Working Relationships and Outcomes in Multidisciplinary Collaborative Practice Settings

A multidisciplinary research team of academics and community practitioner partners worked together to design and conduct an investigation into the purposes, processes, and outcomes of multidisciplinary collaborative practice. A review of the literature revealed a confusing array of terminology while also pointing to potential benefits and challenges, models for practice, and suggestions for research. The pilot research study consisted of six case studies set in three different programs. The principal finding was that no single model can be applied to all multidisciplinary collaborative endeavors. The appropriate approach depends on the context and goals of the work and on the organizational structure. This study highlights the process for collaboration and its prerequisites: Shared physical space, opportunities for formal and informal communication, consensual decision-making, team/group coordination, and organizational support. Additionally, the role of specific disciplines appears to be less predominant in the process of multidisciplinary collaboration than the commitment of individuals to collaborating. The benefits reported by practitioners were suggested to far outweigh the challenges associated with the approach to practice. Future research should incorporate a stronger client voice, include investigation of inter-group and interagency collaboration, and extend to a wider variety of practice settings. In 1994–95 in British Columbia, a formal inquiry was held to review child protective services, policies, and practices. One conclusion of the inquiry was that child protection services must be delivered in a multidisciplinary, coordinated manner. The British Columbia Ministry for Children and Families was formed in the fall of 1996 to bring together child, youth, and family serving programs from five government ministries. Thus it seems inevitable in British Columbia at least, that individuals working with children, youth, and families will be required to do so in a multidisciplinary, collaborative manner. This study grew out of a desire among academics and practitioners Correspondence should be addressed to Sibylle Artz, Ph.D., School of Child and Youth Care, University of Victoria, P.O. Box 1700, Victoria, B.C. V8W 2Y2 Canada. Child & Youth Care Forum, 29(1), February 2000  2000 Human Sciences Press, Inc. 39 Child & Youth Care Forum 40 in the field to determine why organizations working with children and families would choose a multidisciplinary approach to practice, what the approach actually looks like for the people involved, and to determine if the approach engenders the benefits that are assumed to be associated with the approach. Thus this pilot study of practice in two healthcare settings, employed a phenomenological approach to investigate the lived experience of practitioners and service users. Representatives from two community organizations expressed their interest in the project and joined the project steering committee to assist in guiding the research project. The two research contexts are described in the method section of this article. Review of the Literature Although the value of multidisciplinary collaborative work is often endorsed, numerous authors agree that specific studies of how such relationships work and their impact on relationships with clients, service objectives, and outcomes are hard to find (Billups, 1987; Jones, 1997; Lowe & Herranen, 1981; Opie, 1997; Velianoff, Neely, & Hall, 1993). This review of the literature pertaining to multidisciplinary, collaborative practice describes rationales, purported benefits and challenges, the array of terminology used to describe it, models for practice that include factors for effectiveness, and suggestions for future research. Rationale for Multidisciplinary Practice A broadened conception of the interrelated nature of human problems and the need for comprehensive approaches to human service delivery is purported to have prompted much of the push for increased collaboration (Abramson & Mizrahi, 1996; Billups, 1987; British Columbia Ministry for Children & Families, 1997). Also, several authors suggest that a mandate for increased collaboration has arisen out of changing economic and social conditions that have prompted more demands for cost-efficient and effective health care service delivery (Netting & Williams, 1996; Abramson, & Mizrahi, 1996; Christ, 1996). Benefits of Multidisciplinary Practice Other authors highlight the benefits that a multidisciplinary, collaborative approach to practice affords service users. Billups (1987) suggests that the outcomes of interprofessional team efforts can be considerably greater in scope and value than the cumulative effects of the perforDiana Nicholson, Sibylle Artz, Andrew Armitage, and Joel Fagan 41 mance of individual practitioners or educators working separately. Christ (1996) states that, There exists an expanded and deepened competence that occurs as a practitioner moves back and forth between the depth of specialized practice and the breadth of the generalist knowledge and skill. In fact, the practitioner’s understanding of human behaviour and helping processes may become skewed if he or she maintains too singular a focus. (pp. 60–61) In healthcare, suggested benefits of collaboration extend also to practitioners. Practitioners are reported to enjoy better communication and relationships with their colleagues, the ability to focus on the entire patient, increased efficiency and effectiveness of care delivery (Velianoff et al., 1993), higher productivity, increased satisfaction, and the ability to provide holistic care (Opie, 1997). Bailey and Koney (1996) state that collaboration