Background: Teamcare should, like all patient care, also contribute to evidence-based practice (EBP). Randomized controlled trials (RCTs) focusing on teamcare have been performed but no study has addressed its essentials. How far this EBP has progressed in different health aspects is generally established in systematic reviews of RCTs. Aim: The aim is to determine the essentials of teamcare including the nurse profession in RCTs of multi- or interdisciplinary interventions in somatic care focusing on the stated context, goals, strategies, content as well as effectiveness of quality of care. Methods: A systematic review was performed according to Cochrane review assumptions to identify, appraise and synthesize all empirical evidence meeting pre-specified eligibility criteria. The PRISMA statement guided the data selection process of 27 articles from PubMed and CINAHL. Results: Eighty-five percent of RCTs in somatic care showed a positive effectiveness of teamcare interventions, of which interdisciplinary ones showed a greater effectiveness compared with the multidisciplinary approach (100% vs 76%). Also theory-based RCTs presented higher positive effectiveness (85%) compared with non-theory-based RCTs (79%). The RCTs with positive effectiveness showed greater levels for professional-centered ambition in terms of goals and for team-directed initiatives in terms of strategy, and a significantly higher level for patient-team interaction plans in terms of content was shown. Conclusions: Teamcare RCTs are still grounded in the multidisciplinary approach having a professional-centered ambition while interdisciplinary approaches especially those that are theory-based appear to be essential with regard to positive effectiveness and preferable when person-centered careis applied.
Healthcare professionals, and nurses in particular, are continuously being challenged to find evidence-based ways for improving patient care including the increase of job satisfaction and reduction of costs [
Today’s healthcare services as well as policy-making organizations emphasize the importance of evidence- based knowledge, which is essential for dealing with a clinical condition, through the resources available to healthcare professionals and their skills in using them [
Several multi- and interdisciplinary RCT studies have been performed that aim to disseminate knowledge of how to implement the evidence-based knowledge. These start with a description of how to search for evidence through the PICOT format [
RCTs evaluating the effectiveness of teamcare interventions, comprising the nurse profession in the context of somatic care, were included. A team was defined as consisting of at least two individuals from different healthcare disciplines and only RCTs with at least one nurse in the team was included; defining nurse as a RN. In order to narrow our target area, studies in the field of women’s (gynecology/obstetrics), children’s (pediatrics) and mental (psychiatric) health were excluded. Patients as participants were in focus and thus studies comprising relatives were excluded. Outcome measures of main interest were patient-reported outcome measurements (PROM) [
A review team of 13 researchers, experienced in somatic nursing care, performed a literature search in the databases PubMed and CINAHL between 2007 and 2011 with the following criteria: the English language as the most established international and scientific language and Randomized Control Trials. The following controlled vocabulary was used in the identification: “Medical Subject Headings (MeSH)”; “Patient Teamcare” or “Inter professional Relations” or “Multidisciplinary Teamcare” or “Interdisciplinary Communication”. The literature search also excluded, with the Boolean operator NOT, the following free text words from the search: gynecology, pediatrics, pregnancy, psychiatric, psychiatry, mental, depression. A total of 323 references, found in PubMed and CINAHL after the extraction of duplications (n = 15), were thus available for screening.
A study protocol inspired by the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement [
The review team, under the direction of the first and last authors, abstracted information about and reviewed the publications in accordance with the well-established audit template of The Swedish Council on Health Technology Assessment [
The systematic review was performed in accordance with Cochrane review assumptions [
was reached.
