MULTIDISCIPLINARY CDM

The term multidisciplinary CDM refers to the process in which individuals from different healthcare disciplines collaborate to diagnose problems and manage patients’ care. In this chapter, collaboration is understood to be the cooperative act of working with one another. Multidisciplinary CDM is collaborative in nature; however, we use the term multidisciplinary here to distinguish this process from collaborative decision making (as discussed in Chapter 4), where the focus is on direct collaboration between one or more practitioners and a patient and where the goal is to engage in participative decision making with the patient. The context of collaborative decision making is emancipatory practice. In multidisciplinary CDM, the patient may or may not be seen as a team member and the practice model may vary from biomedical to biopsychosocial to emancipatory approaches; the focus of multidisciplinary CDM is on collaboration among practitioners to make decisions that build on their various disciplinary strengths and expertise.

Multidisciplinary CDM is a complex process in which many factors must be coordinated, including the different skills and experience of a number of health professionals, in order to address the complexity of patients’ problems and organizational contexts. For example, an established team of experienced health professionals, with a clear understanding of disciplinary roles, responsibilities and communication styles, can plan and coordinate the clinical management of an uncomplicated patient condition with ease and familiarity, perhaps initially via a team meeting followed up by informal discussions and emails. Such collaboration may appear deceptively straightforward. However, even apparently straightforward collaboration for multidisciplinary CDM relies extensively on the participating health professionals’ prior experience of practice and collaboration, together with knowledge of self, other disciplines in the team, individuals in the team, team procedures and context. Collaborative processes may be more challenging when collaborating individuals are dealing with complex patient situations or are establishing their understanding of their discipline, self, others, team and context, or when the focus of the multidisciplinary CDM involves areas of conflict or territorial issues. In these situations, multidisciplinary CDM may require skilled communication and negotiation.

PROVISION OF HEALTH SERVICES BY TEAMS

With the increasing specialization of health professions, job transferability and demand for coordination of healthcare services, health professionals may be required during their career to collaborate in a range of different types of teams in different organizational contexts. Multidisciplinary CDM commonly occurs in the context of healthcare teams. Teams of health professionals from different disciplines work in various contexts to provide a range of health service functions. A team is considered here in its broadest sense to be a collective of health professionals regularly collaborating for patient care. Accordingly, teams can take on different structures, memberships and modes of operation, such as:

ORGANIZATIONAL SYSTEMS AND PROCESSES THAT SUPPORT SHARING OF INFORMATION

Multidisciplinary CDM requires effective use of available communication processes and procedures. Sharing of information between collaborating health professionals is a basic requirement of multidisciplinary CDM. The means by which information is formally and informally shared within an organization may depend on available resources, employer and employee preferences, and ethical and legal obligations. For example, assessments, diagnostic reports, progress reports, discharge reports and referrals are different formal written systems that fulfil the dual purpose of information sharing and organization or discipline accountability (McAllister et al 2005). Case conferences and team meetings are formal processes for verbal information sharing, and facilitate face-to-face concurrent multidisciplinary CDM.

Informal communication systems are also used to share information and build relationships between disciplines; these include phone, email, shared work spaces and opportunities for socializing. For example, Cook et al (2001) reported that geographical proximity of a shared open-plan office enhanced timely sharing of information between members of a community health team, and Ellingson (2003) highlighted the importance of ‘backstage communication’ in building collegial relationships in a geriatric oncology team. Informal communication systems also provide a more flexible means of communication than formal case conferences and can facilitate micro-negotiations between team members (Ellingson 2003). There can also be a purposefully opportunistic element in informal communications systems, as evidenced by a rehabilitation team member’s comment: ‘I guess in terms of interaction with the other team members it would be more be bumping into each other and having a quick chat about things.’ (AC)

Team structures within organizations

Underpinning multidisciplinary CDM is a range of factors supporting communication which need to be understood and mastered. One of these is the structure of the team itself. Structures are commonly either distributed (e.g. horizontal) or hierarchical. The decision-making power within a team is more evenly spread when the team’s structure is horizontal and supportive of egalitarian, cooperative teamwork compared with a hierarchical structure with bureaucratic channels of decision making controlled by higher status professionals (Cook et al 2001, Cott 1998). A rehabilitation doctor described decision making at a team meeting as follows, providing an example of shared control for team decision making: ‘We all have an understanding of what everyone else’s thoughts and approach are to a patient, and what our individual goals are, so that we can all sit down and work out together what our overall goals are, to incorporate that together as a joint approach, and get the best outcome for a patient.’ (AC)

Acute care hospital teams tend to work within a more task-oriented hierarchical structure in which the primary CDM control is commonly held by medical staff. Research into collaborative decision making in acute care situations has predominantly focused on intensive care situations. For example, Baggs & Schmitt (1997, p. 76) reported that medical residents in an acute medical intensive care unit saw themselves as the primary decision makers, one saying: ‘The ultimate responsibility, legally and, you know, emotionally lies with the house officer’. Other researchers have reported low levels of collaboration between nurses and physicians, with collaboration tending to be the exception rather than the dominant practice, and with nurses providing input into physicians’ decisions rather than collaborating in the decision-making process (Chaboyer & Patterson 2001, Higgins 1999, Kennard et al 1996, Thomas et al 2003).

