IV. Health care teams.
Geriatrics is one of the areas in health care in which interdisciplinary collaboration on teams has become commonplace. Since the 1980s, health care researchers have drawn attention to the particular needs, preferences, and abilities of elderly patients. The elderly are the fastest growing segment of the U.S. population, with elderly women being the majority of this group (Allman, Ragan, Newsome, Scoufos, & Nussbaum, 1999). Older patients are likely to have fragmented care, seeing a different specialist for each chronic or acute condition and greatly increasing the need for coordination of care and treatment (Beisecker, 1996). Members of different disciplines working together is a cornerstone of geriatric care; older cancer patients are more likely to have more comorbidities and psychosocial needs than younger patients (Stahelski & Tsukuda, 1990).
Geriatric teams are a particular type of team designed to meet the needs of elderly patients. Geriatric evaluation teams are extremely effective at assessment and intervention (Applegate, Miller, Graney, et al., 1990; McCormick, Inui, & Roter, 1996; Rubenstein, Josephson, & Wieland, et al., 1984). The comprehensive geriatric assessment (CGA), defined as "a multidisciplinary diagnostic process intended to determine a frail elderly person's medical, psychosocial, and functional capabilities and limitations in order to develop an overall plan for treatment and long-term follow-up" (Rubenstein, et al., 1991, p. 8s), forms the cornerstone of interdisciplinary geriatric practice. Such assessment and coordination of treatment and services is especially important for older patients because this population of patients is more likely than others to have multiple health needs, as well as complex interactions of medical, psychosocial, and material circumstances (Satin, 1994; Siegel, 1994; Stahelski & Tsukuda, 1990). Geriatric evaluation with management (GEM) programs have become common for the treatment of frail, hospitalized elderly patients (Rubenstein, et al., 1991). GEMs usually use an interdisciplinary team approach that involves a "core" team that sees every patient and an "extended team" of professionals who can be called in for consultation and treatment as needed (e.g., occupational therapy, psychiatry) (Rubenstein, et al., 1991).
The composition, organization, and functioning of teams varies widely among institutions, medical specialties, and types of patient services offered. Health care teams may include a large number of loosely associated personnel or a smaller number of highly interdependent professionals and paraprofessionals. A few examples of team personnel from published studies include physicians, pharmacists, registered nurses, advanced practice nurses, licensed practical nurses, occupational therapists, physical therapists, respiratory therapists, and social workers, radiology technicians, respiratory therapy technicians, as well as non-licensed personnel such as clerks (Jones, 1997); attending physician, expert nurse, clinical nurse IIIs, clinical nurse IIs, clinical nurse residents, chief resident, junior resident, and medical student (McHugh et al, 1996); attending physician, patient and family, consulting physician, ORL [Otorhinolaryngology--ear, nose, and throat] registered nurse, ORL nurse specialist, social/psychosocial worker, dietitian, speech pathologist, maxillofacial prosthodontist, research associate, and pharmacist (Sullivan & Fisher, 1995); or two oncologists, a nurse practitioner, two registered nurses, a registered dietitian, a clinical pharmacist, a licensed social worker, and an administrative assistant (Ellingson, forthcomingA). The team membership varies depending upon the type of illness for which the patient is being treated, the resources of the particular hospital or clinic, politics, and other factors. I now turn to an exploration of conceptualizations of teamwork.
A. Defining Health Care Teamwork
Authors have put forth many definitions of teams in the health care, communication, and management literatures. Researchers of health care teams involving staff from multiple disciplines generally use the terms multidisciplinary, interdisciplinary, transdisciplinary, and pandisciplinary to designate the type and degree of collaboration among team members. I find it most useful to conceive of these terms not as distinct, opposing concepts, but as existing along a continuum from loose (or no) coordination, through interdependency, to boundary/role blurring and synergistic teamwork (Opie, 1997; Sands, 1993; Satin, 1994).
