were characterized as something that expands the
happenings, and can indicate it’s significance in relation to the topic under investigation.
This adapted approach (Norman et al., 1992) was used to investigate the critical happenings
in effective and ineffective teamwork, and the critical meanings behind them.

Methods
The physiotherapy and occupational therapy managers of 13 neurological rehabilitation
teams were approached by the researcher to ascertain whether they wished to participate.
These teams approached included Stroke Units, specialist inpatient/outpatient neurological
services, specialist neurological rehabilitation centres, and community neurological
rehabilitation teams based in the Thames Region. Four responses from the occupational
therapy and physiotherapy staff from two Stroke Units, one rehabilitation centre, and one
community team were received. The first three teams that responded were selected to
continue. Ethical approval was then obtained from the relevant Local Research Ethics
Committees.
Using three different neurological teams allowed the study to explore team working as a
whole, not concentrating on one isolated team or one aspect of the team work process.
The research procedure consisted of nine stages (Figure 1). Using a Topic Guide semi-
structured interviews were carried out involving five occupational therapists and five
 Teamwork in neurological rehabilitation 673

Figure 1. A flow diagram demonstrating the procedure for the data collection and processing.

physiotherapists working within three teams involved with the neurological rehabilitation of
adults.

. Team A: neurological rehabilitation centre team (PTs: 1 – 3, OTs: 4 – 6)

. Team B: community neuro-rehabilitation team (PT: 7, OT: 8)
. Team C: specialist stroke unit based in a General Hospital (PT: 9, OT: 10)
674 K. M. Suddick & L. H. De Souza

The sample was purposive and occupational therapists and physiotherapists with less than
one month experience of working within their team were excluded. The three teams were
different in terms of size and structure and the number of available physiotherapy and
occupational therapy team members. This meant that a greater proportion of the
participants were recruited from Team A.
The number of years since qualification for the study population ranged from 1.5 to 13
years (mean ¼ 5.75, SD ¼ 3.61), and length of time in their current job ranged from two
months to five years (mean ¼ 1.9, SD ¼ 1.66). Eight of the participants were female. The
remaining two were a male OT and a male PT, both working within Team A.
Within the main section of each interview participants were asked to describe critical
incidents of effective and ineffective team work within their current neuro-rehabilitation
team, and expand on the perceived critical factors (happenings) and their effects (meanings).
Interviews were transcribed and sent for respondent validation.
At the analysis stage, each critical incident was organized into critical happenings
and critical meanings (Norman et al., 1992) and presented in a summary document
(pamphlet) for respondent validation. Respondent amendments were recorded on the
original pamphlet and were considered additional data. The happenings and meanings
were then analysed for emerging themes. The themes were developed through the
researcher’s submersion into the data. The thematic areas were coded, and expanded
and collapsed as appropriate (Bryman & Burgess, 1994). Research rigour was
increased by the detailed exposition of the procedural methods used and the analysis
undertaken.

Findings
Figure 2 demonstrates the critical happenings and meanings that were produced from a
single critical incident. The influencing factors (critical happenings) for effective and
ineffective teamwork as a whole are presented in Figure 3.
The largest proportion of the critical happenings was organized under the
communication theme, followed by team members’ characteristics. Team members’ character-
istics were most frequently reported as influencing ineffective team work, and for
communication: both effective and ineffective teamwork. Factors discussed under the
shared and collaborative working theme were perceived to influence effective teamwork
more often than ineffective teamwork. However as there were a disproportionate number
of subjects from each team, these estimated frequencies have to be considered with an
element of caution.
The following sections present the critical happenings in effective and ineffective team
work. Where appropriate the critical meanings are presented alongside.

Communication
Whether communication occurred, who it involved, and the timing, frequency, and type of
communication were all reported as critical happenings in both effective and ineffective
teamwork (Figure 3). The type of communication that could facilitate effective team
working included the following: updates, meetings, discussions, communication with
family, whether or not it raised issues and was consistent, constructive, and informal.
Ineffective sub themes included miscommunication between those involved: the team, and
the team and external services (i.e. referring hospital), and a lack of clear communication to
the patient.
 Teamwork in neurological rehabilitation

Figure 2. Critical happenings and meanings arising from a single ineffective team work incident.
675
676 K. M. Suddick & L. H. De Souza

Figure 2. (Continued).
 Teamwork in neurological rehabilitation

Figure 3. Influencing factors (critical happenings) for effective and ineffective team work.
677
678 K. M. Suddick & L. H. De Souza

In the instances where communication was perceived to be important, it was believed to

influence the teamwork outcome on a number of levels. It was thought to benefit the patient,
the team, the individual team members, and the service. In the following incident it was
reported to affect the ultimate effectiveness of the team: better rehabilitative outcome.

