T H E A N AT O M Y O F

INTERPROFESSIONAL
LEADERSHIP
An Investigation of Leadership Behaviors in
Team-Based Health Care

JUNE M. S. ANONSON, LINDA FERGUSON, MARY B. MACDONALD,

B. LEE MURRAY, SUSAN FOWLER-KERRY, AND JILL M. G. BALLY

Increasing specialization among health care professions has heightened the need for proficient interprofessional teamwork. Within the team context for practice, leadership becomes a competency expected of all practitioners who must recognize the necessity of situational leadership dependent on
patient needs and the professional competencies to meet those needs. Although this need for leadership within interprofessional practice is recognized, the behavioral components of that leadership competency have not been delineated. In this article, the authors report on a study to identify the
behavioral components of interprofessional practice and highlight the indicators of leadership competency in interprofessional patient-centered care. This qualitative study involved in-depth interviews
with 24 participants from nine professions engaged in collaborative team care of clients or patients in
a variety of community and acute-based health care facilities. Interprofessional competencies were explored using grounded theory, with coding of participants responses. In this article, the authors have
highlighted leadership in interprofessional practice, and discussed the behavioral indicators of leadership that could be used in preparation of students, faculty, and practitioners for interprofessional
practice, as well as in evaluation of that practice for purposes of professional growth.

Note: We acknowledge Megan A. Young, University of Saskatchewan, for editorial contributions to the article.

JOURNAL OF LEADERSHIP STUDIES, Volume 3, Number 3, 2009

2009 University of Phoenix
Published online in Wiley InterScience (www.interscience.wiley.com) DOI:10.1002/jls.20120

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Interprofessional health care teams have healed patients

for decades; recent budget constraints on the health care
system now necessitate them (Calhoun et al., 2008;
Davoli & Fine, 2004; Steevenson, 2006). Effective and
competent interprofessional teams integrating the work
of physicians, nurses, and other health care professionals
will enhance teamwork, and health care outcomes will be
improved (Mendez, Armayor, Navarlaz, & Wakefield,
2008). Increasing specialization, beneficial to the development of a more comprehensive health care system,
contributes to potential fragmentation in the continuity of patient care. Conversely, specialization, with its
complexity of knowledge, increases the need for interprofessional teamwork (Hall & Weaver, 2001). Some of
the research findings of Gevedons study (1992) espoused
the importance of leadership and how the success or effectiveness of organizations is directly related to the leadership occurring in that organization: Leadership serves
as a vital competency in interprofessional healthcare
team practice [within current integrated healthcare delivery models] (p.122).
In this article, the authors explored the team leadership competency in depth, identified behavioral indicators of the leadership competency, and discussed the
implications of these indicators for the education of
nursing students. The basis for this discussion are findings from a qualitative study of the behavioral indicators
of the interprofessional competencies, as identified by
Curran (2004), and specifically exploring the behavioral indicators of the team leadership competency. The
authors describe the research project itself and then discuss findings of the team leadership competency in
terms of the literature on leadership.

outcomes through collaborative and cooperative teamwork (Health Canada, 2006).

Patient outcome, a major indication of efficacy and
quality of health care, has been demonstrated to improve with interprofessional care. For example, team
collaboration has been shown to improve the health
status of older adults with chronic illness (Sommers,
Marton, Barbaccia, & Randolph, 2000). Collaborations
draw together a variety of competent professionals with
a common vision, having the potential to explore solutions from different perspectives and supply resources
to accomplish team goals (Davoli & Fine, 2004). Interprofessional teams create practical forums for discussion among specializations, with the intent to
provide more efficient and effective patient care.
Despite the momentum toward interprofessional
health care, critics express concern that studies produce
more favorable reports on this model of care than does
actual practice (Leggat, 2007). As Whitehead (2007)
explained, the potential for conflict rises with the involvement of a variety of professions, especially when
there is overlap of functions. Diverse approaches to patient care and perceptions of other professions affect
team activity and progress (Curran, Deacon, & Fleet,
2005; Robson & Kitchen, 2007). Recognition of potential barriers to interprofessional teamwork in the climate of professional specialization and fiscal concerns
necessitate interprofessional collaboration to address patient issues and enhance patient outcomes. Collective
ownership of goals is vital to successful collaboration.
The teams focus on the desired outcome and consistent participation to achieve this end are integral to an
effective collaboration. Team leadership is essential to
attainment of these goals.

