A cluster-randomized controlled study to evaluate a team coaching concept for improving teamwork and patient-centeredness in rehabilitation teams
A cluster-randomized controlled study to evaluate a team coaching concept for improving teamwork and patient- centeredness in rehabilitation teams
Mirjam KoÈ rner 0 1
Leonie Luzay 0 1
Anne Plewnia 0 1
Sonja Becker 0 1
Manfred Rundel 0
Linda Zimmermann 0
Christian MuÈ ller 0 2
0 Editor: Michel Botbol, Universite de Bretagne Occidentale , FRANCE
1 Medical Psychology and Medical Sociology, Medical Faculty, Albert-Ludwigs-University , Freiburg, Germany, 2 Celenus-Kliniken GmbH, Offenburg, Germany, 3 Moving-Concept, Freiburg , Germany
2 Saarland University of Cooperative Education in Health Care and Welfare , Saarbr uÈcken , Germany
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Funding: This study was supported by
Bundesministerium fuÈr Bildung und Forschung,
Home/home_node.html, grant number: 01GX1024.
The funders had no role in study design, data
In order to analyze the effect of TCC on internal participation and teamwork, 305
questionnaires were included for t1 and 213 for t2 in the staff survey. In the patient survey, 523
questionnaires were included for t1 and 545 for t2. The TCC improved team organization,
willingness to accept responsibility and knowledge integration according to staff, with small
effect sizes (univariate: η2=.010±.017), whereas other parameters including internal
participation, team leadership and cohesion did not improve due to the intervention. The patient
survey did not show any improvements on the assessed dimensions.
collection and analysis, decision to publish, or
preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
The TCC improved dimensions that were addressed directly by the approach and were
linked to the clinics' needs, such as restructured team meetings and better exchange of
information. The TCC can be used to improve team organization, willingness to accept
responsibility, and knowledge integration in rehabilitation practice, but some further
evaluation is needed to understand contextual factors and processes regarding the implementation
of the intervention.
Interprofessional teamwork is becoming more and more significant based on current
developments, for instance the discussion of quality and safety of care, the focus on patient-centered
care, shifting demographics and an increase in chronic illnesses, patient empowerment and
participation linked with rising consumerism and increasing costs of care [
teamwork in health care is defined as a collaborative interaction among at least two different
health care professionals with different abilities and fields of activities to solve a common task
and reach a common goal [
]. Key dimensions of interprofessional teamwork are clear goals,
shared team identity, shared commitment, clear team roles and responsibilities, interdependence
between team members and integration of different work practices [
]. Additional important
elements include good communication, understanding of the other persons' roles, the
development of joint protocols, training and work practices, and regular and effective team meetings [
]. Teamwork in healthcare is proven to have benefits for patients, for example enhanced
satisfaction, acceptance of treatment and improved health outcomes, as well as for team members,
such as enhanced job satisfaction, greater role clarity and enhanced well-being [
Besides interprofessional teamwork, patient-centeredness is another important concept in
modern healthcare and is emphasized as an important quality and outcome criterion [6±8]. In
contrast to traditional health care models, the provider's focus in patient-centered care is ªon
the patient versus the health concern or problemº [
]. There are several concepts and models
of patient-centeredness (e.g. [8, 10±13]). Some of them focus mainly on the patient-physician/
professional interaction [
12, 14, 15
], whereas others are broader and also consider
organizational and structural aspects [
6, 8, 13, 16
]. Concerning these organizational and structural
aspects, interprofessional teamwork and coordination play an important role . Scholl et al
] conducted a review in order to postulate an integrated model of patient-centeredness,
which includes the dimensions patient as individual, patient participation in the treatment
process, patient information, healthcare professional-patient communication and patient
empowerment. In addition to these points, the model of integrated patient-centeredness
developed by KoÈrner et al. [
] includes internal and external participation as two aspects of patient
centeredness. While external participation emphasizes patient-provider communication,