Representing an extreme not included in others' conceptions of a continuum of teamwork, Satin (1994) describes two models of disciplinary relationships that are not defined as teamwork at all: unidisciplinary in which all tasks are carried out by members of different disciplines with no awareness or interest in the activities of other disciplines, and paradisciplinary, in which awareness and courtesy exist between members of disciplines, but no coordination of efforts or joint planning takes place. Most scholars conceptualize teamwork on a continuum beginning with multi-disciplinary collaboration at one end. Campbell and Cole (1987) define a multidisciplinary team as a group of professionals working independently from each other and interacting formally. Jones (1997) expands this definition somewhat, viewing multidisciplinary collaboration as "a multimethod, channel type process of communication that can be verbal, written, two-way, or multiway involving health care providers, patients, and families in planning, problem solving, and coordinating for common patient goals" (p. 11). Members of multidisciplinary teams work toward common goals but function largely independently of one another, relying on formal channels of communication (e.g., memoranda, staff meetings) to keep other members informed of assessments and actions (Satin, 1994).
Moving along the continuum to a more interdependent form of team, Wieland, et al. (1996) define interdisciplinary teams as a "group of professionals [who] work interdependently in the same setting, interacting both formally and informally" (p. 656). Schmitt, et al. (1988) offer a list of criteria for interdisciplinary teams:
(1) multiple health disciplines are involved in the care of the same patients, (2) the disciplines encompass a diversity of dissimilar knowledge and skills required by the patients, (3) the plan of care reflects an integrated set of goals shared by the providers of care, and (4) the team members share information and coordinate their services through a systematic communication process... [involving] the participation of the disciplines in regularly scheduled face-to-face meetings. (p. 753)
Interdisciplinary team members achieve a significant degree of coordination and integration of their services and assessments of patients. Some role shifting and evolution may occur over time (Satin, 1994).
In some cases, interdisciplinary teams evolve into transdisciplinary teams, in which "members have developed sufficient trust and mutual confidence to engage in teaching and learning across disciplinary boundaries" (Wieland et al., 1996, p. 656; see also Opie, 1997; Sands, 1993). Disciplinary boundaries are very flexible in this model of teamwork, and staff comfortably share their "turf" with other team members as they work toward common goals. Stable membership on the team generally is a prerequisite to developing such a deep level of trust. Pike (1991) argues that, at their best, relationships between team members are synergistic, enabling high quality patient care and a high level of job satisfaction for providers.
Still further on the continuum, Satin (1994) proposes a "pandisciplinary" model in which geriatrics (or another specialty) could be seen as a distinct, unitary discipline, rather than as a subspecialization across several traditional health care disciplines. In this model, team members do not represent distinct disciplines (e.g., medicine or social work), but include members sharing a unique geriatrics perspective without loyalty to a traditional discipline's values and practices. Tasks would be divided according to preference, ability, and workload rather than specialty, and training would be highly interdisciplinary.
Of all of the available models for teamwork, Satin (1994) argues for the strengths of the interdisciplinary team approach (a level of interdependency and boundary blurring that Wieland et al., 1996 and Opie, 1997 refer to as transdisciplinary), which:
consciously recognizes and conscientiously implements the overlap in spheres of competence among the disciplines...; entails the most intimate and flexible working relationship among disciplines...; entails the most extensive knowledge of the preparation, expertise, and responsibilities of the other disciplines, respect for them, and an interest in sharing tasks and learning with them....; assign[s tasks] not solely by discipline, but by competence determined also by characteristics of team members and the demands of the project at hand and its environment ... ; participants are flexible about the assignment of clinical, teaching, and administrative roles ...; [and] competence and identity are not developed solely within the parent disciplines but are also influenced by professional experience, personal talents and interacts, and, most significantly, by contact with other disciplines. (pp. 399-400)
Siegel (1994) concurs with Satin's assessment, arguing that, "Only in the interdisciplinary model ... is there an overlapping of roles that leads to the ideal forms of teamwork, including interdependence, reciprocity of influence, and the hoped-for synergy among team members" (p. 406). Optimum functioning of teams is difficult to achieve. Negotiation of overlapping roles and tasks is sometimes difficult because of territorial behavior by members of different disciplines, and successful negotiation (and renegotiation over time) is considered a hallmark of a well functioning interdisciplinary team (Germain, 1984; Sands, 1993).
