Interprofessional Healthcare Teams in the Military: A Scoping Literature Review

Interprofessional Healthcare Teams in the Military: A Scoping Literature Review Abstract Introduction Research into healthcare delivered via interprofessional healthcare teams (IHTs) has uncovered that IHT can improve patient satisfaction, enhance collaborative behaviors, reduce clinical error rates, and streamline management of care delivery. Importantly, these achievements are attained by IHTs that have been trained via interprofessional education (IPE). Research indicates that interprofessional healthcare team training must be contextualized to suit the demands of each care context. However, research into the unique demands required of military IHTs has yet to be explored. For any form of IPE to be successfully implemented in the military, we need a clear understanding of how interprofessional healthcare team competencies must be tailored to suit military care contexts. Specifically, we must know: (1) What evidence is currently available regarding IHTs in the military?; and (2) What gaps in the evidence need to be addressed for IPE to be customized to meet the needs of military healthcare delivery? Method We conducted a scoping review of the literature was conducted to identify the breadth of knowledge currently available regarding MIHTs. A search of PubMed, EMBASE, PsycInfo, ERIC, DTIC.mil, and NYAM Gray Literature databases was conducted without date restrictions. The search terms were: (interprofessional* OR interprofessional*) AND (military OR Army OR Navy OR Navy OR Marines OR “Air Force” OR “Public Health Service”) AND (health OR medicine). Of the 675 articles identified via the initial search, only 21 articles met inclusion criteria (i.e., involved military personnel, teams were medically focused, comprised at least two professional disciplines, and at least two people). Results The manuscripts included: seven original research studies, six commentaries, five reviews, one letter, one annual report, and one innovation report. Analyses identified three themes (i.e., effective communication, supportive team environments, members) related to successful MIHT collaborations and five related to unsuccessful MIHT collaborations (i.e., inability to develop team cohesion, lack of trust, ineffective communication and communication breakdowns, unaddressed or unresolved conflicts, rank conflicts). These manuscripts highlighted contextual factors that shape MIHTs. For example, MIHTs often work and live together for extended periods of time when deployed. Also, military rank can facilitate collaboration by establishing clear lines of reporting, but can problematize collaboration when inexperienced care providers (e.g., early career physicians) outrank other team members (e.g., medics) who have more experience providing care in deployment contexts. Discussion Given the experiences of military personnel can be perilous and unpredictable, the military has an obligation to study the unique contexts of care where interprofessional healthcare teams are employed. In doing so, better interprofessional education interventions can be tailored to better aid our service men, women, and their families. Healthcare delivered via interprofessional healthcare teams (IHTs) has been found to improve patient satisfaction, enhance collaborative behaviors, reduce clinical error rates, and streamline management of care delivery.1 These achievements were attained by IHTs trained via interprofessional education (IPE).1 The rewards of IHTs are not reaped simply by requiring different healthcare professionals to work together; they are reaped by teams that have learned how to work together. There are general principles to guide IPE efforts; however, these interprofessional competencies are constructed as “overall guidelines” that must be contextualized to align with the culture and expectations of individual institutions, clinics, and professions.2 Tailoring IHT competencies to fit specific contexts makes intuitive sense. A successful IHT working in a busy urban Emergency Department functions differently than one in an outpatient pediatric clinic. And yet, the U.S. military healthcare and medical education systems have not explored what makes military IHTs unique. We do not know if or how IHT competencies should be tailored to suit military care contexts. Anecdotes abound about how IHT collaboration is impacted by the chain of command, the variations in rank, and the chaotic realities of deployments. But anecdotes are not evidence. Little has been written about the unique characteristics of successful IHTs working in military contexts. How can the military target their IHT education efforts when we do not know if or how IHT competencies must be modified to align with U.S. military healthcare contexts? The U.S. military has been part of spearheading the promotion and incorporation of IPE into educational and healthcare delivery practices. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was developed by the Health and Human Services Agency for Healthcare Research and Quality (AHRQ) in collaboration with the Department of Defense (DoD) Health Care Team Coordination Program (HCTCP).3 TeamSTEPPS is an evidence-based program designed to improve performance among healthcare profession teams, allowing them to quickly respond to a variety of situations.4 It rests on four integrated core competencies that, together, “foster delivery of safe, quality care as a cohesive patient care team”3: leadership, situation monitoring, communication, and mutual support. These competencies are broad in scope, and need to be shaped to fit the context(s) in which the IHT is working. This is part of the power of the TeamSTEPPS program: it can be tailored to suit diverse contexts.5–9 For any form of IPE to be successfully implemented in the military, we need a clear understanding of how IHT competencies must be tailored to suit military care contexts. Specifically, we must know: (1) What empirical evidence is currently available regarding IHTs in the military?; and (2) What gaps in the evidence need to be addressed for IPE to be customized to meet the needs of military healthcare delivery? To answer these questions, we conducted a literature review. METHOD Five kinds of literature reviews are commonly used in healthcare research and health professions education research: systematic, narrative, scoping, critical-realist, and open peer commentary.10 The goal of our review was to explore what is known about military interprofessional healthcare teams (MIHTs). This question could not be refined to a focused, hypothesis-driven research question. Furthermore, given the small pool of literature available on MIHTs, and lack of statistical evidence available in that literature, our review could not generate objective findings and interpretations. Therefore, instead of a systematic review, we engaged in a scoping literature review. Scoping reviews “collect, evaluate and present findings from existing research”11 in order to “map key concepts contained in a research domain – their breadth, limits and features.”10 Scoping reviews map out the breadth of knowledge about a particular topic, and identify gaps in that knowledge, making it ideally suited for our purposes.12,13 Relying on Arksey and O’Malley’s12 framework for scoping reviews and the revisions to that framework offered by Levac et al.14 our review followed the following six steps: (1) develop research questions, (2) identify relevant literature, (3) select specific articles, (4) extract data, (5) summarize and report results, and (6) consult with key informants. We report each of these steps below, noting that steps two, three and four are described together to highlight the iterative work completed to refine our data collection processes. The overall review process is illustrated in Supplementary Figure 1. Step One: Develop research questions The questions informing this review were: (1) What empirical evidence is currently available regarding MIHTs?; and (2) What gaps in the evidence need to be addressed for IPE to be customized to meet the needs of military healthcare delivery? Eligible literature included all peer-reviewed articles and manuscripts from the gray literature. Steps Two, Three, and Four: Identify Relevant Literature, Select Specific Articles, and Data Extraction Search terms and inclusion/exclusion criteria were developed and then refined by the team collaborating on the review. A pilot search was conducted in January 2017 using PubMed, DTIC.mil, EMBASE, and the NYAM Gray Literature database. The obtained literature (n = 367) was reviewed, and search terms/databases were revised to broaden the scope of inclusion. The final search was conducted in April 2017 using PubMed, EMBASE, PsycInfo, ERIC, DTIC.mil, and the NYAM Gray Literature database. The entirety of each database was searched; no date restrictions were imposed. The search terms were: (interprofessional* OR interprofessional*) AND (military OR army OR navy OR naval OR marines OR “air force” OR “public health service”) AND (health OR medicine). A total of 675 articles were identified for screening, with 559 articles remaining after removing duplicates and non-English articles. The titles and abstracts of these articles were reviewed to verify each article addressed (1) military (2) healthcare teams, that were (3) interprofessional (i.e., included team members from at least two health professions [e.g., medicine and nursing]). Only 46 of the 559 articles met these criteria. We reviewed the 46 articles in four phases using a computer software program to facilitate literature coding (Distiller). In phase one, six members of our teach each reviewed two articles, with no two individuals co-reviewing more than one article. An initial draft of the data extraction tool (v1) was developed and used to review six articles. During review, reviewers identified weaknesses of the data extraction tool, after which. The tool was revised (v2) for the team to use for reviewing the six phase one articles. Reviews completed in phase one were compared and all co-reviewer discrepancies were discussed at a team meeting until consensus was achieved. The data extraction tool was revised (v3) incorporating team consensus decisions. In phase two, new set of six articles were reviewed. Team coding was reviewed, discrepancies were identified and presented at a team meeting, and group discussion was held until