Inter-professional Working and the Needs of the Patients

QUESTION I

“Not sharing information is detrimental to inter-professional working”

Indeed, the needs of patients are best met by the inter-professional team, the evidence indicates that collaboration can promote coordination, cooperation between carers and significantly improve patient outcome and resource management (DoH, 2000, 2001a, 2001b). ‘Inter-professional’ working has thus become popular following pivotal policies drafted to structurally re-shape the National Health System (NHS) and influence how professional groups work together (DoH 2000, 1998, 1997). The literature has thus seen an upsurge in studies investigating patient oriented inter-professional collaborations with evidence for the positive impact of good, innovative inter-professional practice (Freeman et al, 2000), some of which have been seen in the areas of acquisition of clinical skills via inter-professional approach (Freeth, 2001, Freeth and Nicol 1998), management of acutely ill patients (Smith et al, 2002), palliative care (Vickridge, 1998) and in the sphere of care of older people (Tierney and Vallis, 1999). Collaboration between professionals and their teams, mutual respect, the sharing of knowledge, skills, decisions and the recognition of the contribution of participating professional/teams highlight the integrated nature of inter-professional work (Molyneux 2001; Ovretveit (1997). Nevertheless, several factor militates against inter-professional working; these include information unshared, poor communications skills/methods and language differences (Caldwell and Atwal 2003; Pietroni, 1992; DOH, 1991), role overlap and confusion (Caldwell and Atwal 2003), conflicting and unequal power relationships (Caldwell and Atwal 2003; Blane,1991), different ideologies (Caldwell and Atwal 2003), differing perception of patients needs and treatment goals (Stevenson 1985) role confusion (Opuko, 1992) and a persisting tendency to promote professionalism in work settings.

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Areskog (1988) and Carpenter (1995) suggested that if collaboration ideologies is included in the qualification programmes of professionals and exemplified at that early stage, it will lead to better inter-professional working as issues of differing perceptions of treatment goals and patients’ needs will be tackled along with professional ‘stereotype’ that become impediments of meaningful inter-professional work. In view of this, the work of Freeth and Nicol (1998, attached) is an important study that sheds light on the barrier, opportunities, benefits and perhaps the way forward for inter-professional education and practice. The study was described as innovative programme of shared learning in acute care, involving final year medical students and newly qualified staff nurses and was developed in response to the indistinct professional role of junior doctors and the expanded roles of nurses. The programme utilized patient scenario which was pertinent to the participants’ area of practice for the training purpose.

The authors defined inter-professional education as “learning with and from each other” and reports from a supportive climate, the description and analysis of an inter-professional clinical skill course for newly registered nurses and senior medical students. While the benefits of inter-professional working was a strong motivation for the training/study, the authors deemed inter-professional learning as difficult and fraught with practical problems; the non-resolution of which may lend further support to critics of the initiative.

The Clinical Skills Initiative was a collaborative venture between a School of Nursing & Midwifery and a Medical School (Studdy et al 1994). The importance of information sharing was underscored by the fact that the entire programme had communication skills taught, and role played using realistic patient scenarios. This was thought to have made for a ‘balanced diet” of clinical and communication skills that is vital for high quality patient care. A background to this was the development of the Inter-professional Skills Centre that ensured that the channels of communication between the two Schools were strengthened and inter-professional relationships was well established. This in the opinion of the authors provided the inter-professional initiatives with an infrastructure, and a supportive climate underpinned by common understandings, thus, enhancing the chances of success (Freeth and Nicol 1998). The course provided an inter-professional arrangement that allowed for an inter-change of information thus enabling members of the nursing and medical professions to learn from each other. Such sharing of information was shown from the analysis of field notes, interviews, flip chart and questionnaires to have promoted mutual appreciation of expertise and the roles of both profession in contributing to overall patient care.

In a case scenario where the participants were told that conservative management of a patient’s leg ulcer has failed and surgery was needed, it was interesting to note that both professionals, in small inter-professional groups, explored issues surrounding informed consent, focusing on the information needed to make an informed decision and the way in which this should be communicated to patients and relatives (Freeth and Nicol 1998). Undoubtedly the sharing of information here improved the outcome of the deliberation. The result suggests that the study was a positive experience for the participants; they were able to contribute something to the overall patient problem solving, drawing upon each other’s practical experience, and specialized knowledge. They shared information even during social interactions, as much of any waiting time was employed to enquire about each other’s ward-based experiences (Freeth and Nicol 1998).