Almost 90% (n = 24) of the 27 teamcare RCTs in somatic care originated in six European countries (n = 13) and North America (n = 11) (
Title | Authors and country [ref.] | Context of care and sample size (target group; intervention/ control) | Teamcare intervention | Effect based on primary outcome | *Team work | ||
---|---|---|---|---|---|---|---|
Main Goal | Main Strategy | Main Content | |||||
Effects of structured versus usual care on renal endpoint in type 2 diabetes: the SURE study: a randomized multicenter translational study | Chan et al. 2009, China [ | Medical (diabetes; 104/101) | Adherence | Monitoring | Education | Yes, reduced the need for dialyses | Multi |
aA randomized controlled trial of a health promotion education programme for people with multiple sclerosis | Ennis et al. 2006, UK [ | Medical (multiple sclerosis; 32/30) | Self-care behavior | Self-efficacy | Comprehensive learning | Yes, improved health-promoting behaviour | Multi |
aImpact of an inpatient palliative care team: a randomized control trial | Gade et al. 2008, USA [ | Medical (life-limiting illnesses; 275/237) | Patient satisfaction | Dialogue | Support | Yes, greater satisfaction with care | Inter |
A reengineered hospital discharge program to decrease rehospitalization: a randomized trial | Jack et al. 2009, USA [ | Medical (general medicine; 370/368) | Prevention | Care plans | Advice | Yes, decreased rehospitalization | Inter |
aCostly patients with unexplained medical symptoms: a high-risk population | Margalit and El-Ad, 2008, Israel [ | Medical (unexplained symptoms; 21/21) | Prevention | Dialogue | Comprehensive learning | Yes, decline in visits to medical settings | Multi |
aMultidisciplinary patient education in groups increases knowledge on osteoporosis: a randomized controlled trial | Nielsen et al. 2008, Denmark [ | Medical (osteoporosis; 141/128) | Self- management | Empowerment | Education | Yes, increased patient knowledge on osteoporosis | Multi |
aPatient education in groups increases knowledge of osteoporosis and adherence to treatment: a two-year randomized controlled trial | Nielsen et al. 2010, Denmark [ | Medical (osteoporosis; 136/130) | Adherence | Empowerment | Education | Yes, increased knowledge and adherence to treatment | Multi |
aA randomised controlled clinical trial of nurse-, dietitian- and pedagogist-led Group Care for the management of Type 2 diabetes | Trento et al. 2008, Italy [ | Medical (diabetes; 25/24) | Prevention | Dialogue | Care- management | Yes, improved metabolic control | Multi |
Five-year follow-up findings from a randomized controlled trial of cardiac rehabilitation for heart failure | Austin et al. 2008, UK [ | Cardiac (heart failure; 57/55) | QoL | Follow-up | Comprehensive learning | Yes, no deterioration in walking distance | Multi |
aLessons learned from a multidisciplinary heart failure clinic for older women: a randomised controlled trial | Azad et al. 2008, Canada [ | Cardiac (heart failure; 45/46) | QoL | Dialogue | Comprehensive learning | No effect on heart-failure specific QoL | Multi |
aCan a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients? | Davidson et al. 2010, Australia [ | Cardiac (heart failure; 53/52) | Self- management | Empowerment | Comprehensive learning | Yes, reduced readmissions rates | Multi |
Lack of long-term benefits of a 6-month heart failure disease management program | Nguyen et al. 2007, Canada [ | Cardiac (heart failure; 94/96) | Prevention | Assessment | Disease- management | No long-term effect on readmissions | Multi |
Two-year outcome of a prospective, controlled study of a disease management programme for elderly patients with heart failure | Sindaco et al. 2007, Italy [ | Cardiac (heart failure; 86/87) | Prevention | Care plan | Disease- management | Yes, decreased number of readmissions | Multi |
aNurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial | Wood et al. 2008, UK [ | Cardiac (cardiovascular; 1189/1128) | Prevention | Monitoring | Counselling | Yes, reduced risk of cardiovascular disease | Multi |
