As the phrase ‘health care reform’ circulates with increasing
regularity and alacrity, many are stepping forward and purporting
possible definitions and implications of this ideal, and what actions
are required to truly bring it about.
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As the phrase ‘health care reform’ circulates with increasing regularity and alacrity, many are stepping forward and purporting possible definitions and implications of this ideal, and what actions are required to truly bring it about.
One perspective for change includes the idea of practitioners of all disciplines coming together in ways that increase system efficiency and improve patient access to services while providing a more holistic approach to health care that is better streamlined to address patients’ problems and guide them to wellness. This perspective is being reflected in the increasing complexity of group practice structures that have emerged. Many of these have piqued the interest of the chiropractic profession as it seeks to broaden its field of recognition, accessibility and acceptance within the health care system. Chiropractic is finding, within certain group practice situations, an opportunity to reach more patients in order to provide conservative and wellness-oriented care for an increasing scope of issues, while building its profile within the health care community. But are chiropractors sufficiently equipped, through their training and experience, to successfully harness a group situation?
There are various group practice models now open to chiropractors who wish to work within a team atmosphere: multi/interdisciplinary or not, collaborative or not (or somewhere in between), within the same location or a geographically dispersed network – these are just some examples. This article will describe some interprofessional group practices that involve chiropractors, with a focus on levels of collaboration within each group. But first, the idea of interprofessional collaborative practice will be examined to isolate dynamics that may lead to, or away from, its success as a forum for chiropractic growth and integration into the health care system, and as a patient-centered endeavour. (Questions of income, within a group practice, are not included within the scope of this article.)
The information here is, by no means, conclusive with respect to this topic but is meant to point out some considerations and questions that may be relevant to the profession as it explores this type of practice for its members.
Defining interdisciplinary collaborative practice
Professional collaboration, to a health care worker, can take on many forms. Collaboration may take place on an intra-disciplinary level, within interdisciplinary groups, or may even be cross-jurisdictional, when necessary. The point behind all collaboration should be to provide better service and care for the patient but can also serve to bring its participants together to work toward a common goal thus fostering respect and familiarization with each other’s work, and lessening tensions that may have existed prior to the collaborative activity.1
According to Health Canada, “Collaborative patient-centred practice is designed to promote the active participation of several health care disciplines and professions. It enhances patient-family and community-centred goals and values, provides mechanisms for continuous communication among health care providers, optimizes staff participation in clinical decision making (within and across disciplines), and fosters respect for the contributions of all providers.” 2
In the collaborative health care model, patients may become participants3 in a customized, multi-modality care plan into which they are entered after evaluation by an individual within the practice system (for example, a nurse practitioner, a family physician, one of the chiropractors, etc). Collaborative practices often – but not always – are made up of practitioners who can address a particular focus of concern (for example, pain management) and, as such, a patient has available, to him/her, strategies from a variety of healing practices to address the physical as well as mental/spiritual/social elements of their illness. What is particularly attractive, for a patient, is finding all of these “under one roof,” thus simplifying the clinical elements of the healing process.
Also worth pointing out, “Collaboration is a complex activity taking a variety of forms and changing over time.” 4 Within a group health care practice, collaboration may be informal or may involve a referral/planning/execution/follow-up structure that includes regular group ‘rounds’ and, even, educational sessions.
The themes that immediately emerge, then, are that interprofessional collaborative practice requires a team dynamic, a patient-centred focus, and that it is a process.
Features of interprofessional collaborative practice
There exists a wide body of literature discussing the group dynamics, advantages and possible pitfalls of interdisciplinary collaborative practice, including how this pertains to those disciplines that, for various reasons, struggle for recognition and/or acceptance within the medical system.
In a 2003 review of the pertinent research and experience in this area, Laura Bronstein identifies five elements of an interdisciplinary collaboration model that reflect the challenges and rewards inherent in this sort of work. These are interdependence, newly created professional activities, flexibility, collective ownership of goals and reflection on process. As she expands on each of these, some salient points stand out:
A solid professional identity, on the part of each member is necessary for successful teamwork. If a member of the team is part of a profession where identity is not well established – or the member is not well entrenched within this identity – it will undermine the security of that member within the team, thus diminishing his/her impact and utility to the group and the client.
Collaboration can result in protocols and activities that are more effective than if the same professionals were to work on their own. This can also serve to increase the expertise of each member of the collaborative team.