consensus was achieved. In phase three, the remaining 34 articles were reviewed, with each article being reviewed by two team members. Twenty-eight articles were excluded because the reviewers determined that the articles did not meet inclusion criteria, leaving 18 articles for inclusion in the review. In phase four, all 18 articles were hand-searched for publically available references that were relevant to the review’s questions. Three additional articles were identified, which were reviewed by two team members. In sum, 21 articles met inclusion criteria and are included in this scoping review. Step 5: Summarize and Report Results Both qualitative and quantitative data from the articles were analyzed. Quantitative data highlighted: the nature of articles addressing MIHTs, the nationality of the researchers, the geographical contexts where MIHTs worked (including all five levels of care and transitions between levels), the contexts in which care was provided, and the professions included in the MIHTs. The qualitative data were analyzed thematically15 by grouping data excerpts into thematic clusters, and verifying that all the data collected via the extraction tool were accounted for and compared.15 Step 6: Consult with Key Informants An oversight committee was struck for this study, consisting of 10 experts from an array of different healthcare professions (i.e., physicians [n = 6], dentists [n = 1], nurses [n = 2], and medical technicians [n = 1]) and from each branch of military service (Army [n = 2], Air Force [n = 4], and Navy [n = 3]) and one civilian IPE expert. The scoping review results were presented to and assessed by the oversight committee at a meeting held in September 2017. The oversight committee offered additional comments and suggestions, which were reviewed and applied to our final analyses. RESULTS Nature and Distribution of Articles Twenty-one articles published between 1966 and 2016 met inclusion criteria and were included in this review. Overall inter-rater reliability was high (Kappa = 0.83). Supplementary Table 1 provides descriptive data about the MIHTs discussed in each manuscript including: the nationality of the MIHT in question; the care context in which the MIHT was working (e.g., combat mission, peacekeeping mission, US-based healthcare center, etc.); the geographical location of the care delivered by the MIHT (by continent); the level of care designation for the MIHT care activity; the MIHT’s branch of military affiliation; the health professionals working as members of the MIHT; the size of the MIHT; and the care activities performed by the MIHT. Supplementary Table 2 provides information as to each manuscript’s type (e.g., original research article, commentary, etc.) as well as the contributions made to what is known about MIHTs (e.g., primary findings related to MIHTs, descriptions of (un)successful MIHT collaborations, etc.). Eight articles16–23 (38%) were original research articles that used quantitative (n = 4)17,18,20,21 or qualitative (n = 2)19,22 methods. There were two mixed methods studies.23,24 The original research articles were primarily conducted on U.S. MIHTs (n = 8), offering care in the USA (n = 6)17,20,22–24 and abroad (n = 2).18,19 Working primarily at level 5 of care17,20–22 (i.e., U.S. based healthcare centers), the MIHTs represented in the research articles were commonly part of the Army.17,20,22–24 These MIHTs were generally small in size (having between 2 and 9 team members) where the team was generally composed of at least one physician working with a nurse (n = 6),17–21,24 or with another health professional (n = 2).22,23 The types of care activities performed by the MIHTs studies in the original research articles were wide ranging, including: diagnostics,23 treating male sexual dysfunction,22 ICU care20,21 critical care air flight support,19 forward surgical teams,17,18 and OBGYN care.24 Thematic Analysis We clustered comments about MIHTs around (1) successful MIHTs, including the facilitators of that success; and (2) unsuccessful MIHTs, including the impediments to success. We noted that many of the facilitators of success were identified inversely as obstacles of success (e.g., good communication is a facilitator; poor communication is an inhibitor). In this reporting of results, we align data themes with the arguments and emphases of the authors of the original manuscripts, while also streamlining the results to avoid unnecessary repetition. Successful MIHTs and the Facilitators of That Success Three major themes were related to the success of MIHTs and the facilitators of that success: effective communication; supportive team environments; and shared role understanding and equity among team members. Table I lists definitions for each of these themes. Table I. Definitions of Themes Relating to Successful MIHTs and the Facilitators of That Success Label  Definition  Effective communication  Ability to collaborate using effective verbal and written communication strategies between team members (e.g., dyad or triad) and across the team as a whole  Supportive team environments  Providing appropriate structures and guidelines to ensure teams are able to collaborate sufficiently (e.g., manuals, guidelines, appropriate team membership, troubleshooting strategies)  Shared role understanding and equity among team members  Team members’ roles are equally valued and respected, regardless of their professional role or military rank (e.g., nurses, physicians, and corpsmen participate in the MIHT as equally valuable members of the team)  Label  Definition  Effective communication  Ability to collaborate using effective verbal and written communication strategies between team members (e.g., dyad or triad) and across the team as a whole  Supportive team environments  Providing appropriate structures and guidelines to ensure teams are able to collaborate sufficiently (e.g., manuals, guidelines, appropriate team membership, troubleshooting strategies)  Shared role understanding and equity among team members  Team members’ roles are equally valued and respected, regardless of their professional role or military rank (e.g., nurses, physicians, and corpsmen participate in the MIHT as equally valuable members of the team)  Table I. Definitions of Themes Relating to Successful MIHTs and the Facilitators of That Success Label  Definition  Effective communication  Ability to collaborate using effective verbal and written communication strategies between team members (e.g., dyad or triad) and across the team as a whole  Supportive team environments  Providing appropriate structures and guidelines to ensure teams are able to collaborate sufficiently (e.g., manuals, guidelines, appropriate team membership, troubleshooting strategies)  Shared role understanding and equity among team members  Team members’ roles are equally valued and respected, regardless of their professional role or military rank (e.g., nurses, physicians, and corpsmen participate in the MIHT as equally valuable members of the team)  Label  Definition  Effective communication  Ability to collaborate using effective verbal and written communication strategies between team members (e.g., dyad or triad) and across the team as a whole  Supportive team environments  Providing appropriate structures and guidelines to ensure teams are able to collaborate sufficiently (e.g., manuals, guidelines, appropriate team membership, troubleshooting strategies)  Shared role understanding and equity among team members  Team members’ roles are equally valued and respected, regardless of their professional role or military rank (e.g., nurses, physicians, and corpsmen participate in the MIHT as equally valuable members of the team)  Effective Communication The papers addressing this theme3,18,24–29 reported that MIHT collaboration was successful when there was clear, continuous communication between individual members of the care team as well as across the team as a whole. For example, one article studying Critical Care Air Support Teams (CCAST)28 teams working in remote locations with the Air Force, observed that the MIHT being studied had been successful “as a result of the importance placed on communication.”28 The importance placed on effective communication as contributing to MIHT success was emphatically reported in all eight articles. In fact, one article noted that communication was seen as contributing to minimizing patient care errors.18 David and Blight 21 succinctly summarized the importance of open communication as a means of enabling the MIHT’s collaborative success: “open communication is the key to finding integrated solutions and unveiling the source of conflict (differences).” Goodman stated that MIHT team members “recognize that better communication improves decision making and decreases stress.”27 Supportive Team Environments These articles18,19,30 highlighted that, when MIHTs were provided with appropriate structures and clear guidelines, the team was able to collaborate successfully. One article described successful teams as a “marriage of team cohesion, patient satisfaction and safety, and improved medical outcomes.”27 Appropriate structures that contributed to a supportive team environment were: repeated exposure to feedback, appropriate team structure, positive leadership, mutual support, and situation monitoring.30 Each structure provided scaffolding for encouraging individual and team success and growth. Clear guidelines that facilitated MIHT success were described as shared patient goals, pertinent/deliberate training, flexibility, and standardized protocols.27 Interestingly, these articles did not offer a specified training timeline required for teams to become supportive collaborators, but did suggest that training was necessary for team success. The importance of a clear goal and/or mission alignment to foster a supportive team environment was often related to greater team success and improved patient outcomes.21,27 Shared Role Understanding and Equity Among Team Members Six articles12,19,26–28,30 described how MIHT collaboration was successful when members of the team had an explicit and shared understanding of each team member’s role. Lamb described how “the importance of role equality within a team and the subsequent feeling of value this promotes, effective communication and positive “can do” attitudes contribute to making the team work.”27 Here, role equality refers to all health professional roles being equally