The effects of guided care on the perceived quality of health care for multi-morbid older persons: 18-month outcomes from a cluster-randomized controlled trial | Boyd et al. 2010, USA [ | Primary care (elderly multi-morbid; 485/419) | Patient satisfaction | Care plans | Comprehensive learning | Yes, improved self-reported quality of Care | Inter |
---|---|---|---|---|---|---|---|
aGeriatric care management for low-income seniors: a randomized controlled trial | Counsell et al. 2007, USA [ | Primary care (low-income seniors; 474/477) | QoL | Care plans | Care- management | Yes, improved quality of life | Multi and inter |
Randomized controlled trial of anticipatory and preventive multidisciplinary team care: for complex patients in a community-based primary care setting | Hogg et al. 2009, Canada [ | Primary care (elderly at risk of adverse events; 120/121) | Prevention | Care plans | Care- management | Yes, improved Quality of Care | Multi |
The impact of a multidisciplinary information technology-supported program on blood pressure control in primary care | Rinfret et al. 2009, Canada [ | Primary care (hypertension; 111/112) | Adherence | Monitoring | Education | Yes, improved blood pressure levels | Multi |
Changes in walking activity and endurance following rehabilitation for people with Parkinson disease | White et al. 2009, USA [ | Primary care (Parkinson; 35+37/35) | Self-management | Practical training | Education | Yes, improved walking activity and endurance | Inter |
Evaluation of a fall-prevention program in older people after femoral neck fracture: a one-year follow-up | Berggren et al. 2008, Sweden [ | Orthopedic (femoral neck fracture; 84/76) | Prevention | Assessment | Comprehensive learning | No effect on number of fall after one year | Multi |
aLack of effectiveness of a multidisciplinary fall-prevention program in elderly people at risk: a randomized, controlled trial | Hendriks et al. 2008, the Netherlands [ | Orthopedic (elderly after fall; 124/134) | Prevention | Assessment | Disease- management | No effect on falls and daily functioning | Multi |
A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture | Stenvall et al. 2007a, Sweden [ | Orthopedic (femoral neck fracture; 102/97) | Prevention | Assessment | Comprehensive learning | Yes, reduced postoperative falls | Multi |
Improved performance in activities of daily living and mobility after a multidisciplinary postoperative rehabilitation in older people with femoral neck fracture: a randomized controlled trial with 1-year follow-up | Stenvall et al. 2007b, Sweden [ | Orthopedic (femoral neck fracture; 102/97) | Prevention | Assessment | Comprehensive learning | Yes, enhanced activities of daily living performance and mobility | Multi |
Will improvement in quality of life impact fatigue in patients receiving radiation therapy for advanced cancer? | Brown et al. 2006, USA [ | Oncological (cancer; 49/54) | QoL | Dialogue | Advice | No effect of fatigue | Multi |
Therapeutic exercise during outpatient radiation therapy for advanced cancer: Feasibility and impact on physical well-being | Cheville et al. 2010, USA [ | Oncological (advanced cancer; 49/54) | QoL | Dialogue | Advice | Yes, physical wellbeing improved at 4 week | Multi |
aQuality of life after self-management cancer rehabilitation: a randomized controlled trial comparing physical and cognitive-behavioral training versus physical training | Korstjens et al. 2008, the Netherlands [ | Oncological (cancer survivors; 71+76/62) | Self-management | Practical training | Support | Yes, physical training improved QoL | Multi |
aFast-track in open intestinal surgery: prospective randomized study | Serclová et al. 2009, Czech Republic [ | Surgical (intestinal resection; 51/52) | Patient safety | Monitoring | Disease- management | Yes, reduced postoperative complications and hospital stay | Inter |
QoL = Quality of Life, *Team work; multidisciplinary (multi) or interdisciplinary (inter) approach, a = Theory-based intervention.
