For the purpose of this essay, the importance of interprofessional working (IPW) in effective patient care will be discussed, along with the challenges and constraints. A patient case study will be used for example purposes; all names and places will be changed in line with Nursing Midwifery Council (NMC, 2008) guidelines. According to The British Medical Association (2005), interprofessional collaboration is loosely defined as professionals working together to improve the quality of patient care. The insurgence into creating a well-oiled professional work force is well documented throughout healthcare over the last decade. The Department of Health (DH, 2007) argues that the areas of interprofessional, interagency, inter-sectoral education and practice, need vast progression to improve interprofessional relations.
IPW has been supported in a global sense by the World Health Organisation (WHO, 2010). They have stated that the planning, policy making and relations between interprofessional teams need to integrate to improve patient care. A collaborative practice team is key to moving healthcare systems ‘from fragmentation to a position of strength’ (WHO, 2010). The DH (2007) issued a supplement; ‘Creating an Interprofessional Workforce’. This document reconfirms the need to have an integrated healthcare system with details of initiatives that have and will be implemented to support this. These strategies encompass involving the patient/family/carers/ in decisions and improving both leadership and education to improve patient care, satisfaction, safety and the health service in general.
Due to these reasons, interprofessional collaboration is important in the effectiveness of patient care (Hoffman et al, 2007). The level of patient care can be difficult to measure due to the methods being unquantifiable and difficult to assess (Martin, 2010). Patient care surveys are argued to be an efficient and vital way to measure and improve care, especially when results are publicly released; as quality enhancement activity increases (Fung, 2008). Meterko et al (2004) investigated the correlation between the teamwork culture in hospitals and reports from patient satisfaction surveys about their care. From this analysis, there was a significant and positive relation between the prominence of teamwork and patient satisfaction of their care; survey scores were higher when patients felt there was a MDT caring for them.
It is argued by Schramm (2006) that a high level of IPW reduces the amount of healthcare acquired infections (HCAIs) in a hospital setting. She states that if a culture develops between nursing and domestic staff on the exact methods to clean efficiently, patient care would vastly improve due to the reduction in risk for infection. This simple example supports the idea of sharing work and individual roles contributing to a team, which in turn improves healthcare (Reeves, 2010). The development of relationships between professions will bring about respect for supplementary disciplines, therefore improving the care of the patient.
Effective multidisciplinary working would also mean that the patient receives the most appropriate method of care for their condition with all possible options being considered (Flessig, 2006). Patients should be reassured that the team caring for them is providing them with the widest range of options (Carter, 2003). In the case of cancer care, The Cancer Plan (2000) stated that multidisciplinary care causes a reduction in delays for treatments and provides consistent information for patients. There is even evidence that a well-oiled multidisciplinary team (MDT) can increase rates of survival (Junor, 1994 as cited in Ruhstaller, 2006) and reduce length of stay in hospital. Some evidence suggests twice daily multidisciplinary ward rounds have doubled discharges and halved lengths of stay (Ahmad, 2011).
Alternatively, Caldwell (2003) states that there are four main challenges and constraints associated with IPW. These are categorised as; unequal power, different ideologies (or different goals), communication and role overlap and confusion.
Unequal power in healthcare can cause problems between the staff, as the more established medical professions tend to have a greater supremacy (Baker et al, 2011). This research showed that practitioners such as doctors described
themselves as working alone and as ‘leaders’, whereas nurses, therapists and other practitioners focussed more on holistic care and being a ‘team player’. Physicians also believed themselves to be at the top of the hierarchy due to length and cost of training, salary and the fact that they are ultimately liable for decisions made. Lewis (2001) identified that nursing staff received a negative reaction from other healthcare professionals when suggestions were made for nurses to lead cases due to upsetting the balance of power. It has also been suggested that nurses will submit to medical domination in day-to-day situations (Hewitt, 2002).
Gender differences within hospital settings could also have an impact on power relations. Only 28% of hospital doctors are female (Ozbilgin et al, 2011) whereas nursing is female dominated at 89% (NMC, 2008). This points to the upper sector of the hierarchy being dominated by men. Heever (2011) found that 24 % of female medical students felt they were not taken seriously by their male peers, leaving an unbalanced working environment. Hannson (2009) disagrees stating that there is no correlation concerning gender when general practitioners and district nurses are working together.
The fundamental ideological differences that occur between healthcare professionals can cause problems in interprofessional collaboration (Caldwell, 2003). Due to each profession having struggled to gain its own identity, each area now has its own set of ideologies related to common experiences, skills, norms and values (Hall, 2005). This can make it difficult to work as a multidisciplinary team as the idea of a goal is dissimilar. The issue of communication is an important one due to the effects that reverberate into patient care. In 2003, the Joint Commission on the Accreditation of Healthcare Organisations (JCAHO) stated that communication failures contribute to 60% of incidental events (Doran, 2005).
Leonard et al (2004) believe communication issues could be drastically reduced by creating a ‘common mental model’, thus meaning all members of staff are using the same clinical language and working towards the same goal. Research carried out by Westli (2010) displayed that teams performing more efficiently showed ‘more effective information exchange and communication’. Empirical evidence found in this study highlighted that advanced levels of teamwork skills increased levels of performance, therefore increasing patient care.
Role overlap and confusion is another aspect that may reduce effective interprofessional collaboration. The DH (2000) issued a supplement that described professionals having a lack of clarity over what their role was in a healthcare setting. This could possibly lead to a breakdown in communication and have a direct negative impact on the patient. Caldwell (2003) argues that the issue of role overlap is rarely acknowledged and so is not addressed. She also argues that the curriculum in undergraduate courses should be more established when considering interprofessional relations to improve this.
