Inter-professional practice in health care

David Patrick Ryan, Ph.D.

Director of Education & Knowledge Processes, Regional Geriatric Director of Education & Knowledge Processes, Regional Geriatric Program of TorontoProgram of Toronto

Assistant Professor, Faculty of Medicine, University of TorontoAssistant Professor, Faculty of Medicine, University of Toronto

What is an interprofessional team?

• People from several professions • Each trained to use different tools and concepts• Whose labor organized around a common problem• With continuous communication and frequent reflection

on both the groups work and its process• Usually with group responsibility for the final product

Interest in Teamwork Ebbs and Flows (Ryan 1996)

From moral treatment to mental hospitals

The medical model and the orthopsychiatric trinity

The Trinity won the right to treat

Sociotherapy and broadening of the mental health team

Community Mental Health and sociotherapy’s democracy

Hospitals emptied and community mental health funding dwindled

DRG’s managed care and mental health fragmentation

Integrated care and inter-team collaboration

# of Articles

Decades

Patient safety is linked to the quality of collaboration

56

16

23

8

5

11

50

0

5

10

15

20

25+

30s 40s 50s 60s 70s 80s 90s 00s

Estimate 2000-2010

Teamwork Articles in the Journal of Orthopsychiatry by Decade Since the Journal Began in 1930

Chronic Disease and FrailtyPatient SafetySuccess of Quality Improvement The Quality of Working LifeLocal Health Integration Networks HealthForce Ontario’s Inter-Professional Care Blueprint for Action Primary Care and Family Health Teams

Why Interprofessional Practice? Why Now?

Province-Wide investment in Inter-Professional Education

Inter-professional Mentoring

Inter-professional Coaching

Inter-professional Preceptorships

Inter-professional prevention of delirium in the ED

Impact inter-professional practice within primary care groups

Inter-Professional Practice and Hospital/LTC accreditation

The Journal of Inter-Professional Care

GiiC – the geriatrics, inter-professional practice & inter-organizational collaboration initiative for family health teams and community health centers

Current Initiatives in Interprofessional Care

Barriers to interprofessional teamwork: practice based issues

• There is a lack of preparation for interdisciplinary hostility . . . If the practice of this specialized form of aggression is to be placed on a higher level, at least as high as professional wrestling…the subtle arts of patronage, insult and innuendo must be taught. Brody & Weithorn, 1965

• Unrealistic expectations, lack of knowledge and perceived threats to autonomy Fried & Leatt, 1986

• Professional jealousies and role boundary issues Strasser et al 1994

• We practice together but we train apart

Barriers to teamwork: professions think differently (from Qualls and Czirr, 1988)

Logic of assessment: from ruling out to ruling in

Focus of efforts: from acute episodes to quality of life

Locus of Responsibility: from executive to collaborative

Pace of Action

Focus of attention: from task to process

Interprofessional stereotypes

Decision making expectations: from executive to consensus

Beliefs about professional independence: from autonomy to interdependence

Barriers to teamwork: Though we practice together until recently we trained apart (from Cleary & Howell, 2003)

A framework for examining teamwork

DecisionsAuthorityAccount-

bility

Roles &Inter-

dependence

Communication&

ConflictManagement

Team Member Skills &

Strengths

Clarity/Coherence

of Goals

PerceivedSupport fromOrganization

THE DIMENSIONS OF TEAMWORK

OU

TC

OM

ES

OF

T

EA

MW

OR

K

CustomerNeeds &Interteam

Issues

CustomerFocused

Outcomes

InternalFocused

Outcomes

FinancialFocused

Outcomes

InnovationFocused Outcomes

Ad hoc Inter-agency Shared Care Teams

Acute Care Teams

Continuing care and Rehabilitation teams

Specialized Geriatric Services Teams

Management Teams

TYPES OF TEAMS

Primary Care Teams

History of Teamwork in Health Care The Original Team - Romantic Era (circa 1900)

General Practitioner

History of Teamwork in Health Care Classic Sequential Teamwork and the Specialist Era

(circa 1920)

Specialist Specialist

Nurse Nurse

History of Teamwork in Health Care Sequential Multi-Professional Practice Teams

(circa 1930)

Specialist

Nurse

PsychologySocialWork

Rehab

History of Teamwork in Health Care Dynamic Multi-Professional Team (circa 1960)

from a cadre of professionals

Physician

Nutrition

Psychology

Physio

Nurse Social Work

SLP

OT

Pharmacy

Dentist Recreation

History of Teamwork in Health Care Dynamic Multi-Professional Team (circa 1960)

a team is convened around the needs of a particular patient

Physician

Social WorkNurse

Psychology

OT

SLP

History of Teamwork in Health Care Dynamic Inter-Professional Team (circa 1985)

from a cadre of professionals

Physician

Nutrition

Psychology

Physio

Nurse Social Work

SLP

OT

Pharmacy

Dentist Recreation

History of Teamwork in Health Care Dynamic Inter-Professional Team (circa 1985)