valued by all team members. No one role is more meaningful than another; instead, team member roles and their associated responsibilities are all vital to team’s success. Further, three articles24,27,31 stressed the importance for MIHT team members to be valued and respected as equal members of the team, regardless of their professional role or military rank. As Ebbs et al. revealed, rapport among the MIHT team members was positive when “parties allowed the relaxation of rank,” thereby enabling professionalism to trump rank.19 Lamb affirmed the positive contributions that a sense of equality gives to MIHTs stating that “role equality within the CCAST [the MIHT studied] promotes feelings of value among the team and effective team working.”28 Unsuccessful MIHTs and the Inhibitors That Impeded Success Five themes related to unsuccessful MIHTs and the inhibitors that impeded team success. These were: inability to develop team cohesion; lack of trust; ineffective communication and communication breakdowns; unaddressed or unresolved conflicts; and rank conflicts. Table II offers definitions for each of these themes. Table II. Definitions of Themes Relating to Unsuccessful MIHTs and the Inhibitors Impeding Success Label  Definition  Inability to develop team cohesion  Teams were not able to unify, to develop mutual support, or to work together to accomplish collaboration goals. This resulted from a number of different factors including insufficient time together and/or aspects of the team’s interactions  Lack of trust  Occurs when team members were unsure if they could rely on the character, ability, or strength of a team member  Ineffective communication and communication breakdowns  Verbal and/or written communication failed to achieve its desired goal  Unaddressed or unresolved conflicts  Questions and or problematic subjects that existed between individual team members, as well as the team as a whole, were not discussed or resolved  Rank conflicts  When a team, or members of a team, was conflicted by existing military rank, leading to a sense of inequity and diminished sense of partnership  Label  Definition  Inability to develop team cohesion  Teams were not able to unify, to develop mutual support, or to work together to accomplish collaboration goals. This resulted from a number of different factors including insufficient time together and/or aspects of the team’s interactions  Lack of trust  Occurs when team members were unsure if they could rely on the character, ability, or strength of a team member  Ineffective communication and communication breakdowns  Verbal and/or written communication failed to achieve its desired goal  Unaddressed or unresolved conflicts  Questions and or problematic subjects that existed between individual team members, as well as the team as a whole, were not discussed or resolved  Rank conflicts  When a team, or members of a team, was conflicted by existing military rank, leading to a sense of inequity and diminished sense of partnership  Table II. Definitions of Themes Relating to Unsuccessful MIHTs and the Inhibitors Impeding Success Label  Definition  Inability to develop team cohesion  Teams were not able to unify, to develop mutual support, or to work together to accomplish collaboration goals. This resulted from a number of different factors including insufficient time together and/or aspects of the team’s interactions  Lack of trust  Occurs when team members were unsure if they could rely on the character, ability, or strength of a team member  Ineffective communication and communication breakdowns  Verbal and/or written communication failed to achieve its desired goal  Unaddressed or unresolved conflicts  Questions and or problematic subjects that existed between individual team members, as well as the team as a whole, were not discussed or resolved  Rank conflicts  When a team, or members of a team, was conflicted by existing military rank, leading to a sense of inequity and diminished sense of partnership  Label  Definition  Inability to develop team cohesion  Teams were not able to unify, to develop mutual support, or to work together to accomplish collaboration goals. This resulted from a number of different factors including insufficient time together and/or aspects of the team’s interactions  Lack of trust  Occurs when team members were unsure if they could rely on the character, ability, or strength of a team member  Ineffective communication and communication breakdowns  Verbal and/or written communication failed to achieve its desired goal  Unaddressed or unresolved conflicts  Questions and or problematic subjects that existed between individual team members, as well as the team as a whole, were not discussed or resolved  Rank conflicts  When a team, or members of a team, was conflicted by existing military rank, leading to a sense of inequity and diminished sense of partnership  Inability to Develop Team Cohesion Not all MIHTs were able to come together as a group. In these instances, the failure to unify, develop mutual support, and engage in collaborative behaviors resulted in an inability for the MIHT to develop team cohesion. Chief among the reasons for this lack of cohesion were insufficient time together as a team and aspects of the team interactions. One characteristic of MIHTs distinguishing them from civilian IHTs was that, in the military context, teams could expect to spend a lot of time together. As Ebbs acknowledged: “A key difference from civilian health services is the amount of time that military doctors and nurses may have to spend together. Within the civilian ICU environment personnel see each other in a professional capacity, whereas in the military there are times that you may live and work together 24 hours a day, 7 days a week.”28 However, extended time together should not be equated with time spent developing team cohesion. Goodman explained that successful MIHT collaboration requires that team members be accessible to each other so that they can communicate about care activities.27 However, “the physical layout of offices often precludes team members from interacting in a meaningful way. The lack of specific time to regroup and feedback or plan the daily events has also been cited as an obstacle.”27 Another obstacle to team cohesion related to team interactions. For instance, as Nielsen observed, “effective team skills are inherent in the personalities of some individuals.”28 In contrast, for teams to overcome personalities that inhibit successful MIHT collaboration required “diligence and conscious adherence to the principles of effective teamwork.”28 Lack of Trust Another inhibitor of MIHT collaborative success was a lack of trust amongst team members. When team members were unsure if they could rely on the character, ability, or strength of a team member, trust was eroded and so was the success of the MIHT. These aspects (i.e., character, ability, and strength) refer to those an individual possesses, as well as how the individual’s characteristics then combine in a team context. King addressed the importance of trust in MIHTs when discussing the interactions between physicians and nurses on the collaborative team: “The extent to which nurses and physicians practice collaboratively in delivering patient care is directly related to how well they know and trust each other.”21 Nielsen noted that “conflicts that are unaddressed, unresolved, or unjustly handled can be detrimental to the viability of a partnership and can quickly unravel the bonds of mutual trust and respect.”24 Failure to develop and maintain a sense of trust among team members may have deteriorated the relationships within the team, and ultimately damaged the overall success they, and their patients, experienced. It should be noted that trust was not discussed in relation to an individual’s competence, although the two may, in fact, be related. Ineffective Communication and Communication Breakdowns The vital role of communication was emphasized as authors reflected on the ways and extent to which ineffective communication and communication breakdowns impeded MIHTs from achieving collaborative success. These communication problems could be verbal or written. Regardless of modality, MIHT success was inhibited when communications failed to achieve their desired goals. For example, team collaboration was significantly diminished when misunderstandings regarding the content of communications or failing to speak to interprofessional team members when necessary. Anderson explored how professional boundaries contributed to communication breakdowns in MIHTs, stating that “the nurses’ discontent with communication with physicians arose out of their desire for a more collaborative role with physicians.”20 These communication barriers not only negatively impacted the MIHT but also the patients they cared for: “It is necessary that physicians and nurses work as a team in order to provide the most efficacious care in a cost-contained environment. If one member of the team is not permitted to communicate and participate as a team member, it is not only the provider and the organization that will suffer, but, ultimately, the patient as well.”18 Unaddressed or Unresolved Conflicts Conflicts left unaddressed or unresolved were identified as inhibiting the success of MIHTs. Questions or contentious issues could create tension between individual team members, and even across the team as a whole. If they were not discussed and resolved, these conflicts were identified as the root of MIHT collaboration collapse. As Nielsen stated: “A collaborative practice does not eliminate disagreements, but they need not result in conflict.”24 Of additional concern were issues related to conflict formation. These surrounded issues of failure to adopt protocols or agree on patient care, team member reticence to collaborate, and perceived lack of respect. Often this lack of respect was related to a sense of unwillingness to take on additional responsibilities, or devote additional time to the case at hand.27 Rank Conflicts Military rank, a contextual factor that is part of every MIHT, was described as inhibiting MIHT success when a team, or members of a team, experienced conflict because of differences in rank, leading to a sense of inequity and a diminished sense of partnership. This was yet another instance where the military contexts of care importantly differ from civilian contexts. As Ebbs explained, this rank differential