Abstract
The way that psychiatrists and other mental health professionals work together has an impact on standards of clinical care and professional satisfaction. Although in the past many psychiatrists have worked in relative isolation, today it is rare for mental health care to be provided by a single professional, even where one person is designated as the primary direct-care provider.
Public-sector mental health services in Australia and New Zealand are predominantly provided by specialized multidisciplinary teams working in inpatient and other community settings [1, 2]. As teams often work across settings to promote the required continuity of care, there is growing acknowledgement of the need for an expanded notion of ‘teamwork’ operating between professionals, relatives and carers, self-help groups, nongovernment agencies, and statutory authorities providing housing and social security [3, 4]. Although the range of available professionals and services may be different in the private sector, most people receiving services from psychiatrists will receive services from others as well, regardless of the setting. As evidence of this, of the 10 641 persons surveyed in the National Survey of Health and Well-being [5], 235 had seen a psychiatrist in the survey period (our analyses). Respondents were also asked whether they had seen other health professionals, including GPs, psychologists, social workers, drug and alcohol counsellors, nurses, and a mental health team, among others. Only 11, or less than 5%, of the 235 who saw a psychiatrist, did not see one or more of the others in the list. This percentage might be even lower if informal carers had been included.
The advantages of teamwork include continuity of care [6], the capacity to take a comprehensive view of the patient's networks and problems [7], the availability of a range of skills [8], and mutual support and education [9]. A well-functioning team with a shared sense of responsibility may be more than the sum of its parts: the team can produce more and better work than its individual members working as solo practitioners [4], p.349]. Working in clinical teams, however, which are not functioning well can also be a source of professional dissatisfaction for psychiatrists and other clinicians [10], and can contribute to unsatisfactory care for patients and families. We reviewed some of the issues involved in clinical teamwork, and make recommendations based on our review.
Method
The Professional Liaison Committee of the Board of Professional and Community Relations of RANZCP identified the betterment of working relationships between psychiatrists and other mental health professionals as a matter of pressing concern. The committee obtained a strategic planning grant from the College to examine the problems facing psychiatrists in professional relationships, and to make recommendations to the College in the areas of training, maintenance of professional standards, and leadership and management.
The committee is based in Melbourne and has representation from a range of mental health professions. It convened a workshop ‘Defining best practice in inter-disciplinary teamwork’ at the Mental Health Services conference in Sydney in 1997 and presented the central themes emerging from that workshop at the MHS conference the following year in Hobart [11]. The work was also presented at the congress of the RANZCP in Melbourne in May 1998.
Subsequently, the committee held a series of eight meetings over nine months, facilitated by JW, in which ideas were continuously developed and refined. Between meetings, notes of the meetings, summaries of the relevant literature, and draft analyses and recommendations were circulated to members for consideration at the next meeting. Methods included consideration of relevant literature (obtained by TT), brainstorming, refinement of interim conclusions, ongoing critical analysis, and development of recommendations. The committee has produced a report that will form the basis of a College position statement after the College consults with consumer and carer, government and other professional organizations.
Results
At its simplest, a team can be thought of as a small group of people who come together for a common purpose. Williams and Laungani [12] have identified the core features of a team as: common purpose and goals; clear understanding of each others’ roles and abilities; regular formal and informal interaction; a shared knowledge base and collective responsibility; task-orientation; and diverse complementary skills. They cite a definition of teamwork as ‘actions, processes and behaviours which contribute to the team's ability to achieve specific, shared, and valued objectives’ [13], p.3]. Others have identified another important ingredient: an articulated vision or philosophy. Onyett argues that community mental health teams (CMHTs) require an explicit ideology of care, and the absence of a strong, shared philosophy of care has been listed as one reason for problems in such teams [14].
Our process identified a number of obstacles to effective teamwork and collaboration that will be discussed under the following headings:
Ambiguity or conflict over roles. Conflict and confusion over leadership. Differing understandings of responsibility and accountability. Interprofessional misperceptions. Differing rewards between professions.
Ambiguity or conflict over roles
Abundant evidence exists that ambiguity or conflict over roles in teams can lead to personal strain and poor function [7, 15–18]. Tension appears to exist between team members’ desire for clarity of roles and the need for flexibility. At one extreme, role clarity is interpreted as specifying the unique contribution of each profession. For example, Leigh sees the main contribution of the social worker as attending to the family, the nurse as providing support, and the psychologist as performing assessment [19], while Goldberg has them attending to psychosocial problems, events on the ward, and assessment, respectively [20]. While these views may have a somewhat dated feel, similar models can be found more recently [21]. For the most part, formulations that emphasize the uniqueness of professions are accompanied by the view that the psychiatrist is the natural team leader, usually on the basis of the broadest range of training [22, 23]. Indeed, the roles of nonmedical staff may be construed as ‘professions allied to medicine’ or even ‘physician-extenders’ [24]. Other formulations, in contrast, highlight the shared nature of roles in a team. Studies of clinical teams, based on both observation and inquiry, suggest a significant overlap between the activities and functions of various members, and that most of their time is spent on nonprofession-specific activities [25]. It has been observed that the nonmedical professions aspire to the more glamorous, ‘virtuoso’ roles, which are about curing, as opposed to general caring roles, which are about tending [26], pp.[95–96]. Studies in primary health care suggest that flexible team roles contribute to a team's ability to find creative solutions to problems, and that rigid, narrowly defined roles are symptomatic of teams that function poorly [27]. There is no inherent contradiction between role clarity and role overlap. Role ambiguity may arise when overlapping roles are unacknowledged, whereas role conflict arises when team members compete for exclusive ownership of certain roles. More often observed among the higher-status members of the team, competition and rivalry is often most intense for a role that many see as capable of belonging to one person only, that of leader.