Defining Interprofessional
Terms referring to teams consisting of various professions often are used erratically and imprecisely,
particularly in actual health care practice (McCallin,
2001). The nuances of like terms beginning with inter-,
intra-, multi-, and trans- and ending with -agency, and
-professional, are copious. According to Walsh, Gordon,
Marshall, Wilson, and Hunt (2005), interprofessional
efforts consist of two or more professional disciplines
working together. The term interprofessional, as used in
this article, refers to a set of competent professionals from
various disciplines achieving effective, patient-centered

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Competency Within the Team

Context
Individual professional competency informs team competency. Lack of professional competency in interprofessional teamwork may come at the expense of mutual
trust and respect among team members. McCallin
(2003) listed professional competence itself as a team
competency: The stereotypical image that all professionals are competent can no longer be taken for granted.
Competence is about the currency of knowledge, skill,
experience, performance, reliability and credibility

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(p. 22). She identified recognition of each members

competency and equality as the benchmark condition
that allows all team members to willingly share responsibilities.
Because the interprofessional approach to health care
relies on teams of professionals, team competency influences outcome. Many agree that without a goal a
team of any nature cannot function to its fullest
potential (McCallin, 2003; Outhwaite, 2003; PorterOGrady, Alexander, & Minkara, 2006). McCray (2003)
proposed a multipronged interprofessional practice
framework: conflict management, transforming capability, empowerment, knowledge, contextual socialization, and individual practitioner and interprofessional
reflection on actions. Like McCrays components for interprofessional practice, current literature suggests that
professionals working in teams need to master both
knowledge-based and interpersonal competencies.
Knowledge-based competencies serve as a basis for
transfer, assessment, and interpretation of information
or performance of outcome-oriented tasks. Team competency is a set of abilities to perform tasks produced by
team input. Knowledge of ones own profession, as well
as knowledge of other team members competencies and
clear delineation of professional skill sets (McNair,
Brown, Stone, & Sims, 2001), enables professionals to
engage in discussion more fully. Acquiring, interpreting,
and accurately communicating information, along with
creating and generating knowledge (Porter-OGrady,
Alexander, & Minkara, 2006), coordinating information (McCallin, 2003), and defining roles (Robson &
Kitchen, 2007), are competencies that create a solid basis
for collective knowledge and informed actions.
Interpersonal competencies are pragmatic in nature
and evolve from an ethos of trust and reliability. These
people-oriented competencies are not simply personality adjustments but mechanisms influencing productivity. Shortell et al. (2004) listed as interpersonal
competencies meaningful communication, strong leadership, and an appreciation of roles among multiple
disciplines. Several attributes of interpersonal competency have been described, among them the ability to
dialogue and assess team values (McCallin, 2003),
communicate clearly and relay decisions (PorterOGrady, Alexander, & Minkara, 2006), lead, demonstrate respect for others contributions, produce

collaborative decision making, partake in teamwork,

resolve conflict particularly relating to roles (Curran,
2004; Morison, Boohan, Moutray, & Jenkins, 2004;
Walsh et al., 2005), be flexible, secure accountability
to individuals and the team as a whole (Iles & Auluck,
1990), cope with unusual situations (Porter-OGrady
et al., 2003), and ensure discretion to deliver distinct
team professionalism.

Interprofessional Leadership
HISTORY AND MODELS

The concept of leadership and its structure is changing

in the field of health care delivery, particularly with the
rise of team care. The interprofessional approach creates democratization unparalleled in traditional leadership. New models for leadership and its relation to team
members focus on leadership attributes and highlight
interpersonal competencies (McCallin, 2003). According to Ogawa and Bossert (2000), leadership traits are
complex and dynamic, embedded in context, and interactive and reciprocal in nature. Because leadership is
dynamic, leaders and their traits should not be studied
outside of context. Unlike traditional hierarchical models of leadership, in interprofessional leadership the platform on which member-leaders relate is horizontal,
relational, and situational. Effective leadership combines
both professional competency and the ability to foster
team dynamics.
AS A COMPETENCY