coordination, and cooperation such as shared decision making, internal participation, which will
be the focus of this study, focuses on teamwork. Research findings show that interprofessional
teamwork is a main predictor of patient-centeredness [
]; therefore interprofessional
teamwork is regarded as a key component of patient-centered treatment in healthcare. This is
particularly important in the rehabilitation sector, where many different health professionals
work together in interprofessional teams in order to provide high quality and safe treatment
for patients with chronic conditions [
1, 2, 18
2 / 20
Interventions aiming to improve patient-centered care often focus on external participation
or rather patient-professional interaction, e.g. shared decision-making [
] or health
]. However, it could also be shown that team interventions in health care have a
positive impact on interprofessional teamwork [
1, 21, 22
]. Internationally, several team
interventions are available for the health care sector [
1, 4, 23
]; they include team trainings,
integrated care pathways, case management, feedback sessions or changes in team composition,
such as the establishment of a new position in the team. It has been concluded that ªthe
optimal approach is the implementation of a combination of interventions, with adaptations to fit
unique clinical settings and local cultureº [
]. A team coaching intervention can be defined as
ªcollaborative, individualized, solution focused, results orientated, systematic, stretching, (and
it) fosters self-directed learningº[
]. Team coaching can therefore be described as enabling
team members to make use of their collective resources [
] rather than deliver proposed
solutions. The effectiveness of coaching in health care teams has hardly been evaluated so far;
simultaneously, the use and differentiation of terminology such as team training, team
building and team coaching is blurred in the field of interventions in healthcare. One study by Klein
and colleagues [
] investigates the effectiveness of team building actions which ought to
consist ªof four components: 1) goal-setting, 2) interpersonal relations, 3) role clarification, and 4)
problem solvingº. It could be shown that such team building interventions had a moderate
effect on team outcomes, especially on affective outcomes (e.g. trust, attitude) and process
outcomes (e.g. communication, coordination), and the component goal setting accounted for the
most variance in team functioning (14%). The effectiveness and implementation of healthcare
team training have been examined in several reviews [21±23, 27±30], but they all focused on
interventions in acute care and post-acute care settings. The results are mixed and vary among
types of intervention and health care settings. One systematic review in chronic care found 14
intervention studies. Most of them combined different actions for improving the teams and
were very heterogeneous in content and complexity. For all interventions except one, positive
effects were described [
]. Nonetheless, no studies on a TCC for interprofessional teams could
be found. In summary, it must be emphasized that comprehensive models of
] consider (interprofessional) teamwork as an enabler, but there are currently no
interventions for improving team interaction and in consequence patient-centeredness at
rehabilitation clinics in Germany.
Aim of the study
The aim of the present study was to evaluate the below-described TCC. The research questions
were as follows:
Can the TCC improve a) teamwork and b) patient-centeredness?
Based on the model of integrated patient-centeredness [
], we expected that the TCC can
improve both aspects. On the basis of research findings suggesting that team interventions in
health care have a positive impact on teamwork [
1, 4, 23
], the first hypothesis is that the TCC
will improve interprofessional teamwork in medical rehabilitation. Furthermore, previous
research has shown that interprofessional teamwork is a main predictor of
]. Therefore, it can be expected that the TCC will enhance patient-centeredness
A multicenter, cluster randomized, controlled intervention study was used for evaluation.
Data was collected during two data collection periods (pre-intervention from June to
September 2013, post-intervention six months after the implementation of the team intervention) by
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means of patient and staff surveys. After the first data collection period, the team intervention
approach was implemented at five intervention clinics, whereas the control clinics received no
intervention. The study was approved by the Ethics Committee of the University of Freiburg
(official approval number: 190/12). A positive ethics committee vote is available.
