Chapter 6. The collectivity of healthcare: multidisciplinary team care
Eileen Willis, Judith Dwyer and Sandra Dunn
Introduction
Threaded through this discussion are excerpts from a case study of the care of a single child with brain cancer (‘Teamwork for Keown’) presenting the perspectives and insights of four members of this family’s healthcare team in ways that we hope illustrate the major themes in current thinking about teamwork in healthcare. We use both a narrative and thematic approach drawing on the experiences of: a paediatric oncologist; a paediatric palliative care nurse practitioner; a physiotherapist with experience in paediatrics, oncology, adult rehabilitation and domiciliary care teams; and Sandra, mother of five children and professor of nursing. Professor Sandra Dunn is an author of this paper in both capacities, and her family has consented to this use of Keown’s story.
In 1998 Keown, Sandra and James’s youngest child, was diagnosed with medulloblastoma, cancer of the brain. He died in 2003 at the age of 10. Interviews and thematic analysis were conducted by the first two authors following ethics approval and focused on the participant’s experiences and beliefs about client/family-centred multidisciplinary care. The framing of these interviews was based on a review of the literature and a reading of the narrative account presented by Sandra, although the focus of the interviews was not on Keown exclusively, but rather on teamwork more generally. We use the case study to remind the reader that in the last analysis the organisation of clinical treatment is about dealing with human need and suffering. The first narrative of the case study is below.
Box 6.1
Sandra: On 15 August 1998, aged five years and four months, Keown James Dunn, my youngest son, was diagnosed with a medulloblastoma, cancer of the brain. In the coming years my husband and I learned more than we ever wanted to know about the paediatric oncology experience – from the parent’s side of the looking glass.
Keown had had maybe a year of occasional morning headaches, sometimes vomiting – not enough to get much attention in the chaos of getting seven people off to school and work. Then one morning came the call from school – ‘Keown has a bad headache. He’s crying and the light hurts his eyes.’ The nurses in the ER stood with me and my husband, listened to our questions, told us what was said when our ears were too full of fear to hear the doctors’ discussion. Then the CAT scan, the first set of films, the radiologist arriving to inject contrast. For me, it truly started then. Then surgery. There were no real choices. With that presentation, there weren’t options; there wasn’t time.
Post-op … waiting. Did they get it all? Will he wake up? And if he does, will he still be our son? As Keown lay in paeds ICU, the neurosurgeon came to see us, telling us what had happened, reassuring us that the surgery had gone well. The nurses answered and re-answered our questions, the same questions over and over, reassuring, moving with purpose and skill.
After surgery came the looking for answers: How do we help our son? We didn’t even know the questions, let alone the answers.
Teamwork in organisations
The concept of the team is an old one, originally referring to harnessed animals pulling loads together and now used extensively for groups of people playing sport or working together. It implies interdependence, common goals and effort, and its positive meaning is related to the idea that the whole is more than the sum of its parts. A team can be defined as two or more individuals performing a range of interdependent tasks with a clear division of labour (Baker et al 2006). More technically, it is defined as
[A] collection of individuals who are interdependent in their tasks, who share responsibility for outcomes, who see themselves and are seen by others as an intact social entity embedded in one or more larger social systems and who manage their relationships across organisational borders.
(Cohen & Bailey 1997:241)
Teams can be lasting structures – such as the staff of a dialysis unit or a community health centre – or short-term groups that form to meet the needs of an individual family or situation such as those responding to a local outbreak of infection in a child care centre, or a project team introducing a new system or service.
Over the past several decades attention to teamwork has been a strong component of contemporary management theory with a number of experts suggesting that it contributes to increases in efficiency, productivity, problem solving and workplace creativity (Morris 1996). Management literature in the 1980s and 1990s on the flexible firm and flexible specialisation suggested that teamwork produced flatter structures and a breakdown of the rigid division of labour, bringing the production process closer to the customer and their needs (Mathews, 1989, Mathews, 1991, Mathews, 1992a and Mathews, 1992b, Robbins & Barnwell 2002). As Sutcliffe and Callus (1994:67) note the aim is to enhance the links between the market and the organisation in an arena where technological change increasingly requires more flexible work practices. Two questions arise from this work: first, it is not clear from the literature what exactly it is about teamwork that brings the production process closer to the customer; and second, whether the rationale for team-based work outlined by Mathews, 1991 and Mathews, 1992a and others as suitable for industry is directly transferable or desirable for healthcare settings. Teamwork is after all a means to an end, not a goal in itself, and like all methods, has limits to its application. Further, there are real costs to effective teamwork, and attention must be paid to ensuring that costs are contained and proportional to the benefits (West et al 2002).