Leaders direct others toward a goal, elicit commitment

(Porter-OGrady et al., 2006), act as facilitators to
actualize group potential and identify conflicts
(Outhwaite, 2003), anticipate the future (Sievers &
Wolf, 2006), empower others, and take responsibility
for productivity (Anonson, 2002). Leaders are more
than managers; they inspire vision and action. Within
the interprofessional team context, each member-leader
practices leadership competencies. In a study investigating attributes of nurse leaders during a time of great
organizational upheaval, six traits were mentioned repeatedly: being an optimistic visionary, having a moral
center, being able to manage crisis with knowledge
expertise, having a personal connection with nurses
and participating in teamwork and communication,

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facilitating professional growth, and empowering others

(Anonson, 2002).
The processes of team development and leadership
are closely linked. Hall and Weaver (2001) delineated
stages of team leadership as a well-timed approach,
bringing to a team both guidance and freedom to develop to its fullest potential. Within this model, the
leader must be keenly aware of the stages of team progress and guide accordingly. In the beginning, the leader
should emphasize tasks and goals. Next, the leader encourages the teams sense of ownership and responsibility. As the team takes ownership of its tasks, the leader
furnishes less interpersonal support. This corresponds
to the storming stage, in which conflicts, role disruption, and the formation and clash of subgroups are dissipated for the sake of team functionality (Davoli & Fine,
2004, p. 267). Power and recognition of authority, past
and present, as well as poor communication arising
from such issues may prevent the team from pursuing
team goals (OConnor, Fisher, & Guilfoyle, 2006). The
leadership process is a coordinated series of responses
and actions. Interprofessional leadership becomes more
complicated and requires more coordination than in a
team-with-single-leader scenario, as all of the members
are leaders for their discipline.

Method
Ferguson et al. (2008) explored interprofessional team
practice in a grounded theory study of the experiences
of practitioners, faculty, and students currently engaged
in interprofessional practice. This study involved
in-depth interviews with 24 participants engaged in collaborative team care of clients and patients in a variety
of acute care and community-based contexts. The
goal of the study was to identify the competencies of
interprofessional collaboration and the behavioral indicators of the competencies for interprofessional practice. Professional groups represented in this study
included nursing, medicine, pharmacy, physical therapy, primary health care practitioners, addiction counselors, educators, psychological counselors, and health
care managers. Interviews were audiotaped and transcribed verbatim. All six authors/researchers participated
in analysis of the transcripts, construction of the behavioral indicators of the competencies, and validation
of the indicators with health care professionals from a

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variety of contexts. Findings were determined through

consensus of all researchers. Findings were validated
with subsequent participants as well as by a panel of experts. The study was approved on ethical grounds by
the Research Ethics Board of the university.

Findings
In this study, the researchers (Ferguson et al., 2008)
identified from the participants responses six competencies of interprofessional practice: communication,
knowledge of ones own profession, knowledge of the
others professions, teamwork, leadership, and negotiation for conflict resolution. A prominent recurring competency was team leadership. As such, the authors have
explored the team leadership competency in depth,
identified behavioral indicators of leadership competency (see the list below), and discussed the implications of these indicators for the education of nursing
students.
Behavioral Indicators for Competency Leadership in Interprofessional Practice
Co-creates a climate for shared leadership and
collaborative practice
Expresses willingness to assume leadership
Assumes situational leadership of team for client
benefit
Identifies strengths and limitations as they relate
to the leadership role
Accepts responsibility for decision making as
conveyed by the team
Supports and enacts decisions made by the team
Shows sensitivity to the leadership patterns in the
community
Encourages the contributions of all team members
Supports client participation within the team
Shares leadership with other health care professionals to address changing client needs
Coordinates health care professionals around
issues of care
Champions collaborative practice for client care
Obtains resources to support team function for
client care

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Within the context of team practice, leadership as a

competency assumed a prominent position. Participants, whether students, faculty, or practitioners, identified a number of themes regarding leadership in health
care collaborative teamwork for patient care. These
themes have been validated by many of the participants
as well as experts in the field of interprofessional teamwork and interprofessional education.
SHARED LEADERSHIP

All participants agreed that shared leadership within the

team was an essential element of effective interprofessional collaborative team practice. As one participant
indicated,
There has to be leadership but it doesnt necessarily
have to be one individual . . . it has to be whos the
best leader for the situation with the patient, and
thats patient-focused care. . . . In every situation,
theres always someone who should be in charge, who
knows more than anyone else (to deal with the patient need).