The registered nurses saw the inter-professional training as a great chance to learn new clinical skills and commented that the education made obvious what should have been done in their past experiences. Additionally, some participants from the medical profession had technical questions relating to ward procedures and their rationale. These were addressed to the staff nurses and information exchange was again beneficial to both team members, thus confirming the authors’ assumption that nurses’ ward experience is an asset for inter-professional training. A member of the medical team considered the inter-professional education to have ‘un-smudged’ some of the boundaries in roles and highlighted the need to work together and communicate. Overall, this article is relevant to the understanding of the vital ingredients needed for an inter-professional education that will promote current health policies and maximize patients’ benefits. The article indicates the importance of ‘information sharing amongst professionals’ for the success of inter-professional collaborations.

Caldwell and Atwal (2003) highlighted a number of problems of hospital inter-professional practice, a significant number of which can be attributed to ‘not sharing information’. A case involving a staff nurse, a consultant, an occupational therapist, social services, the patient and a hoist was described. The staff nurse considered the hoist as important for the authorised discharge of the patient and was concerned that one has not been issued; this was expressed at a multidisciplinary team meeting. However, underlying the ill-feelings of the professionals is the fact that information about varying perception of what should be the optimum care strategy for the patient has not been shared or negotiated. According to Caldwell and Atwal (2003), uknown to the occupational therapist the staff nurse had received pressure from the consultant to discharge this patient, and unknown to the staff nurse the occupational therapist is contending with social services who are suggesting that this patient could benefit from further rehabilitation and therefore should not be issued a hoist. It is thus reasonable to suppose at this point that team members’ innate un-willingness or the inability to share information or communicate is detrimental to inter-professional working. Professionals in such teams or settings should necessarily share information to promote an understanding of each others role and care plan thus fostering the approach of a team working toward optimum patient oriented goals in a well orchestrated manner (Cooper et al, 2001).

The issue of role boundaries was also highlighted in the Freeth and Nicol (1998) study; sometimes however, it is a case of role overlap and confusion amongst professionals, for example, nurses and junior doctors. This has become apparent especially since Government policies now favour expansion of nurses’ role and reduction in the hours worked by junior doctors (DoH (1994). Clarity of these professional functions is important for practitioners in the ever changing inter-professional interface (Taylor 1996). It may be argued for instance, that why should a physiotherapist wait to have a wheelchair prescribed only after patient assessment by an occupational therapist when the former also have the requisite assessment skills. Clear definition of roles and optimum utilisation of professional resource capacities will make for an enhanced inter-professional practice and patients benefit.

Other issues of importance to inter-professional working identified in the article included stereotypes, inter-professional barriers, and a tendency for some professionals to minimize the importance or value of the work of other professionals owing probably to excessive emphasis on professionalism during training. These issues are constraints to effective patient care and need be properly addressed for the optimum functioning of an inter-professional initiative. While works, such as those of Freeth and Nicol (1998) clearly demonstrate the benefits of inter-professional education, background schooling for the majority of professionals still take place in mono-disciplinary settings that fosters professionalism and stereotyped image/ expectations of other professionals (Leiba 1996). This trend cannot achieve the policy aims of effective collaborative working (DoH, 2000; 2001a; 2001b; 1998; 1997). A key solution will be the provision of support for inter-profession education/training as exemplified by Freeth and Nicol (1998); it is an integrated approach with potential for preparing professionals to encourage inter-professional practice.

QUESTION II

Part A:

Points learnt include:

• The benefits of inter-profession working
• A positive outlook on multi-disciplinary teams that inter-relate for better patient outcome
• The need for interest in other professions and an understanding of their roles.
• The importance of ‘sharing information’ effectively with other healthcare professionals, patients and relatives while maintaining patient’s autonomy and confidentiality
• Professional need for effective communicate skills
• The need to be involved in therapeutic decision making and care plan formulation that earns patients’ concordance.

An important practical message in the considering of inter-professional education/work is the need for attitudinal changes; the immediate effect of which in clinical practice, includes the readiness to share relevant information with clinicians to promote effective delivery of care, the perception of other professional as equally making valuable indispensable contributions to patient care as well as a positive outlook on inter-professional working. These attitudinal changes are necessary for the efficient local practice of inter-professional working. McGrath (1991) showed that the benefits of inter-professional working includes but is not limited to (1) efficiency in human resource allocation and the optimum utilization of capacity within the team, i.e. specialist staff focus on specialist skills/cases (2) efficient delivery of health care with improved patient outcome and (3) increase in job satisfaction for members of the inter-professional team arising from the support of willing team members and an enabling work environment.

