The growing importance of interdisciplinary teamwork in health care
The changing organization, financing, and priorities of the health care system are creating new imperatives for interdisciplinary teamwork. Well-coordinated collaboration across professions has the potential to allow comprehensive, population-based, cost-effective patient care and a new emphasis on health promotion and disease prevention, which will be essential in meeting contemporary health care challenges (Baldwin, 1994; Grant et al., 1995; Tresolini et al., 1995). The chart below summarizes the advantages of interdisciplinary team care.
Learning goals for health professions students
As students prepare for contemporary practice, development of knowledge, skills, and values related to interdisciplinary teamwork will be essential. Core learning goals related to interdisciplinary teamwork are listed below, followed in the next section by ideas for helping students achieve these goals.
1. Describe the interdisciplinary team approach to health care
An interdisciplinary team consists of practitioners from different professions who share a common patient population and common patient care goals and have responsibility for complementary tasks. The team is actively interdependent, with an established means of ongoing communication among team members and with patients and families to ensure that various aspects of patients’ health care needs are integrated and addressed.
Students should recognize that this interdisciplinary team approach is in contrast to the following approaches: (1) the disciplinary or independent medical management approach, in which a practitioner works autonomously with limited input from other practitioners; (2) the multidisciplinary care approach, which involves various health care professionals working independently--not collaboratively--and in parallel, each responsible for a different patient care need, and (3) the consultative approach, in which one practitioner retains central responsibility and consults with others as needed (Grant et al., 1995; Stritter et al., 1993).
2. Understand and appreciate the professional roles of team members
Health professions education remains largely segregated by profession. Students have few opportunities to learn about or with students in other professions. Learning to understand the roles and responsibilities of other professionals is necessary to function effectively on a team. While training and legal scopes of practice largely determine team members’ roles, the skills of various primary care practitioners overlap to some extent. Several professionals, for example, have expertise in patient interaction, developing care plans, and educating patients. Consequently, division of tasks among team members may be based more on individual patient problems and needs than on traditional role definitions. In practice settings with fewer resources and a limited number of professionals, additional blurring of traditional distinctions may occur (Grant et al., 1995).
Some key professionals whose roles and practice traditions students should understand include (but are not limited to) the following: nurses (including registered nurses, nurse practitioners, and certified nurse-midwives), physicians (generalist and subspecialist), physician assistants, pharmacists, social workers, dietitians, physical therapists, occupational therapists, speech/language pathologists, psychologists, and dentists. In addition, students need to learn about the essential roles of those who manage the context of patient care: office managers, practice administrators, receptionists, medical record workers, health plan employees, and others.
3. Identify the tasks and activities of the interdisciplinary team
Students should learn about three essential, overlapping tasks of the team--coordination, communication, and shared responsibility (Fink, 1993). The first step in coordination is to determine which team members will be responsible for a particular patient problem. Because the focus of the team should be on the needs of the patient, patient care goals determine the composition of the team or team subset that will be responsible for a particular patient problem. Students should recognize, however, that the patient and the patient’s family always are central members of the team.
Because team care involves interactions separated by space and time, individual team members’ efforts must be organized so that that are completed in a coordinated and logical way. Effective communication is needed to facilitate coordinated care. An ideal communication system would include a well-designed record system, regularly scheduled meetings to discuss patient care issues, and a mechanism for communicating with external systems (Grant et al., 1995).
The task of sharing responsibility raises issues related to leadership and decision-making. Although, historically, physicians have been the leaders and primary decision-makers in health care--in large measure because of their legal responsibility for patient care decisions as well as their possession of extensive education and training--both leadership and decision-making now are often shared. In many primary care settings, the nature of the patient care problem determines who will take on the leadership role and how decision-making will be shared.
Students should also learn about the activities of a team as it goes about accomplishing its tasks. Typically, a team will complete the following activities sequentially:
• define the problem and decide on goals,
• gather information about the problem,
• seek opinions about the problem from appropriate team members,
• discuss and expand the problem, each contributing his or her own unique professional perspective,
• develop potential solutions or management plans,
• offer opinions about each potential solution,
• evaluate potential solutions and choose the best one or integrate several into one,
• summarize the plan and agree on distribution of tasks across team members.
4. Participate in collaboration and conflict management
Joint deliberation by team members who have different perspectives and areas of expertise often results in insights and solutions to problems that seldom can be achieved by one health professional working in isolation (Westberg and Jason, 1993). Students should become aware that because of the professional diversity present on the team, differences of opinion and conflict are not only inevitable but are in fact necessary and desirable. Conflict may encourage innovation and creative problem-solving, and successful resolution of differences may foster increased trust and understanding among team members. Failure to deal effectively with conflict, however, may lead to low morale, withdrawal, condescension, anger, and burn-out (Grant et al., 1995).
