teamwork

Interdisciplinary? Or serial monotherapy?


Teamwork can be a mixed blessing. Knowing that other members of the team are working alongside you is wonderful but a team that’s not functioning well can be a destructive animal that can tear itself apart.

I’ll begin with some definitions:

Monotherapy means having a single type of intervention. This is useful for acute problems, or very simple problems. For example, if I sprain my ankle, I might need to see a physiotherapist to improve my mobility. In New Zealand, the ACC-funded Psychological Pain Management sessions are a good example.

Multidisciplinary means more than one discipline working with an individual, but not necessarily working with one another. This is useful where coordination is difficult, such as in a busy Emergency Department, or where the problem doesn’t need collaboration, for example possible neuropathic pain post-deQuervains release where the patient needs physiotherapy, medication and help to return to work. In New Zealand, a good number of the ACC-funded Activity Focused Programmes run this way.

There may be a physiotherapist, occupational therapist and psychologist working with the same patient, and although they may share notes their interventions remain focused on their individual disciplinary contributions. The way the disciplines conceptualise the patient’s problems remains within the individual professional’s model. So the physiotherapist might focus on biomechanics and strength, the occupational therapist may consider how the individual manages his or her driving and work tasks, while the psychologist may consider the person’s thoughts and beliefs about pain. Although the disciplines acknowledge one another’s contribution, clinicians focus on their own intervention and clinical reasoning with little reference in their own sessions to anything another clinician has looked at.

Interdisciplinary means professionals from a variety of disciplines working together in an integrated way with joint goals and ongoing communication. A common model is used, joint goals developed, clinicians contribute in the area/s most needed by the patient/client, share session content and communicate regularly so other team members can provide the same message in their sessions. This might mean the physiotherapist uses cognitive reframing during exercises, the occupational therapist discusses medications and side-effects during activity planning sessions, the psychologist talks about exercise timing and intensity during a session using biofeedback.

The popularity of interdisciplinary pain management has waned somewhat since the days of the mid-1980’s to late 1990’s. Health administrators look askance at large teams because they seem expensive, time is tied up in meetings, there are turf wars, people talk about role conflict and role confusion, time is needed for induction, and there’s always a suspicion that having a team leads to over-servicing and too many cooks spoiling the broth. I’ve watched the integrated interdisciplinary approach gradually being replaced by a multidisciplinary approach, although the language may not have caught up with this!

Teams are a complex beast. To understand teams we need to draw on cognitive psychology, social psychology, rehabilitation research, general systems theory and, dare I say it, management theory.  Not only do clinicians in an interdisciplinary team need to know their profession’s contributions, they must also communicate effectively as individuals, have learned how to collaborate, and the team must be supported in a structural way to do its job well.

What does this mean in practical terms?

There must be effective selection and induction process for new team members – members need to be chosen for teams on the basis not only of their proficiency in their individual discipline, but also on what they can contribute individually to a team. Personally I don’t think a decision to appoint an individual to a team should occur without the team being involved in the selection process.  Induction needs to involve not only where the first aid kit is, but more importantly, the team’s philosophy and clinical model, sharing what each individual member can contribute to the team – especially when a new member is appointed, how decisions are made, how disputes are resolved, and the team’s values.

Time must be set aside for team development and that hackneyed term “team building”. This is an ongoing need – because trusting one another is critical to effective teamwork. This means learning about other clinician’s contributions – enough to be able to provide the same kind of input within your own clinical session, so a consistent message reaches the patient.

Communication must be pretty robust at times! What I mean by this is that it’s vital to be able to disagree, challenge one another’s viewpoint and take the time to reach alignment, if not agreement. A team that can’t or won’t openly disagree with one another is likely to hold onto disputes, souring the relationships and creating distrust. Over time, the team’s effectiveness is lost as patients/clients can tell where the weakest links lie.

