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I love to hear a choir. I love the humanity: to see the faces of real people devoting themselves to a piece of music. I like the teamwork. It makes me feel optimistic about the human race when I see them cooperating like that. Paul McCartney

frames, tribes
and teamwork

Paul (2002) defines three important team approaches to clinical service delivery:  multi-disciplinary, inter-disciplinary, and trans-disciplinary, more or less as follows.

MULTI-DISCIPLINARY TEAMS
An approach to service provision in which professionals from different disciplines work independently and report to the team.

INTER-DISCIPLINARY TEAMS
A team approach in which professionals perform tasks within their discipline while sharing information and coordinating services.

TRANS-DISCIPLINARY TEAMS
A team approach in which members from different disciplines work collaboratively to focus on shared goals and outcomes. Team members work together and may cross discipline lines. Trans-disciplinary service delivery relies upon active, ongoing communication between all team members regardless of background or specialization in order to maximize effective client intervention. The client is a member of the team. 

frames
Whatever its structure, a team that includes an individual with a communication impairment may find that embracing a strong sociolinguistic stance when framing goals is conducive to effective functioning. 

In a sociolinguistic frame, a client's communicative function, mental and physical performance, activities of daily living, and optimal states of health and wellbeing, are seen as ways of achieving economic and social endeavour. This means that the client is viewed holistically within his or her culture, and within a range of contexts that may include the family, the wider social network, and educational, vocational or rehabilitation settings. This is exemplified in the work of Skeat, Perry, Morris, Unsworth, Duckett and Taylor (2003) and their application of the ICF to the Australian approach to allied health outcome measures, the AustToms. Marvellous. 

As a consumer-driven style, in the sociolinguistic frame a client's social goals and expectations are constantly at the forefront. Individuals sourcing professional services themselves, or for those they care for, have integral roles as advocates, informing the service delivery process, and pathways of assessment and treatment.

tribes
But hold on, wait a minute! Would adopting a sociolinguistic frame give the team's social worker and speech-language pathologist some feeling of "ownership" or "inside knowledge" within a team on the "socio" and "linguistic" angles respectively? And could this be a barrier to successful team functioning? Well, potentially, yes, according to investigators from the Scottish Council for Research in Education.

Reporting the findings of a two-year Department of Health funded study of multidisciplinary education in health care, Wilson and Pirrie (2000) identified professional tribalism as one of the potent inhibitors of effective multidisciplinary teamwork:

"Attitudes of exclusivity which new initiates into a profession acquire in initial training, and fear of a ‘dilution’ of professional standards may be confirmed and strengthened in practice. How to confront these attitudes remains the challenge for multidisciplinary team-working." (4.4.2)

INHIBITORS
Summarising the significant inhibitors, in addition to the absence of key facilitators of teamwork (see below), Wilson and Pirrie singled out:

1. lack of appropriate accommodation and resources;
2. the role of professional bodies and profession-specific training; and,
3. attitudes of team members, especially those that reinforce traditional professional hierarchies.

DISTANCE
Comments in the report on the role of Scottish professional associations as the guardians of practice standards through the accreditation of professional competencies had a familiar ring.

"In practice, there is little liaison between different professional bodies, some of whose members may work in proximity to each other with the same client groups; this has led to the growth of unsynchronised validation cycles and profession-accreditation of competence." 4.3.2

In an Australian context the comment does not seem particularly relevant to professional associations, which have a good record of cooperation, but it is a reminder of the distance, and poor communication that can exist between education and health bureaucracies and workplaces.

FACILITATORS
In the best of teams, members not only communicate and collaborate. As well, they support and sustain each other, conscious that a few words of encouragement during a miserable or difficult time, or after a foul up, are likely to be more helpful to everyone on the team than basking in self-congratulation after an obvious success.

Under the heading, "What encourages multidisciplinary team working?" Wilson and Pirrie report that there was complete agreement from multidisciplinary (health) team members on the importance of feedback. They found that the main points to emerge from the study as facilitators of multidisciplinary process were the value of having:

1. committed, enthusiastic individuals as team players;
2. personnel working together to develop a common sense of purpose;
3. team roles clearly negotiated with members; and, most significantly,
4. explicit support from any host organisation.

teamwork
Megan Hodge, whose “host organisation” and employer is the University of Alberta, has given a lot of thought to the trans-disciplinary team structure and its suitability for speech impaired children and young people with severe, complex and changing intervention needs (Hodge, 2002). But she has also had the personally and professionally challenging, and ultimately satisfying, experience of being a co-founder of a trans-disciplinary research team, the Applied Developmental Neuroscience (ADN) group. In the supportive and encouraging atmosphere of the University, highly motivated and committed team members from medicine, occupational therapy, speech pathology and physiotherapy, began as an interdisciplinary team, interacting across disciplines with group-defined goals and activities.