can become a focal point for conflict and breakdowns in the MIHT: “often the medical officer outranks those on the flight deck and even though the doctor is present in a medical capacity, rank becomes an extra issue.”19 Military MIHT team members who have experience with civilian IHTs are well positioned to identify how rank conflict can interfere with MIHT success. One anesthesiologist participating in Ebb’s study expressed role conflict clearly stating: “if you work in a clinical team then rank is irrelevant and it’s a clinical team…it’s got nothing to do with the military, we’re professionals…I personally feel that rank becomes a barrier because people aren’t quite as comfortable and don’t interact in the same way because you outrank them.”19 DISCUSSION The purpose of this scoping review was to explore the current state of knowledge about MIHTs. Given that only 21 articles were identified, it seems clear that there are many gaps in this literature that need to be addressed. Our review establishes that little research attention has been paid to understanding the characteristics of successful MIHTs in general, and in deployed contexts in particular – be those deployments for humanitarian, peacekeeping, or combat mission purposes. Only seven articles addressed these deployments, and of those only one contained empirical data. The remainder of the articles exploring deployed contexts were commentaries,30–32 reviews,33,34 or letters.35 Clearly, more research is needed about all MIHTs; but, at present, the available literature neglects to attend to the unique challenges MIHTs face in deployed settings. Our analysis identified three themes related to successful MIHT collaborations and five related to unsuccessful MIHT collaborations. It is important to acknowledge that these themes do not exist in isolation of each other. Time and again, the authors of these articles discussed themes together to demonstrate interdependence. For example: There is a significant barrier in team members’ ability to forthrightly discuss daily issues due to a perceived lack of respect, ignorance of role, or different styles of relaying information.27 Additional research should explore these themes further, search out additional themes, and endeavor to understand how different themes relate to each other. We hypothesize that these interrelations are important for understanding how MIHTs can effectively collaborate. For example, a valuable line of research might explore how rank differences impact the ability of teams to cohere. Only eight of the articles included in this review were original research articles. Empirical research must investigate the unique contexts of care where they require MIHT providers to collaborate. Only then can interprofessional education interventions be tailored to suit these contexts. As the analysis of the articles in this review demonstrates, some of the qualities of successful MIHTs are similar to those of their civilian counterparts (e.g., the need for effective communication between team members). However, our analysis highlights aspects of military contexts that are truly unique and must inform MIHT training and collaborative practices (e.g., dealing with rank conflicts). We were surprised to find six review articles that addressed MIHTs given the paucity of original research that has been conducted on MIHTs. However, several of these reviews focused on composite elements of MIHTs (e.g., physicians as members of MIHTs). Alonso highlights six considerations the Department of Defense must attend to: the cultural conflicts that exist between the military and healthcare cultures; diverse sets of technical skills; the cultural norms associated with each branch of the military (i.e., Army, Navy, and Air Force); extreme transition or turnover of personnel at all levels; the reduced number of resources, financial and otherwise during war; and greater degree of regulations than civilian organization such as those imposed by the office of the Surgeon General and the Office of the Inspector General.3 Unfortunately, the literature currently available about MIHTs fails to address these six considerations in any depth. The U.S. military has a responsibility to train their health professionals to work effectively in the myriad of contexts where MIHTs operate. This training should be based on a robust body of evidence that reports on the characteristics of successful MIHT collaborations, best practices for implementation in a variety of care contexts, and ways to support MIHT collaborations effectively. Specifically, if we are going to prepare our service members to provide life-saving care in interprofessional healthcare teams, we need to understand the characteristics that enable their success, and train those members to embody those characteristics. With so few articles over the last several decades, we are lacking sufficient evidence on which to base our training. We contend that this gap must be addressed – and urgently so – because the care providers in our MIHTs and the patients they support deserve every advantage we can offer them. The first step in addressing this gap will be to study MIHTs to learn what characterizes successful teams, then to implement additional training programs to help prepare our health professionals to succeed in MIHTs. Supplementary Material Supplementary material is available at Military Medicine online. Funding Uniformed Services University of the Health Sciences. Acknowledgements We would like to thank the following members of this research team’s Oversight Committee, whose valuable insights have contributed to the success of this important research endeavor: Dr Diane Seibert (Committee Chair), Dr Carol Aschenbrener, Dr Bruce Doll, Dr Paul Hemmer, Dr Jeffrey Hutchinson, Dr Martin Ottolini, Dr Louis Pangaro, Dr Lula Pelayo, Dr Brian Reamy, and MCPO Jose Romero. References 1 Reeves S, Zwarenstein M, Goldman J, et al.  : Interprofessional education: effects on professional practice and healthcare outcomes. 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Google Scholar CrossRef Search ADS   16 Ainsworth C, Pamplin J, Allen D, Linfoot J, Chund K: A Bedside communication tool did not improve the alignment of multidisciplinary team’s goals for intensive care unit patients. J Crit Care  2013; 28: 112e.7– 112e.13. Google Scholar CrossRef Search ADS   17 Deering S, Rosen M, Ludi V, et al.  : On the front lines of patient safety: implementation and evaluation of team training in Iraq. Joint Comm J Qual Patient Saf  2011; 37( 8): 350– 6. Google Scholar CrossRef Search ADS   18 Ebbs N, Timmons S: Inter-professional working in the RAF Critical Care Air Support Team (CCAST). Intens Crit Care Nurs  2008; 24: 51– 8. Google Scholar CrossRef Search ADS   19 Anderson F, Brown D, Maloney J, Hardy M, Oliver D: Nurse-physician communication: perceptions of nurses at an army medical center. Mil Med  1996; 161( 7): 411– 5. Google Scholar CrossRef Search ADS PubMed  20 King L, Lee J: Perceptions of collaborative practice between Navy nurses and physicians in the ICU setting. Am J Crit Care  1994; 3( 5): 331– 6. Google Scholar PubMed  21 David J, Blight E: Interdisciplinary treatment of male sexual dysfunction in a military health care setting. J Sex Marital Ther  1978; 4( 1): 29– 34. Google Scholar CrossRef Search ADS PubMed  22 Robinson H, Thompson H: Tri-service physician assistants programs. Mil Med  1977; 142( 5): 353– 6. Google Scholar CrossRef Search ADS PubMed  23 Nielsen P, Munroe M, Foglia L, et al.  : Collaborative medical practice model: Madigan Army Medical Center. Obstet Gynecol Clin North Am  2012; 39: 399– 410. Google Scholar CrossRef Search ADS PubMed  24 Alonso A, Baker D, Holtzman A, et al.  : Reducing medical error in the Military Health System: How can team training help? Hum Res Manage Rev  2006; 16: 396– 415. 25 Gewertz B Military Operating Room of the Future. Report 2012: 1–105. Fort Detrick, MD, U.S. Army medical Research and Materiel Command. 26 Goodman T High-Performing Primary Care Teams: Creating the Air Force Medical Home Advantage. Research report 2015:1–32. Air War College; Air University. 27 Lamb D: Collaboration in practice-Assessment of an RAF CCAST. Brit J Nurs  2006; 15( 10): 552– 7. Google Scholar CrossRef Search ADS   28 Pamplin J, Murray S, Chung K: Phases-of-illness paradigm: better communication, better outcomes. Crit Care  2011; 15: 309– 16. Google Scholar CrossRef Search ADS PubMed  29 Turner T, Parodi A: Theoretically-driven infrastructure for supporting health care teams training at a military treatment facility. Mil Med  2012; 177( 2): 139– 44. Google Scholar CrossRef Search ADS PubMed  30 Lamb D: Could simulated emergency procedures practiced in a static environment improve the clinical performance of a Critical Care Air Support Team (CCAST)? A literature review. Intens Crit Care Nurs  2007; 23: 33– 42. Google Scholar CrossRef Search ADS   31 MacVicar A: Community psychiatry in the Canadian Air Division, Europe. Can Med Assoc J  1966; 95: 307– 12. Google Scholar PubMed  32 D’Angelo M, Saperstein A, Seibert D, Durning S, Varpio L: Military interprofessional health care teams: how USU is working to harness the power of collaboration. Mil Med  2016; 11/12: 1404. Google Scholar CrossRef Search ADS   33 Boren D, Forbus R, Bibeau P, McKenzie R, McKinsey K: Managing critical care casualties on the Navy’s hospital ships. Crit Care Nurs Clin  2003; 2: 183– 91. Google Scholar CrossRef Search ADS   34 Whitcomb J, Newell K: Skill set requirements for nurses deployed with an expeditionary medical unit based on lessons learned. Crit Care Nurs Clin  2008; 1: 13– 22. Google Scholar CrossRef Search ADS   35 Vonfosson C: Preparing to return home: the forward surgical team concludes its year in Afghanistan. Am J Nurs  2011; 111( 4): 47– 9. Google Scholar CrossRef Search ADS   Author notes The views expressed in this manuscript are solely those of the authors and do not necessarily reflect those of the Uniformed Services University of the Health Sciences, the US Navy, or the US Department of Defense. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Military Medicine Oxford University Press

Interprofessional Healthcare Teams in the Military: A Scoping Literature Review

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Association of Military Surgeons of the United States
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Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018.