Inter-professional working could thus have improved the clinical outcomes in a number of the hospital cases that in my experience has led to grave loss or patient suffering. The recent experience was in the care of hospital in-patients with a clinical diagnosis of osteoporosis without any history of fracture and on a frailer group of patients with advance bone changes usually having sustained fracture/s (CSP 2002) and for which NICE (2005) has provided a guideline for the secondary prevention of fragility fractures. The patients were managed at any of the 11 wards representing medicine, surgery, orthopaedic and elderly care wards of a tertiary care facility in London during an 8-week placement period.

Gross observation revealed treatment gaps in meeting guideline recommendations for the management of these patients in the areas of risk of fall assessment and referral to multi-factorial fall risk assessment and intervention clinic. There did not seem to be a unified format or standard for the assessment of fall risk within the 11 wards and risk of fall was not assessed in more than 50% of the cases in which this was a guideline requirement, perhaps, due to confusion in role identity and the location of this responsibility amongst the professional concerned. The clinical records of these patients showed that both nurses and physiotherapist assessed fall risk criteria and reported this in different formats. Proper integration of the services and communications between these professionals as prescribed within the frame work of inter-professional working will avoid needless duplication of effort, the waste of resources and clinicians time. Saved time could then be expended by either of the professionals in improving quality of care and quality time spent with patient; this is in addition to improved consistency in patients’ records and the ease of continued care should there be a need for patients to moved between wards of the unit.

Part B:

While Government policy has reflected a cultural shift by way of imposition of radical changes to the way in which health services are organized and delivered, there are distressing problems that make inter-professional working an arduous task. The issue of power and its distribution within the health institution is here of prime importance.

There exist unequal power distributions between health care professionals, often leading to organizational and working structures that are impediments to inter-professional working. (Carrier and Kendall, 1995; Kgppeli’ 1995; Blane, 1991). Power is often in the domain of the older, more established medical profession; and there has been a pattern of domination over other professionalized disciplines, such as nursing, social work and other allied health professions (Kgppeli’ 1995; Hugman, 1991). The study of Manias and Street (2001) revealed that nurses faced many difficulties that practically precluded them from participating in therapeutic decision making for patients to whom they maintain permanent physical, emotional and sensitory closeness (Kgppeli’ 1995). Manias and Street (2001) found that nurses on medical ward rounds answered ‘doctors’ questions only, were not encouraged to give unsolicited information about the patient and hence found it very difficult to present relevant patient issues during a medical ward round. An enormous amount of literature has been written on the nurse-doctor relation; a significant portion of these appear to imply that the powers and influences of medical profession are hindrances to development of nursing. From a historical standpoint, it is logical to think of health professions as complementary to each other, however, the fact that they are organised ‘around’ a patient, that they ought to cooperate for his benefit seems secondary if not trivial (Kgppeli’ 1995). There is a lingering tendency to maintain professionalism and to expect ‘predetermined behavior’ of other health care professionals.

The domination of one professional over the others within a health team is a major factor that can strengthen the boundaries between the professional groups engaged in inter-professional working and constrain effective teamwork (Beattie, 1995). Power in-balance within the inter-professional team will also encourage the making of many ‘rules’ and regulations that are capable of controlling major aspects of professional practice (Kgppeli’ 1995), thus making un-necessary any substantial discussion intended to individualise care and improve clinical and social patient outcome.

The care and management of a hospitalised patient cannot be achieved by one person, neither is one professional group capable of the task. It is always a complex multidisciplinary phenomenon (Kgppeli’ 1995) in which the integrated knowledge and skill of people with different professional backgrounds makes for better clinical and social patient outcome. Hence, leadership within inter-professional team should not be ‘zoned’ to one profession as such will be detrimental to the optimal functioning of the initiative. The leadership need be more inspirational and stimulating, enabling other team members to respond positively to opportunities presented by developing improved knowledge and skills in managing professional practice and inter-professional relationships. According to Colyer (1999), non medical professional members of the team who are willing to assume the demanding responsibilities of full membership of the inter-professional teams should also be made to feel a sense of belonging and responsibility to the integrated patient oriented goal of the team.

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