Teamwork is the totality of methods of collaboration in pursuit of shared purposes used by members of a team. Given this definition much is made of the importance of multidisciplinary teamwork in healthcare (e.g. Moorin 2005), which is seen as both vitally important and difficult to achieve. It is important because the different professions or disciplines (including specialties within professions) bring different skills and perspectives. These skills and perspectives need to be integrated to ensure that goals and decision making are based on the best available understanding and that commitment to the decisions is shared by team members. However, teamwork is difficult to achieve not only because it requires time and attention to the way people work together, but also because the training of health professionals tends to emphasise individual accountability and skill (and a preference for working with one’s own profession), as do systems for remuneration and reward (Leggat 2007).
What is multidisciplinary team care?
In authentic multidisciplinary care, team members rely on cross-disciplinary input in planning their own clinical care, in the development of a collaborative individual treatment plan for a patient (National Breast Cancer Centre 2003:2), and in emergence of new activities arising from this collaboration. There is a clear understanding of the array of professional expertise, but a willingness to be flexible, to share skills and in some cases to tolerate role substitution, collective ownership of the care plan and a capacity to reflect on these processes. Bronstein (2003:114) extends this to suggest that team members have to see the collaboration as positive and believe that the goals could only be achieved through collaboration with each other. Perhaps more than in other industries, multidisciplinary teamwork in healthcare is achieved through a combination of structural units (such as the oncology unit) and ‘virtual teams’ – the health professionals who work together across organisational units to plan and deliver the care for an individual or a group of patients (such as pharmacists, radiologists, pathologists and others working with the oncology unit).
Box 6.2
Keown’s carers defined multidisciplinary teams as a small core group of professionals, as well as others who may at times form part of the group, but are often on the outer rings. In the acute phase (post surgery), the core team was the oncology unit, along with the pharmacist, radiologist, play therapist and pathologist. They did not regard the patient or his family as core members of the team, but recognised the family’s role in decision making about treatment options.
In the palliative phase, the team is ‘a virtual team’ drawn from those available in the patient’s community – every health professional who can contribute and is willing to work with the team philosophy. In this phase, the family was seen as the centre of the team – the palliative care nurse practitioner saw her role as ‘creating a nest for that family’ while they coped with the reality of their child dying. Perhaps because of their inability to change the course of Keown’s illness, the professionals worried that they may have let Keown’s family down in the palliative phase, but Sandra felt that her whole family had been supported and cared for.
In the professionals’ view the inclusion of patients and their families into the team has emerged at the current time because of the need for the treating team to share the same goals as the patient. They note that sometimes clinicians have goals directed towards a ‘cure at any cost’, while clients may wish to pursue quality-of-life approaches. In such situations decision making requires bringing the client into the team as an equal member, entitled not just to consent to treatment, but to be able to say what treatment is provided and of course to know their treatment options. Keown participated in decisions to do with his own quality of life and brain function. He knew he had bad cells and good cells and that the radiotherapy would attack the bad cells and also damage good ones. At age nine, with the hindsight of seeing other children, he said to his parents, ‘I don’t want to do that, I don’t want to be like X (who had a brain injury from treatment); I know I can die from this, but if all the good cells are going to die, I don’t want to do that.’
The significant characteristic of MTC is that the various professionals come together to pool their expertise in all relevant aspects of the patient’s care, and together plan a program of care tailored to each patient (Herrman et al 2002; Liberman et al 2001). Why this approach should emerge at this point in history is partly explained by developments in healthcare and in society. Cancer care has been a focus of attention to MTC because it requires a set of complex decisions to be made over diagnosis, treatment options, and efficacy for specific individuals. Chronic illness more generally requires the interventions of an array of health professionals over an extended period. Further, sick individuals are not only clinically specific, they are also patients with rights, and are increasingly well informed.
Some commentators and researchers have used definitions with lower thresholds for multidisciplinarity – any care involving more than one discipline (Britton et al 2006, Karjalainen et al 2007). However, an important criterion in our definition is that the group of health professionals bring their shared expertise to the diagnostic, treatment, rehabilitation and/or care processes. Treatment and care may come from any member of the team at various stages in the patient’s illness. As a consequence senior medical professionals may not always take the lead. Leadership may come from the patient’s GP, their specialist nurse, or dietician (Wilson et al 2005).