Team coaching concept (TCC)
The TCC was developed for medical rehabilitation based on a systematic literature search on
team development [
] and a qualitative pilot study including interviews with executives, group
interviews with team members as well as focus groups with patients. The pilot study shows
that the wishes and requests concerning team coaching varied widely among the clinics [
Therefore a standardized training program is not possible. However, the TCC is standardized
in its process but not in content, meaning that the individual needs and requests of each clinic
can be taken into consideration. The TCC  concentrates on working processes, team
organization, distribution of roles and responsibilities and optimization of communication rather
than focusing on changes in individual team members. The aim is to enhance teamwork and
team performance. Methodologically we combined solution-focused, task-related and systemic
team development approaches into one concept. The process includes the following four
distinct, sequential phases:
1. Identification of the expectations for team coaching (need-specific)
2. Definition of the coaching goals (task-related)
3. Development of the solution (solution-focused)
4. Maintenance of the solution (systemic)
The aim of the first phase is to identify the clinic's expectations (clarification of the
contract) for TCC and to specify the tasks of the interprofessional team in collaboration with the
medical director, the administration manager and optimally the leader of the team in which
the intervention should be implemented. It is checked whether the expectations can be met via
the method of TCC. A request could be to ªoptimize the selection of patients that are discussed
in the interprofessional team meetingº and to ªfacilitate the exchange of information regarding
the patients among the different professional groupsº. In the second phase, the tasks and
objectives defined by the executives are discussed within the team to establish a consensus between
staff and executives concerning the goals and tasks of the team (target state). During this
process, the goal should be clearly and measurably specified and conceptualized (e.g. ªall the
information needed to reach the rehabilitation goal is accessible to every team memberº). To
determine the current state, every team member is asked to rate to what extent the goal has
already been reached at this point (current state). In the third phase, ideas are collected on
how to close the gap between the current and target state. These ideas are prioritized and
discussed with respect to their practicability and benefits, and precise steps and responsibilities
are blueprinted for better implementation. The continuous process is oriented towards
resources and solutions. At the end of the training, in phase four, a procedure is outlined for
maintaining the results within the organization (system), and responsibilities for the future are
agreed upon. The essential points of the TCC are described more precisely in a manual
available in German and English, which can be requested from the first author of this article. The
German version is available online . The concept was implemented at five rehabilitation
clinics (one interprofessional team per clinic), which were then compared to five control
clinics that had received no intervention. At each clinic, two trainers were responsible for the
sessions. The trainers were part of the research team, were skilled in systemic coaching and had
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Fig 1. Team coaching concept (TCC).
been involved in the development of the TCC. The number of sessions and time span between
these sessions differed between the clinics, ranging from 1 to 6 sessions within the time span of
1 to 15 months, according to goals and processes. In total, 71 participants took part in the
intervention. Fig 1 summarizes the TCC.
5 / 20
The principles of the team development approach require implementation on a group level
(teams), but outcome criteria were assessed on an individual level. For this reason, and due to
the fact that the study was conducted at clinics of different specializations, cluster
randomization was necessary. We intended to use five clusters. For inclusion in clusters, clinics had to be
rehabilitation clinics in Germany, and the approval of clinic management had to be available.
One hundred fourteen clinics in southwest Germany were informed about the project and
offered the option of participating. The clinics were extracted from a web-based database
(www.rehakliniken.de). Out of these, 24 clinics were generally interested in participation.
After contact was initiated and further information provided, ten rehabilitation clinics agreed
to participate. These ten clinics (clusters) were placed in pairs that were matched as closely as
possible in terms of their specialization (orthopedics, cardiology, oncology and neurology) and
size (80±310 beds). Randomization was insured by writing the names of the clinics down and
blindly drawing them from a box in order to allocate them to the intervention group (the
matched clinic with the same indication field was accordingly assigned to the control group).
Each clinic determined a contact person responsible for the study process, and all
questionnaires were sent to this person, who distributed them at the clinic. The number of
questionnaires they received depended on the information they provided on clinic size. Patients were
not aware of which group they belonged to, whereas the study coordinator and staff were.
At two data collection times (time 1 (t1) and 6 months after intervention=time 2 (t2)), all
healthcare professionals working at the clinic were asked to complete the survey anonymously,
with participation being optional. Regarding patients, physicians were asked to hand out the
questionnaire to every patient they treated until all questionnaires were handed out. Therefore,
the patient sample was not dependent, whereas the staff sample was at least partly dependent
(but not completely, due to absence, leave or dropout). To be included in the study, staff
members had to be health care professionals, work at rehabilitation clinics, have patient contact,
have been members of the rehabilitation team for over 1 year, be actively practicing, be over 18
years of age and have sufficient German language abilities. All members of staff who met these
criteria were asked to participate in the survey. This was done because a dissemination effect
in multi-team systems in rehabilitation was expected, meaning that the achieved effects in the
trained team would spread to other teams in the clinic . Inclusion criteria for patients were
suffering from chronic disease(s), receiving inpatient rehabilitation, being over 18 years of age,
having sufficient German language abilities, exhibiting no major cognitive impairments and
having signed the informed consent form. Table 1 specifies case numbers, indication fields
and cluster allocations of each clinic.
At one neurological clinic (clinic 8), patients could not fill out the questionnaires due to
cognitive impairments. This clinic treats patients with very severe brain injuries (early stage of
rehabilitation, which is phase B according to the German national association for
rehabilitation), whereas the treatment focus of its matched control clinic is on occupational
rehabilitation for less impaired patients (phases C and D). Ultimately, only nine clinics took part in the
patient survey (see Fig 2).
