MODELS OF TEAM PRACTICE

Early models

Primary Care Practice models have been described in the literature by a number of authors in recent years. Early descriptions include a limited number of providers of health care and were an outgrowth of the movement to train and utilize "non-physician" health care providers in "expanded roles" in primary care. Three practice models commonly used in primary care were described. These models include only the physician and the "non-physician provider", who was a physician assistant and/or a nurse practitioner.

1. The Parallel Model: The non-physician provider provided care to stable patients, and the physician cared for the more medically complex patients.
   
2. The Sequential Model: The nurse practitioner or physician assistant performs an initial history and physical exam while the physician assumes responsibility for differential diagnosis and management. Alternatively the physician may see patients initially to screen for complexity, with the less complex patients being assigned to the non-physician.
   
3. The Shared Model: Care is provided to patients by all providers on an alternating basis regardless of diagnosis and complexity.

The Collaborative Model is an extension of the concept of team practice and the leadership focus is modified. Patients choose their provider as desired, regardless of the complexity of their problems. All providers collaborate as needed to provide safe, high quality care yet each provider practices autonomously. (Arcangelo et al, 1996)

Collaboration is defined as a joint communication and decision-making process with the goal of satisfying the health care needs of a target population. The basis of collaboration is the belief that quality patient care is achieved by the contribution of all care providers. A true collaborative practice has no hierarchy. It is assumed that the contribution of each participant is based on knowledge or expertise brought to the practice rather than the traditional employer/employee relationship (Archangelo, et al; p106)

Components of the Collaborative Practice model:

• A common group of patients
  
• Common goals for patient outcome and a shared commitment to meeting these goals
  
• Member functions are appropriate to an individuals education and expertise
  
• Team members understand each others role
  
• A mechanism for communication
  
• A mechanism for monitoring patient outcome
  

• Trust among all parties establishes a quality working relationship that develops overtimes as the parties become more acquainted.
  
• Knowledge is a necessary component for the development of trust. Knowledge and trust remove the need for supervision.
  
• Shared responsibility suggests joint decision making for patient care outcomes and practice issues within the organization.
  
• Mutual respect for the expertise of all members of the team is the norm. This respect is communicated to the patients.
  
• Communication that is not hierarchic but rather two-way facilitating sharing of patient information and knowledge. Questioning of the approach to care of either partner cannot be delivered in a manner that is construed as criticism but as a method to enhance knowledge and improve patient care.
  
• Cooperation and coordination promote the use of the skills of all team members, prevent duplication, and enhance productivity of the practice.
  
• Optimism that this is the most effective method of delivery of quality care promotes success.

Drinka defines the Interdisciplinary Health Care Team (IHCT) as "a group of individuals with diverse training and backgrounds who work together as an identified unit or system. Team members consistently collaborate to solve patient problems that are too complex to be solved by one discipline or many disciplines in sequence. In order to provide care as efficiently as possible, an IHCT creates "formal" and "informal" structures that encourage collaborative problem solving. Team members determine the team’s mission and common goals: work interdependently to define and treat patient problems; and learn to accept and capitalize on disciplinary differences, differential power and overlapping roles. To accomplish these they share leadership that is appropriate to the presenting problem and promote the use of differences for confrontation and collaboration."

In this model Drinka explains that multiple methods of team practice should be part of the arsenal of the health care professional. The need for ongoing interdependence and collaboration are the triggers to determine which method of team practice is the correct way to address the particular problem encountered, whether it is related to patient care or to the operation of the health care system. For an Interdisciplinary Health Care Team to function well, it must have the capacity to adapt to changing and complex situations. (Drinka, 2000, p47).

Figure 2.5 conceptualizes how the teamwork system would work. (Click on IDT Model)

Two or more professionals may belong to a core interdisciplinary team and at the same time use additional methods of practice with individuals, teams or groups depending on the particular need or problem.

Methods of Interdisciplinary Health Care Practice: Six methods of team practice are outlined that can function as a system for providing efficient health care when understood and utilized appropriately.

