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Teams, roles, and contributions


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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?”

  1. 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.
  2. 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.
  3. 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.
  4. It would be good to have someone who understands behaviour, and interactions between behaviour, emotions and cognitions.
  5. 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.
  6. 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

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7 comments

  1. Im not sure if it is creating a discussion if I just say “I agree with you”?
    I am a physiotherapist working in a persistent pain team. I think we need clinicians who understand each others approaches and can overlap and support each others approaches.
    I think the key is educated and skillful clinicians. I have listened to a pain physician tell a patient how to start an exercise program that suggested ‘using pain as your guide’ – I did get (pleasantly!) involved at that point.
    Mirror box wise,I have seen physios using graded motor imagery in a not great way – being a physio doesn’t mean Im automatically good at it – I need to learn the skills. If OTs etc seek training in that – great.
    all clinicians ‘should’ work with patients goals – pointless endevour if we don’t.
    Cheers,
    Megan

    1. Thanks Megan – agreeing is fine! Graded motor imagery is, to my mind anyway, part of graded exposure – so a psychologist, occupational therapist, nurse, social worker or physical therapist can all use it – provided they learn the underlying theory for it, and use it appropriately.
      It’s hard to understand how a Doctor could say “let pain be your guide” – if they’re working in chronic pain management, surely this is one of the main things to learn? Well done you on getting involved, pleasantly or otherwise.
      cheers
      Bronnie

  2. GMI doesn’t belong to any one profession, but as you say, it better belong to people who have a deep understanding of pain science and the lived experience of pain. And, yes, GMI is part of graded exposure, and we can do that with so many techniques.
    GMI is really ‘just’ a way to provide the person in pain with an inconsistent experience – something contrary to what’s been happening, or as some say, contrary to the nervous systems’ assessment of threat. We need people to experience that they can think about a part of their body, or think about moving a part of their body, or feel touch sensations in the area of the pain, or do a gentle isometric contraction, or move a joint, or perform an activity, …, without it creating uncontrolled pain. Then we need to find a way to expose them to more, fostering hope, self-efficacy, fearlessness, …
    You mention that knowledge is key for team members. The trouble with GMI, and many useful pain management techniques, is that the individuals providing them do not have the experience or knowledge in this area, so they can’t see them in a broader context. If one professional doesn’t know this, then other team members hopefully can be mentors.
    Teams are not always groups of equally skilled clinicians. They are a process of mentorship. This of course has a huge impact on who does what … getting back to your point again about knowledge and expertise. This, I think, is much more important of a factor in ‘who does what’ that professional designations.

    1. I love the way you put it – a team is a process of mentorship. That’s exactly what I think occurs over time as a team develops.
      KNOWLEDGE is so very important – but each team member has unique knowledge that is often unshared because teams tend to share common knowledge. Groups that share unique information make better decisions.
      My view of GMI tends more towards the psychological graded exposure approach where, by engaging in something slightly anxiety-provoking, and learning that the anticipated disaster doesn’t happen, the individual develops greater tolerance to being exposed to the stressor. This is enhanced by using mindfulness so that the experiences are noticed rather than avoided or focused on. I have some concerns about GMI’s focus on NOT exacerbating pain, because it can lead to greater avoidance and anxiety about experiencing pain fluctuations. There’s a pretty fine line to walk to determine when avoiding pain fluctuations is useful as in GMI, or when it becomes unhelpful, which is the viewpoint from graded exposure.
      Again, this is why teamwork is critical – appreciating both one another as clinicians, and the client as key goal-setter. If the entire team can contribute to decision-making the process can be far smoother, more coherent and much better for the patient.

  3. I would like to divert this conversation a little. I am in the process of writing up a study about interprofessional supervision and am looking for good references on the topic – this is because my mandate was to update the literature review. Given that there is a general agreement here that team work involves blurring of boundaries, does this extend to supervision as well?

    1. Hi Linda
      As someone who has rarely turned to my usual profession for supervision related to pain management, I think so. I don’t have references for this – but it seems to me that an occupational therapist working in another field such as, for example, spinal cord injury, might have little knowledge of the interprofessional issues, clinical issues, psychosocial demands on the therapist and so on that might be involved in the kind of interprofessional work that I think is optimal for chronic pain management. While there are undoubtedly some clinicians, and I pick clinical psychologists as an example, who don’t stray far from their own profession for supervision, I’ve had wonderful supervision from physiotherapists, clinical psychologists, medical practitioners, social workers, and nurses. To me it’s been much more around “how can I deal more effectively with the issues facing this group of clients?” than “how does an occupational therapist meet these clients needs?”. This has caused some strife amongst fellow occupational therapists who might see this as watering down the professional contribution of the profession – but within an interprofessional team, the individual discipline matters far less than the synergy amongst the collective team who all hold a common clinical model. I think each person needs to have a very strong image of what their contribution might be, but for me, I felt it more important to provide evidence-based interventions and do so competently, than provide occupational therapy-specific interventions that have rather less of an evidence-base, and do so to keep the peace amongst other occupational therapists. My journey to feeling comfortable with doing what I do in pain management has led me to reflect on what it is that occupational therapy is intended to promote – and its therapeutic media – and after a lot of pondering, my focus has always been on providing an appropriately graded environment which can elicit the kind of occupational performance the client can manage (more correctly, just beyond what the client can manage comfortably – needs to be a stretch!), and I use a range of interpersonal strategies mainly drawn from cognitive behavioural therapy and exposure therapy, but directly related to what the individual wants to, or needs to do in their daily life. I may even be more “physically” oriented than many of my colleagues suspect, because I think it’s also important to draw on exercise physiology, neurology and developmental function to help the person achieve what they want or need to do. I hope I have helped explain where I am coming from – maybe I’ll even post on here about it!

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