Whereas staff questionnaires (see S1 Quest) were used to measure internal participation and
other aspects of teamwork like team organization and leadership, patient questionnaires (see
S2 Quest) aimed to assess external participation for patient-centeredness [
]. The following
instruments were used:
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ID: Clinic Identification number of clinics, n: questionnaires sent to the clinic, rr: total number of questionnaires received back, rr%: response rate
(percentage of questionnaires received back among distributed questionnaires), IG: Intervention Group, CG: Control Group
Staff questionnaire. The Internal Participation Scale (IPS) is based on the model of
] and defines internal participation as interprofessional,
patientcentered teamwork, including processes like communication, cooperation, coordination,
climate, agreement and respect. The items of the scale can be rated on a four-point Likert scale,
ranging from 1 to 4 (1=does not apply at all, 2=does not generally apply, 3=generally applies,
4=fully applies), with the additional option ªI can't judge this.º Internal consistency can be
considered as good, with Cronbach's alpha equaling .87 for the staff sample .
For assessing team leadership and team organization, two scales of the TeamPuls
questionnaire (eight items each) were used. The ratings were also based on a four-point Likert scale
from 1 (does not apply at all) to 4 (fully applies) . The reliability of the scales can be
considered good (team leadership α=.91, team organization α=.80).
The Questionnaire on Teamwork (FAT)  was used to measure four further aspects of
teamwork. The scale on ªstructure orientationº includes the subscales ªobjective orientationº
and ªtask accomplishment.º The scale on ªperson orientationº is composed of the subscales on
ªcohesionº and ªwillingness to accept responsibility.º The subscales build upon each other.
The questionnaire consists of 24 items. The items are bipolar, for instance ªThe objectives of
the team are clearº versus ªThe objectives of the team are unclear.º The reliability of structure
orientation is α=.83 and person orientation α=.89.
The modified “Scale of knowledge integration problems”(KIP Scale; in German: WIP-Skala)
 was applied to assess knowledge integration in the interprofessional team. The first item
of the original questionnaire (ªThe team members are not prepared to consider other points of
viewª) was eliminated in order to shorten the questionnaire and to adapt it to the present
research context. This left a total of seven Likert-scaled items. The scales ranged from 0 (does
not apply at all) to 4 (fully applies). Internal consistency can be evaluated as good (CronbachÂs
Patient questionnaire. In the patient survey, the Client-Centered Rehabilitation
Questionnaire (CCRQ) by Cott, Teare, McGilton and Leneker [
] was translated into German and
underwent confirmatory testing . In the original version, it consists of 33 items that are matched to
seven scales: participation in decision-making and goal-setting, client-centered education, client
evaluation of outcomes, family involvement, emotional support, physical comfort, and
coordination and continuity. The confirmatory factor analysis with the patient sample from the first data
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Fig 2. Flowchart study process. Legend: n=number of questionnaires sent to clinics, (nr)=number of questionnaires returned,
t1=preintervention, t2=post intervention, TCC=Team Coaching Concept.
8 / 20
collection period did not allow the replication of the seven scales. Instead a three-factor structure
emerged. The revised and validated short-version CCRQ-15 surveys  exhibits 15 items in the
following three dimensions of patient-centeredness: decision-making/communication
(CCRQscale 1), self-management/empowerment (CCRQ-scale 2), and psychosocial well-being
(CCRQscale 3). The four to six items on three scales are rated using a five-point Likert Scale (1=strongly
disagree to 5=strongly agree). The response option "does not apply" (= 0) was also available. High
item scores (and high subscale scores) stand for higher perceived patient-centeredness. The
internal consistency of the scales results in Cronbach's α=.83±.87.
Data quality was controlled by means of double data entry of random samples and verification
of plausibility. Missing data analysis was performed, and questionnaires with more than 30%
missing values were excluded . The extent of within-cluster similarity for the end points
(dependent variables) as an important design feature of a cluster-randomized controlled study
was tested by calculating the intraclass correlation coefficient (ICC) for all data collection
periods (for staff and patient samples). Hierarchical linear modelling only allows a solid estimation
of level-two effects if the study sample consists of at least 30 level-two units (rehabilitation
clinics) and the ICC is bigger than 0.1 [40, 41]. Since our study comprised not more than 10
rehabilitation clinics and the ICCs do not meet the criteria, an analysis that takes into account the
two-level structure could not be applied. Therefore, data collected on an individual level was
aggregated to a group level (intervention vs. control group) for each data collection period
(t1 and t2). On a cluster-level, only descriptive analysis was done. For the comparison of the
intervention and control groups, pre- and post-intervention multivariate analysis of variance
(MANOVA) was performed to investigate differences in teamwork variables (internal
participation, team organization and team leadership, objective orientation, task accomplishment,
cohesion, willingness to accept responsibility, problems with knowledge integration).