Forty-eight percent (n = 13) of the RCTs in somatic care presented a theoretical standpoint related to teamcare intervention (
A total of 85% of the RCTs in somatic care (n = 22) showed positive effectiveness of a teamcare intervention, of which the interdisciplinary team had 100% positive effectiveness (6 of 6) compared to that of the multidisciplinary team of 76% (16 of 21). There was a somewhat higher proportion (11 of 13; 85%) for the theory-based RCTs in terms of positive effectiveness compared to that for the non-theory-based RCTs (11 of 14; 79%). Furthermore, when comparing the RCT studies with positive effectivenesswith those without effectiveness, the former showed a somewhat greater level for professional-centered ambition in terms of goals and for team-di- rected initiatives in terms of strategy, and a significantly higher level for patient-team interaction plan in terms of content (
Studies | Theoretical standpoint | References used in the studies |
---|---|---|
Hendriks et al. 2008 [ | EBC; Prevention of falls in the elderly trial (PROFET) | Close et al. 1999 [ |
Nielsen et al. 2008 [ | EBC; Guidelines for facilitating a patient empowerment program | Arnold et al. 1995 [ |
Serclová et al. 2009 [ | EBC; ESPEN guidelines on enteral nutrition | Weimann et al. 2006 [ |
Wood et al. 2008 [ | EBC; Prevention of coronary heart disease in clinical practice: recommendation of the second joint task force of European and other societies on coronary prevention | Wood et al. 1998 [ |
Azad et al. 2008 [ | Partners in care for congestive heart failure | Harrison et al. 1996 [ |
Counsell et al. 2007 [ | The GRACE (Geriatric Resources for Assessment and Care of Elders) model | Counsell et al. 1996 [ |
Davidson et al. 2010 [ | Empowerment for self-management | Grady et al. 2000 [ |
Ennis et al. 2006 [ | Bandura’s self-efficacy theory | Bandura et al. 1977 [ |
Gade et al. 2008 [ | Weismann key palliative care components | Weismann et al. 1997 [ |
Korstjens et al. 2008 [ | Self-management and cognitive behavioral therapy | Mesters et al. 2002 [ |
Margalit and El-Ad, 2008 [ | Short-term family therapy in ambulatory care | Eshet et al. 1993 [ |
Trento et al. 2008 [ | Adult-learning | Newman et al. 2002 [ |
EBC = Evidence-Based Care.
Goal | Strategy | Content | |||
---|---|---|---|---|---|
Category | Main category | Category | Main category | Category | Main category |
Prevention (11) Adherence (3) Patient safety (1) | Professional-centered ambition (15) | Assessment (5) Care plans (5) Follow-up (1) | Team-directed initiatives (11) | Comprehensive learning (9) Education (5) Advice (3) Support (2) Counselling (1) | Patient-team interaction plan (20) |
Quality of life (5) Self-management (4) Patient satisfaction (2) Self-care behaviour (1) | Patient-centered ambition (12) | Dialogue (6) Empowerment (3) | Patient-team-directed initiatives (9) | Disease-management (4) Care-management (3) | Team-management plan (7) |
Monitoring (4) Practical training (2) Self-efficacy (1) | Patient-directed initiatives (7) |
Intervention | Studies with effect, n (%) | Studies without effect, n (%) |
---|---|---|
Intervention goal | ||
Professional-centered ambition | 12 (55) | 3 (60) |
Patient-centered ambition | 10 (45) | 2 (40) |
Intervention strategy | ||
Team-directed initiatives | 8 (36) | 3 (60) |
Patient team-directed initiatives | 7 (32) | 2 (40) |
Patient-directed initiatives | 7 (32) | 0 (0) |
Intervention content | ||
Patient team-interaaction plan | 17 (77) | 3 (60) |
Team-management plan | 5 (23) | 2(40) |
It is noteworthy that fewer than 10% of the identified RCTs remained for the final review process thus indicating the importance of dictating relevant inclusion and exclusion criteria as well as quality assessment, even for RCT-designs. It is also important to remember that qualitative designs are essential for identifying patients’ needs in order to develop the most appropriate and effective PROM-interventions [
Considering the fact that almost all teamcare intervention studies had been carried out in Europe and North America, it is questionable how well the results can be generalized outside these continents. On the other hand the need for more teamcare interventions has been emphasized [
Teamcare RCTs are still founded on the multidisciplinary approach having a professional-centered ambition with the team-directed initiative whilst utilizing a patient team-interaction plan. Interdisciplinary approaches especially those that are theory-based appear to be essential with regard to positive effectiveness, preferably when person-centered care is applied based on evidence-based practice. More literature reviews are needed in order to compare teamcare RCTs in somatic care with those focusing on children’s and women’s health as well as mental health.
BengtFridlund,Ewa K.Andersson,Sidona-ValentinaBala,Gull-BrittDahlman,Anna K.Ekwall,StinneGlasdam,AmiHommel,CatharinaLindberg,Eva I.Persson,AndreasRantala,AnnicaSjöström-Strand,JonasWihlborg,KarinSamuelson, (2015) Essentials of Teamcare in Randomized Controlled Trials of Multidisciplinary or Interdisciplinary Interventions in Somatic Care: A Systematic Review. Open Journal of Nursing,05,1089-1101. doi: 10.4236/ojn.2015.512116