Develop a structure for presenting information
–Optimum amount of information – 3-7 from each person
–Most likely to be forgotten – presented first
–Lowest prestige – presented early
–Share unique information rather than shared
–Use a timer to limit discussion – egg timer?
–Consider using delphi, or other structured decision process (nominal group technique, SWOT, decisional balance, cognitive mapping)
Identify functional roles as well as clinical roles in a team, support these roles – this means some people are the “organisers” in the team, some are the “comforters”, some are “rule makers”, some are “enforcers”. These interpersonal roles are as important as clinical roles because they facilitate team functioning. And the professions traditionally expected to “lead” or “organise” may not be the best individuals to do so in a particular team.
Develop a process for resolving differences – this might mean sitting and thrashing a problem out in discussion, or it might mean bringing another person in to mediate/arbitrate, or it could mean giving a decision-making role to one individual within the team, though this can mean developing a hierarchy and this is less positive within an interdisciplinary team.
Managers must recognise that interdisciplinary teams need time to learn to work together, that teams are less effective when team membership changes, that members of teams often know what they need and who they need as members and that external managers or even clinicians working outside a team may have little knowledge either of how the team works, or of what the team needs to be effective.
Are interdisciplinary teams effective?
This is a slightly difficult question to answer, but overall the indications are that interdisciplinary teams are effective in terms of patient outcomes, and they are also better for the individuals involved in them. This report, somewhat old now but still relevant, found that IDTs are better for mental health of members and there is lower staff turnover.  This report, from 2013, finds that the data are not yet clear about cost effectiveness.
What seems evident is that the more complex a patient’s problems, and the more chronic, the greater the need for interdisciplinary teams, and the more cost effective the outcomes.
Human Resources for Health provides this summary – 10 Principles of Good Interdisciplinary Team Work
I love working in a team. I love being able to trust the other members of the team to provide seamless integration of the things I contribute, and I love being able to support the other clinicians in their approach. I know it’s not easy to develop good teamwork, but there’s enough information available from research to know what can help. What I definitely know is that defining what one profession will do without also considering both the other professional’s contribution AND the personal strengths and vulnerabilities of the individuals involved is likely to lead to subversive behaviour, dissention and ultimately failure for the person at the centre of it: the client/patient.

Friday Funnies!


Oh yes, it’s back again – Friday Funnies, and more opportunities for me to ‘treat’ you to my warped humour.  My apologies in advance.

First up, a quick quiz…

Can you cry under water?

How important does a person have to be before they are considered assassinated instead of just murdered?

Why does a round pizza come in a square box?

How is it that we put man on the moon before we figured out it would be a good idea to put wheels on luggage?

Why is it that people say they ‘slept like a baby’ when babies wake up like every two hours?

Why is ‘bra’ singular and ‘panties’ plural?

Why do toasters always have a setting that burns the toast to a horrible crisp, which no decent human being would eat?

Why, when you blow in a dog’s face, he gets mad at you, but when you take him for a car ride, he sticks his head out the window?

Our manager is keen to help us develop teamwork – perhaps this would work?

The loaded mini-van pulled in to the only remaining campsite. Four children leaped from the vehicle and began feverishly unloading gear and setting up the tent. The boys rushed to gather firewood, while the girls and their mother set up the camp stove and cooking utensils.

A nearby camper marveled to the youngsters’ father, “That, sir, is some display of teamwork.”

The father replied, “I have a system. No one goes to the bathroom until the camp is set up.”

Oh, I forgot – that’s why meetings are so long.  (on a more serious note: this is a good, albeit simplistic, paper on teamwork in health settings)

’nuff for today, except to leave you with something from my travels in Molesworth Station.

It’s hard work researching teamwork


ResearchBlogging.org
After writing about teams and models and the distinct possibility of talking past each other, I had a very quick search for a paper on teamwork and models this morning, and came across this one by a group of Canadian researchers. It is, like many of these pieces of research into the messy and complex area of decision-making and teams, a qualitative piece of work. It examines process and identifies underlying values within a team.

Values are interesting things – they’re the often unspoken ‘things we think are important’, and possibly represent the very things that we both share in common with each other – and at the same time, can be the very things that underlie our major differences of opinion with each other too.

In this study by Loisel, Falardeau, Baril, José-Durand, Langley, Sauvé, & Gervais, (hereafter ‘the authors’), they observed a single team discussing the cases of 22 workers off work due to musculoskeletal pain.  They painstakingly transcribed then analysed the discussions (338 meetings, 75 hours of discussion transcribed!)…

The team consisted of : general practitioner, occupational therapist, kinesiologist, psychologist, ergonomist, and team coordinator.  They held weekly team meetings to decide on progress, messages to give to employer and participant (an investment in meetings that I don’t see happening on a regular basis in many pain management settings today).

Data analysis is modelled after Glaser & Strauss, although thankfully they acknowledge they are not using grounded theory – instead, they coded, wrote memo’s, created flowcharts and looked for similarities and differences between each coded category until they came up with explanatory hypotheses that cohered to form a theoretical explanation for how the teams worked.  For a full description of the types of grounded theory (so you can see how this study differed from a methodologically sound grounded theory) you can go to here and here.

The findings identified ‘ten common values and were shown as supporting the team’s decisionmaking process during case management. They repeatedly appeared during interdisciplinary team meetings and were reinforced by team leaders.’ The researchers thought they fell into four main groups: (1) team-related values, (2) stakeholder-related values, (3) worker-related values, and (4) general values influencing the intervention.

Team-related values

Team unity and credibility – this reflected the approach of the team to both arrive at consensus, and then act in consensus so that there were no ‘gaps’ or opportunities for the participant or employer to split the team.

Stakeholder-related values

Collaboration with stakeholders – this represented coordination of care, and the team worked hard to bring participants alongside with the team’s view, so that the person returning to work had consistency of management.

