Discuss the potential benefits and difficulties associated with inter-professional collaborative working, drawing examples from your own experiences of the collaborative group work which forms an integral aspect of the module.
Student number: 03973107
Discuss the potential benefits and difficulties associated with inter-professional collaborative working, drawing examples from your own experiences of the collaborative group work which forms an integral aspect of the module.
Collaboration according to both the Oxford Dictionary of Current English and Webster's means simply to "labour together" or to work jointly. Michaund (1970) defined inter-professional collaboration as involving the shared training, which aims to help professionals work together more effectively in the interests of their clients and patients by enhancing cooperation. Payne (1990) described three forms to a team being collaborative, leader centred and individualistic to from a basis to multidisciplinary working. Overtrait (1997a) felt that there were four parts to an inter-professional approach these were, integration, team membership, client pathway and decision-making and the management structure of a team.
This essay will firstly address some of the issues that have highlighted the need for inter-professional collaboration. Secondly it will look at some of the policy initiatives that advocate inter-professional collaboration and attempt to identify opportunities and furthermore outline some of the challenges that arise from collaboration. Finally the essay will attempt to illustrate my personal experience of collaboration in an educational setting, in which, policies have outlined that inter-professional collaboration in an educational setting in the form of learning collaboratively, lays down foundations for inter-professional collaboration in the workforce.
The importance of interprofessional working has been a topic debated within health and social services for well over a quarter of a century. Inquiry after Inquiry on issues such as child abuse has pointed the finger at health and social work professionals for their failure to work cooperatively and collaboratively together. Recently the Victoria Climbie Inquiry examined and found failures in collaboration, which resulted in Victoria's death. The inquiry concluded that the extent of the failure to protect Victoria was lamentable. The report went on to say that tragically it required nothing more than basic good practice being put into operation. In his opening statement to the inquiry, Neil Garnham QC listed no fewer than 12 key occasions when the relevant services had the opportunity to successfully intervene. Sometimes it needed
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nothing more than a manager doing their job by asking pertinent questions or taking the time to look in a case file. The suffering and death of Victoria was a gross failure of the system and was inexcusable. A theme that frequently appeared, across a range of agencies, in the inquiry was that of lack in communication. It outlined nurses had raised doubts yet nothing was mentioned in any documentation. Furthermore a consultant at the Central Middlesex hospital examined cuts on Victoria and presumed they were probably due to scabies. Victoria was therefore discharged and released back into the care of her abusers. Dr Schwartz told the inquiry that she assumed social services would investigate further. Had this assumption not been made but instead acted upon it is quite possible Victoria could be alive But this was not the only error made this was just one of many. Two weeks later Victoria was back in hospital this time at the North Middlesex but this time the picture of incompetence was different this time it was insufficient communication where a consultant had concerns over Victoria but on her notes she wrote able to discharge this confused staff and Victoria was again discharged. The inquiry also heard how a metropolitan police officer had cancelled an appointment to inspect Victoria's home because of a fear of catching scabies. Again these are just some of the catalogue of errors that added to the exposure of incompetence and error at every level. The report outlined that there is no doubt that the effective support of children and families cannot be achieved by single agencies acting alone. It depends on a number of agencies working well together.
Furthermore there should be awareness that child abuse is not the only area where collaboration could be a key contribution to the outcome. There have been reports published following mental health tragedies that have been fiercely critical of professionals for these very same reasons.
Department Of Health policy for the last 10 years has seen a momentum develop in striving to achieve "working as one" team collaboration. It is recognised that effectiveness of a team is based on better communication, which results in a coordinated service delivery with more prompt referrals and furthermore it is recognised ...
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Furthermore there should be awareness that child abuse is not the only area where collaboration could be a key contribution to the outcome. There have been reports published following mental health tragedies that have been fiercely critical of professionals for these very same reasons.
Department Of Health policy for the last 10 years has seen a momentum develop in striving to achieve "working as one" team collaboration. It is recognised that effectiveness of a team is based on better communication, which results in a coordinated service delivery with more prompt referrals and furthermore it is recognised clients will be much less likely to 'fall through the gaps' in
such weaknesses that are known to exist in service planning within and between
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sectors. Through inter-professional working a single assessment process, resulting in a comprehensive care plan, can be achieved which could include a coordinated path that would connect the various services required (Cook, G., 2001.et al 2001 Decision-making in teams: issues arising from two U.K evaluations. Journal of Inter-professional care, 15(2) pp 141-151.
Recent focuses on health are necessarily broad encompassing what may be regarded as everyday health issues through to specialised and complex health needs. Therefore the recognition that many factors should be considered when planning a response to a vast array of health needs. The present review of services is intended to provide a strategic framework that will pave the way for coordinated service delivery. Initiatives relating specifically to developing the workforce have included reviews of the education, roles and responsibilities of NHS staff to support more flexible working practices and strategies to improve equal opportunities, enhance career opportunities and ensure a better work-life balance for staff (DOH, 2000; NHS Executive, 1999; NHS Executive, 2000).
