Multi-Professional Teams Working In Primary Care - Literature review Example

Running Head: MULTI-PROFESSIONAL TEAMS WORKING IN PRIMARY CARE Multi-Professional Teams Working In Hospitals and Primary Care Settings Introduction How primary care is delivered can be seen as changing rapidly to meet the diverse needs of service users, ‘based on making radical changes for the benefit of patients, the focus being on promoting a culture of innovation, support and best practice by: • generating and sharing ideas • information and research support • taking action at national, regional and local level to overcome any barriers • disseminating pilot outcomes • supporting staff fully embed new ways of working • supporting individual staff to take their ideas forward’ (HoH 2001a). Documents such as the NHS Plan (Doll 2000), The Way to Go Home (Audit Commission 2000) and the National Service Framework for Patients (DoH 2001b) focus on the potential of therapeutic working that enables and empowers individuals. This potential is widely recognised and emphasises the need to put patient, their needs and those of their families at the centre of policy and practice. For this reason, great importance is placed on the benefits of multi-professional working. To achieve this, it is important for practitioners to have a clear understanding of the different methods of multi-professional team-working, the implications for person-centred practice, the potential barriers to multi-professional working, and a recognition of the important part they play within the multi-professional team. Teamwork According to Madge and Khair (2000) the renewed interest in various practitioners working together in physiotherapy teams has led to many definitions and descriptions, including ‘multi-professional’ (Cott 1997), ‘interprofessional’ (Barr 1997) and ‘trans-professional’ (Rosen et al 1998). Madge and Khair (2000) suggest that despite the varying terminology and differing definitions it is of paramount importance that professionals are able to identify their places within ‘the group’ and their roles with patients. Lack of understanding by practitioners of the definitions and values associated with the three main differing approaches to team-working can be seen as contributing to lack of clarity and potential confusion. According to Porter-O'Grady (1995): ‘In today's team-based organisations there are many issues that have to be addressed to ensure effectiveness … The greatest problem in these emerging multiprofessional physiotherapy teams is their ability to deliberate and interact in a way that results in a valid and timely outcome.’ Lary et al (1997) suggest that primary care today and in the future is dependent on both accurate diagnosis and coordinated treatment plans. They believe that in ‘today's high tech primary care environments’ there are critical requirements for primary care practitioners not only to be able to communicate effectively but to be able to integrate sources of patient information available to them. This will help practitioners co-ordinate and implement complete or holistic treatment plans for all patients. Therefore, the need to utilise the expertise of all primary care team members is vital in order to benefit the patient. In essence there is a need for practitioners not just to provide a holistic approach to care/treatment, but also to blur the boundaries of professional practice; to be able to think, problem-solve and understand key multi-professional issues within the scope of their own professional practice. Wiles and Robinson (1994) provide a broader definition of team-work within primary care, without specifically referring to either multi-professional, inter-professional or trans-professional working: ‘Teamwork has come to be seen as a group of people at or from primary care practice with common health goals and objectives.’ When developing a physiotherapy team approach to practice a vital element is that team members all share common values and beliefs in relation to the potential of ‘team’ work and that they feel and are supported in the transition from uni to multi/inter/trans-professional working. Much of the literature uses the term ‘multi-professional’ to describe a process or way of team-working. However, by definition ‘multi-professional’ is itself a specific model of multi-professional working. To understand the part we play (as nurses) within the multi-professional physiotherapy team it is important to understand the different approaches taken and the implications for professional, person-centred practice. Multi-Professional Physiotherapy Teams The multi-professional approach is characterised by each discipline within the therapy team working towards discipline-related goals. Team members work within the boundaries of their professional practice; progress is formally discussed at team meetings, effective communication is considered vital and the client's role is minimal (Whitlock 1999). This approach can be seen as being reflective of uni-professional physiotherapy teams working, potentially, in professional isolation from each other but contributing to the overall treatment of the individual. For the patient accessing the skills and expertise of the multi-professional team, the need for effective communication and collaboration, not only between team members but with the patient and his or her family/home contacts, is vital. In a multi-professional setting, the need for effective co-ordination of the person's treatment plan should be implicit in the way the team works; if this is not the case, there is a greater likelihood of potential for ‘failure’ when planning discharge or transfer of care, as the whole process of therapeutic working can become disjointed, uncoordinated and poorly planed. The result is that the patient becomes disempowered by the process as a whole. Practitioners working within multi-professional physiotherapy teams can also feel frustrated by both the professional and organisational boundaries associated with multi-professional working. Communication is vital, but in practice there is potential for communication breakdown due to the nature of uni-professional working and lack of understanding of the roles and function of other disciplines. Embling (1995) endorses this and suggests that often team members have little understanding of each other's roles and that the effective co-ordination of an individual's care is difficult to achieve. McGrath (1991) further suggests that individuals working within a multi-professional team have to contend with dual loyalty, first to the team and second to either their professional or service manager, or to both, if this role is taken by two different people. Rosen et al (1998) concur with this and suggest those team roles are clearly defined within a multi-professional physiotherapy team and that communication is relatively limited. For this reason the effective management, leadership and co-ordination of multi-professional teams are vital. But in practice, no matter how committed team members may be to working together and providing a person-centred approach to therapy, this can prove problematic due to the physical nature of uni-professional working. Barriers To Multi-Professional Working Dominance by any one profession can be seen as introducing a professional hierarchy that could be counter-productive to effective team collaboration and working. Donnelly (1999) describes ‘tribalism’ as a potential barrier, occurring when individual practitioners and professions are over-protective of their roles and responsibilities for service provision. Tribalism can be seen as a clear barrier to collaborative working and person-centred practice within a multi-professional team. The traditional relationship between medicine and other professional disciplines can be seen in some cases as acting as a controlling influence, reinforced by traditional ways of working and practising. Much literature discusses the nurse-doctor relationship (Binnie and Titchen 1999, Holyoake 1998, Warelow 1996) but very little refers to the relationship of other professions with medicine. Warelow (1996) says: ‘The powerful position of medicine tends to oppress other professional disciplines’, and Wilson (1970,cited by Warelow 1996) concurs: ‘Each variety of health worker gauges his/her status and professional self-hood in terms of how closely she/he approaches the doctor on a scale of privilege (power) and responsibility.’ A key factor that both Warelow (1996) and Wilson (1970) elude to is that if organisations reinforce traditional ways of working then hierarchy and professional dominance will remain. But if there is a culture in which all professional disciplines are valued and are perceived as equal then this becomes the cultural ‘norm’. Stein (1978) described a highly ritualised pattern of indirect communication which he described in doctor-nurse interactions and which he labelled ‘the doctor-nurse game.’ The ‘game’ allowed nurses to use their initiative and to make significant recommendations about patients' treatments, but they were only to do so in a subtle, veiled manner, so that doctors could reproduce the recommendations as their own instructions. McClelland (1990) concurred with this and identified that frequently a multi-disciplinary team found a physical diagnosis was often ‘delivered by the doctor [after being] constructed by the team.’ ‘Playing the game’ meant that nurses' valuable knowledge, insight and experience was used for the benefit of patients, without there being any threat to the apparent omniscience and omnipotence of doctors. In a later paper Stein et al (1990) observed that many nurses were no longer prepared to ‘play the game’. Changes in nurse training and professional registration meant nurses had their own professional contribution to make to the healthcare team in which doctors were now an equal member. Evers (1981) suggests that teamwork in the care of patients is often a myth. The notion of teamwork is accepted in situations where the diagnosis and treatment follow the predictable medical model. However, when there is a more difficult case, a ‘non-conformer’ to the treatment model, the inadequacies of the team concept are highlighted. The social context in which practitioners work is instrumental to effective team care and a team philosophy. Barber et al (1980) suggests that the ‘smoothness’ with which individuals work together depends greatly on personalities and individual compatibility. Although developing a team that complements each other is vital when recruiting a multi-professional team, equally the individual team members should feel supported and facilitated when conflict does occur, enabling conflict to be addressed as it happens. The ability of practitioners to work together is dependent on the social context in which they are working and collaborating. Even the most compatible personalities will find it difficult to co-operate in situations where they are expected to behave in conflicting ways (Barber et al 1980); for example, enforced hierarchy based on professional power, and dominance or role domination based on traditional ways of working. How practitioners perceive themselves and their skills within a multi-professional team is vital. If individual practitioners do not value or perceive their roles as being an important part of the multi-professional team, then other team members may well dismiss their contributions a whole. Likewise, it is vital that practitioners are perceived as being credible and that practice is grounded in evidence-based research and not anecdotal or traditional practices. This forms a huge challenge for multi-professional teams because much clinical research is discipline or diagnosis-related and the challenge is not only to bridge the theory/practice gap, but to bridge the gap between individual professional disciplines and practices. In referring to multi-professional education, Lary et al (1997)state that an integrated approach to education will help prepare practitioners working within primary care who are able to integrate into their practice both basic science and clinical skills. The outcome is the delivery of ‘comprehensive, quality primary care.’ The authors suggest that due to the ‘changing climate of primary care’ organisations offering training that leads to professional registration may be forced to incorporate multi-professional education into their curricula. Alternatively, multi-professional models of education can be seen as providing practitioners with greater skills to enhance their own professional practice. Conclusion Lack of clarification in language when referring to multi-professional working is seen by many practitioners as a potential barrier to understanding effective team-working and the part they play in this process. Critical analysis of the literature can prove problematic due to the plethora of anecdotal information and lack of sound research. In practice, we know that there are many benefits to multi-professional physiotherapy teamwork, but there is little sound research that identifies why and how these teams function so effectively and the potential for enabling and empowering patient. Likewise there is very little literature that views multi-professional working from an patient's perspective. The lack of sound research in this whole area of professional practice highlights a need for further in-depth exploration. Clear leadership and a shared philosophy can be seen as being vital elements in any form of team-working. If physiotherapy teams are not nurtured and supported and practitioners valued, their success and effectiveness in embracing person-centred ways of working that recognise and welcome the beliefs, values and desires of patients will be limited. Professional education needs to play a vital part in equipping and supporting practitioners to work within a multi-professional environment. ‘Tribalism’ and professional domination can have no place in team-working if practice is to be truly person-centred and if all practitioners are to be valued and viewed as being equal. The success of multi-professional physiotherapy teams primary care is dependent not only on support at a local level but a commitment nationally to develop innovative ways of working that are truly person-centred and that focus on supporting and enabling individuals. For patients accessing services and multi-professional teams it is vital that they are seen as partners in the therapeutic relationship and not passive recipients. To achieve this, organisations will, in some cases, need to amend their organisational culture and structure to facilitate this change of focus. Key documents such as The Way to Go Home (Audit Commission 2000), The NHS Plan (Doll 2000) and the National Service Framework for Patients (Doll 2001b) can be seen as giving a clear direction for the development of multi-professional working. However, long-term sustainability will only be achieved if there is a commitment for future development. References Audit Commission (2000) The Way to Go Home. Rehabilitation and Remedial Services for Older People. London, Audit Commission Publications. Bakheit A (1996) Effective teamwork in rehabilitation. International Journal of Rehabilitation Research. 19, 301–306. Barr O (1997) Interdisciplinary teamwork: consideration of the challenges. 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