I’m quite keen to generate some more discussion about how individual professions can contribute within Interdisciplinary/Interprofessional Team without being defensive of their contribution, nor allowing other disciplines to encroach on their specialist skills.
I really struggle with the whole concept of “role definition” because so often I see “the OT role is…” without considering that there are a number of core areas many health professionals in pain management use such as goal setting, relaxation, pain “education”, activity pacing/management, relaxation, biofeedback, cognitive behavioural therapy.
Some examples: Once I heard an occupational therapist say that only occupational therapists should “set functional goals”. Yet if goal-setting is client-centred, I can see how physiotherapists, nurses, social workers, psychologists and doctors can ALL work with a person to “set functional goals”.
I also heard an occupational therapist suggest that “only” occupational therapists should go into the home, or workplace. Yet I’ve had some fabulous physiotherapists and psychologists go into both these places and do fantastic work.
The current debate is whether occupational therapists or physiotherapists should do mirror therapy or laterality training.
Sadly I also heard of a doctor who told the interdisciplinary team that he thought it was fine to advise a person to begin a walking programme – without consulting a physiotherapist! Oh no! How dare he! Actually, isn’t this what many nonmedical clinicians have been wanting our doctors to do? And if a physiotherapist begins talking about function in the real world, isn’t this what occupational therapists have been saying physiotherapy doesn’t do but should? Seems to me we don’t recognise our own cognitive dissonance even when it’s sitting right in front of us.
To be quite honest – I don’t care WHO does what! As long as a clinician is competent, the client has had a hand in establishing priorities, and there aren’t two clinicians doing exactly the same work, to me it does not matter.
BUT I’d love to find out some other points of view, and poke holes in my assumptions – so, go to it ladies and gentlemen!
Someone asked me “so what are the skills people should have to work in chronic pain management?”
- I’m thinking about this right now – firstly, people who “get” pain. So well-educated, knowledgeable people who have a really good grasp on neurobiology and psychology of pain. I don’t really care about the professional background, but I’d like someone who can reassure patients/clients that their pain (a) has a name (b) doesn’t mean its harmful (c) can be managed. I would help if one person in the team can prescribe rationally.
- Someone should address movement and pain - don’t care if it’s an occupational therapist, physiotherapist, exercise physiologist or whatever. Best if this person can grade movement from simple/low intensity to higher and definitely functional intensity. And critically, that person needs to know the relevance of any exercise on what the client/patient does in daily life.
- Someone else needs to talk about the meaning of pain on the sense of self, and help the person understand that doing things differently doesn’t mean losing your self concept.
- It would be good to have someone who understands behaviour, and interactions between behaviour, emotions and cognitions.
- Absolutely, someone in the team needs to help the person identify what they WANT to, or NEED to do to feel complete, then help the person work out ways to do that.
- And I think it’s vital someone can interpret psychometrics, and knows enough about outcome measurement to produce regular reports on how participants in pain management are doing once they leave the service.
And all the other things like using biofeedback, diet, relaxation, communication, health literacy, would need to be incorporated by those will skills in these areas.
I think teams need someone who will bat for them in management, someone who really cares about the team and how it functions, and will wave the flag in terms of retaining an interdisciplinary self management focus, ensuring the team remains client-focused and team-focused, rather than discipline-focused.
Teams need to negotiate their contributions (note I say contributions not “roles” – contributions are offered, roles are defined and possessive). Team members need to renegotiate what they can offer when new team members join the team, or when a team member develops a new skill. Defining one “role” means, implicitly, that other roles are also “defined”. Sometimes this happens without negotiation. And if role definitions are not regularly reviewed, innovation and responsiveness drops, positions get reified – and we end up with a cookbook approach to pain management that means the personal relationship between the person who has pain and his or her clinicians is valued less highly than the professional title of the clinician. I don’t see this as client-centredness.
One argument for defining roles is to avoid duplicating skills. It’s intended to ensure “the right clinician with the right skills sees the right patient at the right time”. I think this ignores the common skills all clinicians working in chronic pain management need. It ignores individual team member development. It means clinicians who are not “meant” to do the tasks nominated within another role’s definition can’t develop their skills to support one another within the team. It creates barriers and obstacles to developing a common language, using a common model (cognitive behavioural approach, in the case of chronic pain management), developing common goals. It can lead to multidisciplinary practice instead of interdisciplinary/interprofessional teamwork.
It can, unintentionally, create over-servicing because instead of selecting clinicians to work together on the basis of what the client/patient needs, professional demarcation lines are drawn and THREE clinicians need to work with the client/patient instead of two. Maybe even more because if the person needs to develop communication skills at work – maybe the occupational therapist “should” work on this; if the person needs to develop effective communication at home – maybe the social worker “should” be involved; maybe it “should” be the psychologist because it’s about the person’s core schema. See how complex this can become? It’s even more difficult if we look at activity management. Should the occupational therapist be involved because it’s about occupation? Or the psychologist because it’s about contingencies and core schema? Or the physiotherapist because it’s about building exercise tolerance? Or the social worker because it’s about negotiating boundaries with other people?
Teamwork – more than a group of clinicians who happen to work with the same patient.
Sandra G Leggat (2007). Effective healthcare teams require effective team members:
defining teamwork competencies BMC Health Services Research, 7 (17), 1-10 : 10.1186/1472-6963-7-17