Table 2.5 shows the six methods of team practice. (click on IDT Table 2.5)

Read the following articles to learn about two different examples of interdisciplinary team practice:

Hartwig, Mary and Landis BJ (1999). The Arkansas AHEC Model of Community-Oriented Primary Care Holistic Nursing Practice 13(4), 28-37

  This article describes the Arkansas AHEC model of COPC. Two case studies re-used to illustrate the approach to COPC:

1. Selection of interdisciplinary, multidisciplinary and transdisciplinary approaches to management of a patient with chronic illness and
   
2. the sexual assault nurse examiners training project.

Milligan Renee A., Gilroy Jean, Katz Kathy, Rodan Margaret and Subramanian LN Siva. (1999). Developing a shared language: interdisciplinary communication among diverse health care professionals. Holistic Nursing Practice 13(2), 47-53.

  This article describes how the "web of causation" pubic health framework was used for interdisciplinary health care professional interaction related to infant mortality in the District of Columbia. A series of research protocols that affect the care of mothers and infants was developed.

You may have the opportunity at some time to create or develop an interdisciplinary team in your primary care practice setting.

Building a strong interdisciplinary team requires careful planning, commitment and constant nurturing. This section is adapted from the Pew Health Professions Commission Model Curriculum and Resource Guide (1995). It describes the important components of team formation. The student is encouraged to read more information from this guide that offers several case examples.

Membership on a health care team should ideally be determined by the disciplines and skills that are required for the effective realization of the goals of the team. Some professionals may only be required on an occasional basis so it is often useful to consider a "core" or "nuclear" team consisting of members that regularly function together on a full-time basis. Additional "extended" or "consulting" individuals provide important skills and services on an intermittent basis.

Visit again Drinka Model.   The Interdisciplinary Teamwork System Fig 2.5

In the early stages of development, the team members need to spend time planning the following: Goals, Tasks and Roles, Leadership and Decision-Making, Communication, Conflict Resolution. This might include considering members of the core and extended teams, specific role definition for each member and members’ role expectations, definition of issues that need to be addressed by the team as a whole, members’ information needs, mechanism for coordinating exchange of information, mechanism for evaluation outcomes and making adjustments to the team.

In other words, a team needs to know where it’s going, what it wants to do, who is going to do it, and how it will get done.

Goals: It is often helpful to begin with a broad mission statement to which all members can subscribe. From this statement, the team can then devise specific goals that have clear, realizable endpoints and objectives that provide a specific means of achieving this goal. Prioritizing these goals will further help to clarify the mission of the team and serves as a useful activity to develop team cohesiveness. The dimensions of the goals may be long-term or short term or may arise from professional needs, patient needs or team needs.

The goads initially described by the team are not necessarily fixed, and it is important to continually re-examine, redefine, and re-prioritize the goals of the team as required over time.

Tasks and Roles: In primary care there is often some overlap in the skills of the various providers. Several professionals, for example, have expertise in interacting with patients, forming care plans, and educating patients. Several primary care providers can diagnosis and treat illness. Thus, rather than attempting to define rigid boundaries of practice to segregate team members, it is more valuable to develop effective ways of sharing some responsibilities and tasks. See section on Team Members for more information on members of a health care team.

It is better to begin by differentiating tasks before negotiating roles in the process of defining functions of team members. This emphasis on tasks before roles tends to diminish issues of professional territoriality and ownership.

The central issue in role negotiation is whether traditional professional roles and skills are unique or merely distinctive. Because of the issue of overlapping skills, members must clearly define the role expectations for the team. Are expectations clearly defined? Do roles conflict or are they compatible? Can an individual meet all expectations?

The decisions of who does what can be guided by provider availability, level of training, or member preferences. As with the setting of goals, it is important to periodically review and revise member roles as necessary.