Worker values

Worker’s internal motivation – the team worked hard to strengthen the worker’s internal motivation, so the worker was encouraged to be autonomous and assertive.

Worker’s adherence to the program – the team worked hard to ensure the person returning to work followed the team’s recommendations, seeing this as vital to the success of the programme.  The authors found that it seemed important that the worker and the team were ‘thinking in the same way’, that they became ‘allies’.

Worker’s reactivation – being active = good, being inactive = bad.  All workers were thought to be able to return to work irrespective of their diagnosis.

Delivering a single message – unity and consensus seemed critical to ensure everyone heard the same message and the aim of the programme was achieved.

Reassurance

Worker’s reassurance – that the person was doing no harm to themselves, that they would ‘make it’, and that the team was supporting them.

Stakeholders’ reassurance – to ensure the stakeholders felt comfortable with accepting someone back to work even if they weren’t at full physical capacity.

General values

Interventions should be graded – because workers had been off work for some time, the team agreed that they should be gradually reintroduced to the workplace.

Pain is multidimensional and must be actively controlled – both physical and psychosocial factors were actively addressed throughout the programme, including ensuring the participant knew about the multidimensional nature of pain.

Work is therapeutic – the team supported the idea that being back at work is good in itself.

Discussion

For me, this study illustrates that even if a team hasn’t clearly or explicitly discussed underlying values or models, they hold them.  It’s probably (and I’m hypothesising here) a more effective team that is open amongst the members about the values or model they have, so that differences of opinion can be openly aired, and especially given that at least in this team, being united was thought to be so important.

I’ve recorded and tracked the discussion patterns across team members, and also looked at roles participants play within a team, but I’ve never examined the underlying values. 

I think it’s an interesting approach to how living teams function, and it begs the question: how long does a team need to be together to cohere values?  What is the effect of introducing a new person to a team? How does a team work to integrate or exclude values brought in by new team members that don’t align with the rest of the team?

It also brings into question the process of selecting a new team participant – maybe it’s much less about what the person knows, and much more about how comfortable that new team member is with the ‘way we do things around here’, or the values and culture of teamwork.

Loisel, P., Falardeau, M., Baril, R., José-Durand, M., Langley, A., Sauvé, S., & Gervais, J. (2005). The values underlying team decision-making in work rehabilitation for musculoskeletal disorders Disability & Rehabilitation, 27 (10), 561-569 DOI: 10.1080/09638280400018502

The complexities of interdisciplinary teams


ResearchBlogging.org
Pain management, especially chronic pain management, is characterised by using an interdisciplinary approach rather than a multidisciplinary one. Distinguishing between the two can be a case of splitting hairs at times, but the fundamental difference is that in multidisciplinary teams, treatment is carried out by different team members who may work with the patient concurrently, but not necessarily using the same underlying model or framework for treatment. In an interdisciplinary team, treatment is carried out by different team members using a common model to address common goals – working collaboratively and in close communication with each other.

Interdisciplinary teams take time to develop. The members of the team learn more about each other’s professional roles the longer they work together. They become familiar with, and trust each other to support the common messages such as ‘don’t use pain as your guide’, or ‘do no less on a bad day, do no more on a good day’. Interdisciplinary teams rely on each other to help the person with pain move forward towards the life they want to live.  To become effective, interdisciplinary team members need to learn to trust each others practice, to have confidence in their own practice, and to develop a common language and approach to clinical situations they encounter.

The problem with these teams is that much of the ‘work’ of a team occurs during meetings, and meetings of groups of health professionals look costly. Five or more therapists sitting together for a couple of hours seems to be an inordinate waste of productivity when you think of the number of patients they could be seeing during that time! Not only that, but developing effective team processes including good induction and dispute resolution also takes time. And it’s invisible input with little visible output. No wonder managers think teams like this could surely be done differently.

The research on effectiveness of interdisciplinary pain management continues to support this model, despite erosion of it in some countries (notably North America). I’m not going to review the literature here, but a couple of good references (and yes, these are old ones, but still relevant) are Turk and Okifuji (1998), and Okifuji, Turk & Kalauokalani (1999), and of course, Main and Spanswick who wrote the book Pain Management: An interdisciplinary approach (2000). A more recent edition of this book has been published, further extending the application of the biopsychosocial model in pain management.

When we’re trying to identify what constitutes an effective interdisciplinary team so we can perhaps develop it more quickly, or refine it, the elements that make up a good team become incredibly complex.  The individuals themselves, the communication style, the procedures that structure their work, the roles people play within the team – all of these elements need to be understood to work out how a good team becomes more than the sum of its parts.