Low levels of collaboration for decision making can also be found in rehabilitation teams. In Anne’s study a rehabilitation specialist reported, ‘I can remember distinctly, when I was an intern, the consultant telling the therapists exactly what was going to happen.’ However, his experience in another team was different: ‘the therapists ran the whole [meeting], the consultant gave advice when requested’, and he subsequently preferred ‘the unobtrusive approach, the consultant that sits there and is willing to listen more than talk’. (AC)

Power differences between professions within a hierarchical structure have been identified as contributing to low levels of collaboration between medical and nursing staff, and medical and social work staff in acute care settings (Abramson & Mizahi 2003, Baggs & Schmitt 1997). However, such power differences are not necessarily consistent across professions. Abramson & Mizahi found that, although not the dominant pattern, some physicians in metropolitan hospitals did share responsibility and decision making with other professional groups. An awareness of power differences within a team and the implications of these differences for decision making, enables team members to understand their ‘allocated’ role in multidisciplinary CDM, and may provide the basis for negotiation of decision-making roles within the team.

Team supervision or management can influence decision making in teams (Hyrkas & Appelqvist-Schidlechner 2003). There does not appear to be one ideal team management structure for enhancing decision making for all teams. For example, Cook et al (2001) noted that community primary health teams demonstrated an evenness of power distribution in decision making when the teams moved from a nurse manager model to a self-managed model. In contrast, Hyrkas & Appelqvist-Schidlechner found that some health professionals perceived an improvement of joint decision making following the introduction of team supervision. There is no guarantee that an egalitarian approach to teamwork will result in shared leadership and decision making; it could result in chaos, ineffectual decision making and disorder as people jockey for power or sit back and provide no leadership input. Improving collaboration in multidisciplinary CDM may require a review of team management in relation to the model of team management used, the context of the team and the power relationship between team members.

Some healthcare teams rely on clinical practice guidelines to standardize decision-making points and thus decrease the need for collaborative decision making. Grumbach & Bodenheimer (2004) claimed that a single specialty primary care practice with clear role delineation and clear divisions of labour can minimize the collaborative component of multidisciplinary CDM by ensuring that team members have defined tasks, task training, systems to support practice tasks, effective communication, on-the-job team training and time for team training. They reported that in this context, cohesive primary care teams could be formed where ‘team members do not attend endless team meetings’ (p. 1248). However, for many healthcare teams the diversity of clinical situations and patient needs precludes such a task-oriented structure, and regular team meetings provide a welcome and positive avenue for the dialogue required for collaborative multidisciplinary CDM.

ORGANIZATIONAL AND DEPARTMENTAL BOUNDARIES

Some teams are composed of members from separate organizations or departments. Straddling organizational and departmental boundaries adds another challenge to multidisciplinary CDM, as team members may be required to deal with different models of care and different organizational or departmental cultures and processes (Boaden & Leaviss 2000). For example, the work rehabilitation centre team described by Lingard et al (2004) faced inter-organizational challenges when collaborating with external stakeholders. Obstacles identified included lack of understanding of patients’ programmes and decisions being made without consulting the team. Conversely, the community mental health teams studied by Carpenter et al (2003) placed more value on shared responsibilities between mental and health services when those services were integrated. An understanding of obstacles to inter-organizational or interdepartmental collaboration provides a basis for team members to develop strategies to straddle or minimize organizational boundaries. Thus we see that multidisciplinary CDM can also include multisectoral decision making on organizational matters and also on matters that directly relate to patient care.

DISCIPLINE DIFFERENCES

Achieving an understanding of the roles of different disciplines is an important precursor to decision making in teams. The socialization process involved in preparing to enter a particular profession means that each new member tends to adopt the views and identity of their professional culture. Members of each discipline have ‘common experiences, values, approaches to problem solving and language for professional tools’ (Hall 2005, p. 190), as well as ‘distinct models of care, different skills sets … and diverse political agendas’ (Lingard et al 2004, p. 407). With different disciplines perceiving issues differently, teams can view issues from a wider perspective than is achieved by one discipline alone (Cook et al 2001). However, health professional cultures can also act as barriers to collaboration; members of different professions use different jargon, have different priorities and meanings for tasks and events, and have different expectations of their roles in patient care. For example, Abramson & Mizahi (1996) found that social workers tended to seek a higher degree of shared responsibility and mutuality with interdisciplinary care than was sought by physicians.

