Collaboration and Conflict in Interdisciplinary Teams

One chilly December day about 12 years into my career as a prosthetist, I received a call from a physical therapist who was working with a patient who needed a transfemoral prosthesis. For financial reasons the prosthesis had to be delivered before the last day of the year. The practice to which the therapist usually referred patients was not able to accommodate the request, and since our facility did not regularly receive referrals from her, I was determined to do whatever could be done to provide the prosthesis in an expedited fashion. Not only would the patient receive what he needed, but this was an opportunity to demonstrate the level of service our facility offered. I assured the therapist that we could provide the prosthesis by the deadline, provided the patient was available for repeated appointments, we received the necessary paperwork from the physician's office, and approval from the insurance company could be obtained within the short time frame. The therapist requested that I come to the next therapy appointment so that we could perform the initial evaluation together. I explained that while I would normally be happy to do so, I would need to see the patient sooner than the next therapy appointment since we had only about ten days to complete all of the administrative, clinical, and technical work necessary to provide the prosthesis. I asked her to have the patient contact me directly to arrange an appointment for an evaluation as soon as possible. The therapist responded that she needed to be part of the initial evaluation to select the proper components. Surprised by this, I explained that I considered component selection part of my responsibility and assured her that I would contact her after my initial evaluation to discuss the patient's strength, function, and rehabilitation before making any recommendations to the ordering physician. After she again insisted that component and design decisions were her responsibility, I asked if she was familiar with components options and any specific recommendations. She requested that I bring supplier catalogs with me to the next therapy appointment, so she could select the proper components. When further discussion made it clear that a mutually satisfactory resolution was unlikely, I reiterated the terms under which I could accommodate the short time frame, asked her to have the patient contact me, and ended the discussion. We never heard from the patient or the therapist. I've described this exchange because the experience was significant for a number of reasons. First, it is one of only two occasions that I can recall in over twenty years of working with therapists when the encounter went so poorly that it was not possible to proceed with providing care. Second, in the dozen years before or since that exchange, I have never heard another allied health professional articulate a view of our respective professional responsibilities that I considered this dismissive and disrespectful. Third, this story serves as an interesting backdrop for a discussion of collaboration and conflict in interprofessional teams. This article applies principles found in published reports on collaboration and teamwork in interdisciplinary teams to this scenario and explores how specific strategies could have been used to handle the conflict differently. Complexity Requires Teamwork In an article published earlier this year in the journal American Psychologist , a group of researchers reviewed relevant articles published between 2000 and 2017 to "synthesize the evidence examining teams and teamwork in healthcare delivery settings in order to characterize the current state of the science…." 1 The authors begin by pointing out the need to coordinate care effectively to reduce medical errors. Communication failures are a common cause of errors, and transitions of care in acute settings are "high risk interactions in which critical information about a patient's status and plan of care can be miscommunicated." 1 Adding to the problem, in many organizations division of labor is emphasized more than coordination and integration. The complexity of medical care requires that providers specialize in specific aspects of care and rely on providers with differing expertise to provide the optimal treatment for each patient. Since "no one individual can assure a patient receives the highest standard of care, nor can he or she protect the patient from all potential harms," this collaboration is a critical part of avoiding errors and optimizing outcomes.1 Given the high rate of errors in medical care, the authors state that "ineffective care coordination and the underlying suboptimal teamwork processes are a public health issue…. The coordination and delivery of safe, high-quality care demands reliable teamwork and collaboration within, as well as across, organizational, disciplinary, technical, and cultural boundaries." 1 The majority of research on how healthcare teams function is focused on "acute care settings and tightly coupled collocated action teams" such as those found in surgery, trauma, emergency, and critical care contexts. 1 Care provided in a rehabilitation setting, on the other hand, involves "managing independent work over longer periods of time in looser team structures…" with more episodic consultations by a variety of clinicians. 1 "Communication across specialties is often informal, unstandardized, and fragmented." 1 The research differentiates teamwork from task work, both of which are required by members "to fully contribute to team outcomes." 1 Research on teamwork in acute care settings demonstrates the importance of "adaptability, implicit and explicit coordination, shared leadership, and conflict resolution" in these dynamic environments. While all of the conclusions based on teamwork in acute care settings may not apply directly to rehabilitation, there are principles that are likely to translate across care environments. The patients we see in O&P practice often have chronic health conditions that complicate their care. According to Rosen et al., "Patients with the greatest number of chronic conditions see 14 different physicians and fill 50 prescriptions, on average, per year…." Providing rehabilitative O&P care to these patients often requires effective interactions with multiple medical providers without the benefits of a close working relationship within one institution or work setting. Defining and Training Teamwork Skills Research on teamwork in medical practice distinguishes between technical competencies that involve clinical procedures and skills and nontechnical competencies that include social and cognitive skills. 1 Nontechnical knowledge, skills, and attitudes necessary for effective care include "intentional listening, translation of information coming from disciplines with highly specialized languages," and "speaking up deliberately in contexts in which psychological safety may be low and hierarchical norms strong." 1 Defining and training these skills can be challenging, but effective strategies exist for developing and improving them. One example of a training resource is the TeamSTEPPS program, which was developed by the federal Agency for Healthcare Research and Quality to be "an evidence-based teamwork system to improve communication and teamwork skills among healthcare professionals…." 2 In 2015, this training had been completed by more than 1.5 million healthcare workers. 1 The program focuses on four skills: communication, leadership, situation monitoring, and mutual support. 