includes an enhanced potential for resource exchange and a movement toward power parity among members (Bailey & Koney, 1996). Exposure to other professionals allows individuals to expand their knowledge and expertise while providing support, dividing responsibility, and cushioning the effect of failure (Abramson & Mizrahi, 1996). However, Schellenberg (1997) questions whether shared responsibility always translates into shared accountability, especially when things go wrong. Challenges of Multidisciplinary Practice Bringing people together usually entails bringing differences together. Sheehan (1996) describes the differences as often being a “clash of cultures” (p. 76) characterized by differences in values, language, problem-solving strategies, and other elements of professional behaviour. To achieve effective collaboration, team members must not resist differences (Poulin, Walter, & Walker, 1994). Ways to use differences for benefit must be a primary consideration in multidisciplinary collaborative work. Given that each discipline develops a body of knowledge that gives a unique perspective on the phenomena central to the discipline (Knapp, Barnard, Brandon, Gehrke, Smith, & Teather, 1993), different disciplines contribute separate and often competing philosophies, diagnoses of need and pathology, and models of the way the world works. Each discipline alone is not capable of addressing challenges related to the whole individual, complex families, and communities. Thus, cooperation and coordination are required between professionals and between services. Further, the more groups are expected to collaborate closely, Child & Youth Care Forum 42 the more they need thorough procedures to coordinate their work (Tjosvold, 1986b). Terminology of Multidisciplinary Practice Many different terms (interdisciplinary, multidisciplinary, transdisciplinary, interprofessional) are used in the literature without an understanding of their meaning. Terms are often used interchangeably to mean different things. Literature on collaborative practice often does not state whether it is specific to workers from one or a variety of disciplinary backgrounds. Orelove and Sobsey (1991) have offered different terms that refer to varying degrees of integration of work among professionals from different disciplines. They describe the transdisciplinary team model as representing the highest level of integration, or the transfer of information across traditional discipline boundaries. They note that “transdisciplinary” practice has been embraced most predominantly by programs serving children with multiple disabilities. Models for Multidisciplinary Practice According to Murphy (1995), multidisciplinary, collaborative practice is likely to be strongly characterized by embracing and utilizing individual differences and cooperation and coordination of efforts. Further, multidisciplinary work requires a shared understanding of aims, objectives, and of what constitutes good practice. The components of multidisciplinary collaborative practice most often mentioned in the literature are: • organizational structure • cooperation • roles • communication • leadership • decision-making • conflict • attention to collaborative process The following elaboration of these components illustrates how each influences multidisciplinary collaborative practice. Organizational Structure. Ovretveit (1993) states that organizational structure is a critical component of team development. Others agree that the structure of the system in which multidisciplinary work occurs Diana Nicholson, Sibylle Artz, Andrew Armitage, and Joel Fagan 43 is of key importance to practice effectiveness (Murphy, 1995; Resnick & Tighe, 1997). Teamwork can only occur when it is supported and sanctioned by the environment in which it exists (Lowe & Herranen, 1981). Cooperation. Personal characteristics have been suggested to have less influence on group functioning (Ovretveit, 1993), although Kline (1995) and Landerholm (1990) contend that individuals must be willing to become multidisciplinary, that is, to share their knowledge and learn from the knowledge offered by other disciplines. Additionally, individuals must strive to understand the roles and responsibilities of others, their feelings, values, perspectives, and motives (Murphy, 1995; Roberts, 1989; Tjosvold, 1986). Tjosvold (1986b) states that collaboration cannot occur effectively in competitive environments. Such environments are characterized by: a) no concrete, common task; b) no rewards for collective success; c) individuals don’t know each other as people; and d) reasons to compete exist. Conversely, collaborative models build structures and processes around the nature of the task rather than starting with a hierarchical structure and force-fitting the task to it (Kraus, 1980, p. 101). Further, in collaborative organizations, values such as openness, trust, honesty, concern for others, power sharing, and expansion and tolerance for ambiguity influence structures and processes. Roles. Research also suggests that to work effectively in a multidisciplinary way, team members need to understand, clarify, and manage influences on their roles, especially when conflicting expectations exist (Ovretveit, 1993). Thus team members need to be able to understand and explain their formal responsibilities, to be accountable, and clarify with other members what scope they have to negotiate what they do (Ovretveit, 1993; Peace & McMaster, 1989; Murphy, 1995). Sheehan (1996) supports this in asserting that clear guidelines and expectations about roles must be established. In addition to defining roles clearly, Billups (1987, p. 148) notes that attention must also be given to avoid incompatible expectations in roles (“role