ISSN
0026-4075
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1930-613X
D.O.I.
10.1093/milmed/usy087
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Abstract

Abstract Introduction Research into healthcare delivered via interprofessional healthcare teams (IHTs) has uncovered that IHT can improve patient satisfaction, enhance collaborative behaviors, reduce clinical error rates, and streamline management of care delivery. Importantly, these achievements are attained by IHTs that have been trained via interprofessional education (IPE). Research indicates that interprofessional healthcare team training must be contextualized to suit the demands of each care context. However, research into the unique demands required of military IHTs has yet to be explored. For any form of IPE to be successfully implemented in the military, we need a clear understanding of how interprofessional healthcare team competencies must be tailored to suit military care contexts. Specifically, we must know: (1) What evidence is currently available regarding IHTs in the military?; and (2) What gaps in the evidence need to be addressed for IPE to be customized to meet the needs of military healthcare delivery? Method We conducted a scoping review of the literature was conducted to identify the breadth of knowledge currently available regarding MIHTs. A search of PubMed, EMBASE, PsycInfo, ERIC, DTIC.mil, and NYAM Gray Literature databases was conducted without date restrictions. The search terms were: (interprofessional* OR interprofessional*) AND (military OR Army OR Navy OR Navy OR Marines OR “Air Force” OR “Public Health Service”) AND (health OR medicine). Of the 675 articles identified via the initial search, only 21 articles met inclusion criteria (i.e., involved military personnel, teams were medically focused, comprised at least two professional disciplines, and at least two people). Results The manuscripts included: seven original research studies, six commentaries, five reviews, one letter, one annual report, and one innovation report. Analyses identified three themes (i.e., effective communication, supportive team environments, members) related to successful MIHT collaborations and five related to unsuccessful MIHT collaborations (i.e., inability to develop team cohesion, lack of trust, ineffective communication and communication breakdowns, unaddressed or unresolved conflicts, rank conflicts). These manuscripts highlighted contextual factors that shape MIHTs. For example, MIHTs often work and live together for extended periods of time when deployed. Also, military rank can facilitate collaboration by establishing clear lines of reporting, but can problematize collaboration when inexperienced care providers (e.g., early career physicians) outrank other team members (e.g., medics) who have more experience providing care in deployment contexts. Discussion Given the experiences of military personnel can be perilous and unpredictable, the military has an obligation to study the unique contexts of care where interprofessional healthcare teams are employed. In doing so, better interprofessional education interventions can be tailored to better aid our service men, women, and their families. Healthcare delivered via interprofessional healthcare teams (IHTs) has been found to improve patient satisfaction, enhance collaborative behaviors, reduce clinical error rates, and streamline management of care delivery.1 These achievements were attained by IHTs trained via interprofessional education (IPE).1 The rewards of IHTs are not reaped simply by requiring different healthcare professionals to work together; they are reaped by teams that have learned how to work together. There are general principles to guide IPE efforts; however, these interprofessional competencies are constructed as “overall guidelines” that must be contextualized to align with the culture and expectations of individual institutions, clinics, and professions.2 Tailoring IHT competencies to fit specific contexts makes intuitive sense. A successful IHT working in a busy urban Emergency Department functions differently than one in an outpatient pediatric clinic. And yet, the U.S. military healthcare and medical education systems have not explored what makes military IHTs unique. We do not know if or how IHT competencies should be tailored to suit military care contexts. Anecdotes abound about how IHT collaboration is impacted by the chain of command, the variations in rank, and the chaotic realities of deployments. But anecdotes are not evidence. Little has been written about the unique characteristics of successful IHTs working in military contexts. How can the military target their IHT education efforts when we do not know if or how IHT competencies must be modified to align with U.S. military healthcare contexts? The U.S. military has been part of spearheading the promotion and incorporation of IPE into educational and healthcare delivery practices. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was developed by the Health and Human Services Agency for Healthcare Research and Quality (AHRQ) in collaboration with the Department of Defense (DoD) Health Care Team Coordination Program (HCTCP).3 TeamSTEPPS is an evidence-based program designed to improve performance among healthcare profession teams, allowing them to quickly respond to a variety of situations.4 It rests on four integrated core competencies that, together, “foster delivery of safe, quality care as a cohesive patient care team”3: leadership, situation monitoring, communication, and mutual support. These competencies are broad in scope, and need to be shaped to fit the context(s) in which the IHT is working. This is part of the power of the TeamSTEPPS program: it can be tailored to suit diverse contexts.5–9 For any form of IPE to be successfully implemented in the military, we need a clear understanding of how IHT competencies must be tailored to suit military care contexts. Specifically, we must know: (1) What empirical evidence is currently available regarding IHTs in the military?; and (2) What gaps in the evidence need to be addressed for IPE to be customized to meet the needs of military healthcare delivery? To answer these questions, we conducted a literature review. METHOD Five kinds of literature reviews are commonly used in healthcare research and health professions education research: systematic, narrative, scoping, critical-realist, and open peer commentary.10 The goal of our review was to explore what is known about military interprofessional healthcare teams (MIHTs). This question could not be refined to a focused, hypothesis-driven research question. Furthermore, given the small pool of literature available on MIHTs, and lack of statistical evidence available in that literature, our review could not generate objective findings and interpretations. Therefore, instead of a systematic review, we engaged in a scoping literature review. Scoping reviews “collect, evaluate and present findings from existing research”11 in order to “map key concepts contained in a research domain – their breadth, limits and features.”10 Scoping reviews map out the breadth of knowledge about a particular topic, and identify gaps in that knowledge, making it ideally suited for our purposes.12,13 Relying on Arksey and O’Malley’s12 framework for scoping reviews and the revisions to that framework offered by Levac et al.14 our review followed the following six steps: (1) develop research questions, (2) identify relevant literature, (3) select specific articles, (4) extract data, (5) summarize and report results, and (6) consult with key informants. We report each of these steps below, noting that steps two, three and four are described together to highlight the iterative work completed to refine our data collection processes. The overall review process is illustrated in Supplementary Figure 1. Step One: Develop research questions The questions informing this review were: (1) What empirical evidence is currently available regarding MIHTs?; and (2) What gaps in the evidence need to be addressed for IPE to be customized to meet the needs of military healthcare delivery? Eligible literature included all peer-reviewed articles and manuscripts from the gray literature. Steps Two, Three, and Four: Identify Relevant Literature, Select Specific Articles, and Data Extraction Search terms and inclusion/exclusion criteria were developed and then refined by the team collaborating on the review. A pilot search was conducted in January 2017 using PubMed, DTIC.mil, EMBASE, and the NYAM Gray Literature database. The obtained literature (n = 367) was reviewed, and search terms/databases were revised to broaden the scope of inclusion. The final search was conducted in April 2017 using PubMed, EMBASE, PsycInfo, ERIC, DTIC.mil, and the NYAM Gray Literature database. The entirety of each database was searched; no date restrictions were imposed. The search terms were: (interprofessional* OR interprofessional*) AND (military OR army OR navy OR naval OR marines OR “air force” OR “public health service”) AND (health OR medicine). A total of 675 articles were identified for screening, with 559 articles remaining after removing duplicates and non-English articles. The titles and abstracts of these articles were reviewed to verify each article addressed (1) military (2) healthcare teams, that were (3) interprofessional (i.e., included team members from at least two health professions [e.g., medicine and nursing]). Only 46 of the 559 articles met these criteria. We reviewed the 46 articles in four phases using a computer software program to facilitate literature coding (Distiller). In phase one, six members of our teach each