Communication In Multidisciplinary Health Teams - Essay Example

COMMUNICATION IN MULTIDISCIPLINARY HEALTH TEAMS INTRODUCTION 'Health' is described by the World Health Organization, not only as the absence of disease, but as the integral wellbeing of all different levels of experience in man: physical, emotional, rational and spiritual, relating in harmony with his/her external surroundings. This accepted complexity of man requires a holistic multidisciplinary approach. 'Well-ness' requires alignment between man's physical, emotional, rational and spiritual inner being to harmonise with external living conditions. Nurses have dealt with this complexity integrating medical (inner) and social (external) health-care for centuries. Their historic experience has made nursing and midwifery the unifying catalysts in health teams. Their sustaining nodal core has been their humane 'caring'. However, the World Health Organization (WHO) estimates a shortage of more than 4 million doctors, nurses, midwives, worldwide (1600 medical schools; 6000 nursing schools; 375 public health schools). Inadequate remuneration adds to the loss of trained health-care personnel, to emigration (a recent analysis of nearly 400 emigr nurses in London found that as many as two thirds of them were recruited from Cameroon by agencies to work in Britain). An additional 2% of the nursing workforce is lost to retirement, each year. The existing local health resources, left, have to confront the growing burden of high-priority services required to meet the Millenium Development Goals (MDGs)(2) established by WHO: 1- Reducing Child Mortality 2- Improving Maternal Health 3- Combating HIV/AIDS, malaria and other diseases To confront this world challenge with the existing shortage of nurses, the World Health Organisation has proposed the development of multidisciplinary teamwork at country level (3). This strategy multiplies existing health workforce in a synergy to surpass the sum of each individual. However, teamwork requires the leadership of nurses and midwifery to integrate and coordinate collaborative partnership, enhancing information exchange, as advanced technology creates medical specialisation and sub-specialisation. DEFINITION Shannon-Weiner had described linear communication process as the flow of INFORMATION (message) between an INPUT (emissary), and an OUTPUT (receptor), through a modelling CHANNEL. Now-a-days, the INPUT runs the INFORMATION through the 'black box' (channel with an unknown inner mechanism, that gives an unpredictable OUTPUT), in system analogy. This exchange of a heterogeneous, concurrently running process distributes message transactions with unreliable execution. Non-linearity must be harnessed by clear inter-process workflow mechanisms to avoid entropy (the natural tendency towards disorganization and chaos). To better understand communication in multidisciplinary teams, we must first delve into the deeper meaning implied in each of these words, for a comprehensive analysis: "Teams" differs from "groups", because they unite people in a common purpose; whereas "groups" are encounter, meeting spaces where feelings, experience or ideas are shared and exchanged, without a fixed agenda. The original word, "team" comes from the Greek, meaning two horses or oxen, together, driving a plough. Multidisciplinary is a term coined recently to describe the multiple specialities (functional disciplines) that interact in a common job. Unlike interdisciplinary, which describes the interaction within the team, multidisciplinary teams work together towards a common objective. Multidisciplinary is external networking; interdisciplinary is internal interaction. Communication which comes from the latin "comunicare" stems for 'common'. It is interactive information that binds a "common" network. If, however, it is broken down into the prefix: cum- with and munio/munire- defense, historic origins from the need for defense to make for survival. Information has become the bonding link that fortifies a common front of understanding and protects against division. If, however, it is used destructively, it can disintegrate a team, rendering goal-reaching, impossible. Communication has evolved into technological extensions that project man's perception expansively, beyond his physical senses. Television projects man's outreach; radio projects his audition; computers project thought-process. Multiple channels add contextual complexity to linear communication with simultaneous tracks of vertical, cross sectional and in-depth flows of information. Mass media add another dimension to complexity projecting man outwards, leading him further astray from inner self-knowledge. Drawn away from his innate, intuitive, emotional and rational inner perception, man draws away from understanding self and others. External communication is reduced to information exchange when inner communication does not develop mutuality and empathy. Comprehensive communication strategies have to unfold along these internal and external tracks deal with content complexity. The challenge is to integrate the content of messages in alignment with the pivot of integrity. Authenticity and veracity will then lead to credibility. Contents must also be reviewed, ethically, because they can either create or destroy. If used constructively, they will create bridges of understanding; if used destructively, they will build barriers to set obstacles between people. This difference in contents determines understanding or misunderstanding SITUATIONAL DIAGNOSIS IN WALES To fully grant health service to almost three million inhabitants, the Welsh Health System has built strategic interventions at local, community and national levels. It has 22 local Health Boards; 13 NHS Trusts (plus one all Wales NHS Trust); 3 regional