The extent to which discipline differences inhibit collaboration can be minimized by clarifying and negotiating disciplines’ and team members’ roles. However, such negotiations may require confidence, assertiveness and an openness to the views of others, as evidenced by comments from rehabilitation team members in Anne’s study:

An example of successful collaboration was demonstrated in Stephen’s research by an experienced multidisciplinary pain team with a well-established routine for coordinating their assessment findings (Loftus 2006). In this team, separate assessments of new patients by the doctor, physiotherapist and psychologist were followed by a case conference. The format of the case conference required the findings of the hour long assessment to be reduced to a 1 or 2 minute summary. In addition, to avoid needless repetition of findings and to ensure key points were emphasized, the physiotherapist and psychologist were required to dynamically alter their summaries as they listened to their predecessors’ summaries. At a deeper level the team members were also coordinating different perspectives of patient care into the CDM process. The doctors tended to adopt a pathophysiological paradigm of health care, looking for identifiable pathology that could be definitively treated. The other health professionals tended to adopt a more functional paradigm, identifying disability and ways of improving function. The team members recognized that the two paradigms were superficially opposed to each other. However, in practice the multidisciplinary approach allowed the two paradigms to be dialectically combined, bringing their strengths together.

WORKING IN TEAMS

Organization theory and management practice, when considered in the context of patient care, can provide frameworks for understanding and developing teams in health care (Shortell & Kalunzy 1994). The stages of ‘forming, storming, norming and performing’ (Tuckman 1965, Tuckman & Jensen 1977) are frequently used to describe team development. When groups of undergraduates used these stages as a basis for developing multidisciplinary teams to implement a health-related community action project, they reported improved skills in conflict resolution, collective decision making, action implementation and respect for individual team members, as well as improved understanding of the function of other disciplines (Hope et al 2005). However, in clinical practice not all healthcare teams have sufficiently stable membership to allow progression through the stages of team development. Rather, a team may be described as ‘a complex and fluid entity composed of core and expanded groups’ (Lingard et al 2004, p. 404). Teams may have to continually adapt to changes of membership. In some of the rehabilitation teams in Anne’s project the staff continually rotated: ‘We’ve had OTs come and go, physios come and go, they do their stint and then they move on’ (AC). As well as impacting on team development, constant staff changes also disrupt the continuity of the collaborative relationships underpinning multidisciplinary CDM, as described by a physiotherapist in a rehabilitation team: ‘I was negotiating to find out what they had on their mind, because I’m happy to work with [new] people but it gets a bit tiring when you’ve just got to do that over and over and over and over’ (AC). It can be argued that the multidisciplinary pain team in Stephen’s study could attribute a large part of its success to the stability of its core membership.

Lingard et al (2004) contended that for individuals to function as a collaborative team they each need to understand the ‘rules of the game’, which involves negotiating ownership of roles and ‘trading’ of equipment, resources, knowledge and goodwill. These authors contended that the aim of this negotiation should not necessarily be to overcome tensions, but rather to acknowledge and articulate these tensions in an effort to ‘sustain the delicate balance between achieving a shared goal and competing for agency and status in the interprofessional setting’ (Lingard et al 2004, p. 407). In Anne’s project an awareness of role tension was expressed by an occupational therapist in reflecting on how a new team member was going to fit in with the team: ‘Is she going to tread on our toes?’ (AC). Having an awareness of the ‘rules of the game’ and being able to negotiate role ownership and boundaries are important precursors of multidisciplinary CDM.

An awareness of appropriate styles of interaction between team members provides a good basis for negotiation of team roles and resources. Team members’ personal characteristics may influence team dynamics via preferred communication styles. McKinnon (1998) provided a classification system, proposing that team members can be: (a) introverts, preferring written communication to talking, and needing time to consider issues; (b) extroverts, making instant decisions and being energized by being with other people; (c) ‘feeling’ people, valuing harmony and considering the implications on others in decision-making; and (d) thinking–logical people, using logic as a basis for decision making and being unaware of the emotional issues surrounding decisions. Although it is a simplistic representation of complex individual situations and interpersonal relationships, McKinnon’s classification provides a basis for developing appropriate styles of interaction between individual team members during role negotiation and for the process of multidisciplinary CDM.

COMMUNICATION AND INTERRELATIONAL SKILLS

Communication in teams has a dual role of sharing of information and building working relationships (Wicke et al 2004). To facilitate adequate sharing of information for multidisciplinary CDM, health professionals need to write clearly, succinctly, informatively and in a timely manner (McAllister et al 2005) and to be competent in the generic communication skills of listening, questioning, clarifying and explaining for verbal interactions. A rehabilitation team speech therapist highlighted the need for communication skills in collaborative relationships: ‘You have to be able to listen effectively, and I guess with the consideration [that] your views might differ to other people’s, but understanding where they’re coming from, you need good communication skills to be able to express your views and your goals, and how you’re feeling about certain issues.’ (AC)

When performed sensitively, the dialogue between health professionals working in multidisciplinary CDM can produce a rich and multidimensional picture of a patient that is both a thorough assessment and paves the way to humane and comprehensive management (Loftus 2006).