reviewed two articles, with no two individuals co-reviewing more than one article. An initial draft of the data extraction tool (v1) was developed and used to review six articles. During review, reviewers identified weaknesses of the data extraction tool, after which. The tool was revised (v2) for the team to use for reviewing the six phase one articles. Reviews completed in phase one were compared and all co-reviewer discrepancies were discussed at a team meeting until consensus was achieved. The data extraction tool was revised (v3) incorporating team consensus decisions. In phase two, new set of six articles were reviewed. Team coding was reviewed, discrepancies were identified and presented at a team meeting, and group discussion was held until consensus was achieved. In phase three, the remaining 34 articles were reviewed, with each article being reviewed by two team members. Twenty-eight articles were excluded because the reviewers determined that the articles did not meet inclusion criteria, leaving 18 articles for inclusion in the review. In phase four, all 18 articles were hand-searched for publically available references that were relevant to the review’s questions. Three additional articles were identified, which were reviewed by two team members. In sum, 21 articles met inclusion criteria and are included in this scoping review. Step 5: Summarize and Report Results Both qualitative and quantitative data from the articles were analyzed. Quantitative data highlighted: the nature of articles addressing MIHTs, the nationality of the researchers, the geographical contexts where MIHTs worked (including all five levels of care and transitions between levels), the contexts in which care was provided, and the professions included in the MIHTs. The qualitative data were analyzed thematically15 by grouping data excerpts into thematic clusters, and verifying that all the data collected via the extraction tool were accounted for and compared.15 Step 6: Consult with Key Informants An oversight committee was struck for this study, consisting of 10 experts from an array of different healthcare professions (i.e., physicians [n = 6], dentists [n = 1], nurses [n = 2], and medical technicians [n = 1]) and from each branch of military service (Army [n = 2], Air Force [n = 4], and Navy [n = 3]) and one civilian IPE expert. The scoping review results were presented to and assessed by the oversight committee at a meeting held in September 2017. The oversight committee offered additional comments and suggestions, which were reviewed and applied to our final analyses. RESULTS Nature and Distribution of Articles Twenty-one articles published between 1966 and 2016 met inclusion criteria and were included in this review. Overall inter-rater reliability was high (Kappa = 0.83). Supplementary Table 1 provides descriptive data about the MIHTs discussed in each manuscript including: the nationality of the MIHT in question; the care context in which the MIHT was working (e.g., combat mission, peacekeeping mission, US-based healthcare center, etc.); the geographical location of the care delivered by the MIHT (by continent); the level of care designation for the MIHT care activity; the MIHT’s branch of military affiliation; the health professionals working as members of the MIHT; the size of the MIHT; and the care activities performed by the MIHT. Supplementary Table 2 provides information as to each manuscript’s type (e.g., original research article, commentary, etc.) as well as the contributions made to what is known about MIHTs (e.g., primary findings related to MIHTs, descriptions of (un)successful MIHT collaborations, etc.). Eight articles16–23 (38%) were original research articles that used quantitative (n = 4)17,18,20,21 or qualitative (n = 2)19,22 methods. There were two mixed methods studies.23,24 The original research articles were primarily conducted on U.S. MIHTs (n = 8), offering care in the USA (n = 6)17,20,22–24 and abroad (n = 2).18,19 Working primarily at level 5 of care17,20–22 (i.e., U.S. based healthcare centers), the MIHTs represented in the research articles were commonly part of the Army.17,20,22–24 These MIHTs were generally small in size (having between 2 and 9 team members) where the team was generally composed of at least one physician working with a nurse (n = 6),17–21,24 or with another health professional (n = 2).22,23 The types of care activities performed by the MIHTs studies in the original research articles were wide ranging, including: diagnostics,23 treating male sexual dysfunction,22 ICU care20,21 critical care air flight support,19 forward surgical teams,17,18 and OBGYN care.24 Thematic Analysis We clustered comments about MIHTs around (1) successful MIHTs, including the facilitators of that success; and (2) unsuccessful MIHTs, including the impediments to success. We noted that many of the facilitators of success were identified inversely as obstacles of success (e.g., good communication is a facilitator; poor communication is an inhibitor). In this reporting of results, we align data themes with the arguments and emphases of the authors of the original manuscripts, while also streamlining the results to avoid unnecessary repetition. Successful MIHTs and the Facilitators of That Success Three major themes were related to the success of MIHTs and the facilitators of that success: effective communication; supportive team environments; and shared role understanding and equity among team members. Table I lists definitions for each of these themes. Table I. Definitions of Themes Relating to Successful MIHTs and the Facilitators of That Success Label  Definition  Effective communication  Ability to collaborate using effective verbal and written communication strategies between team members (e.g., dyad or triad) and across the team as a whole  Supportive team environments  Providing appropriate structures and guidelines to ensure teams are able to collaborate sufficiently (e.g., manuals, guidelines, appropriate team membership, troubleshooting strategies)  Shared role understanding and equity among team members  Team members’ roles are equally valued and respected, regardless of their professional role or military rank (e.g., nurses, physicians, and corpsmen participate in the MIHT as equally valuable members of the team)  Label  Definition  Effective communication  Ability to collaborate using effective verbal and written communication strategies between team members (e.g., dyad or triad) and across the team as a whole  Supportive team environments  Providing appropriate structures and guidelines to ensure teams are able to collaborate sufficiently (e.g., manuals, guidelines, appropriate team membership, troubleshooting strategies)  Shared role understanding and equity among team members  Team members’ roles are equally valued and respected, regardless of their professional role or military rank (e.g., nurses, physicians, and corpsmen participate in the MIHT as equally valuable members of the team)  Table I. Definitions of Themes Relating to Successful MIHTs and the Facilitators of That Success Label  Definition  Effective communication  Ability to collaborate using effective verbal and written communication strategies between team members (e.g., dyad or triad) and across the team as a whole  Supportive team environments  Providing appropriate structures and guidelines to ensure teams are able to collaborate sufficiently (e.g., manuals, guidelines, appropriate team membership, troubleshooting strategies)  Shared role understanding and equity among team members  Team members’ roles are equally valued and respected, regardless of their professional role or military rank (e.g., nurses, physicians, and corpsmen participate in the MIHT as equally valuable members of the team)  Label  Definition  Effective communication  Ability to collaborate using effective verbal and written communication strategies between team members (e.g., dyad or triad) and across the team as a whole  Supportive team environments  Providing appropriate structures and guidelines to ensure teams are able to collaborate sufficiently (e.g., manuals, guidelines, appropriate team membership, troubleshooting strategies)  Shared role understanding and equity among team members  Team members’ roles are equally valued and respected, regardless of their professional role or military rank (e.g., nurses, physicians, and corpsmen participate in the MIHT as equally valuable members of the team)  Effective Communication The papers addressing this theme3,18,24–29 reported that MIHT collaboration was successful when there was clear, continuous communication between individual members of the care team as well as across the team as a whole. For example, one article studying Critical Care Air Support Teams (CCAST)28 teams working in remote locations with the Air Force, observed that the MIHT being studied had been successful “as a result of the importance placed on communication.”28 The importance placed on effective communication as contributing to MIHT success was emphatically reported in all eight articles. In fact, one article noted that communication was seen as contributing to minimizing patient care errors.18 David and Blight 21 succinctly summarized the importance of open communication as a means of enabling the MIHT’s collaborative success: “open communication is the key to finding integrated solutions and unveiling the source of conflict (differences).” Goodman stated that MIHT team members “recognize that better communication improves decision making and decreases stress.”27 Supportive Team Environments These articles18,19,30 highlighted that, when MIHTs were provided with appropriate structures and clear guidelines, the