Pitfalls arising from lack of role clarification:

• new members are confused regarding what is expected of them and what they can expect from others
• increased conflicts between team members
• crises arise when members assume that someone else was responsible for handling the situation
• team decisions are not carried out effectively

Leadership and Decision-Making: There are several approaches to the leadership of an interdisciplinary collaborative team. Historically, physicians have had the role of team leader in health care settings due to various cultural, gender, and power factors. Still relevant today remains the issue of legal responsibility for patient care. An emerging pattern in many primary care teams, however, involves equal participation and responsibility on the part of team members with "shifting" leadership determined by the nature of the problem to be solved. Emphasis by the team on "health care" rather than the more narrow focus of "medical care" broadens the roles and responsibilities on non-physician providers. See IDT Table, Methods of Interdisciplinary Team Practice Drinka Table 2.5 (click on word above or see IDT Table in resources section)

A team must address the following questions in developing a mechanism for making decisions:

1. What needs to be decided?
2. Who should be involved in the process?
3. What decision-making process should be used?
4. Who will be responsible for carrying out the decision?
5. Who needs to be informed about the decision?

Communication: An effective, coordinated team must have an efficient mechanism for exchange of information. At the simplest level, this requires the time, space, and regular opportunity for members to meet.

An ideal system for communication would include:

• a well-designed record system
• a regularly scheduled forum for members to discuss patient management issues
• a regular forum for discussion and evaluation of team function and development, as well as related interpersonal issues
• a mechanism for communicating with the external systems within which the team operates

Conflict Resolution: Given the mixture of skills and professional backgrounds, and the complexity of interdisciplinary collaboration, a diversity of views and differences of opinion are inevitable. It is important to recognize, however, that conflict is both necessary and desirable in order for the team to grow and thereby develop greater efficiency and effectiveness. Conflict encourages innovation and creative problem solving, while successful confrontation and resolution of differences engenders increased trust and understanding between team members. Signs of failure to deal effectively with conflict, in contrast, include low morale, withdrawal, lack of involvement, condescension, depression, anger, and provider "burn-out."

Barriers to dealing effectively with conflict include:

• an idealized sense of "togetherness" that inhibits feedback and confrontation over differences
• a professional tradition of obedience to authority and corresponding unwillingness to disagree
• "banding together" of members of the same profession when there is disagreement between professions
• misunderstanding of the roles, skills, and responsibilities of other team members

Members need to focus on the overall mission of the team and the care of the patient when dealing with conflicts in order to avoid making differences of opinion "personal." Agree to ground rules before attempting to solve the conflict. It may be helpful to have a team facilitator who does not have a “stake” in the outcome.

Negotiation strategies to consider:

1. separate people from the problem (i.e. diffuse the emotional component of the conflict by showing respect, listening carefully, and giving all parties an opportunity to express their views
2. clarify the conflict/recognize the problem
3. involved parties need to agree to work toward a solution
4. deal with one problem at a time, beginning with the easier issues
5. brainstorm about possible solutions
6. focus on common interests, not positions
7. use objective criteria when possible
8. invent new solutions where both parties gain
9. implement the plan
10. evaluate and review the problem-solving process after implementing the plan

Possible outcomes of team conflicts:

• avoidance: conflicting members avoid each other or conflicting issues are avoided in team discussion; leads to stagnation
• capitulation/domination: leaves “winners and losers”; divisive for team
• compromise: each party gives up something important; may lead to divisiveness and avoidance since members may feel that they have lost out
• collaborative problem-solving: each party states clear, observable terms; solutions are sought that maximize net gains for both parties; members feel positively about a solution that is to the greatest benefit of the team

Health Professionals that are exposed early in their training to working with interdisciplinary teams will have more chance for success in team building and team practice.

Read the following article to see how nursing and medical students team for service learning in community-based settings in the District of Columbia.

Sternas Kathleen, O’Hare Patricia, Lehman, Karen & Mulligan, Renee. (1999) Nursing and medical student teaming for service learning in partnership with the community: an emerging holistic model for interdisciplinary education and practice. Holistic Nursing Practice 13(2) 66-77