offices; one healthcare Services Commission and a large number of various health agencies (4). Despite its comprehensive model, the Welsh Health System is accused of being cumbersome and costing more than it should. Thinking of reorganising it, would only distract strategic attention away from actual improvements to the service. The Royal College of Nursing, Wales has identified some of the health priorities that need confronting (5). These include: The Boards (more recently established) overlap in a confusing fashion with the Trusts (oldest and largest health organisation in Wales). Strategic partnerships are necessary to enhance an integrated approach to the Regional specialised services, and develop actual operational control of primary, community and secondary health services. Nursing staff feel patient care is being compromised by unsustainable workloads that stress the existing nursing staff and health care professionals alike. Training and experience are being curtailed because each Trust currently recognises only its own training programmes (though they may not differ). A national recognition agreement should allow training and competency in skills (such as cannulation, administration o IV drug additives, requesting X ray, administering anaesthetic, analgesic or antibiotics..) to be recognised across Wales.- The "Strategic Directions for Strengthening Nursing Midwifery Services" drawn up by the Global Network of WHO Collaborating Centres for Nursing and Midwifery Development for 2002-2008, has identified five key result areas (KRAs) that require immediate intervention. Proposals to the Welsh National Assembly drafted this year hold a parallelism with these world health concerns. 1.- Health planning, advocacy and political commitment require nursing and midwifery services and expertise. The Office of the Chief Nursing Officer (OCNO), under Mrs. Rosemary Kennedy supports the Welsh Assembly Government by providing good quality professional nursing advice (6). Her expert professional advice to the Secretary of State for Wales and Ministers, though heading the largest single group of health professionals employed outside the NHS in other public and private sectors, industry and commerce, is not enough. Advice should be accompanied with simultaneous operative authority. Strategies should not only be proposed but implemented and supervised. In addition, the Royal College of Nursing (RCN- the world's largest professional union of nurses, representing over 390,000 nurses, midwives, specialist community public health nurses, health care support workers and nursing students, including 22,000 members in Wales), welcomes modernising health care from hospitalised services back into the heart of the community to improve patient experience (7). The importance of keeping patients in the community was again emphasised, in the Welsh NHS Confederation, during a study tour of the Kaiser Healthcare System in Colorado in 2005 (8). 2.- Gender sensitivity, safe working conditions, equitable rewards and recognition of competencies is necessary for nursing and health personnel management to guarantee adequate workforce conditions. Fairer charging was proposed to the Welsh National Assembly to increase the "buffer" and on the disability-related expenditure in local authority, charging for domiciliary care services. (RCN Policy 10/11/06) Health, social care and housing needs of lesbian, gay and bisexual and transgender older people was presented by a Stonewall Cymru commissioned study done by the University of Wales (RCN Policy 26/09/06). The Mental Health Review Tribunal for Wales fights for equality in dealing with both, the English and Welsh languages (RCN Policy 22/08/06). 3.- Practice and health system improvement require integrated decision-making. Redesigning management of respiratory chronic conditions was a proposal launched on October 2006 by the Service Development and Commissioning Directives for Respiratory Conditions. The Mental Capacity Act passed in 2005 is still adjusting arrangement for people who lose capacity during the course of a research study (RCN Policy 29/08/06). Wales has not yet planned its National Screening Programme for Bowel Cancer, which will require training and nurse-led community interventions. 4.- Education of health personnel for nursing and midwifery services requires skill mix to deal effectively with growing challenges. The Wales audit office reported in October of 2005 needs in psychological therapy, counselling services and residential settings. Mental Health Services in primary care should also be strengthened to develop emotional resilience in children, requiring better trained school health nurses and counselling (9). The Carlile Report, the Waterhouse Report and the Clywch Report of the Children's Commissioner for Wales identified inadequate levels of appropriately trained staff where children and young people are cared for, in Wales. Provision should be made to train more children's nurses with governmental commitment to ensure career development. Local Welsh education authorities still employ school health nurses (150 whole time nurses), isolating them from nursing peers, with subsequent under valuing, when they should be deployed as a team by the local health organisation to serve the community (10). 5.