Conflict and confusion over leadership
A considerable amount of literature proposes that the psychiatrist is the natural leader of the multidisciplinary team [28–31]. In a critical review of this position, Rosen reminds us that ‘Psychiatrists are still socialized to assume the central role and overall responsibility for the treatment of their patients, and to expect unchallenged leadership of mental health services or facilities’ because ‘it is often assumed that the psychiatrist has had the longest, widest, deepest and most practical apprenticeship-based training, and therefore is usually in the best position to provide ‘comprehensive biopsychosocial management plans’, to offer ‘higher order’ diagnostic and treatment skill and ‘higher order’ consultant opinions on management of complex cases’ [32], p.[612–613].
Also, others suggest that length and breadth of clinical training do not necessarily make a good team leader. Beigel and Santiago suggested that training should prepare the psychiatrist for a variety of roles and levels of authority, but warned that ‘… he or she may not be team leader’ [33], p.771]. Thus more curricular emphasis should be placed on preparing the psychiatrist to participate effectively in different roles and with different degrees of authority’. Tobin [34] pointed out that leadership of the mental health team is earned, and not bestowed. Boyce and Tobin list the leadership and management opportunities as incentives for psychiatrists to work in the public sector [2]. Not all, however, enjoy these roles. Maybe the expectation that they lead and manage deters some psychiatrists from approaching the more teamorientated environment of public sector psychiatry. Some may even feel that they are ‘letting the side down’ if they prefer to focus on the activity for which they were primarily trained, seeing patients. Others may wish to undertake, and be well suited to, leadership, administrative or management roles.
Not all teams have leaders, and not all who think they are leaders are acknowledged as such. In a national survey of community mental health teams in the UK, Onyett et al. found that only three-quarters of teams had a ‘team manager or coordinator’[35]. When Trauer asked members of several clinical multidisciplinary teams to identify the leader of their team, responses varied between no-one and three people [Trauer T: unpublished report]. In some situations, multi-person leadership may have certain desirable features [1, 36].
Differing understandings of responsibility and accountability
Leadership of a team is usefully distinguished from professional responsibility and accountability. Equating these can lead psychiatrists to have reservations about working in teams, as well as cloud the discussion about team leadership. The perception of responsibility for the work of a team, without the corresponding authority, is a recognized source of stress and burnout for psychiatrists [10, 37]. The importance of keeping leadership and responsibility separate has been recognized for some time [38]. The basis of their separation has been summarized by Onyett:
‘It follows from the circumscribed nature of professional responsibility that no professional can be held accountable for another professional's actions except in part by negligent delegation or inappropriate referral (British Psychological Society, 1986). This resolves the unhelpful conflation of medical responsibility and ultimate clinical responsibility. Medical responsibility is best regarded as a particular instance of professional responsibility whereby practitioners are accountable for those tasks for which they are recognized as competent as a result of their medical training. Ultimate clinical responsibility is claimed by the senior medical member of the team when he/she asserts that he/she is accountable for the work of the team as a whole should disaster occur. The latter is unjustified. The Nodder Report concluded that there is “… no basis in law for the commonly expressed idea that a consultant may be held responsible for negligence on the part of others simply because he [sic] is the ‘responsible medical officer’; or that, though personally blameless, he may be held accountable after the style of a military commander. A multidisciplinary team has no ‘commander’ in this sense (DHSS, 1980)”.’ [40], pp.[281–282].
Responsibility refers to being called to account for one's actions, while leadership refers to a function or activity. The former is individual and the latter is interpersonal. Teams cannot be held legally responsible for their actions, but team members can be severally responsible for such matters as duty of care and standards of care.
The concept of clinical authority may be useful. The clinical authority vested in the psychiatrist or other mental health professional by virtue of training and experience can be supported rather than weakened by good teamwork.