A team is convened around the needs of a particular patient

Core skillsCore skills

Core Skills

Core skills

Social Work

Physician

Pharmacy

Nurse

Multiprofessional Interprofessional

• Independent practice• Guided by professional

standards• Professions report to

depts.• Leadership by rank or

profession• Rigid role boundaries• Conflict attributed to

individuals• Little attention to team

process

• Interdependent practice• guided by professional &

team standards• Discussion &

collaboration• Leadership by skill or

primary issue• Flexible role boundaries• Conflict is a team

responsibility• Routine attention to team

process issues

Myths about Teamwork

• There are no leaders on teams; everyone is equal• If we just work together, we will eventually become a

high performance team• Everyone is accountable for everything on teams• Teams take a long time to get up and running• All team decisions must be made by consensus• Conflict must be worked out for a team to be productive• On the best teams, everyone likes everyone else• The most important work takes place in team meetings• Confrontation means conflict

Just putting people together to work in teams doesn’t

necessarily produce effective interprofessional teamwork

Some of the things a team can do to maximize performance

Develop expertise to facilitate interprofessional practice

Annually monitor and reflect on team culture

Balance attention to task and process functions

Develop clear goals and monitor outcomes

Understand the dynamic nature of team development

Recruit or develop the right mix of skills

Value professional and personal diversity

The Dimensions of Teamwork Annual Survey

• Customer and inter-team issues

• Team member strengths and skills

• Communication and conflict management

• Roles and interdependence

• Clarity of team goals

• Decision-making and leadership

• Perceived organizational support

Quarterly review of informal team role performance

Task Roles

Initiating/energizing

Information/opinion giving

Information seeking

Reality Testing

Coordinating

Orienting

Technician

Maintenance Roles

Harmonizing

Gate keeping

Encouraging

Following

Acclimatizing

Individual roles

Blocking/aggression

Out of field

Digressing

Recognition seeking

Stage LeaderBehaviour and Informal Style

Team MemberBehaviour andInformal Roles

Emotional Climate and Team

Ritual

The Teams Style of Humour

Stage 1: Forming

The leader seeks tocontrol and direct

Dependency seekingcharacterizes teammember behaviour.

Refreshments reduce anxiety

Leaders joke to soften control Member joke about the team and about patients

Stage 2: Storming

The leader tries to convince the team.

Team members resist.

Scapegoating is evident Clowning reduces

tension

Conflict emerge often in response to minor issues which take on broader symbolic meanings.

Humour is often barbed and personal, interspersed with the clowns buffoonery.

Stage 3: Norming

Leadership exercised by coalitions of members based on Perceptions of competence

Members are colleagues who are able to defer to a each other’s relevant experience.

Members provide mutual support . Parties express solidarity. Team symbols emerge

Sharing of team deprecating humor. Self-disparaging jokes. In-jokes emphasize membership

Stage 4: Performing

Authority exercised by a coalitions depending on skills and emergent needs

Members find opportunities for interdependence and resist earlier activities such as scapegoat and clowning

Members have pride in the teams accomplishments. Team meetings become constructive and enjoyable. Team legends emerge and team anniversaries celebrated.

The team laughs at itself but explains its in-jokes to new or non-members. It enjoys it's own funny stories and myths. Humour typically at the expense of the team but without loss of task orientation.

Routinely reflect on the stage of team development

Value one another's diverse personal styles

I stay cool, calm and collected and tend to keep my thoughts and feelings to myself

I get pretty excited and energetic and tend to let my thoughts and feelings show

C 4 3 2 1 0 1 2 3 4 E

I get into new things quickly, make up my mind fast and hate to wait.

When new things come I prefer to wait, watch, ask questions and hear all sides before reacting

J 4 3 2 1 0 1 2 3 4 S

Use the ratings to plot your place on the “So Simple” grid. The results can be amusing even insightful. Remember we are not rating whether someone is good or bad. We are trying to better understand difference.

C 4 3 2 1 0 1 2 3 4 E

J4

3

2

1

1

2

3

4

S

DRIVERS prefer to move ahead calmly, watching results, staying organized and asking “what’s next”

ENTHUSIASTS like to jump into new things, sets everyone on fire by “just doing it” and asking “Why not?”.

ANALYSTS like to hear the details, see facts and figures and asks “How is this going to work?”

HARMONISTS like to give everyone the opportunity to express themselves and their opinions often asking “how is everyone feeling?”

Stay cool calm and collected

Let feelings and emotions show

React quickly and hate to wait

Wait, watch, hear all sides

Value one another's diverse personal styles

To summarize

It has taken us more than 100 years to get to this point of recognizing interprofessional interdependence

The provincial interprofessional care blueprint is removing barriers

Frailty and chronic disease demand high quality interprofessional practice

Effective teamwork doesn’t just happen it needs ongoing care and tending

Teamwork can enhanced by a few strategic interventions

GiiC provide family health teams and community health centres with several useful tools

GiiC has embedded interprofessional thinking within each geriatric topic

GiiC provides a consultant to help you to facilitate your team