Requirements for computation of a MANOVA were checked but not met, but since no established
non-parametric methods are available for this research question, the MANOVA was still
calculated. For the patient survey, a MANOVA was equally performed to analyze time and group
differences in decision-making/communication (CCRQ-scale 1),
self-management/empowerment (CCRQ-scale 2), and psychosocial well-being (CCRQ-scale 3). The extent of differences
between the groups was measured using partial eta-squared (η2) as effect size, categorized as
follows: η2=0.01(small); η2=0.06 (medium); η2=0.14 (high) . Additionally, individual
ANOVA analyses were carried out to detect for which individual teamwork variables effects of
the team intervention could be shown. Data was analyzed using IBM Statistics SPSS (Version
22) for Windows (see S1 and S2 SPSS). The alpha level was set to .05.
Since persisting conflicts at one clinic had a negative effect on team development and could
not be resolved by the method, the effectiveness of and satisfaction with the concept were
evaluated negatively in the process evaluation of this clinic . Thus this clinic and its matched
control clinic (clinics 3 and 9) were excluded in a second data analysis to be able to estimate
the effect of the intervention on teamwork under the condition that the approach is accepted
by the interprofessional team. For reduced sample sizes, see Fig 2.
Sample of healthcare professionals
At t1 and t2, 890 and 633 questionnaires were distributed to staff, and 317 and 226
questionnaires were completed. This equaled a response rate of 37% and 36%, respectively (for
clinicspecific response rates see Table 1).
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t1: period of data collection before intervention; t2: period of data collection six months after intervention
In total, 990 patient questionnaires were sent to nine clinics at t1, of which 850 were handed
out. The questionnaires were completed by 539 patients, which led to a response rate of 63%.
Out of the 768 patients asked at t2 (n=940 sent out), 567 filled out the questionnaire, resulting
in a response rate of 74%. Clinic-specific response rates are displayed in Table 1. The difference
in questionnaires distributed in the patient sample was due to the distribution process in the
clinics and due to the fact that not the same cohort of patients was examined in the pre and
Overall, more women than men participated in the patient survey (see Table 3). Most of the
patients were married, and most indicated a lower education level. The majority was no longer
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employed. This is compatible with the high average age of the sample (M=62.73, SD=12.80). In
terms of specialization, it is important to note the large percentage of orthopedic (and
rheumatologic) indications. The onset of illness was between six months and three years ago for most
of the patients, and another large percentage indicated an onset more than six years ago.
t1(n = 351) t2 (n = 381)
n % n %
t1 (n = 172) t2 (n = 164)
n % n %
t1: period of data collection before intervention; t2: period of data collection six months after intervention
Intraclass correlation coefficient
The ICCs were below 0.1 for the dependent variables in all data collection periods in the staff
sample and for most of the variables in the patient sample (see Table 4) [40, 41] so that the aggregation
of data of different clinics into groups (intervention- and control group) was justified.
Results of staff survey
The means of teamwork variables were in a medium to positive range (for clinic-specific
means, see Tables 5 and 6, for group-specific means, see Table 7). The comparison of baseline
levels showed that means were higher for the control group than for the intervention group on
all teamwork variables analyzed.
The multivariate analysis of teamwork variables showed significant main effects of time,
F(8,434)=3.46, p < .01, η2 =.060, and group, F(8,434)=4.03, p < .001 η2 =.069, but no
interaction effect between time and group, F(8,434)=1.54, p=.14, η2 =.028. Subsequent univariate tests
showed significant interaction effects for team organization and willingness to accept
responsibility, with higher mean values for t2 than for t1 in the intervention group and higher mean
values for t1 than for t2 in the control group (see Table 7).