More than half the participants (primarily faculty and

practitioners) identified a model of shared leadership
over time where patient need dictated the professional
who could best lead the team at a given time. Leadership was conveyed by the team, where, as one participant stated, leadership is given to you by others. Its a
very democratic kind of model . . . theres recognition
that you [a specific health care professional] need to be
in charge. Participants described how leadership moves
to the professional with the necessary skills to lead
the team around specific issues, overview the patient situation, have in-depth knowledge of the specific situation, and where necessary, recommend the final decision
when the team is unable to reach consensus on an approach. One psychologist described this phenomenon as
generosity of spirit. I think you have to have a generosity of spirit around sharing of knowledge, sharing
of decision making authority, sharing of leadership.
I really think when you function in a team your satisfaction comes less from a lot of ego satisfaction and
more from the success of the team.

Three-quarters of the faculty and practitioner participants advocated for a shared leadership approach

wherein the leadership of the team could vary over time,

depending on the client situation and the professional
expertise of team members, or as one participant indicated, situational leadership. A participant described
this leadership as based in expertise: So there has to be
leadership but it doesnt necessarily have to be one individual [professional] and it has to be whats the best
leader for the situation with the patient and thats that
patient focused care. In addition, several participants
cautioned that team members must be prepared to
transfer leadership to, or share it with, the most appropriate team member as needed to facilitate optimal
client/patient care.
WILLINGNESS TO ASSUME LEADERSHIP

Participants indicated that in effective teams members

co-create a climate for shared leadership and express willingness to assume leadership within ones expertise. They
also indicated that once a person accepted leadership of
the team, certain roles were expected of the leader. One
participant stated, Theres no one designated leader, so
that their decision making is shared and each profession
makes decisions in consultation with the others but
within the context of their scope of practice. A level of
trust and respect within the team facilitates sharing leadership; as one participant put it, This comes down to
the trust issue. A team that understands each role, that
the roles are distinct, but rather each brings a skill
set that is complementary to the other skills then were all
working together. Many participants noted, however,
that each member must be willing to assume leadership,
and once in the role, the team member must demonstrate objective, fair, intelligent leadership combined with
experience in professional practice and leadership to facilitate the goals for patient/client care. Several participants stated that each leader must accept responsibility
for having an overall view of the patient/client situation
and informing others of relevant and significant information. Communication is exceedingly important to
many team-based practitioners; as one person stated,
Team players very naturally think of communication
as a part of being a team . . . you really need to include
everyone and make sure that everybody has all the
information they need. As leader, this health care professional may have more interactions with the patient/client and thus be seen by the patient and

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the team as the communication point person for other

health care professionals.
SELF-REGUL ATION OF TEAM FUNCTION

Because team members may have varying levels of competence in leadership, evaluation and self-regulation of
group function should include discussion of the process
of team function, including the effectiveness of leadership
offered by various team members. This stipulation required that prospective leaders be able to identify their
strengths and limitations as they relate to the team leadership role and to self-regulate professional behavior for
effective leadership. Such feedback has the potential to
facilitate development of leadership skills. In highfunctioning teams, all share the responsibility and demonstrate active support for decisions made by the team. Some
participants described how, with clear communication,
redundant roles are eliminated and team members share
patient care activities within their scope of practice. Thus
they felt that shared professional competencies are enacted
effectively by one designated health care professional rather
than repeated by each professional, for the benefit of the
client/patient. Several described how in situations such as
palliative care, chronic illness management, and rehabilitation client/patient (and family) participation in team
decision making is beneficial, requiring team and individual responsibility for patient outcomes.
Participants stated that because team members may approach problems from their own professional perspectives,
team leaders need to identify situations where independent or shared practice is appropriate, and where necessary
the unique contributions of a specific professional group
are needed. Participants also expressed that everyone,
whether leader or member, is responsible for encouraging
the contributions of all team members and offering their
unique contributions to patient care appropriately. They
acknowledged that the current leader of a health care team
has the responsibility of coordinating care for the best
patient/client outcomes, but the team may also identify
the need for additional resources or other professional
members of the team, expecting the current team leader
to facilitate acquisition of the needed resources.
ADVOCACY FOR TEAM PRACTICE