A key aim of the modernisation agenda of the current government is to develop a more user-orientated and responsive health service (Ham, 1999). The new emphasis demands not only that the NHS is adequately and appropriately staffed, but also the staffing structure is tailored to provide a more flexible user-orientated service. Patient centred planning is a process of continual listening and learning, focused on what is important to someone now and in the future and acting upon this in alliance with other team members and family. There are implications for partnership working at the levels of the individual, different services and strategic development in informing commissioners and managers about the ways services and systems need to change.
Innovative use of staff helps to achieve the National Service Framework implementation by using the principles of skill mixing and team development (DOH, 2002, National service Framework organisational development) Both the NHS Plan and Shifting The Balance Of Power stressed the need for team working to help
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improve the quality of care to patients. This is backed by a growing body of evidence that working collaboratively can have a significant impact not only on the quality of
care but also on the efficient use of resources and on staff satisfaction. Evaluations of two U.K teams concluded that practitioners working within a multi professional team could give a more holistic approach and feel more satisfied with their work. The team members felt there was more support and became more pro-active and less bureaucratic with greater flexibility (Cook,G., et al 2001: Decision making in teams: issues arising from two UK evaluations, Journal of interprofessional care, 15 (2), p141-151).
The NHS Plan and later implementation documents such as Investment And Reforms For NHS Staff taking forward the NHS Plan and changing work force programmes (2001) all promote concepts such as integrated pathways and reconfiguration of jobs to combine tasks differently. This development of workforce that is flexibly diversely skilled enables flexible continuity in line with changing patient needs. Furthermore flexible-working patterns may improve cross boundary and team continuity by reducing communication barriers between professions. The healthcare system is increasingly built on teamwork but the blurring of the boundaries of one's discipline is a factor that may create a competitive atmosphere rather than a collaborative one. Furthermore a fundamental failure in appreciating each other's role and level of expertise can further discourage interprofessional collaboration.
In the context of interprofessional working, practitioners are being urged to learn from and about each other so that professional boundaries can be effectively crossed. However, there is an awareness that situations could arise where flexible practices that are intended to increase continuity, where several professionals are able to complete same tasks, could in practice lead to a role and skills shift resulting in more fragmented care. In which practitioners would no longer see specific tasks as theirs.
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It is recognised that collaboration is not reserved for practitioners. The Health and Social Care Act (2001) placed a duty of partnership on individual agencies. As part of this, Health authorities and Primary care groups and Trusts are required to have representation on their boards from the local authority. The partnership flexibilities contained within the Acts offer opportunities for closer working and in some cases are
now a prior requirement in order to access funding. There are many advantages including the delegation of functions to each other, the ability to pool budgets and for integrated provision. The establishment of care trusts has been made possible as one way of enabling the commission of health and social care services to take place within a single organisation framework and within single management, financial and information systems. This integration should provide a continuity of care.
Although there may be obvious and not so obvious collaborative barriers between practitioners they are not compounded by the need to work across agency or developmental boundaries. More often than not in order to deliver continuity of care different combinations of services, workers and skills are required. The problems of coordinating such a service have been tackled in many ways and at all levels including major restructuring of services, reinforcement of procedures, production of guidelines and not least through the cooperative efforts of workers at ground level.
Changes in service provision have brought about Interprofessional groups for training professionals. In this way collaboration becomes and forms part of the training and can be smoothly carried over into individual professions. Interprofessional education plays an essential part in collaboration as it overcomes boundaries such as stereotypes. In learning and working together from ground level, during training, rapport is built and respect and mutual understanding of professions and what they have to offer is gained. It is only with an increased understanding and awareness that an improvement in interpersonal skills can be achieved. If common problems in working relationships are identified, within the safety net of an educational setting, and described they can be better understood. Furthermore this awareness allows individuals to identify problems and deal with them more efficiently, which prevents an escalation and therefore an assimilation of further problems.
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The Government in its drive for a 'first class service' has clearly stated that in the future integrated care of patients will rely on models of training and education which give staff a clear understanding of how their own roles fit with others in both the health and social care professions (DOH 1998:41). A thorough understanding and appreciation of the contribution that each profession makes to a patients care is absolutely crucial. And this can only be achieved through learning and working together from the outset of an individual's professional career to the day they retire. Interprofessional education is commonly cited as a potential route to resolving the problems surrounding collaboration (DOH 2000). Barr and Waterton (1996) said "Effective Interprofessional education works to improve the quality of care; focuses on the needs of service users and carers and encourages professions to learn with, from and about one another; enhances practice within professionals, respects integrity and contribution of each profession and increases professional satisfaction."