conflict”) and the inability to meet multiple expectations (“role overload”). Further, as well as understanding one’s own role, individuals working in collaborative settings must strive to gain knowledge and understanding of the professional expertise and roles of others (Lowe & Herranen, 1981; British Columbia Ministry for Children and Families, 1997; Murphy, 1995; Netting & Williams, 1996; Orelove & Sobsey, 1991; Sheehan, 1996). Communication. Researchers on multidisciplinary practice have also noted that the quality of communication within a team is a good index Child & Youth Care Forum 44 of its levels of organization and the health of the relationships between members (Ovretveit, 1993). David (1994) suggests that listening skills are a critical factor in effective communication and should be part of training for collaborative teams. Others have pointed out that effective communication requires avoiding the use of professional jargon and establishing clear guidelines concerning information exchange (Kline, 1995; Rutman & Swets, 1995; Sands et al., 1990; Sheehan, 1996). According to Klein (1990), successful teamwork depends on tending to the communication process. Finally, Lowe and Herranen (1981) have suggested that determining the nature of interdependence or who needs what information from whom is an essential part of teamwork. Leadership. Another dimension of effective, multidisciplinary practice is high quality leadership. Ovretveit (1993) states that more team problems are caused by inadequate leadership than by any other single factor. Problems with leadership usually involve an ambiguous leadership role or one that is not appropriate for the type of team or situation (Ovretveit, 1993). Leadership in teams should aim to help different disciplines to act toward a common purpose (Ovretveit, 1993; Tjosvold, 1986b). Decision-Making. Along with adequate leadership, productive and balanced decision-making processes are essential to the success of multidisciplinary practice. Decision-making is about determining how the tasks and goals of a team, group, or unit get accomplished (Lowe & Herranen, 1981). Coordination is critical for problem-solving and decision-making (Tjosvold, 1986b). In order to make the most of different skills and perspectives of members, teams must have agreed-upon procedures for making decisions (Ovretveit, 1993). Ovretveit (1993) distinguishes between the types of decisions facing teams: a) decisions about one client; and b) policy decisions about the team’s services to all clients and about how the team works. In collaboration, team members’ sharing of decision-making power facilitates a functional focus rather than an authority or power focus (Kraus, 1980). Conflict. An additional dimension of multidisciplinary practice that requires attention is conflict. Conflict occurs most often because of differences in socialization, goal incompatibility, task uncertainty, differences in performance expectations, and resource limitations (Fargason, et al., 1994). Effective conflict management involves problem characterization, acknowledgment of relevant goals and interests, and negotiation when interests are in conflict (Schneider & Galloway, 1994, p. 863). Teams must strive to raise, recognize, and resolve differences (Ovretveit, 1993). Minimizing, denying, or accentuating differences are Diana Nicholson, Sibylle Artz, Andrew Armitage, and Joel Fagan 45 all detrimental to team effectiveness. Making use of differences requires the use of clear and effective decision-making processes. Attention to Collaborative Process. Finally, the literature on multidisciplinary practice suggests that teamwork as a concept must be understood, practiced, and studied in order to fulfill its potential (Lowe & Herranen, 1981). Interprofessional collaboration includes attending to what a team does and how it goes about doing it (Billups, 1987). Thus time and resources must be allocated to facilitate team development and effective team work (Billups, 1987; Iles & Auluck, 1990; Opie, 1995; Opie, 1997; Rutman & Swets, 1995). Allowing time for relationshipbuilding among individuals from different disciplines is important for effective practice (Ministry for Children and Families, 1997; Netting & Williams, 1996). Gaps in the Literature The literature provides a number of suggestions for future research: Involving practitioners in research (Jones, 1997), including the client voice in evaluations of practice, and providing evidence for the benefits purported to be derived from multidisciplinary, collaborative practice (Billups, 1987; Lowe & Herranan, 1981; Opie, 1997). Research is also needed that would provide benchmarks for the developmental process of interdisciplinary collaborative groups (Velianoff et al., 1993). The literature review conducted for this study also highlighted the need for all research in this area to include explicit definitions for the terms used. Purpose of the Study This research project responds to the need for an improved understanding of a multidisciplinary, collaborative approach to healthcare practice and its benefits. The lived experiences of practitioners and service users are highlighted in this study in order to give their voices prominence. Due to available funding, this study was designed as a pilot project that would provide some new understandings while identifying key issues for exploration in additional practice contexts. This project was guided by a steering committee composed of representatives from the University of Victoria’s Schools of Child & Youth Care, Social Work, Nursing and Faculty of Education, and two community healthcare organizations that have engaged in forms of multidisciplinary practice for more than five years. Child & Youth Care Forum 46