Participants indicated that members of the team,

whether in the leadership role or not, must consistently

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advocate for interprofessional practice. In this study,

team members indicated that they were often characterized by their professional valuing of teamwork and
their predisposition to create teams to address complex
client situations. Such professional values-in-action set
an example for others, and when team members advocated for interprofessional teamwork their actions were
congruent with their words. All health care professional
participants in team practice also stressed the need to
determine when team practice was needed for effective
patient care, recognizing the additional time and energy that is necessitated by collaborative practice. They
acknowledged that interprofessional team practice as a
cultural norm is ideal, but not all patients need a team
for care. All agreed that more complex patient situations, including conditions of chronic illness, would
improve patient outcomes and increase client patient
satisfaction with care.
Participants agreed that as the coordinator of the team
the leader is often involved in facilitating the teams establishment of priority of patient/client needs and subsequent priorities of care. As one participant stated,
I like the concept of case manager much more myself
because what it says is, in every situation, theres
always somebody who should be in charge. In doing so,
the leader must be sensitive to the context of the clients
community and practice norms within the professional
community of practice, especially when working crossculturally. Participants felt it was important that memberleaders encourage the contributions of all members.
CHALLENGES IN TEAM-BASED PRACTICE

Leadership was discussed extensively by participants as a

challenging and thorny issue in effective team function,
particularly in those settings where certain health professionals assumed positions of leadership. Physicians were
identified by most participants as at times inappropriately assuming the role of leader. Participants felt all team
members must be willing to assume leadership as needed
by the team, and to accept leadership that is within ones
professional expertise and skills for the benefit of the
client. Several participants, particularly the practitioners,
described the leader of the team as the face of the team
within the larger context and, in many instances, with
the client, especially in situations where the client has not
been engaged in team discussion. Participants stated that

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the leader must be willing to accept responsibility for decision making on the part of the team, and support and
enact these decisions. In many instances, the leader, on
behalf of the team, also accepts responsibility for client
outcomes, especially when outcomes are not positive and
clients or family members are upset. The leader often
speaks for the team and accepts responsibility for those
outcomes as appropriate.
Several participants emphasized, however, that effective team function is time-consuming and should be
used only where necessary for effective patient care. It
may not be necessary to convene a team meeting to address all aspects of a client situation or care. As an example, referral of a client to a physical therapist to
address gait instability may be a logical way to address
a client need without the more cumbersome process
of a team conference.

Discussion
Participants in this study of interprofessional practice
were clear in their opinions about leadership of interprofessional teams, strongly reinforcing Currans identification (2004) of team leadership as a basic
competency for interprofessional practice. The focus of
participant discussions was on the nature of the leadership offered to the team, rather than a focus on a particular professional groups role in leadership. As is the
case in the literature, these participants were unanimous
in their opinion that effective interprofessional teambased practice improved patient outcomes (Mendez
et al., 2008; Sommers et al., 2001). As with Hall and
Weaver (2001), participants were clear that each professional brought strength to the team but that his or
her unique contributions to patient care were enhanced
through teamwork; indeed, many had skills and abilities
in common. Consistently among participants, leadership of interprofessional teams was viewed as a shared responsibility of the whole interprofessional team.
A very strong emphasis on shared leadership and the
willingness of all professionals to assume leadership as
necessary for the benefit of the patient is evident
throughout the findings. Because all interprofessional
team approaches necessarily implement collaborative
leadership, McCallin (2001) suggested applying the idea
of stewardship; it decentralizes power in that all team

members are empowered, are self-responsible, and take

colleagueship seriously in their support of a vision.
Commitment to outcome over and above ones own disciplinary preferences defines the steward-leader and reflects the ultimate goal of collaborative health care
teams. This model seems particularly appropriate in
team-based practice.
STUDENT EDUCATIONAL EXPERIENCES