Analyses excluding the staff of clinics 3 and 9 showed again significant main effects of time,
F(8,336)=4.49, p < .001, η2 =.097, and group, F(8,336)=2.50, p < .05 η 2=.056, and also a
significant interaction effect between time and group, F(8,336)=2.18, p < .05, η2 =.049. Subsequent
univariate tests showed significant interaction effects for team organization, F(1,343)=6.01,
p < .05, η2=.017, and willingness to accept responsibility, F(1,343)=5.68, p < .05, η2=.016, and
additionally problems with knowledge integration, F(1,343)=4.39, p < .05, η2=.014, with
higher mean values for t2 than for t1 in the intervention group and higher mean values for t1
than for t2 in the control group.
Results of the patient survey
The comparison of baseline levels showed higher mean values for the control group than for
the intervention group on all CCRQ scales.
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t1: period of data collection before intervention; t2: period of data collection six months after intervention; M: mean; SD: standard deviation
t1: period of data collection before intervention; t2: period of data collection six months after intervention; M: mean; SD: standard deviation
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The means of outcome criteria were in a medium to positive range (for clinic-specific
means, see Tables 8 and 9, for group means see Table 10). The multivariate test showed a
significant main effect of group, F(3,1028)=10.39, p < .001, η2=.029, whereas the main effect of
time, F(3,1028)=1.81, p=.11, η2 =.005, and the main effect of group x time, F(3,1028)=0.75,
p=.52, η2=.002, were not significant. The tests of effects between subjects yielded a significant
main effect of group for the CCRQ scales decision-making/communication,
self-management/empowerment and psychosocial well-being, with higher means for the control than the
intervention group (for univariate effects see Table 10).
Cluster 4 (Orthopaedics/Cardiology)
clinic 4 (IG)
clinic 6 (CG)
Cluster 5 (Orthopaedics)
clinic 5 (IG)
clinic 10 (CG)
t1 (n = 30)
t1: period of data collection before intervention; t2: period of data collection six months after intervention; M: mean, SD: standard deviation; effect size:
partial eta-square η2; η2 =0.01 (small); η2=0.06 (medium); η2=0.14 (large)
1Pillai's trace (multivariate test).
As in the staff survey, the analysis was conducted again excluding patients of clinics 3 and 9
(and also clinic 8 for the patient survey only).
The multivariate test showed a significant main effect of group, F(3,721)=3.77, p=.01,
η2 =.015, although the main effect of time, F(3,721)=1.51, p=.21, η2=.006, and the main effect
of group x time, F(3,721)=0.48, p=.70, η2=.002, were not significant. The tests of effects
between subjects yielded a significant main effect of group for the CCRQ scale self-management/
empowerment, F(3,723)=4.57, p < .05, η2 =.006, with higher mean values for the control group
(M=3.77, SD=0.07) than for the intervention group (M=3.60, SD=0.04).
Overall, for some dimensions of teamwork, there were small significant interaction effects
between the intervention and control group over time in the staff survey. Analysis showed that
after the intervention means of dimension such as team organization and willingness to accept
responsibility (and knowledge integration when excluding two clinics from the analysis)
improved. Those univariate effects must be regarded as small . The multivariate interaction
effect over all analyzed teamwork dimensions in the staff survey only reached significance
when excluding two clinics from analysis and could then be considered as moderate, with the
restriction that this result can only be regarded a hint towards possible additional effects if staff
Cluster 1 (Oncology)
clinic 1 (IG) clinic 7 (CG)
t1 (n = 77) t2 (n = 45) t1 (n = 21) t2 (n = 21)
M (SD) M (SD) M (SD) M (SD)
4.29 (0.73) 4.18 (0.75) 4.30 (0.67) 4.12 (0.63)
3.93 (0.80) 3.78 (0.95) 3.95 (0.95) 3.81 (0.66)
4.36 (0.69) 4.13 (0.90) 4.18 (0.96) 4.17 (0.80)
clinic 3 (IG)
t1 (n = 94) t2 (n = 85)
M (SD) M (SD)
3.21 (0.97) 3.21 (1.13)
3.07 (0.98) 3.09 (0.96)
3.40 (0.96) 3.37 (1.11)
clinic 9 (CG)
t1 (n = 57) t2 (n = 71)
M (SD) M (SD)
4.10 (0.84) 3.99 (0.82)
3.87 (0.86) 3.75 (0.87)
4.15 (0.87) 4.05 (0.83)
t1: period of data collection before intervention; t2: period of data collection six months after intervention; M: mean, SD: standard deviation
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t1: period of data collection before intervention; t2: period of data collection six months after intervention, M: mean; SD: standard deviation
support TCC. Descriptive statistics showed that effects were due to an improvement in the
intervention group and a decline in mean values in the control group. For other
teamworkrelated processes (e.g., objective orientation, task accomplishment, cohesion), the intervention
did not result in significant improvements. Therefore, hypothesis one, that the TCC will
improve interprofessional teamwork in medical rehabilitation, was partly supported for some
dimensions of teamwork. Hypothesis two, which states that the team intervention concept can
enhance the external participation aspect of patient-centeredness, could not be confirmed by
the results of the patient survey.