. . . discussion between the team . . . again communication and constant updating within
the team, regular communication in that sense . . . to actually push the patient forwards
and onwards.

1: PT: Team A
Critical happening: communication Critical meaning: patient benefits
Sub theme: type and frequency Better rehabilitative outcome

Team events & team characteristics

The team events and team characteristics that were perceived to be critical are summarized in
Figure 3. Team events included problem solving, planning and organization, and agreeing
shared plans and aims. Team characteristics varied from having a team leader, to being open
and accessible, cohesive, consistent, supportive, responsible and realistic.
In one critical incident the teams’ acceptance of equal responsibility, shared aims and
experience, and its supportive nature, (as well as informal communication, meetings,
and having the time to meet) were perceived to influence the teams’ intermediate
and ultimate effectiveness when developing their service for people with multiple sclerosis.
The team members reported that they felt supported, that they had learnt though other
peoples’ experience, and had also built good working relationships as a result of the process.
It was also thought to have beneficial effects for future patients and the service:

the clients in the long run will benefit . . . . . . client is identifying which areas are a problem
and a priority to them, and which they want to work on first.

. . . we’ve benefited . . . by focusing the time and we’ve built a certain working relationship.

. . . it’s something we can probably share with people around the country as an example of
some work that we’ve done and help [the service] promote its name . . . .

8: OT: Team B
Critical happening: team characteristics Critical meaning: service, team members &
(& communication) patient benefits
Team members: supported, learning, Patient: patient-centred rehabilitation
Team: works effectively, builds team relationships
Service: raised reputation

Other team characteristics such as the inaccessibility of the treating team out of working
hours, lack of team openness, poor planning and organization, as well as a lack of team
problem-solving and the presence of conflict/dispute within the team were perceived to
influence the team working process. The critical meanings included team benefits and
disadvantages. In a number of these instances the patient was also perceived to be
disadvantaged. They did not receive the answers, equipment, joint approach, or
rehabilitation that they needed, or that their rehabilitation was not patient focused.
 Teamwork in neurological rehabilitation 679

Team members’ characteristics

Individual team members’ characteristics were perceived to influence the team working process
in a number of ways. Characteristics that were perceived to influence ineffective teamwork
were knowledge, experience, personality, interpersonal skills, and holding different opinions
and perceptions.

I think it’s a personality problem, maybe I’m working with someone who hasn’t
got the same understanding of team work than me, who doesn’t behave the same
way.

. . . it has affected only myself . . . .it could have affected the patient because I feel like not
trusted . . . not respected . . . it’s really hard to keep your enthusiasm and motivation . . . and
your . . . you need lots of support in rehabilitating patients with stroke.

9: PT: Team C
CH: team members’ characteristics CM: team member disadvantaged
Personality Reduced motivation & enthusiasm
Opinions Does not feel trusted, respected or supported
Understanding

Having a desire to work on the same goals, listening skills, good interpersonal relationships
between team members, as well as being open and willing to explore role overlap, secure in
their understanding of their own role and other disciplines’, were all reported as effective
team members characteristics.

Shared and collaborative working

Shared and collaborative working related to a number of factors. These were specific events,
methods of working and shared and collaborative techniques (Figure 3). Aspects of team
working such as joint sessions, joint working, joint decision making and setting of team
objectives, were perceived to have critical benefits or disadvantages for the team members,
the team, and the patient.

we had decided to keep him and extend his stay and then it was overridden without an
explanation really . . . and then nobody knew why he’d gone. . . . the patient was the person
who was affected most. We were quite angry and upset by it because we had wanted him
to stay and had goals set for him and it was him that was not going to get the benefits of it
[rehabilitation].

3: PT: Team A
CH: shared and collaborative CM: team and patient disadvantaged
working lack of joint decision making Team: angry & upset
Patient: would not benefit from the
rehabilitation planned

This theme also included reference to overall patient and family involvement in joint
working and goal setting. The inclusion of the patient and their family was perceived to assist
the team functioning, as well as the achievement of the team aims:
680 K. M. Suddick & L. H. De Souza

and it was that team approach . . . we sort of sat down and talked to the family, and also
what we did was . . . . when the daughter was there we knew that we would always . . . you
know if they asked questions we would answer them, but keep to the fact that we felt that
she would be better . . . . and it worked, it took a while but it worked, and they both
decided that . . . that she’d go to a residential . . .