- Stewardship and governance involving joint commitment between government, civil society and professional health workers will enhance quality health care. Public consultation is being conducted on smoke-free premises (RCN policy 10/07/06). Government funded strategies should involve public education and reduction of licensing hours to deal with growing alcohol consumption. Educational programmes are required to counteract alcohol abuse in 49% of men and 43% of women in Wales (4). The Government of Wales should give greater prominence to physical education in school curriculum. Health, eating and exercise- requiring guidelines for school lunches, tuck shops and vending machines are necessary to restrict unhealthy choices and guarantee statutory fresh drinking water to all children during the school day. Leisure facilities should also be available and maintained, with safe transport plans for pedestrian and cycle access. Government strategies to target identified deprived wards are required to better housing conditions. Cymru (18) reports a fall out generated by poor housing, homelessness (1,795 dependent children live in temporary accommodations and is on the increase) and consumer debt in surgeries and wards across Wales. Teamwork between the government and health-care systems is required to address both health and living conditions in marginalised communities. Sexual health must be upheld with rapid access to confidential contraception and sexual health advice, including emergency hormonal contraception, as an integral part of school curriculum, and be readily accessible in Secondary Schools (10). PROPOSAL New paradigms of health-care with added workloads and advanced technology require renovation of the academic training curricula in nursing and midwifery, to include communication expertise for multidisciplinary team management. New teaching methods and innovative models should propose reliable effective educational outreach programmes, updated to promote multidisciplinary synergies. The International Council of nurses (ICN) has set up a programme to develop nurses as effective leaders and managers in a constantly changing health environment. However, disseminating guidelines has been insufficient. Guidelines should be part of multifaceted packages of iterative, on-the-job-support, and promotion of experiential feedback, within a comprehensive, multidisciplinary training program. They should be distributed during a training course, supported by peer group discussions with audit and feedback over the contents, associated with subsequent supervisory visits, for their effective implementation. A possible proposal in dealing with these identified problems is for the Government of Wales to enforce comprehensive health promotion programs, developing a Regional Training Centre for Multidisciplinary Team Communication. Expert communication can address team approach required for the management of health conditions along each of the different life stages more broadly, to catalyse effectiveness. Effective communication has to be developed at all levels: individual, group, community, institutional and mass media. Disease will best be counteracted with the collaborative effort of: public- health specialists, policy and service planners, researchers, information technology designers and support personnel. Strategies to foster added collaboration beyond these multidisciplinary teams include teamwork between health workers and patients. Global solidarity sets a last framework for the required team-force in health care. It enhances the knowledge, learning, and assessment necessary to enable policy implementation and crisis response. DEVELOPMENT A comprehensive program for multidisciplinary team communication can shift health accountability from being government and hospital-based to community-based, and self-care. Training multidisciplinary teams in communication can spearhead the political momentum with the possibility to enhance community network synergy. Key policy actions identified by the RCN involve (5) can be tackled with specific communication strategies: Development of nurse-led, no appointment, health centres or "walk-in centres" in the area. Networking community hospitals Development of supplementary nurse-prescribing in Wales Long-term workforce planning for statutory social care National supervision and guidance to ensure equity and access to continuing nursing care. Shared care protocols between dentistry, school nurses, social care and local doctors. Non-professional workers can also be trained with effective communication to help meet some of the demands of health-care. Formal communication networks should be established for these community multidisciplinary teams. The shift from hospital-based to community-based health care must also bridge the gap with the other end of the continuum (specialist and sub-specialist care). Expert communication strategies requiring emphasis on multidisciplinary and inter-sectoral approaches will change roles of staff from vertical hierarchies of power to horizontal networks of collaboration. Piggy-backing on existing health-care mobilisation for separate, single-purpose and community-directed interventions will have greater efficiency in workforce performance, applying two of the cardinal rules for scaling up interventions effectively: 'simplification' and 'delegation'. Simplification improves staff productivity by allowing more to be done, with greater consistency and often by less skilled colleagues. Shifting tasks between health care workers and expanding the clinical team can relieve short-term resource limitations in settings with low resources. Rapid scaling up involves (11): Shifting tasks to the lowest relevant cadre Expanding the clinical team to include the patients' families and significant others Placing strong emphasis on patient self-management and community involvement. To train, sustain and retain trainees' lifelong learning development with relevant competencies, skills, attitudes and behaviours, the Regional Centre for Multidisciplinary Team Communication could benefit from the proved effectiveness of experience described by the Clinical Partners Programme at the Ohio State University College of Pharmacy, which covers a population distribution similar to that of Wales: Practice-based