Amid the debate around the policy and philosophy we must remain mindful of the fact that the focus of interprofessional working is the patient. However the dynamic of care is now shifting away from the availability of services where patients fitted into the system, to a process of healthcare delivery where the focus is the patient (Scott 1999). There is emerging evidence that shows there are many benefits in adopting a patient focused care model including the enhancement of the quality of care, reduction in patients length of stay and focused organisation of the service around the patients needs in one identified centre. One of the key features of patient centred care is the development and implementation of integrated care pathways i.e. collaborative care plans. (NHS.1999. Interprofessional education; A lifetime review)
In the first interprofessional meeting I attended I initially felt I had no contribution to make I perceived that has a student nurse all the other professions in the meeting were much more intelligent and therefore my contribution to the initial meeting was minimal. With hindsight I now realise that my insecurity probably arose from the
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introduction of the group members. Once I had heard the background of the other members, such as a chartered accountant and someone who had previously achieved a degree in physics, I immediately felt inferior to the other non-nurse members of the group. I had inadvertently imposed a sense of hierarchy upon the group. However the initial feeling of previous under achievement was quickly replaced, before the second meeting, when after a conversation with another nurse member of the group, who was also feeling at the bottom of the hierarchy in the group, I realised it was up to us to champion our chosen profession within the group.
In the first few weeks I read as many policy documents as possible and armed myself with as much knowledge as was possible. With the knowledge I acquired came a sense of achievement and a sense of ease, I had not previously felt, when communicating and contributing to group discussions. I soon realised that the hierarchy I had imagined was not actually evident although I do believe that as we gain our professional identities there is a possibility of gaining our professional stereotypes and therefore ultimately a hierarchy may develop in future group meetings. In a discussion before the second meeting a fellow nurse student form the group confided in me that she did not understand what the group was all about. After a long conversation in which I informed her of the principles of collaborative care and the policies that have an impact on the care delivered she thanked me for explaining things to her and told me she thought I should chair the next meeting. My initial feeling of terror at the thought of having to expose myself to the criticisms of others was soon overpowered by a feeling of achievement. Not only could I identify with my fellow nurse student I now felt empowered by her confidence in me to chair a meeting.
By the penultimate meeting I was contributing equally to the group discussions, something I would never have initially thought I would gain confidence in, and because of this I now feel I am equal to every member of the group. I have recognised that although our backgrounds are very different I am able to contribute and learn at the same level. Through my participation in interprofessional education I am able to identify that in order to achieve successful collaboration communication is needed so
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that an environment of trust can be achieved. Some of the skills that have been identified in creating these environments of trust and respect are listening skills, ability to articulate individual and professional contributions, and negotiation skills. Furthermore I now recognised that without this level of communication interprofessional collaboration is likely to be affected at an interpersonal level by issues of status, class and gender. In conclusion to how our group worked I have become aware that the dynamic of the group was such that each session was valuable and that each member equally contributed. Furthermore I gained a sense of responsibility to the group as I feel did the other members, which enthused me to carry out research to feed back to the group. There were no conflicts within the sessions and each of the members opinions were valued and respected. However in the penultimate meeting there were some debates between individuals but I consider these to have shown the extent to which our group has evolved whereby members felt comfortable to challenge opinions. I believe that the basis of these achievements is due to the establishment of good ground rules within the first session. Furthermore before the end of each session we would decide upon an agenda for the following meeting. This structure gave us common goals to aspire to. I consider all of these identified points to be essential components in any successful collaborative team. However in establishing the positive dynamics of our group it becomes clear that an imbalance to any of the dynamics in anyway may cause conflict. An example of which could be if responsibilities were not adhered to some members of a team may have to undertake more work.
Research into the impact on interprofessional education is beginning to show that this form of education can promote effective collaboration. An example of which is the study by Parsell et al (1998) in which it was found that interprofessional education improves poor professional attitudes. Other studies advocating Interprofessional education include Falconer et al (1993) and Brown (2000) in which both studies noted that interprofessional education resulted in an improvement of patient care.
If we are mindful of the numerous ways in which in which inter-professional collaboration is challenged we are armed with an insight that can help us overcome
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such problems and sustain collaboration. Research indicates that the delivery of well co-ordinated effective services can be inhibited by a number of factors. These include uncertainties around overlapping professional roles, confusion over clear management lines relating to different staff (Overtveit, 1993). Interprofessional stereotypes can also have a detrimental effect on collaboration at an interpersonal level. This can be seen in the Jasmine Beckford child abuse inquiry (Blyth & Milner, 1990). The inquiry highlighted that a female health visitor had voiced legitimate concerns yet they were ignored in favour of those of a male doctor. Further suggested factors discouraging collaboration arose from a study at St Bartholomew's School of Nursing and Midwifery (Freeth, D., 2001. Sustaining interprofessional collaboration. Journal of interprofessional care, 15(1). Furthermore despite the drive towards inter-professional working changing the healthcare system and despite the priority being given to this way of working in policy, education and research, there is little evidence that the concept of inter-professional working is filtering down to ward level (Kenny, G, 2002, Interprofessional working: opportunities and challenges. Nursing Standard, 17(6), pp33-35).
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Bibliography:
Mcclosky,J., and Grace,.H.1997. Current issues in nursing.5th edition.USA: Mosby.
Sullivan,H., and Skelcher,C., 2002. Working across boundaries. Hampshire:Palgrave Macmillan.
Hornby, S., 1993.Collaborative care: interprofessional, interagency and interpersonal. Blackwell Scientific.