10: OT: Team C

CH: shared and collaborative working CM: patient & team benefits
patient & family involvement appropriate discharge placement

this case has really shown me how much I do depend on. . . . . ..depend on really working
alongside the patient and their family for planning discharge.

4: OT: Team A

Despite this, some of the therapists suggested that their team was not working as patient-
centred as they would like:

I think there’s still . . . there’s . . . . . .a little bit of lip service played to client centred practice
I think in most settings. I still think that most therapists and most members of the team
probably have their own goals to a certain extent, of what they want to work on with a
patient.
6: OT: Team A

Organizational structures
Within the organizational structures theme (Figure 3), goal planning, and team meetings were
perceived as contributing factors in effective team-work. In an ineffective incident, a lack of
goal planning was perceived to negatively influence the development of a team plan and the
outcome for the patient: aspects of both intermediate and ultimate effectiveness.

. . . poor planning and goal planning, no early goal planning for the patient . . . . . . therefore
the team really, in terms of working together were not focused early on people working in
separate boxes and this patient desperately needed a joint approach to have any
impact . . . on his . . . . disability and impairment.

1: PT: Team A
CH: organizational structures, goal CM: Team: lack of focus
planning (quality & timing) Team: limited cohesive approach
Patient: limited affect on rehabilitative outcome

The inaccessibility and quality of goal planning, its’ timing, and the lack of a chairperson
were perceived to influence ineffective team-work. Other perceived ineffective structures
included a lack of clear policies, protocols, and guidelines.
The remaining themes for effective and ineffective teamwork: environmental, external,
and patient and family related, were less frequently reported. The environmental factors
reported affected the team, the patient and family-related factors: the patient. The external
 Teamwork in neurological rehabilitation 681

factors were reported to influence the service provided by the team as well as the client.
There were also a few references specifically to time constraints in the critical happenings:
the chairperson/team members working hours, and the inaccessibility of the treating team
after hours (i.e., for family and goal planning) (Figure 3).

Discussion
The findings of this study are not new or unexpected. However, this is the first study that has
explored team work in neurological rehabilitation in its entirety, and across different teams.
It has investigated the factors that are thought to influence teamwork, and the perceived
effects on the intermediate process and ultimate outcome. The extensive factors involved in
the teamwork process in neurological rehabilitation, their interdependence and perceived
cumulative effects was a significant finding in this small scale study. It provides a
springboard for further research as well as a baseline from which the teamwork process and
outcome can be evaluated at a more detailed level.
The findings of this study correspond with research that has supported the positive and
negative influence of communication on the team working process in neuro-rehabilitation
(Freeth, 2001; Molyneux, 2001; Stead & Leonard, 1995). In fact communication may be
one of the most crucial factors (Molyneux, 2001).
Other subcategories that emerged from this research such as having a team leader, a plan,
being open, consistent/cohesive, and sharing responsibility have also been supported by Barr
(1997). However, one of the most significant findings of this study was the reported benefits
of the involvement of the patient and their family within the team approach. A number of
critical happenings under the communication theme related to communication with the
patient, and, or their family, and this was perceived as important for the team working effort.
If one of the aims of the team-work effort is rehabilitative (i.e., to maximize the patients
recovery, or optimum discharge placement) there may be significant perceived benefits to
both the team and the patient for their inclusion in the teamwork process. However there
may also be times when less patient-centred practice and the exclusion of the patient within
the team is appropriate. As yet this has not been highlighted within the literature, and would
be a requirement for future research and investigation.
A lack of client-centred goal planning has been reported by other rehabilitation teams
(McGrath et al., 1995; Pethybridge, 2004). Whether the patients’ involvement in goal
planning in these three teams was dependent upon the aims of the team at the time, the
patients cognitive or communication abilities, or the particular perceptions of the team
members as to the extent to which they should be involved, was not clear.
Schut & Stam (1994) have suggested that the benefits of goal planning included improved
planning, evaluation, problem solving, communication and motivation. This was partly
supported by the findings of this study. The teams reported using different goal planning
structures, a similar finding to Playford et al. (2000). Whether the goal planning process was
individually tailored to each team or to the patient could not be determined and further
research is required. External and environmental factors have also been discussed as
influencing effective and ineffective team work (Armitage, 1983; Strasser et al., 1994).
Teamwork is a complex process, and as such there is a large degree of overlap between the
perceived influencing factors and the outcome of effective and ineffective team work in
neurological rehabilitation. In addition it is important to note that some of the subcategories
under each theme may have included only one critical happening. Others were supported by
a number of similar critical happenings. This indicated that a number of factors were
perceived to influence and jointly contribute to the team working process in the three
682 K. M. Suddick & L. H. De Souza