teaching -Bridging the gap between academia and practice -Benefiting students, school, agencies and communities -Involving and developing critical thinking and problem-solving skills -Strengthening interdisciplinary, multidisciplinary and multidimensional networks -Developing learning partnership among academic staff, practitioners and students, to educate teachers, practitioners and researchers. -Incorporating experiential education including critical reflection, observation and learning by doing. Problem-based learning -Identifying problem-resolution -Exploring pre-existing knowledge -Generating hypotheses and possible mechanisms -Identifying objectives and opportunities -Self-study and group learning -Re-evaluation and applications of new knowledge to the problem -Assessment and reflection on learning Patient-focused practice -Integrating teaching and learning with clinical practice -Sharing experiences of illness, disease and recovery with patients -Understanding varying needs for care -Observing and participating in ways in which different service providers work together to -meet the needs of patients. Improving case management skills of health workers, health systems, family and community health practices supports the training of physicians, nurses and other health workers. Training can be set as: In service training- 11-day clinical training block with lectures, active teaching methods and accompanying practical aids catered to specific health professionals and their previous training. Pre-service training Introduction of core-skills to earlier health workers with a core-training module within educational curricula. Benefits of pre-service over in-service training include lower costs and specificity in cadres directed to nurses, paramedics, auxiliary health workers as described by the Integrated Management of Childhood Illness (IMCI) developed in the mid 1990s by WHO, and proven experience in: Bolivia, Ecuador, Egypt; Ethiopia; Indonesia, Moldova, Morocco, Nepal, Philippines, United republic of Tanzania, Uzbekistan, Viet Nam). The Health Inter-Network Access Initiative (HINARI) set up by WHO with the committee involvement of major publishers, enables academic research institutions, government offices and teaching hospitals, particularly in low income countries, to gain access to one of the world's largest collection of biomedical and health literature. Over 3200 full-text journals available for 69 countries. It emphasises: -Regionalization of training -Innovative ways to access teaching expertise and materials -Institutional evaluation of performance, policy, options and actions -Rethinking recruitment options as gateways to multidisciplinary workforce QUALITY CONTROL Long before Christ, Hippocrates, considered the Father of Medicine, described man as having two inner motivations: a life-force (positive tendency towards regeneration and growth) and a death-force (negative effective right-brain, creative participation in health policy development and decision-making tendency towards disease, self-destruction and death). He described 'healing' as the expert strengthening of a patient's innate tendency towards life, counteracting symptoms (dis-order), debilitating disease (dis-ease). In the twentieth century Freud ratified this description, with his discovery of an underlying 'unconscious' in man, where continuous inner conflict (lat.: friction) between "Eros" (Life) and "Tanatos" (Death) generates the "Libido" (vital energy). Inner awareness and voluntary decision-making decide between life-force or death-force. Discernment is control between external and internal awareness. If health care workers are not trained for self-control and awareness they will affect patients. Skill-development is necessary for constructive, creative attitudinal filtering. Destructive negativity must be curbed through personal discipline. Much of this process is innate to nursing and midwifery due to historic leadership in health-care. However nurses' growing inclusion in key positions within the health system requires expert training in communication, to deal effectively with policy and teamwork (1). Quality performance requires implementation of communication strategies to bridge constructive understanding within a team (14). It is necessary to set: 1.- Clear objectives. Understanding common objectives and sharing precise goal-setting, unites individuals into a team. The different disciplines interacting together as health teams, have diverse training, expectations and ways of doing things. Unity must be strengthened by clear-cut, common objectives. 2.- Leadership. Individual leaders uphold the framework of a multidisciplinary team. Their personal strength becomes the cornerstone of development and growth. Daring individuals openly committed to a shared purpose, or goal, within a common frame of values become the leaders of a group. Leaders born from overcoming personal challenge within their lives, develop an inner strength which others look upon, when confronted by adversity. 'Difference' must be awarded merit, promoting the respect and tolerance it entails from the group. 3.- Networking Information exchange through informal networking breaks historic vertical, unidirectional hierarchies of power-play that tend to monopolize information. Communication in a multidisciplinary team must breech the inhereted power-structure of ancient monastic and military set-ups. Multidisciplinary teamwork between health professionals has to be knit together by the recognition of individual strengths, necessary for a common objective. Horizontal, transversal, mutual interaction enhances communication. Negative communication can avoid undesirable, destructive outcomes through skill-development and clear limits. 