Integrated care pathways involving complex interprofessional interventions are increasingly used in stroke care, among other settings [1, 2]. Randomized controlled trials and systematic reviews have demonstrated that integrated stroke services reduce the rates of eventual disability and institutionalization [3] and increase the number of desirable interventions compared with generally-managed patients [4].

Although integrated stroke services produce widely varying outcomes [5], the underlying mechanisms remain poorly understood. We do know that interprofessional teamwork is considered the core component of integrated care [6], a complex activity involving many different health care providers that demands effective team functioning. Much effort has been made to improve interprofessional team collaboration [7]; optimal collaboration and coordination are essential. Ideally, each team member knows the diverse points of view held by all other team professionals and trusts other team members to deliver care that is appropriate to their respective disciplines. Critical elements of care are carried out completely by combining each team member’s capacities and capabilities [8]. Team members are involved in collective information-seeking to address specific problems and may use each other as information sources [9, 10]. Effective teams have been related to better patient responsiveness [11], more efficient use of resources [12, 13], and increases in health gains.

Unfortunately, professionals do not always work well together, a situation that can negatively affect the quality of patient care and services [7]. Involvement of various professionals in stroke care does not guarantee coordinated teamwork [14]. One problem is that interprofessional team members have to simultaneously manage the teamwork process and their individual identities [15]. Research has demonstrated that good communication [15–17], clear role understanding [18–21], and high levels of social well-being [21, 22] improve work processes and patient safety because integrated care requires interventions designed to integrate discrete areas of expertise. Effective integrated care requires that each team member possesses the knowledge required for optimal patient care [8]. The diverse capacities, capabilities and know-how of professionals working in an interprofessional stroke team are combined into a total treatment plan for stroke patients. Each professional is consulted when appropriate to determine the expected clinical course of a specific problem and make decisions about care, which requires that each professional clearly understand her own role as well as the roles of other stroke team members. Training, interprofessional education, and personal development may improve collaboration among professional team members [23, 24]. Personal autonomy has also been recognized as important to team and individual functioning [25, 26].

Shared team-level constructs are attributes that stem from individual members’ perceptions but are shared by the team. Such properties may refer to commonly held experiences, attitudes, values, norms, cognitions, or behaviors. Well-known examples of team-level constructs are cohesion, role understanding, and communication [27]. The more individual members perceive themselves as part of a team instead of a single entity, the more cohesive the team [28, 29], the stronger the team bond, and the more willing members are to show cooperative behavior [30].

Although the success of integrated stroke services relies heavily on interprofessional team functioning, professionals’ perspectives on the factors influencing such functioning remain largely unexamined. Our aim is to examine subjectively professionals’ views on the factors that lead to the success of interprofessional stroke teams and identify mechanisms to improve teamwork. On the individual level we investigated personal autonomy, personal development, communication, role understanding, social well-being, and interprofessional education. On the team level, we investigated the shared constructs of cohesion, communication, and role understanding.

Respondents, who were mostly female (80%), worked in hospitals (44%), rehabilitation centers (39%), or nursing homes (17%) as nurses (44%), physical therapists (12%), physicians (10%), occupational therapists (9%), speech therapists (6%), or other team members, such as social workers, dieticians, and managers (19%) (Table 1). The mean score for interprofessional stroke team functioning was 26.65±3.8 (range: 10–40); respondents considered their team functioning above average. More than half the respondents had received interprofessional education during the past year. Team-level variables used in the multilevel regression analysis are shown in Table 2.

Table 3 shows the multilevel indicators of all examined factors of interprofessional stroke team functioning according to the professionals’ perspectives. In their experience, personal development (p≤0.001), communication and role understanding (p≤0.001), social well-being (p≤0.001) and interprofessional education (p≤0.001) affected interprofessional stroke team functioning at the individual level. We also found that the team-level construct of communication and role understanding (p≤0.05) affected interprofessional stroke team functioning. Personal autonomy (individual level) and team cohesion (team level) had no significant relationship with interprofessional stroke team functioning.

The aim of this study was to examine interprofessional stroke team success factors and identify the mechanisms needed to improve teamwork. Our multilevel regression analysis indicated that social well-being, communication and role understanding were strong contributors to interprofessional stroke team functioning. Suter and colleagues [16] found the same results; other studies have documented the negative impact of communication problems within interprofessional teams on work processes and patient safety [15, 17]. Poor communication can cause confusion and a loss of confidence within the team. Maintaining good communication is thus imperative.

Professionals working in interprofessional teams face the relatively unfamiliar position of defending their professional work domains, in contrast to the well-defined hierarchical power structure of traditional, physician-controlled healthcare cultures [35]. Such a process often leads to role blurring [19, 20] and lower social well-being. Role understanding and social well-being are thus important factors in interprofessional stroke team functioning. Interprofessional teamwork requires management of team processes as well as individual identities, while maintaining agreement within the team that each member’s expertise and contribution to patient care is valuable [36, 37]. Poor role understanding and social discomfort compromise team involvement, management capabilities, and negotiation. Team-level role understanding and communication also affect team functioning. Such constructs result from consensus; the property is essentially shared. While measured at the individual level, the construct refers to the higher team level.

The professionals in our study identified personal development and interprofessional education as strong contributors to interprofessional stroke team functioning. These results are in line with earlier studies that have found training, education, and interpersonal skills potentially important to improving collaboration within interprofessional teams [23, 24]. Sharing knowledge and skills has a positive synergetic influence on patient care [38].

We did not find a significant relationship between team-level social cohesion and interprofessional stroke team functioning, which aligns with findings that working in an integrated care pathway does not automatically create or enhance team cohesion [39]. Team cohesion appears to take time to establish, requiring support and leadership at the outset to assist in the acquisition of a clear, shared and attainable vision, creating a sense of belonging within each team member.

Although personal autonomy has been recognized as a means to improve individual and team functioning [25, 26], our study did not find a significant relationship. This could be because we investigated interprofessional team functioning in an integrated care context, which requires multidisciplinary interventions designed to integrate discrete areas of expertise. Care transitions from individual consultation with high levels of autonomy to interprofessional teamwork with heavy focus on collaboration rather than autonomy. Optimal collaboration and coordination in the delivery of integrated care are essential requirements for providing high-quality stroke care. Interprofessional team processes are known to challenge the established hierarchy’s power, authority, and autonomy [36]. Furthermore, the competencies of professionals in multidisciplinary teams tend to overlap, requiring them to share responsibilities to varying degrees [21].

Our study identified the important contributors to interprofessional stroke team functioning according to professionals working in stroke services. They conveyed that communication and role understanding (at individual and team levels), personal development, interprofessional education, and social well-being were important. Personal autonomy and team-level cohesion did not significantly affect interprofessional stroke team functioning.

The findings increase our understanding of interprofessional stroke team functioning and thus the success of integrated stroke services. Variations in patient care and outcomes within integrated stroke services are due in part to the functioning of interprofessional stroke teams. Our findings suggest that interventions to improve team members’ social well-being, communication, and role understanding will improve team performance. To further advance interprofessional team functioning, healthcare organizations should pay attention to the development of professionals’ interpersonal skills and interprofessional education.