"YOU GO FIRST." "NO, NO, REALLY, AFTER YOU!" 
So unified were they in their endeavour as a team, that when Joyce Magill-Evans, PhD, OT(C), Megan Hodge, PhD, SLP(C) and Johanna Darrah, PhD, PT came to submit their article about the process for publication they could not identify a first author: "our perception was that combined efforts created a unified work that could not be attributed to individual co-authors."

How the team's structure evolved, with a "melding of discipline-specific knowledge into a single framework" as they became a trans-disciplinary team (Magill-Evans, Hodge and Darrah, 2002), and reflected on what they had accomplished, makes for riveting reading.

ALLIES
In an allied health frame, Skeat, Perry, et. al. (2003) talk about the enthusiastic collaboration between OT, Physio and Speech in the development of outcome measures based on the International Classification of Functioning, Disability and Health (ICF) (World Health Organization, 2001). 

In service provision for children, teamwork must be at least as much about parents and teachers as it is about tribes of allied health professionals. Thinking along these lines, McLeod and Bleile (2004) put out a strong, constructive message about cooperation between speech-language pathologists and teachers in an article, available on the publisher's web site. They emphasise that the ICF incorporates both impairment and social factors to be considered when choosing appropriate goals, and propose an ICF-based treatment goal-setting frame. Above all, they are optimistic about the capacity for SLPs and teachers to "work together not only to provide direct intervention with the child, but also to work in partnership with the child's family, friends, school and society."

CHAMPIONS
Whether a team is about publishing a book, journal, paper or report, running a professional association, developing outcome measures, clinical service delivery, collaborative cross-disciplinary research, mounting a conference, or running a department or practice, it all comes down to the calibre of the individuals involved. Pirrie and Wilson again: "It is difficult to overestimate the effect of committed individuals, or ‘champions’ to the success of multidisciplinary team working." These are the champions who bring out the best in the best people.

 

"Organization doesn't really accomplish anything. Plans don't accomplish anything, either. Theories of management don't much matter. Endeavours succeed or fail because of the people involved. Only by attracting the best people will you accomplish great deeds." 
Colin Powell

references
Hodge, M. (2002). Clinical classification of children with developmental speech disorders: A trans-disciplinary perspective. In Shriberg, L.D. and Campbell, T.F. (Eds). Proceedings of the 2002 Childhood Apraxia of Speech Research Symposium. Carlsbad, CA: The Hendrix Foundation, 215-221.

Magill-Evans, J., Hodge, M. & Darrah, J. (2002). Establishing a trans-disciplinary team in academia. Journal of Allied Health 31, 222-226.

McLeod, S. & Bleile, K. (2004). The ICF: A framework for setting goals for children with speech impairment. Child Language Teaching and Therapy, 20, 3, 199-219

Paul, R. ( 2002). Introduction to clinical methods in communication disorders. Paul H. Brookes, Baltimore, Maryland. 

Skeat, J., Perry, A., Morris, M., Unsworth, C., Duckett, S., Dodd, K., & Taylor, N. (2003). The use of the ICF framework in an allied health outcome measure: Australian Therapy Outcome Measures (AusTOMs). In Australian Institute of Health and Welfare (AIHW) ICF Australian User Guide. Version 1.0. Disability Series. AIHW Cat. No. DIS 33. Canberra: AIHW.

Wilson, V, and Pirrie, A, (2000, Sep). Multidisciplinary Teamworking: Beyond the Barriers? A Review of the Issues. Scottish Council for Research in Education. 

World Health Organization (2001). International Classification of Functioning, Disability and Health (ICF). 
  

links
HPCA
Health Professions Council of Australia
Online browser
ICF Children and Youth version is
available in the online browser: 
Choose the ICF-Children from the list 
Scotland 
Allied Health
Searchable ICF 
Available on the WHO web site

http://speech-language-therapy.com/webwords22.htm

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Page updated May 12, 2009