In recent years, professional health care education programs have committed to giving students interprofessional team experiences to prepare them for practice in
more collaborative practice environments (Curran et al.,
2005). Providing health care students with opportunities to function as student members of effectively functioning health care teams creates opportunities for
students to model their practices on effective team practitioners (Health Canada, 2004), and it is seen as a panCanadian strategy to improve the quality of health care.
In addition, students may have a chance to function in
both team member and team leader roles as professional
scope of practice, professional competence, and
patient/client need dictate. Seeing interprofessional practice contribute to improved client/patient outcomes reinforces the necessity for such teamwork. Developing the
leadership skills of each professional health care student
also increases the likelihood that as team members they
will assume team leadership as the situation dictates.
The behavioral indicators specified in this study have
arisen from interviews with students, faculty, and practitioners in interprofessional practice. Several of the indicators may be at a level beyond that of undergraduate
students, specifically (1) coordinating health care professionals around issues of care, (2) championing collaborative practice for client care, and (3) obtaining
resources to support team function for client care. All
reflect a high level of team leadership. In instances where
students may not be able to offer leadership within preexisting teams of health care professionals, they will have
opportunity to observe and reflect on the shared leadership of effectively functioning teams, and on their
role as effective team member (Calhoun et al., 2008;
Leggat, 2007; McCallin, 2001; Outhwaite, 2003;
Porter-OGrady et al., 2006). In circumstances where
student teams are created to furnish interprofessional
experiences at that level, student leadership of such

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teams would be expected. Opportunities to practice

leadership within such a team, especially when alerted
to the behavioral indicators of the leadership competency, will prepare students to value and practice interprofessional teamwork.
There is a secondary benefit to offering students interprofessional team experiences. As well as preparing
them for such experiences, professional education programs also convey the expectation in actuality that
teamwork is the prevailing norm in the practice setting.
Unfortunately, such is not always the case. In preparing students, their faculty, and their supervising practitioners or preceptors for interprofessional experiences
in practice, we are also alerting those practitioners and
faculty not yet committed to interprofessional practice
to this expectation. Specification of behavioral indicators of the leadership competency may be useful to practitioners seeking a framework for their involvement in
interprofessional practice to improve client/patient care
outcomes. The behavioral indicators of the leadership
competency are enabling statements that may create or
support practitioner expectations for shared leadership
and productive team membership.

Conclusion
The current trend toward further interprofessional
health care and research contributes to an increasingly
patient-centered, evidence-based climate of care demand
efficacy and outcome. Collaborative leadership is a key
competency that affects patient outcomes and team effectiveness. This leadership needs to be developed in
health care professionals in practice as well as in their
professional education programs.
The research goal was to elaborate on the competencies
of interprofessional collaboration by developing
behavioral indicators of the competencies for interprofessional practice. From a range of professions, the authors developed indicators for the competencies of
interprofessional practice, including communication,
knowledge of ones own profession, knowledge of the
others professions, teamwork, leadership, and negotiation for conflict resolution. These behavioral indicators of
leadership in health care teams can impart direction in
development of this vital leadership skill. Interprofessional collaborative practice and leadership within that
framework are essential to provision of patient-centered

24

evidence-based care. The quality of our health care system

and the care conferred on our clients and patients depend on it.
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June M. S. Anonson is an associate professor and assistant dean

for the College of Nursing at the University of Saskatchewan.
She holds a Ph.D. in nursing from the University of Alberta. She
can be reached at june.anonson@usask.ca.
Linda Ferguson is a professor in the College of Nursing, University of Saskatchewan. Her Ph.D. is in nursing, and she has a
postgraduate diploma in continuing education. She can be contacted at linda.ferguson@usask.ca.
Mary B. MacDonald is a professor and assistant dean, Academic
Affairs, at the College of Nursing, University of Saskatchewan.
She holds a B.S. in nursing and a masters in continuing education from the University of Saskatchewan. She can be reached
at mary.macdonald@usask.ca.
B. Lee Murray is an associate professor at the College of Nursing, University of Saskatchewan. She holds an M.S. in nursing
from the University of Saskatchewan and is currently a doctoral
student in the College of Education. She may be reached at
lee.murray@udask.ca.
Susan Fowler-Kerry is a professor at the College of Nursing, University of Saskatchewan. She holds a Ph.D. from the University
of Saskatchewan. She can be contacted at Susan.fowlerkerry@usask.ca.
Jill M. G. Bally is a clinical facilitator and Ph.D. student at the
College of Nursing, University of Saskatchewan. She holds an
M.S. degree in nursing from the University of Saskatchewan.
She can be reached at jmb306@mail.usask.ca.

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