The effects on specific teamwork dimensions such as organization, responsibility and
knowledge integration can be explained by looking at the main themes addressed by the
TCC and by the requests of team members and executives expressed in the pilot study [
Although requests varied among clinics, some common themes could be identified, such as an
optimization of team meetings . Consistent with the literature , improvements in the
organization of team meetings, optimal knowledge and information exchange about patients
and agreements on responsibilities were the focus of the interviews and focus groups in the
The rather small effect sizes in our study may be related to the fact that all employees in the
clinics were surveyed, rather than only those who participated in the team intervention. This
approach was deliberately chosen because employees are often members of multiple teams,
meaning that dissemination processes in the sense of organizational learning may be initiated.
Even so, the TCC has initiated some processes of change, such as improvements in team
organization and knowledge integration that can be regarded as a basis for other, slower processes.
t1: period of data collection before intervention; t2: period of data collection six months after intervention; M: mean; SD: standard deviation; effect size:
partial eta-square=η2; η2 =0.01 (small); η2=0.06 (medium); η2=0.14 (large)
1Pillai's trace (multivariate test).
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However, such transfer processes take time, and the intervention may also have been too
specific to be able to involve greater changes in the whole organization.
Given the fact that only a small part of staff completing the questionnaires actually took part
in the team training (56 of 230 at t2), it would be interesting to have a subgroup analysis of only
those staff members that participated in the training. Regrettably, few staff members filled in the
code that would allow for matched comparisons, and many staff members took the survey only
once. Therefore the sample of staff that took part in the intervention and traceably completed
two questionnaires is too small to calculate the inferential statistics used in this study.
In line with the small effect sizes in the staff survey, the missing effects in the patient survey
can be explained by the fact that although the approach was patient-centered, the team
intervention only targeted staff; there was no intervention in which patients themselves could
participate. A combined intervention that includes information materials, decision-making
support and patient education units would probably be perceived as more effective for
improving patient-centeredness. Other studies in the medical setting have shown combined
interventions to be effective in enhancing patient-centered care [46±48]. Moreover, it is very likely that
different patient populations were asked to participate during the two data collection periods.
Even though the samples were comparable, there could be individual differences between
these two samples, for instance in terms of situational awareness and expectations. Another
possibility is that the absent patient effect is due to the small staff effect, meaning that changes
or improvements might have been too small or too specific to be recognizable by patients or
that it would require more time for patients to notice effects.
Although common themes regarding the needs for team training could be identified (see
]), the team intervention was need-specific at a clinic level. Hence, the contents of the
clinic-specific interventions were not standardized, although the process of the intervention
was. As a result, reproducibility between clinics can be considered limited. However, a
description of the concept can be found in a manual that gives practitioners guidelines and toolkits
for carrying out a team intervention based on the principles developed in our study .
There might also be unknown selection effects both on a clinic and individual level. Due to the
fact that participation in the study was voluntary, we do not know if only those clinics took
part that are especially open to measures for improving the quality of treatment and as a result
already practice better teamwork and patient-centered care or if particularly clinics with a high
demand for team development and thus a lower level of teamwork and patient-centeredness
might have taken part. This is, however, a natural self-selection process for interventions, with
only those taking part who are motivated for one reason or another. This goes along with the
fact that the TCC only targets clinics that see a need for improvement, and it would not be
recommended to ªconvinceº clinics to take part in an intervention. Nevertheless, it would be
interesting to examine if the TCC is only effective under special conditions and why some
clinics were not interested in the TCC. This should be part of future research. Certainly, one
reason might be the time required to participate in an intervention during routine operations on
the ward, and it would be of interest to find ways to motivate clinics and design interventions
in a way that they seem applicable to a broad range of clinics. Limitations can also be found in
the data analysis. Although the intervention and control clinics were assigned randomly, the
data analysis showed that the baseline levels for the outcome criteria diverged significantly,
with better baseline levels in the control clinics both in the staff and the patient survey.