The foundation for effective collaboration and conflict resolution comprises a belief in and a continual search for win-win solutions while keeping in mind the foremost goal of solving or managing patient problems (Grant et al., 1995). Strategies that team members may use to maintain group collaboration and resolve conflicts and that students should practice include the following:
• set standards for accomplishing tasks and identify norms for team behavior,
• keep the door open for less talkative members and encourage each to contribute,
• seek harmony when conflict occurs by listening carefully and respectfully to all opinions, brainstorming possible solutions and focusing on common interests,
• seek consensus in arriving at the best decision,
• give and receive feedback about positive and/or negative behavior,
• review and evaluate progress at conclusion of interaction.
5. Participate in the maintenance of cross-professional teamwork
Finally, another learning objective for students is to learn how to participate in the ongoing evaluation of the team’s functioning. Following are questions that team members may ask themselves to assist them in reflecting on how well the team is functioning:
• What is the team’s mission? How is it interdisciplinary? How does it relate to its larger organization?
• Who is the team’s leader at any given time? Is leadership the same or does it change? How is leadership determined? How is it shared?
• What are the roles and qualifications of team members? How does each profession contribute to the team’s task?
• What is the climate for the team’s functioning? Is it constructive and open?
• How are specific objectives generated and agreed upon for each task?
• What are the team’s communication patterns?
• How does the team make decisions?
• How does the team review and evaluate its progress and decisions?
A teaching framework and strategies for precepting
A major goal in teaching about health care teamwork is to help students progress from a disciplinary through a multidisciplinary to an interdisciplinary approach to community-based primary care. This can be accomplished by structuring the preceptorship experience to allow the following sequence of activities:
Provide students experience on a team, both observing diverse professionals as they collaborate and collaborating with those professionals and other students themselves.
Guide students in reflecting on that experience by asking them about their thoughts on what they observed and any questions they may have about the collaboration they witnessed and/or experienced.
Ask students to generalize and describe how their observations or experiences fit into previous knowledge about teams. What specific examples represent principles of teamwork? Is there anything new or unexplained that can add to previous understandings about teamwork?
Give students new team experiences through which to try out new understandings.
Five principles of interdisciplinary precepting
The following five principles can help to systematize the learning of interdisciplinary teamwork further:
1. Orient the learner to the team and negotiate expectations for teamwork. One way to orient the student to the office-based team is to have the student become a "patient," assigning the student a chief complaint that requires contacts with representative professional and office staff, e.g., receptionist, nurse practitioner, physician, x-ray technician, laboratory technician, pharmacist, social worker, etc. (DaRosa et al., 1997).
2. Model collaborative professional practice. Effective role-modeling requires that preceptors articulate their own roles and responsibilities as team members, as well as their reflections on those roles and responsibilities and on the experience of participating as a team member with a diverse group of health care professionals.
3. Create and facilitate opportunities for the student to participate on the team, and assign team responsibilities to the student. These opportunities and responsibilities may include observation and/or participation.
4. Observe the student’s performance as a team member and provide feedback often on this performance. Help the student reflect by debriefing and discussing interdisciplinary teamwork issues.
5. Evaluate the learner’s performance on the team. At the end of the preceptorship, help the student summarize what has been learned about teamwork.
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DaRosa DA, Dunnington GL, Stearns J, Ferenchick G, Bowen JL, Simpson DE. Ambulatory teaching "lite": less clinic time, more fulfilling. Acad Med 1997;72:358-361.
Grant RW, Finocchio LJ, California Primary Care Consortium Subcommittee on Interdisciplinary Collaboration. Interdisciplinary collaborative teams in primary care: a model curriculum and resource guide. San Francisco, California: Pew Health Professions Commission, 1995.
Schmitt MK, Heinemann GD, Farrell MP. Discipline differences in attitudes toward interdisciplinary teams, perceptions of the process of teamwork, and stress levels in geriatric health care teams. In Snyder JR(ed.). Interdisciplinary Health Care Teams: Proceedings of the 16th Annual Conference. Chicago: School of Allied Health Sciences, Indiana University School of Medicine, Indiana University Medical Center.
Stritter FT. Education for interdisciplinary rural health care: program directors’ manual. Rockville, Maryland: Health Resources and Services Administration, Contract #240-92-0030, 1993.
Tresolini CP, Pew Health Professions Commission Advisory Panel on Health Professions Education for Managed Care. Health professions education and managed care: challenges and necessary responses. San Francisco, CA: Pew Health Professions Commission, 1995.
Westberg J, Jason H. Collaborative clinical education: the foundation of effective health care. New York: Springer-Verlag, 1993.Baldwin DC. The role of interdisciplinary education and teamwork in primary care and health care reform. Rockville, Maryland: Health Resources and Services Administration, Bureau of Health Professions, 1994.
Westberg J, Jason H. Collaborative clinical education: the foundation of effective health care. New York: Springer-Verlag, 1993.