team was able to collaborate successfully. One article described successful teams as a “marriage of team cohesion, patient satisfaction and safety, and improved medical outcomes.”27 Appropriate structures that contributed to a supportive team environment were: repeated exposure to feedback, appropriate team structure, positive leadership, mutual support, and situation monitoring.30 Each structure provided scaffolding for encouraging individual and team success and growth. Clear guidelines that facilitated MIHT success were described as shared patient goals, pertinent/deliberate training, flexibility, and standardized protocols.27 Interestingly, these articles did not offer a specified training timeline required for teams to become supportive collaborators, but did suggest that training was necessary for team success. The importance of a clear goal and/or mission alignment to foster a supportive team environment was often related to greater team success and improved patient outcomes.21,27 Shared Role Understanding and Equity Among Team Members Six articles12,19,26–28,30 described how MIHT collaboration was successful when members of the team had an explicit and shared understanding of each team member’s role. Lamb described how “the importance of role equality within a team and the subsequent feeling of value this promotes, effective communication and positive “can do” attitudes contribute to making the team work.”27 Here, role equality refers to all health professional roles being equally valued by all team members. No one role is more meaningful than another; instead, team member roles and their associated responsibilities are all vital to team’s success. Further, three articles24,27,31 stressed the importance for MIHT team members to be valued and respected as equal members of the team, regardless of their professional role or military rank. As Ebbs et al. revealed, rapport among the MIHT team members was positive when “parties allowed the relaxation of rank,” thereby enabling professionalism to trump rank.19 Lamb affirmed the positive contributions that a sense of equality gives to MIHTs stating that “role equality within the CCAST [the MIHT studied] promotes feelings of value among the team and effective team working.”28 Unsuccessful MIHTs and the Inhibitors That Impeded Success Five themes related to unsuccessful MIHTs and the inhibitors that impeded team success. These were: inability to develop team cohesion; lack of trust; ineffective communication and communication breakdowns; unaddressed or unresolved conflicts; and rank conflicts. Table II offers definitions for each of these themes. Table II. Definitions of Themes Relating to Unsuccessful MIHTs and the Inhibitors Impeding Success Label  Definition  Inability to develop team cohesion  Teams were not able to unify, to develop mutual support, or to work together to accomplish collaboration goals. This resulted from a number of different factors including insufficient time together and/or aspects of the team’s interactions  Lack of trust  Occurs when team members were unsure if they could rely on the character, ability, or strength of a team member  Ineffective communication and communication breakdowns  Verbal and/or written communication failed to achieve its desired goal  Unaddressed or unresolved conflicts  Questions and or problematic subjects that existed between individual team members, as well as the team as a whole, were not discussed or resolved  Rank conflicts  When a team, or members of a team, was conflicted by existing military rank, leading to a sense of inequity and diminished sense of partnership  Label  Definition  Inability to develop team cohesion  Teams were not able to unify, to develop mutual support, or to work together to accomplish collaboration goals. This resulted from a number of different factors including insufficient time together and/or aspects of the team’s interactions  Lack of trust  Occurs when team members were unsure if they could rely on the character, ability, or strength of a team member  Ineffective communication and communication breakdowns  Verbal and/or written communication failed to achieve its desired goal  Unaddressed or unresolved conflicts  Questions and or problematic subjects that existed between individual team members, as well as the team as a whole, were not discussed or resolved  Rank conflicts  When a team, or members of a team, was conflicted by existing military rank, leading to a sense of inequity and diminished sense of partnership  Table II. Definitions of Themes Relating to Unsuccessful MIHTs and the Inhibitors Impeding Success Label  Definition  Inability to develop team cohesion  Teams were not able to unify, to develop mutual support, or to work together to accomplish collaboration goals. This resulted from a number of different factors including insufficient time together and/or aspects of the team’s interactions  Lack of trust  Occurs when team members were unsure if they could rely on the character, ability, or strength of a team member  Ineffective communication and communication breakdowns  Verbal and/or written communication failed to achieve its desired goal  Unaddressed or unresolved conflicts  Questions and or problematic subjects that existed between individual team members, as well as the team as a whole, were not discussed or resolved  Rank conflicts  When a team, or members of a team, was conflicted by existing military rank, leading to a sense of inequity and diminished sense of partnership  Label  Definition  Inability to develop team cohesion  Teams were not able to unify, to develop mutual support, or to work together to accomplish collaboration goals. This resulted from a number of different factors including insufficient time together and/or aspects of the team’s interactions  Lack of trust  Occurs when team members were unsure if they could rely on the character, ability, or strength of a team member  Ineffective communication and communication breakdowns  Verbal and/or written communication failed to achieve its desired goal  Unaddressed or unresolved conflicts  Questions and or problematic subjects that existed between individual team members, as well as the team as a whole, were not discussed or resolved  Rank conflicts  When a team, or members of a team, was conflicted by existing military rank, leading to a sense of inequity and diminished sense of partnership  Inability to Develop Team Cohesion Not all MIHTs were able to come together as a group. In these instances, the failure to unify, develop mutual support, and engage in collaborative behaviors resulted in an inability for the MIHT to develop team cohesion. Chief among the reasons for this lack of cohesion were insufficient time together as a team and aspects of the team interactions. One characteristic of MIHTs distinguishing them from civilian IHTs was that, in the military context, teams could expect to spend a lot of time together. As Ebbs acknowledged: “A key difference from civilian health services is the amount of time that military doctors and nurses may have to spend together. Within the civilian ICU environment personnel see each other in a professional capacity, whereas in the military there are times that you may live and work together 24 hours a day, 7 days a week.”28 However, extended time together should not be equated with time spent developing team cohesion. Goodman explained that successful MIHT collaboration requires that team members be accessible to each other so that they can communicate about care activities.27 However, “the physical layout of offices often precludes team members from interacting in a meaningful way. The lack of specific time to regroup and feedback or plan the daily events has also been cited as an obstacle.”27 Another obstacle to team cohesion related to team interactions. For instance, as Nielsen observed, “effective team skills are inherent in the personalities of some individuals.”28 In contrast, for teams to overcome personalities that inhibit successful MIHT collaboration required “diligence and conscious adherence to the principles of effective teamwork.”28 Lack of Trust Another inhibitor of MIHT collaborative success was a lack of trust amongst team members. When team members were unsure if they could rely on the character, ability, or strength of a team member, trust was eroded and so was the success of the MIHT. These aspects (i.e., character, ability, and strength) refer to those an individual possesses, as well as how the individual’s characteristics then combine in a team context. King addressed the importance of trust in MIHTs when discussing the interactions between physicians and nurses on the collaborative team: “The extent to which nurses and physicians practice collaboratively in delivering patient care is directly related to how well they know and trust each other.”21 Nielsen noted that “conflicts that are unaddressed, unresolved, or unjustly handled can be detrimental to the viability of a partnership and can quickly unravel the bonds of mutual trust and respect.”24 Failure to develop and maintain a sense of trust among team members may have deteriorated the relationships within the team, and ultimately damaged the overall success they, and their patients, experienced. It should be noted that trust was not discussed in relation to an individual’s competence, although the two may, in fact, be related. Ineffective Communication and Communication Breakdowns The vital role of communication was emphasized as authors reflected on the ways and extent to which ineffective communication and communication breakdowns impeded MIHTs from achieving collaborative success. These communication problems could be verbal or written. Regardless