Humphrey, Morgeson and Mannor (2009) produced a paper outlining a theory that considers not just the individuals and the roles they play within a team, but also the composition of the roles.  Recognising that not all roles are made equal, in this paper they look at what they call ‘strategic roles’ – those roles that either encounter more problems, or are more involved in critical activities, or are in a central position in the workflow of a team.  This definition describes strategic roles according to the structure of a team rather than the performance of a team.

They then looked at a number of teams (OK, they used sports teams, but the model can apply to health teams too), and identified that it is not the individuals within a team, but the roles they fulfil in a team that make a difference to the effectiveness of a team.  Some roles are more important to the outcome than others.  They then suggest that by investing more heavily in the ‘core roles’ of a team, overall performance increases – this investment could be in terms of resources available for the people fulfilling these roles, or rewards for those individuals in this role, or time available to the people fulfilling those core roles.

Another facet to this study looked at the place of experience and skill on team performance – it matters who has experience depending on the roles that person fulfils.  This suggests that investing time, training and possibly even monetary reward for those people who fulfil important or core roles could pay dividends in terms of output or outcome of the entire team.

Interdisciplinary teams are complex beasts.  While most of us work within some sort of team, many of us don’t know what our contribution actually does within the team.  And most of us haven’t been trained in how to work effectively in teams – after all, our training has been primarily to develop our individual professional skills, rather than to recognise the strengths of a collective.  Perhaps this is an area for us to explore in more detail – and maybe managers can learn from research such as Humphrey, Morgenson & Mannor’s team roles theory, and look at how to resource team members to enhance their work.

If you’ve enjoyed this post, and want to read more, you can subscribe using the RSS feed link above.  Or you can bookmark and come back again! I post most days during the week (look out for Friday Funnies!), and love comments.  Drop me a line if you want to introduce yourself, or just leave a comment and I’ll be sure to reply.

Humphrey, S., Morgeson, F., & Mannor, M. (2009). Developing a theory of the strategic core of teams: A role composition model of team performance. Journal of Applied Psychology, 94 (1), 48-61 DOI: 10.1037/a0012997

Okifuji AA, Turk DC, Kalauokalani D. Clinical outcomes and economic evaluation of the Multidisciplinary Pain Centers. In: Block A, Kremer EE, Fernandez E, editors. Handbook of Pain Syndromes. Mahwah, NJ: Lawrence Erlbaum Publishers; 1999. pp. 77–97.

Turk DC, Okifuji A. Treatment of chronic pain patients: clinical outcomes, cost-effectiveness, and cost-benefits of multidisciplinary pain centers. Critical Reviews in Physical and Rehabilitation Medicine. 1998;10:181–208.

Pre-Christmas gratitude – 5 things I’m grateful for


In these couple of days before Christmas, it’s traditional to review some of the ‘best of’ 2008. It’s been just over a year since I started this blog, and the topic list and readership has grown a whole lot!

What am I grateful for in 2008?

  1. Teamwork – the people I work with are fantastic. You can’t work alone in pain management IMHO,  a team of like-minded people to support you both professionally and personally just can’t be beaten.  I take my hat off to the team at Burwood Pain Management Centre who keep me honest, deflate my ego (gently), cushion my falls, keep me standing and give me inspiration to keep on caring about what I do.
  2. Motivation – using motivational approaches like motivational interviewing to help people make their own choices rather than remaining ambivalent.  Whatever the choice, it’s easier to make changes once you’re moving than remain stuck.  I’m grateful for the sense of freedom that using motivational approaches has given me, and that I’ve been able to apply it in my work.  Now if only it could work with my kids?!
  3. The magic of the interweb – and so many dedicated bloggers. I find it unbelievable that there are so many people who spend time writing intelligent, interesting, provoking and inspiring posts on topics dear to my heart – and it’s all free (provided you can get on the internet).  There are so many topics to choose from, and the quality can be stunning.  I’m not a ‘Web 2.0’ kind of person, and I’m not about to rave about the wonders of interactivity, I’m simply awed at how many people spend time putting up resources so the rest of us can find them. (more…)

Why work in pain management?


I’m curious about why we work in pain management…  My reasons are that it’s one of the most complex areas in health, it uses a wide range of skills, every person I work with has a different set of concerns and coping strategies, and I do enjoy working with people of working age who communicate readily about their problems.

Although chronic pain management is very demanding on clinicians, it’s also rewarding as people develop ways of achieving fulfilment in their lives.  There is never a feeling of ‘same old, same old’ because every person is so very different.  And although sometimes the process takes a long time, the momentum is always forward and onward.

I also really appreciate the team approach – and I simply can’t say too many grateful thanks to the team I work with – fabulous people who are not only sensitive and caring with patients, they are also supportive and enthusiastic and are there for each other.

Why do you work in the field? What keeps you working in it?  Comments are always welcome!

Oh and don’t forget you can subscribe using the RSS feed (look to above left), or bookmark this site and come on back.