Interprofessional misperceptions
Different understanding of responsibility is but one of a number of ways that professionals differ in their perceptions of each other. Real differences exist not just in skills and training, but also in values and culture [40], in socialization [41], and in cognitive styles [42]. Professionals may view their differences with other professionals either positively or negatively. The overly narrow perceptions of professional roles discussed above is an example of the cognitive distortion of stereotyping. Members of any profession generally see their contribution as more important than do members of other professions [7], p.318]. Beyond that, the concentration on differences to the exclusion of shared skills harms interprofessional relationships. There is a tendency for members of one profession to interpret interprofessional differences as deficiencies in the training of the members of the other profession [42]. The more positive construction is that diversity within teams is an important contribution to their effectiveness and is ‘to be celebrated, not homogenized’ [14], p.247].
Differing rewards between professions
Different rewards, notably power, status, and income, are contentious. Team members often avoid addressing and dealing with real and important differences in seniority and status. There are several reasons for this [43]: a fear of undermining the tentative consensus about purpose which is essential to holding the group together and a fear that releasing destructive feelings of jealousy and envy could break the fragile unity of the team. It has also been noted that team members who work toward establishing participatory and equal relations with clients also emphasize equality and democracy between team members themselves. A literal adherence to the ideal of democracy is widely recognized to be a myth that can impede members from addressing underlying problems [44, 45].
Power considerations affect different disciplines in different ways: certain groups may exercise power by exclusion and thereby restricting to its members the benefits of membership, while others exercise power by usurping or challenging the position of the excluders [26], p.41]. It has been suggested that ‘Subordinates are aware of the counter power they possess which limits the power of the boss. They come to know their own jobs better than their superiors know these jobs, and so… superiors then have to depend on their subordinates’ expertise and the latter gain power as a result.’ [46], p.44]. There is little objective evidence that bears upon the perception by psychiatrists of the importance of power in their working lives, but one study is particularly relevant [48]. A group of psychiatric programme directors maintained it was their clinical activities that contributed most to their job satisfaction, but analysis of ratings on a questionnaire showed that the frequency with which they engaged in administrative tasks correlated more highly with their job satisfaction ratings. The explanation of this finding was based on the correlates of power (respect, freedom to act, ability to influence others, and possibly higher income) as mediating factors.
Yet in mental health teams, the doctors’ assumption of authority may not be shared by other professionals, creating conflict and inhibiting team relationships [45], p.226]. Different forms of power can be distinguished [45, 48] and that based on relevant knowledge and expertise is generally held to be more legitimate than that based on other grounds (e.g. charismatic). How well relevant knowledge and expertise relate to type and duration of education is an unexplored question. Equally important is the potential lack of influence or voice of those members of a clinical team, particularly those with the least pay and seniority, with a useful working knowledge of the patient's level of functioning and level of risk [49, 50].
Conclusions and recommendations
Based on the above considerations, the committee was able to draw up a number of recommendations to assist the RANZCP in identifying and dealing with each of the obstacles to effective teamwork and collaboration. These can be presented according to actions possible at three levels:
Education and training. Professional organizations. Workplace organizations.
One set of these recommendations has been discussed with the RANZCP training committee, and educational aims for trainees and supervisors developed [51]. Several recommendations involve collaborative activities with other professional organizations.
At the level of education and training, the recommendations relate to teaching and examination about team dynamics, structure and function, in the context of contemporary understandings about organizations. With the move from the hospital as the main focus of care to the less structured ‘ward in the home’ and clinic, the needs of patients and families have changed. Psychiatrists along with clinicians from other disciplines need training in the principles of teamwork, an important aspect of community psychiatry [10, 52, 53]. Training programmes, perhaps interdisciplinary, could aim to produce a conscious shift in attitude toward working in teams, and the syllabus include training in teamwork and the associated personal skills. Such training could include both didactic and experiential aspects. Teaching could also include consideration of the legal aspects of responsibility, accountability, and leadership.
At the level of the professional organization, relationships with other professions could be enhanced by joint projects, and joint statements on matters of mutual concern (e.g. see [54]). Such joint initiatives should include expectations of ‘best practice of workplace organizations, governments, and healthcare standards bodies about the attitudes and actions of professionals, especially as far as team roles are concerned. Programmes for the maintenance of professional standards could give credit for developmental and educational activities relating to teamwork. Professional leaders could acknowledge and promote the fact there are many valuable and satisfying roles for psychiatrists in teams that include but are not restricted to administrative oversight.
Finally, at the level of the workplace, we identify the desirability of clear and agreed job descriptions, which include expectations of collaborative working. Team protocols which establish the service objectives and the roles and functions of the various members, and position specifications making a clear separation between leadership or coordinating functions, and professional and clinical responsibilities, would achieve a great deal. More opportunities could be created for shared leadership functions.
Success in resolving these problems will assist unity of purpose among the RANZCP fellows, and the advocacy role of the College in ensuring appropriate levels of clinical expertise, supervision and standards in mental health care. Discussion of these issues with other professional groups, governments, policy makers, and representatives of consumers and carers will help shape the ideas and may continue to have an influence on policy and practice.