Many authors use the terms "interdisciplinary," "multidisciplinary," or "collaborative" teams without defining the terms, and/or use the terms interchangeably (Satin, 1994). As demonstrated above, Satin and Siegel use interdisciplinary where Opie and Wieland would use transdisciplinary. Lack of clarity in terms may make it more difficult to make valid comparisons across studies of teams.
B. Effectiveness of Health Care Teams
By far, the majority of studies of health care teams have been devoted to establishing a correlation between the use of a team approach to care and measurable patient outcomes. Interdisciplinary teams improve overall care for patients (Cooke, 1997; Cooley, 1994; Fagin, 1992; McHugh, West, Assatly, Duprat, et al., 1996; Pike, 1991; Wieland, Kramer, Waite, & Rubenstein, 1996), and promote job satisfaction for team members (Abramson & Mizrahi, 1996; Gage, 1998; McHugh, et al, 1996; Pike, 1991; Resnick, 1997; Siegel, 1994). Multidisciplinary teams facilitate and improve training of students in medicine, nursing, and allied health fields, as well as enabling veteran staff to learn from each other (Abramson & Mizrahi, 1996; Edwards & Smith, 1998; Interdisciplinary Health Education Panel of the National League for Nursing, 1998).
Specifically, multidisciplinary and interdisciplinary team care in a wide variety of clinical settings has been associated with the following outcomes: decrease in length of hospital stay (Barker, Williams, Zimmer, Van Buren, et al., 1985; Wieland, Kramer, Waite, & Rubenstein, 1996); nurse perceptions of good quality patient care (Trella, 1993); increased patient satisfaction (Trella, 1993); better coordination of patient care (McHugh, et al., 1996); increased use of hospital rehabilitation services (Schmitt, Farrell, & Heinemann, 1988); improved functioning in "Activities of Daily Living" (Rubenstein, Abrass, & Kane, 1981; Rubenstein, Josephson, Wieland, English, et al., 1984); improved pain control (Trella, 1993); decreased emergency room usage (Rubenstein, Josephson, Wieland, English, et al., 1984); fewer nursing home admissions following hospitalization (Wieland, et al., 1996; Zimmer, Groth-Junker, & McClusker, 1985); decreased mortality one year after discharge (Langhorne, Williams, Gilchrist, & Howie, 1993; Rubenstein, et al., 1991; Wieland, et al., 1996); decreased prescribing of psychotropic drugs among nursing home residents (Schmidt, Claesson, Westerholm, Nilsson, & Svarstad, 1998); and decreased overall health care costs (Williams, Williams, Zimmer, Hall, & Podgorski, 1987).
Institutional context heavily influences team effectiveness (Opie, 1997; Siegel, 1994). Because hospitals are concerned with insurance reimbursement, administrators pressure teams to define services with a great deal of specificity. The essential care giving function of many staff members is difficult to define and hence impossible to be paid for (Estes, 1981). Opie (1997; see also Clark, 1994; McClelland & Sands, 1993; Saltz, 1992) synthesizes the problems of teamwork as follows:
inadequate, or an absence of, organisational support; the absence of training in team work; the absence of orientation programmes for new members joining the team; lack of interprofessional trust resulting in complicated power relations between professionals; an overabundance or, alternatively, an absence of conflict; lack of clear structures and directions; unclear goals; the dominance of particular discourses resulting in the exclusion of others; the existence of tensions between professional discourses resulting in potentially unsafe practices; lack of continuity of members; difficulty of definition of key terms; the production of client discussions which, far from addressing client goals, marginalise them and contribute to clients' disempowerment; and an absence of teams' examination of their processes. (p. 262)
All these contextual factors constrain team effectiveness.
C. Communication and Conflict in Teams
Team meetings are a critical aspect of health care team functioning, and effective communication between all members is needed, but often lacking (Cooley, 1994; Gage, 1998). Effective communication among team members is crucial to successful collaboration on patient care (Abramson & Mizrahi, 1996; Fagin, 1992). Teams often have a diverse membership. For decision-making tasks, diversity in group or team membership--both inherent (age, ethnicity, gender, etc.) and role-related (occupation, status)--increases the number of solutions offered and alternatives considered in meetings (Maznevski, 1994). However, diversity presents great obstacles to smooth interaction processes, more often than not resulting in decreased performance (Adler, 1991), unless the group is able to integrate the diversity of its members through effective communication (Maznevski, 1994). Professional training for health care personnel must focus on interpersonal, interactional skills to improve interactions (Abramson & Mizrahi, 1996; Cooley, 1994).