The argument towards refining interprofessional collaboration by improving interprofessional education (IPE) is widely documented and supported (Rout, 2009). An article in the American Medical News (Trapp, 2011) questioned the amount of interprofessional education that is taking place in universities. It claims that doctors and nurses do not come into contact enough during training, contributing to the problem of professional relations between them and affecting patient care.
Many academics have supported the need for a clear leadership role to improve the effects of a MDT (Martin and Rogers 2004; Ross et al. 2005) and that leadership is at the pivotal centre of an efficient healthcare process. Leadership within a healthcare team can be challenging as the member in charge may change as the care of the patient changes (Reeves et al, 2010). However, it has been argued that there does not need to be one definitive leader in a situation, but that IPW can be exercised through more than one director. Yukl (2002) proposes that leadership is; ‘‘the process of influencing others to understand and agree about what needs to be done and how it can be done effectively, and the process of facilitating individual and collective efforts to accomplish the shared objectives’’.
With this thinking, even the leadership roles involved should become interprofessional so that all decisions are discussed at all levels of care. Collective leadership is becoming an accepted alternative in an interdisciplinary team. Sharing responsibility also helps to build leadership aptitude across the organisation (Huber, 2010). Tregunno (2009) showed that a nursing leader who provides patient care as part of their role increased patient safety. The emotional exhaustion of nurses along with job satisfaction has been found to be directly related to management and leadership decisions (Gunnarsdóttir, 2009). Conclusions from this study showed that maintaining strong relationships with nurses and their managers would increase patient care.
Case study – Mr Peter Dawson
Mr Dawson is an 85-year-old male who is deaf with hearing aids and has a history of hypertension; he is otherwise well. When admitted, his BMI was 23, which is within a healthy range and a Waterlow score of 7, which places him at a low risk of pressure ulcers. He lives with his wife, has three children and a supportive family. He was admitted onto the ward for an elective laryngectomy due to a squamous cell carcinoma of the larynx. A total laryngectomy consists of removal of the larynx including the hyoid bone and the upper rings of the trachea. The anterior wall of the pharynx is closed and the upper end of the trachea is brought out through the skin to create a stoma (Morris & Affifi, 2010) Mr Dawson was seen by an ear, nose and throat (ENT) consultant regarding this carcinoma, who explained the procedure that the patient could elect to have.
Otolaryngologists (commonly referred to as ENT surgeons) deal with the diagnosis, evaluation and management of diseases of head and neck and principally the ENT (Royal College of Surgeons, 2012). A Macmillan nurse then explained the procedure further to Mr Dawson and his family. A Macmillan nurse is a qualified nurse with five years’ experience including two years in palliative or cancer care (Macmillan Cancer Support, 2012). The training of a Macmillan nurse includes managing pain, along with other symptoms, and how to give psychological support. The nurse then liaised with a speech and language therapist (SALT) prior to the surgery, regarding the effects to the patients’ speech post operation. A speech and language therapist is a healthcare professional who deals with the management of speech, language and communication disorders and swallowing in children and adults (Royal College of SALT, 2012).
The case was then discussed in a multi-disciplinary team (MDT) meeting. This meeting is consultant led with input from a range of professions. The team worked together in this meeting to give Mr Dawson the best care through joint decision-making. The outcome was that Mr Dawson was to have a total laryngectomy and right neck dissection carried out by an ENT surgical team. The surgical team consisted of surgeons, anaesthetist and scrub nurses. Anaesthetists are trained doctors who have gone through extensive training in anaesthesia, intensive care medicine and pain management (Royal College of Anaesthetists, 2012); their role includes monitoring of the patient during the perioperative process using an anaesthetic monitoring chart.
In post-operative stages, SALT visited Mr Dawson for a feeding assessment regarding a nasogastric tube. He was also visited by a physiotherapist; whose job is to improve a broad range of physical problems associated with different systems of the body (Chartered Society of Physiotherapy, 2012). The physiotherapist then collaborated with the pain team, ward doctors, nurses and Macmillan nurses via an MDT meeting and using the patients notes to assess Mr Dawson’s pain solutions and mobility problems. Mr Dawson was also seen by a dietitian; their role is the interpretation and communication of the science of nutrition to enable people to make informed and practical choices about food and lifestyle, in both health and disease (The British Dietetic Association, 2012). In Mr Dawson’s case this involved nutritional regime for his nasogastric tube.
Mr Dawson’s care was carefully considered in MDT meetings and through a consultant led ward round; all professionals had an input that was discussed with Mr Dawson before any decisions were made. His care appeared fluid and consistent, with his health and wellbeing staying as the primary influence for all conclusions as per DH guidelines.
In conclusion, interprofessional collaboration is essential in the improvement of quality of patient care. There are still many challenges and constraints surrounding aspects of IPW but the evidence strongly supports an insurgence into this method of operating. Studies show a decrease in length of stay and HAI’s whilst there is an increase in survival rates and patient satisfaction. This shows that patient care benefits from a well-oiled multidisciplinary team where all members are treated as equal and different professional opinions are taken into consideration. Communication and leadership are amongst the most important factors in improving the pathway of the patient as these aspects improve the overall coordination of the team. Collective leadership is a relatively new concept, which will hopefully further improve a patients experience and offer even more choices and options.
The patient case study shows the collective efforts of an interprofessional team and the impact this has on a patient. With the patient being informed and making decisions on their own treatment every step of the way, they become more comfortable and less anxious about the care they are receiving. Explanations from specialists during consultant led ward rounds and the results of MDT meetings mean that each patient is treated as an individual and the pathway of care is suited to them. IPW still has some way to go with the stigma and power struggle that can arise, but studies show that this problem appears to be very much in the minority.
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