4. Understanding Difference leads to conflict. Interactive communication re-enforces understanding between differing, multi-disciplinary efforts fulfilling a common goal. Conflict turns into opportunity when limits are flexible and creative. Multidisciplinary teams must space out their functions to give room enough for the unpredictability of difference to expand and grow. 5.- Trust Stimulating reward systems must re-enforce trust and respect between individuals. Multidisciplinary systems, with different working team-mates develop trust when they share common feelings and fears that promote empathy. Directed encounter groups encourage human development and personal growth. 6.- Creativity Tolerance, flexibility and respect support new, creative, differing attitudes, ideas and behaviour as ways to explore paradigmatic renewal. Thus, "breaking the rules" expands structures and allows growth. 7.-Collaboration Promotion of collaborative skills requires healthy teamwork. Proactive mental attitudes and behaviour are enforced by what WHO has identified as required "Basic Skills for Life": self-knowledge, interactive mutuality, communication skills, decision-making, critical thought, creativity, emotional-control, and personal values (15). 8.- Team Identity Enhancement and maintenance of a common identity comes when individuals cease to strive for a private agenda, ceding their will 'in lieu' of a common good. So personal growth must be stimulated by human awareness programs to guarantee the development of group consciousness. Merits must, in turn, be shared in goal-reaching. Quality is maintained by close supervision and continual evaluation of performance indicators (17), such as: Availability- staff ratios, absence rates, waiting time Competence- Individual/ prescribing practices; Institutional/ readmission rates, live births, cross infections; Responsiveness- Patient satisfaction, assessment of responsiveness Productivity- Occupied beds, outpatient visits, interventions delivered per-worker or facility. CONCLUSION Nurses have upheld feminine leadership throughout History, permeating society with right-brain decision-making. Their personal commitment and dedication; their flexibility, intuition, creativity and broadened-overlooking over the 'whole', rather than fragmented 'parts', has made women innate 'harmonizers' in families, groups and communities. This traditional 'caring' identifies nursing. Her added leadership integrating multidisciplinary health teams is an innovation that must urgently jump-start country based actions to sustain community health 'care' as 'caring' for an extended family. Increased investment and cutting waste must strengthen educational institutions to create new frameworks that align multidisciplinary team training as an added priority to medical technical support. In the referendum of September 18, 1997, Welsh citizens voted to establish a National Assembly. Though this National Assembly is not able to legislate and raise taxes, Wales is now in control of its local affairs (16). Health is local and must as such, be dealt with locally. WHO has established that countries have a ten-year National Health Plan of action with specific strategies for Education, Planning and Development. Wales can make a difference, assuming a self-governing local health plan, returning to the traditional community-based health promotion, that has characterised Welsh warmth and caring. Wales can bridge the gap of difference with multidisciplinary teamwork under nursing and midwifery leadership. The creation of a Regional Centre for Multidisciplinary Team Communication can be a start. REFERENCE (1) Murray CH., Frenk J.: "A framework for Assessing the Performance of Health Systems". Bulletin of the World Health Organization. International Journal of Public Health. Vol.78, Number 6, 2000. 715-865. (2) Global Network of WHO Collaborating Centres for Nursing and Midwifery Development: "Strategic Directions for Strengthening Nursing Midwifery Services 200-2008". WHO, Geneve. (3) Kantrowitz M., Fllop T., Kaufman A., Mennin S., Guilbert J.: Innovative Tracks at established Institutions for the Education of Health Personnel: Experimental approach to health needs. WHO. Geneve, 1987 (4) Key Health Statistics 2005, Statistics Wales (5) Royal College of Nursing: Policy Papers. Wales, March 2006 (6) ASH- factsheet no 2: August 2005. (7) Solomon L., Berzon B.: New Perspectives on Encounter Groups. Jossey-Bass: San Fco. 1972. 13-29. Facts about Carers, Carers UK April 2004 (8) Welsh NHS Confederation: From the Rockies to the Rhondda. 2005 p.6 (9) Wales Audit Office Adult Mental Health Services in Wales: A baseline review of service provision. October 2005 p.8 (10) The Report of the Chief Inspector Social Services in Wales 2004-5 p.3 (11) Kalimo R., El-Batawi M., Cooper C.: Psychosocial Factors at Work and their Relation to Health . WHO, Geneve. 1987. (12) Maxwell J.: The 17 Indisputable Laws of Teamwork. Thomas Nelson: Nashville, Tennesee, 2001. pg 40. (13) WHO: The Community Health Worker: Working Guidelines for Training. Geneve, 1987. 9-13. (14) Goleman D.: Working with Emotional Intelligence. Bantam: N.Y, 2000. 133-297 (15) Corey G.: Theory and Practice of Group Counselling. Books/Cole: California. 1982. 38-127 (16) TIME: Almanac 2006. Pearson Education,890 (17) Stanton M (2004): Hospital Nurse Staffing and Quality Care, Research into Action. Issue 14. Agency for Health Research and Qualit, USA. (18) Social Work in Wales: a profession to value ADSS Cymru 2005 (19) Sutherland Report, Royal Commission of Long-Term Care, with respect to old age: Long Term Care- Rights and Responsibilities. (20) NHS Diagnostic and Therapy Services waiting times. January 2006-11-22 (21) Statistical Release 31/2006 Statistics Wales (22) NHS Staff Vacancies. 31 March 2005 Statistical Release 65/2005 Statistics Wales Read More