of modality, MIHT success was inhibited when communications failed to achieve their desired goals. For example, team collaboration was significantly diminished when misunderstandings regarding the content of communications or failing to speak to interprofessional team members when necessary. Anderson explored how professional boundaries contributed to communication breakdowns in MIHTs, stating that “the nurses’ discontent with communication with physicians arose out of their desire for a more collaborative role with physicians.”20 These communication barriers not only negatively impacted the MIHT but also the patients they cared for: “It is necessary that physicians and nurses work as a team in order to provide the most efficacious care in a cost-contained environment. If one member of the team is not permitted to communicate and participate as a team member, it is not only the provider and the organization that will suffer, but, ultimately, the patient as well.”18 Unaddressed or Unresolved Conflicts Conflicts left unaddressed or unresolved were identified as inhibiting the success of MIHTs. Questions or contentious issues could create tension between individual team members, and even across the team as a whole. If they were not discussed and resolved, these conflicts were identified as the root of MIHT collaboration collapse. As Nielsen stated: “A collaborative practice does not eliminate disagreements, but they need not result in conflict.”24 Of additional concern were issues related to conflict formation. These surrounded issues of failure to adopt protocols or agree on patient care, team member reticence to collaborate, and perceived lack of respect. Often this lack of respect was related to a sense of unwillingness to take on additional responsibilities, or devote additional time to the case at hand.27 Rank Conflicts Military rank, a contextual factor that is part of every MIHT, was described as inhibiting MIHT success when a team, or members of a team, experienced conflict because of differences in rank, leading to a sense of inequity and a diminished sense of partnership. This was yet another instance where the military contexts of care importantly differ from civilian contexts. As Ebbs explained, this rank differential can become a focal point for conflict and breakdowns in the MIHT: “often the medical officer outranks those on the flight deck and even though the doctor is present in a medical capacity, rank becomes an extra issue.”19 Military MIHT team members who have experience with civilian IHTs are well positioned to identify how rank conflict can interfere with MIHT success. One anesthesiologist participating in Ebb’s study expressed role conflict clearly stating: “if you work in a clinical team then rank is irrelevant and it’s a clinical team…it’s got nothing to do with the military, we’re professionals…I personally feel that rank becomes a barrier because people aren’t quite as comfortable and don’t interact in the same way because you outrank them.”19 DISCUSSION The purpose of this scoping review was to explore the current state of knowledge about MIHTs. Given that only 21 articles were identified, it seems clear that there are many gaps in this literature that need to be addressed. Our review establishes that little research attention has been paid to understanding the characteristics of successful MIHTs in general, and in deployed contexts in particular – be those deployments for humanitarian, peacekeeping, or combat mission purposes. Only seven articles addressed these deployments, and of those only one contained empirical data. The remainder of the articles exploring deployed contexts were commentaries,30–32 reviews,33,34 or letters.35 Clearly, more research is needed about all MIHTs; but, at present, the available literature neglects to attend to the unique challenges MIHTs face in deployed settings. Our analysis identified three themes related to successful MIHT collaborations and five related to unsuccessful MIHT collaborations. It is important to acknowledge that these themes do not exist in isolation of each other. Time and again, the authors of these articles discussed themes together to demonstrate interdependence. For example: There is a significant barrier in team members’ ability to forthrightly discuss daily issues due to a perceived lack of respect, ignorance of role, or different styles of relaying information.27 Additional research should explore these themes further, search out additional themes, and endeavor to understand how different themes relate to each other. We hypothesize that these interrelations are important for understanding how MIHTs can effectively collaborate. For example, a valuable line of research might explore how rank differences impact the ability of teams to cohere. Only eight of the articles included in this review were original research articles. Empirical research must investigate the unique contexts of care where they require MIHT providers to collaborate. Only then can interprofessional education interventions be tailored to suit these contexts. As the analysis of the articles in this review demonstrates, some of the qualities of successful MIHTs are similar to those of their civilian counterparts (e.g., the need for effective communication between team members). However, our analysis highlights aspects of military contexts that are truly unique and must inform MIHT training and collaborative practices (e.g., dealing with rank conflicts). We were surprised to find six review articles that addressed MIHTs given the paucity of original research that has been conducted on MIHTs. However, several of these reviews focused on composite elements of MIHTs (e.g., physicians as members of MIHTs). Alonso highlights six considerations the Department of Defense must attend to: the cultural conflicts that exist between the military and healthcare cultures; diverse sets of technical skills; the cultural norms associated with each branch of the military (i.e., Army, Navy, and Air Force); extreme transition or turnover of personnel at all levels; the reduced number of resources, financial and otherwise during war; and greater degree of regulations than civilian organization such as those imposed by the office of the Surgeon General and the Office of the Inspector General.3 Unfortunately, the literature currently available about MIHTs fails to address these six considerations in any depth. The U.S. military has a responsibility to train their health professionals to work effectively in the myriad of contexts where MIHTs operate. This training should be based on a robust body of evidence that reports on the characteristics of successful MIHT collaborations, best practices for implementation in a variety of care contexts, and ways to support MIHT collaborations effectively. Specifically, if we are going to prepare our service members to provide life-saving care in interprofessional healthcare teams, we need to understand the characteristics that enable their success, and train those members to embody those characteristics. With so few articles over the last several decades, we are lacking sufficient evidence on which to base our training. We contend that this gap must be addressed – and urgently so – because the care providers in our MIHTs and the patients they support deserve every advantage we can offer them. The first step in addressing this gap will be to study MIHTs to learn what characterizes successful teams, then to implement additional training programs to help prepare our health professionals to succeed in MIHTs. Supplementary Material Supplementary material is available at Military Medicine online. Funding Uniformed Services University of the Health Sciences. Acknowledgements We would like to thank the following members of this research team’s Oversight Committee, whose valuable insights have contributed to the success of this important research endeavor: Dr Diane Seibert (Committee Chair), Dr Carol Aschenbrener, Dr Bruce Doll, Dr Paul Hemmer, Dr Jeffrey Hutchinson, Dr Martin Ottolini, Dr Louis Pangaro, Dr Lula Pelayo, Dr Brian Reamy, and MCPO Jose Romero. References 1 Reeves S, Zwarenstein M, Goldman J, et al.  : Interprofessional education: effects on professional practice and healthcare outcomes. 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Google Scholar CrossRef Search ADS   16 Ainsworth C, Pamplin J, Allen D, Linfoot J, Chund K: A Bedside communication tool did not improve the alignment of multidisciplinary team’s goals for intensive care unit patients. J Crit Care  2013; 28: 112e.7– 112e.13. Google Scholar CrossRef Search ADS   17 Deering S, Rosen M, Ludi V, et al.  : On the front lines of patient safety: implementation and evaluation of team training in Iraq. Joint Comm J Qual Patient Saf  2011; 37( 8): 350– 6. Google Scholar CrossRef Search ADS   18 Ebbs N, Timmons S: Inter-professional working in the RAF Critical Care Air Support Team (CCAST). Intens Crit Care Nurs  2008; 24: 51– 8. Google Scholar CrossRef Search ADS   19 Anderson F, Brown D, Maloney J, Hardy M, Oliver D: Nurse-physician communication: perceptions of nurses at an army medical center. Mil Med  1996; 161( 7): 411– 5. 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Google Scholar CrossRef Search ADS   Author notes The views expressed in this manuscript are solely those of the authors and do not necessarily reflect those of the Uniformed Services University of the Health Sciences, the US Navy, or the US Department of Defense. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.

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Military MedicineOxford University Press

Published: May 8, 2018

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