neurological rehabilitation teams, and that the list was extensive. At a service delivery level
these findings may support the multiple dimensions under which health-care teams function
(Boaden & Leaviss, 2000).
The critical meanings for effective and ineffective team work corresponded with the
findings from the first part of this study, where participants provided their opinions on why
they worked within a team (Suddick & DeSouza, 2006). The five occupational therapists
and five physiotherapists studied reported diverse benefits for the patient, team, individual
team members, and for improving the effectiveness and efficiency of the service. They also
supported a perceived influence of the teamwork process on rehabilitative outcome. These
critical meanings included aspects of both immediate and ultimate effectiveness. Some
aspects of the teamworking process resulted in intermediate effects such as good working
relationships, improved communication or satisfaction within the team. Some of these
effects went on to become critical happenings that either led and/or contributed to other
outcomes. These often resulted in critical meanings that were more related to group output
(ultimate effectiveness) such as cost efficiency, placement on discharge, and rehabilitative
outcome. Clear causal relationships between the intermediate and ultimate effects of team
work could not be established due to the complicated nature of the interlinking events and
effects.
By establishing the specific quality dimensions under which the neurological
rehabilitation team works, research can be structured to investigate the contributing
factors. Future research needs to focus on individual teams, and team members, and
establish their context and priorities for the intermediate and ultimate effectiveness of their
teamwork. Team members of inpatient acute neurological services may work to different
team priorities that focus on service efficiency. In this study, participants based in the
Stroke Unit team did not report any patient benefits from teamwork. These perceptions
may have been influenced by a number of factors, including the team context and their
individual beliefs. The occupational therapist from the Stroke Unit provided reasoning for
teamwork around service efficiency/effectiveness issues, and the physiotherapist from the
same team focused on individual team members, and team benefits. Other research has
demonstrated that team members can hold different or shared philosophies regarding team
work (Freeman et al., 2000) as well as their role, priorities and successful outcome from
rehabilitation (Pound & Ebrahim, 1997). Having a shared philosophy can promote
communication (Pound & Ebrahim, 2000). On the other hand, if team members hold
different opinions as to what they want their teamwork to achieve, and if they are not
openly communicated or discussed, they may lead to discord and disenchantment. The
perceived rewards from teamwork may not be met, and other team members may be
perceived to be working in opposition to those aims.
Variations in the reported critical happenings between participants, and between the three
teams were also observed. All responses relating to ineffective team work under the
communication theme, and the patient-related theme (effective and ineffective teamwork), had
been provided by physiotherapists and occupational therapists from Team A. This finding
may have been reliant purely on the type of critical incidents given by the participants. On the
other hand, it may represent a team culture or specific areas in which each team is thought to
perform well or not so well. Two participants provided considerable contributions to team
members’ characteristics under ineffective team-work. Again, the type of critical incidents
reported may have been responsible for this finding. Equally these team members may have
perceived specific factors as more important when working in a team.
The findings were generated from the critical incidents provided by the respondents. The
results therefore represented only a small number of instances where the teams studied were
 Teamwork in neurological rehabilitation 683