Some amount of conflict in teams with members from different professions inevitably arises (Cooke, 1997). Conflicts between professionals can undermine the collaborative efforts of the team (Abramson & Mizrahi, 1996; Sands, Stafford, & McClelland, 1990). Each member of the team must sacrifice some degree of autonomy in order for the group to function; at times, role confusion, overlapping responsibilities, and other disciplinary factors can get in the way of collaboration (Berteotti & Seibold, 1994; Campbell-Heider & Pollack, 1987; Hannay, 1980; Kulys & Davis, 1987). Often team members perceive problems with goal and role conflicts as personality conflicts or interpersonal communication problems (Siegel, 1994). Problems with roles can include role conflict, role overload, or role ambiguity (Schofield & Amodeo, 1999). Size of the team is also a factor; Stahelski and Tsukuda (1990) found that increasing group size decreased prosocial behavior by individuals. The complexity of tasks faced by interdisciplinary teams may make large group size especially difficult.
Physicians and social workers cited respect for other staff members, similar perceptions, and the quality of communication as the top three factors crucial for collaboration between members of their professions (Abramson & Mizrahi, 1996). "The ideology of teamwork functions to promote cooperation and collaboration and prevent lack of cooperation that could occur among disparate professionals" (Cott, 1998, p. 869). Pike (1991) adds that professionals must trust and respect others and the work and perspectives they contribute, as well as develop a sense of caring about the other and about the relationship. Effective collaboration leads to a synergy that improves patient care.
Synergy allows the alliance to be more than the sum of its membership. It accounts for the blending, not just mixing, of perspectives. It is not only the sharing of ideas, but also the advancement of thought through communal experience and reflection. The dynamics of interpersonal interactions in collaboration are mutually empowering rather than merely congenial. (Pike, 1991, p. 359)
Teams do not tend to be egalitarian in their collaboration. Physician dominance continues to be the rule in interdisciplinary work (Berteotti & Seibold, 1994). The ideology of teamwork is often not accompanied with egalitarian modes of decision making (Schofield & Amodeo, 1999). Lower ranked team members often use strategies such as humor to resist or attenuate instructions coming from more powerful professionals on the team, without direct confrontation (Griffiths, 1998).
D. Role Overlap on Teams
Overlap of professional roles often proves a challenge in health care professional collaboration across disciplines. The domains of expertise often overlap on interdisciplinary teams and team members tend to view role overlap as problematic and a source of conflict (Kulys & Davis, 1987; Sands, 1993). A balance must be negotiated between the need for collaboration to meet team goals and the need for discrete disciplines to maintain their boundaries; "territorial issues are played out in the way in which the team addresses overlapping roles and implicit rules" (Sands, 1993, p. 546). Sands found a variety of reactions to overlapping roles. Some team members found the redundancy a way of double-checking, inevitable and unproblematic, while others stressed the importance of not repeating too much with the client nor surrendering the position of one's discipline. Furnham, et al. (1981) argue that overlapping functions caused feelings of competition and led professionals such as social workers, occupational therapists, nurses, and physicians to rate members of competing professions negatively, while rating their own group very highly (see also Jones, 1997). In a similar study, Koeske, Koeske, and Mallinger (1993) compared in-group and out-group evaluations of psychologists, psychiatrists, and social workers and concluded that each group rated its own members as more helpful, warm, and expert than members of the other two groups. A constructivist approach to understanding teams suggests that teams re/negotiate meaning as they interact through formal and informal means, in the process establishing norms for their group culture and expectations for behavior by group members in each role (McClelland & Sands, 1993; Sands, 1993). Thus the disciplinary boundaries are drawn and redrawn, and the division of clinical tasks is renegotiated over time.
Laura L. Ellingson, Ph.D.
Department of Commincation
Santa Clara University
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|Title Annotation:||Communication, Collaboration, and Teamwork among Health Care Professionals|
|Author:||Ellingson, Laura L.|
|Publication:||Communication Research Trends|
|Date:||Sep 22, 2002|
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