2 The TeamSTEPPS Pocket Guide app includes information on the basic framework, competencies, key principles, and specific tools that can be used to improve teamwork. 2 (Author's note: The free app is available in the Apple App and Google Play Stores. Visit www.ahrq.gov/teamstepps/instructor/essentials/pocketguideapp.html for quick links to the app.) While the primary focus of this effort is on improving patient safety and the tools are most applicable to teams working in acute, episodic care contexts, they can be adapted for use in other healthcare settings. For example, the SBAR (situation, background, assessment, and recommendation) communication tool described in "Improving Interprofessional Communication" (The O&P EDGE, October 2018) is available in the Pocket Guide. Conflict and Collaboration A 2015 article addressing how power disparity contributes to nurse-physician conflicts in intensive care units concluded that "for true collaboration to occur, all disciplines within the healthcare team must be considered equal partners but with different roles and knowledge." 3 McInnes et al. published an integrative review with the aim of identifying facilitators and barriers to collaboration and teamwork between physicians and nurses in general [family] practice. "Thematic analysis revealed three themes common to the facilitators of and barriers to collaboration and teamwork between GPs in general practice: (1) roles and responsibilities; (2) respect, trust, and communication; and (3) hierarchy, education, and liability." 4 These researchers found that "respect and trust were overwhelmingly represented as facilitating collaboration" and that "confidence in professional competence underpinned trust and respect. Furthermore, in the context of gaining respect for professional competence, trust had to be earned and developed…." 4 [caption id="attachment_184567" align="alignright" width="250"] The three above images from The Pocket Guide are used with permission of the Agency of Healthcare Research and Quality.[/caption] Another group of researchers published the results of "an ethnographic study of interprofessional collaboration in a rehabilitation unit" in the Archives of Physical Medicine and Rehabilitation in 2009. 5 The research involved 40 hours of direct observation on a spinal cord rehabilitation unit, and included observing daily activities, interprofessional meetings, and individual practitioners, as well as individual interviews. "All of the team members indicated that working from a patient-centered, goal-focused approach made it easier for the team to exchange information, track patient care, and work collaboratively. One nurse stated that ‘working with goals makes it easier for everybody to know who is responsible for each patient, and we can see how what we are doing fits with what everybody else is doing.'" 5 The authors concluded that "the long LOS [length of stay] of their patients facilitated this team's focus on IPC [interprofessional collaboration]. Combined with the use of patient-centered goals, a longer LOS was seen as an opportunity for both the team to get to know their patients and to get to know about each other as professionals and as people." 5 Even for practitioners whose practice is disconnected from the daily interactions of a rehabilitation unit, the extended care process provides many opportunities to develop the trust and respect required for healthy teamwork and collaboration. Reflections Disagreements about care are common. Most O&P practitioners have heard stories from therapists about other practitioners whose lack of collaborative behavior created challenges for them and their mutual patients. I was selective in my choice of which scenario to describe at the beginning of this article; it is much easier to describe a scenario in which another team member violated principles of effective collaboration than to describe our own failures in that regard. No doubt clinicians I've worked with on interdisciplinary teams could describe situations when my lack of professionalism and collaboration hindered the provision of optimal care. It can be helpful to step back from the immediacy of a difficult situation and reflect on what could be done or said differently in similar situations in the future. It seems as though the breakdown in collaboration in the scenario I described was tied to the TeamSTEPPS competency of mutual support—the "ability to anticipate and support team members' needs through accurate knowledge about their responsibilities…." 2 Without a common understanding of the roles each of us would play in care, the therapist and I were unable to agree on how to proceed with specific steps. The expedited timeline of care did not create the problem but revealed a low trust level and lack of mutual respect that likely would have shown up even with a more reasonable timeline. However, without the pressure of that deadline, we may have been able to work through the decisions about component selection and other details of care in a way that formed a higher trust level for future encounters. The information available on the TeamSTEPPS website is extensive, and implementing the strategies effectively requires a significant investment in education and training. However, I could have used some of the tools in the Pocket Guide app to facilitate a more constructive discussion. Offering feedback on the interaction with a focus on respectfully describing unhelpful behaviors and making suggestions for future improvements, advocating assertively for a more respectful understanding of each of our roles, and explicitly connecting the expectations to the specific goals (including the delivery timeline) may have favorably influenced the outcome of the discussion. Conclusion The scenario I described stands in stark contrast to the overwhelming number of positive and constructive experiences with physical therapists and other providers that O&P practitioners have on a daily basis. Differing perspectives about care are to be expected, and most disagreements are resolved respectfully and professionally. When individuals can build on a foundation of trust and mutual respect, conflicts can be avoided, minimized, or worked through in a constructive manner. Implementing communication tools like those included in the TeamSTEPPS process can help individual practitioners function more effectively as part of the healthcare team. John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has more than 20 years of experience treating a wide variety of patients. References Rosen, M. A., D. DiazGranados, A. S. Dietz, L. E. Benishek, D. Thompson, P. J. Pronovost, S. J. Weaver. 2018. Teamwork in healthcare: Key discoveries enabling safer, high-quality care. American Psychologist 73(4):433. https://www.ahrq.gov/teamstepps/about-teamstepps/index.html Hartog C. S., J. Benbenishty. 2015. Understanding nurse-physician conflicts in the ICU. Intensive Care Medicine 1;41(2):331-3. McInnes, S., K. Peters, A. Bonney, E. Halcomb. 2015. An integrative review of facilitators and barriers influencing collaboration and teamwork between general practitioners and nurses working in general practice. Journal of Advanced Nursing 71(9):1973-85. Sinclair, L. B., L.A. Lingard, R. N. Mohabeer. 2009. What's so great about rehabilitation teams? An ethnographic study of interprofessional collaboration in a rehabilitation unit. Archives of Physical Medicine and Rehabilitation 90(7):1196-201.

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