perceived to work effectively or ineffectively. The findings are exploratory and cannot
exclude any other factors and variables that may be perceived as influencing the team
working process. Neither could specific causal relationships be drawn from the findings due
to the multiple factors reported, the perceived interdependence of the factors, and the nature
and scope of the research undertaken.
This study has established that a number of factors already discussed within the literature
may be important to neurological rehabilitation teams. The findings have highlighted that
client and family centred approaches, collaborative goal setting, team reflection and training,
as well as other components of teamwork, may require further development. Other aspects
that relate to the patient and their family have not been previously acknowledged as
influencing the process. The findings support key roles for communication, organizational
structures and shared and collaborative working practices in neurological teams. These
findings could contribute to the development of appropriate team work strategies for specific
teams and best practice models urgently required for those working with clients with
neurological and long-term conditions.
This project has also provided findings that may assist in the development of future
studies to evaluate the effectiveness of the neuro-rehabilitation team work effort. This study
has generated a number of possible areas for the development of future research. Some of
the critical happenings may have been of a greater perceived influence to the teamwork
process than others – this was not investigated in this piece of work. Neither was the
perceived weighting of the critical happenings and meanings. Focus groups could then be
used to explore the priorities for neurological rehabilitation teams within the context within
which they work.
Further research is required to directly substantiate the benefits of teamwork in
neurological rehabilitation. It will need to take into account the intermediate and the
ultimate effectiveness of the teamwork process, the team context, and that the team outcome
may be evaluated from the team, team member, patient and service perspective. Further
study of the experiences and perceptions of other members of the neuro-rehabilitation team
is also required, including those of the patient and their family.
Using the critical incident technique allowed the complex process of teamwork to be
explored. Norman et al. (1992) went some way in developing the critical incident technique
so that it could deal with complex interlinking events and their meanings. The technique
requires further development and investigation to deal with cumulative happenings and
meanings, and could be developed as a tool for structured team reflection and evaluation.
A key element of the research method was the use of respondent validation. Respondent
validation of the pamphlet information ensured that the inferences drawn by the researcher
during the analysis stages were checked by the study participants as being an accurate
representation of their views. The minimal amendments that were required at this stage of
the procedure supported the methods for collecting, organizing and analysing the data.
The addition of respondent validation of the themes and sub themes as well as a
second researcher to verify the thematic analysis would have increased the validity of the
findings.
The study was also limited in its scale. It only focused on the opinions and perceptions of
a small number of therapists from only three neurological teams and two professions. It
cannot provide substantive evidence or a causative link between teamwork and its effects.
The findings of this study could not exclude the existence of additional factors that may have
influenced the team-working process. In fact the extensive range of factors that related to
effective and ineffective teamwork from a small number of subjects could indicate that this
study has only scratched the surface.
684 K. M. Suddick & L. H. De Souza

Conclusion
The study indicated that effective and ineffective teamwork was perceived to be influenced
by an extensive number of factors, which affected the team outcome from the perspective of
the patient, the team, individual team members, and the service. The results supported
previous literature that has investigated aspects of teamwork in other health care teams,
neurological teams, and in different contexts (Freeman et al., 2000; Freeth, 2001;
Molyneux, 2001; Pound & Ebrahim, 1997; Stead & Leonard, 1995; Strasser et al., 1994).
The findings highlighted a need for further development of patient- and family-centred
practice, collaborative goal setting, team reflection, and other aspects of the team-working
process. They suggested that communication, collaborative and organizational strategies can
be used to assist the team-working process and outcome, and that the team and individual
team members have a key role to play.
Teamwork is a complex, constantly changing process that brings with it its own rewards
and benefits on a number of levels. It may also bring multiple challenges, and require
extensive resources, investment and commitment if the team is to work to its optimum. The
results from this study were the organized reportings and perceptions of people who were
experiencing working within the neurological rehabilitation team on a regular basis.
Therefore they provided a rare and valuable insight into the complex processes occurring in
the neurological rehabilitation team.
The nature of this piece of research was exploratory and as such cannot provide definitive
conclusions. However, the findings support the perceived value of team work within neuro-
rehabilitation. The teamwork effort was perceived to have rewards for the team, the patient,
individual team members, and the neurological rehabilitation service. However, the flip side
of the coin cannot be ignored. Equally, if the team does not work well together, occupational
therapists and physiotherapists perceived the negative effects to impact on a number of
comparative levels.
There needs to be a frank discussion between team members working in
neurological rehabilitation, and within the scientific literature. The reality of providing
an efficient collaborative team effort needs to be addressed. Further research is required
to directly substantiate the benefits of team work in neurological rehabilitation, to
determine how these factors influence each other, and to explore the priorities for
neurological team work in different contexts. It will need to take into account the
prioritized aims of each individual team in regards to the intermediate and ultimate
effectiveness and that team outcome may be evaluated from the team, team member,
patient, and service perspective. Further study of the experiences and perceptions of
other members of the neuro-rehabilitation team; including those of the patient and their
family, as well as further investigation into their level of involvement in the process, is
also required.

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