Moreover, the deterioration of means in the control group over time suggests a different
explanation. Employees who were dissatisfied with teamwork at their clinics may have been more
likely to complete the quite extensive questionnaire for a second time, whereas employees who
were satisfied may have been less motivated to complete it again. Another limiting factor is the
low, but not unusual, response rate. Since drop-out analysis was not possible, an attrition bias
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might exist. However, the process evaluation  showed that staff accepted the training, so
that we cannot draw the conclusion that the low response rate was due to low engagement or
acceptance; instead, it is probably due to the high workload of staff. On the other hand it must
be noted that of 71 participants in the training, 56 completed the questionnaire at t2. Here it
should also be acknowledged that one clinic failed to engage with the intervention because of
persisting conflict on a more global, structural level. This shows that the intervention is not
suitable for solving problems that go beyond the team level.
Regarding the statistical analysis, as mentioned above, a MANOVA is not the optimal
statistical procedure to examine the research question, which has to be regarded as a limitation of
the study. Unfortunately, the data did not allow calculating a repeated measures design as only
very few of the participants filled in the code that allows matching the questionnaires.
In summary, the TCC can be recommended to improve teamwork, especially team
organization, willingness to accept responsibility and knowledge integration. The TCC meets the
challenges of a holistic treatment approach by optimizing knowledge integration of the
different health care professionals working together in an interprofessional team. The TCC is a
combination of focusing tasks, processes and cooperation in the team. It supported teams in their
reflection how to accomplish the common task best. It is a time-saving and effective approach
to both use the capabilities of every team member and join together to become a whole team.
The first implementation showed that the concept is well accepted by the teams and is a
feasible team development approach. As the first team intervention approach for rehabilitation
clinics in Germany, it permits a standardized procedure but since every team is unique it is
needs-specific and therefore applicable to different clinical settings where effective teamwork
is required. The approach has been evaluated in a cluster-randomized controlled study and, as
one of very few studies, also considered the patient perspective in its development [
further evaluation of the approach should be carried out in a larger study that includes more
clinics. Furthermore, collecting data at more points in time would both allow for a continuous
formative evaluation and help to measure processes that might take longer than six months.
The collection of qualitative data could help answer unresolved questions regarding how the
intervention was perceived by staff and what factors potentially lead to success or failure of an
intervention. It is suspected that there might be effects of the intervention that were not
captured by the assessment tools, such as effects on information flow or the effectiveness of team
meetings. Those gaps are estimated to be filled in a follow-up study with a more qualitative
design. In further a study, multilevel analyses might also bring to light structural conditions on
the clinic level that benefit or hinder the implementation of the intervention.
To achieve sustainable improvements in healthcare, the TCC is manualized, and a
train-thetrainer concept will be developed on its basis in order to achieve more widespread use of the
approach in the future. The aim is to empower team leaders to coach their teams rather than
employ an external counselor. Furthermore, the TCC is not specific to rehabilitation. It could also
be used in acute care or other health care settings because content can be matched individually.
S1 SPSS. SPSS datafile of staff data. Data of staff survey for both data collection periods
without missing values.
S2 SPSS. SPSS datafile of patient data. Data of patient survey for both data collection periods
without missing values.
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S1 Quest. Staff questionnaire.
S2 Quest. Patient questionnaire.
Conceptualization: Mirjam KoÈrner.
Formal analysis: Leonie Luzay, Anne Plewnia.
Funding acquisition: Mirjam KoÈrner.
Methodology: Mirjam KoÈrner.
Project administration: Mirjam KoÈrner.
Resources: Sonja Becker, Christian MuÈller.
Supervision: Mirjam KoÈrner.
Investigation: Mirjam KoÈrner, Manfred Rundel, Linda Zimmermann, Christian MuÈller.
Validation: Mirjam KoÈrner, Leonie Luzay, Anne Plewnia, Sonja Becker, Manfred Rundel,
Linda Zimmermann, Christian MuÈller.
Visualization: Leonie Luzay, Anne Plewnia, Sonja Becker.
Writing ± original draft: Mirjam KoÈrner, Leonie Luzay, Anne Plewnia, Sonja Becker.
Writing ± review & editing: Mirjam KoÈrner, Manfred Rundel, Linda Zimmermann, Christian
18 / 20
19 / 20
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