Flexibility includes the ability to compromise, of course, but also encompasses the fortitude to allow some shifting, within the group, when designating leadership roles. Leadership, in a particular project, should reflect individual patient needs rather than preconceived professional hierarchical distinctions.
There should be shared responsibility in reaching team goals – all team members should be included throughout the process. This also means there will be shared accountability.
Collaborators must continue to pay attention to the development of the collaborative process of which they are members and must be willing to discuss their progress within the collaborative journey, how it can be improved upon, and how to strengthen the effectiveness of relationships within the group.
Bronstein’s review also summarizes the factors that influence this interdisciplinary collaborative process. These, she lists as:
professional role (strong values and ethics, commitment to the team),
structural characteristics (are case-loads, schedules, etc, manageable?),
personal characteristics (including how members view other people’s roles and disciplines) and whether the members have a history of collaboration or not.
Patient-centred, patient-centred, patient-centred
A point of caution is to be made vis-a-vis the possible consequences of collaboration for patient advocacy. The concern is that within a collaborative group, advocacy may be compromised in the name of deferring to others’ opinions – this is different from compromise – either out of group pressure, or because of lack of strong identity either on the part of the advocating member, or the group’s perception of that member’s role. Deferring, compromise or dominating in any patient situation should be based on “sound professional judgment and on an active evaluation of what is best for the client.” 5
Implications for training and continuing education
The profession of chiropractic is increasingly endorsing interprofessional collaborative practice opportunities for a variety of reasons. Along with its potential benefits, both in strengthening the profile of disciplines within the health care system and in providing more complete and accessible care for various patient populations, studies have found that “successful collaborative efforts involved mechanisms for broad-based reform that affects clients, programs, policy and organizational bureaucracy.” 6
On an individual level, though, a practitioner who is thinking of participating in an interprofessional collaborative practice option must be sure that this type of environment is right for him/her, and must enter into it with a patient-centred mindset, but also with the firm realization that he/she will be representing the whole profession in all aspects of daily work.
As one begins to delve into what exactly this means and entails, it becomes clear that it can be quite complex and that entrance into this sort of practice should reflect a well-informed and educated decision. Wither, then, should the training to inform and prepare DCs for successful collaboration ensue?
Roy Romanov, on page 109 of his final report on the Commission on the Future of Health Care in Canada wrote: “. . . in view of . . . changing trends, corresponding changes must be made in the way health care providers are educated and trained. If health care providers are expected to work together and share expertise in a team environment, it makes sense that their education and training should prepare them for this type of working
arrangement.”
Romanov’s statement points to the institutions that train health care professionals as ground-zero for each practitioner’s knowledge and understanding of the interprofessional collaboration process. By extension, continuing education efforts, on the part of colleges, associations, etc, can educate those already in practice on the finer points of collaborative work.
The point is that good collaboration amongst health care providers, especially across the different disciplines, is not just something that necessarily springs into being naturally – its success, for all involved (especially patients), can be better assured if those who are called to participate in it have some formal understanding of exactly what it is they are being asked to do, and how they can best do it.
In Part 2 of this article, we will examine practice situations and interprofessional collaborative work, in a variety of settings.
References for Part 1
- Mailik, Mildred D. and Ardythe, Ashley, A. Politics of Interprofessional Collaboration: Challenge to Advocacy. The Journal of Contemporary Casework, March 1981. page 131-137.
- Health Canada, Interprofessional Education for Collaborative Patient Centered Practice at http://www.hc-sc.gc.ca/hcs-sss/hhr-rhs/strateg/interprof/index-eng.php, March 3, 2010.
- Westrom, K. et al. Individualized chiropractic and integrative care for low back pain: the design of a randomized clinical trial using a mixed-methods approach. Trials 2010, 11:24 at http://www.trialsjournal.com/info/instructions/
- Weiner, Hyman, Knowledge and Skills for Collaborative Care. Paper presented at the Institute on Collaborative Practice in Health Care, Long Island Jewish-Hillside Medical Center, New Hyde Park, New York, February 8, 1979.
- Bronstein, Laura, R. A Model for Interdisciplinary Collaboration. Social Work, Volume 48, Number 3, July 2003. Pages 297 – 306.
- Mailik, Mildred D. and Ardythe, Ashley, A. Politics of Interprofessional Collaboration: Challenge to Advocacy. The Journal of Contemporary Casework, March 1981. page 131-137.
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