Further ambiguity in defining MTC occurs in the Australian context, where team members may work across significant geographical distances. Recognising this, the National Multidisciplinary Care Demonstration Project (NMCDP) in breast cancer developed a set of five essential principles in defining multidisciplinary care (National Breast Cancer Centre 2003:5). These are:
1. a team approach involving core disciplines integral to the provision of good care, with input from other specialities as required (the ‘core’ disciplines are surgery, radiology, medical and radiation oncology, pathology and supportive care)
2. communication occurs among team members regarding treatment planning
3. access to the full therapeutic range for all women, regardless of geographical remoteness or size of institution
4. care is provided in accordance with nationally agreed standards
5. involvement of the woman in decisions about her care.
The limitation of confining the team to medical specialists has been highlighted in the care of patients with cancer, who usually require input from several clinical disciplines in the acute phase, but also in rehabilitation and palliative phases of care (National Cancer Control Initiative 2003).
In the Australian context multidisciplinary care teams can be found in intensive care units (ICUs), cancer and palliative care, in geriatric and rehabilitation services (Karjalainen et al 2007), in crisis mental health teams (Joy et al 2006), in the organisation of care for people with chronic conditions, in aged care and in many other areas. In the UK multidisciplinary teamwork has been endorsed as the major way to organise care for cancer patients (Fleissig et al 2006:935), and in Canada as the major approach to re-structuring the healthcare system in the light of increasing expectations, rising costs and the ageing population (Canadian Health Services Research Foundation (CHSRF) 2006). Multidisciplinary care teams appear to operate best in situations where patients require long-term healthcare interventions across a variety of areas requiring input from a range of professionals, or where care is provided in small and cohesive units such as ICUs or community mental health teams. MTC is also found where diagnosis and treatment are characterised by ambiguity or lack of certainty.
Clinical effectiveness of multidisciplinary team care – the evidence
Evidence on the value of MTC in relevant aspects of healthcare is growing. In a major review of the evidence for MTC in the treatment of cancer, Moorin (2005) reported on 14 studies that provided evidence of reduced mortality and increased quality of life for patients receiving multidisciplinary care. However, some of those studies simply demonstrated the value of the learning curve (that is, better outcomes for those surgeons experienced with and specialising in, for example, breast cancer) and the use of multiple therapies and/or the existence of defined relationships with other disciplines (which may relate to a multidisciplinary team approach) rather than MTC directly (Sainsbury et al 1995). Five of the studies limited the definition of MTC to medical specialists, and one examined the effect of introducing a specialist breast nurse with a role in support and coordination for patients (National Breast Cancer Centre 2003). Several studies examined patient satisfaction and other indicators (such as reduced time to treatment) (Gabel et al 1997) and higher levels of physical functioning (Frost et al 1999).
Proponents of MTC argue that multidisciplinary teams provide benefits for patients ranging from ensuring equal access to specialist services for patients with similar diagnosis, smoother referral between services as communication between treating team members is enhanced, less duplication and delay of diagnostic tests, speedier implementation of treatment plans that conform to internationally accepted standards, less variation in patient survival rates, and increases in the recruitment of patients into clinical trials (Burns & Lloyd 2004, Fleissig et al 2006, Moorin 2005). These and other authors conclude that the benefits are the result of consensus decision making within the team, and a wider awareness of the treatment options available, and in the case of cancer care, possible differences in the staging of treatment (Howard et al 2001). What is clear is that a MTC approach results in increased patient satisfaction arising from enhanced support and a clearer sense of the organisation of care (Fleissig et al 2006, Moorin 2005).
Box 6.3
Sandra began her interview by telling us how terrible the healthcare system is for patients – it is like a machine, set up to serve itself, she said. There is a cost to families in attending, waiting, and undergoing routine tests, and time for ordinary activities is lost. Hospitals appear not to have the capacity to schedule appointments to suit daily life, so that clients have to make daily, but significant adjustments. Sandra found she had to struggle to make the treating team aware of her child’s practical needs, and R∗ and M∗ both saw negotiating between patients and ‘the system’ as one of their primary roles. For Sandra in her role as mother this meant ensuring Keown got to kindergarten to play with his friends irrespective of appointments for radiotherapy, for R it meant rescheduling appointments to reduce the client’s discomfort, costs, and disruption. For M it meant supplying letters of referral when Sandra and her family went on holiday and during the palliative stage in case they might need to call an ambulance or take Keown to the emergency department. In effect the clinical team worked to soften the system, so the family felt cocooned and able to get through the rigours of painful treatment, and then what was going to be a bad outcome. These observations are consistent with the research evidence that patients report speedier services, treatment schedules that reduce waiting times and less impact on their daily lives.
The review by Joy et al (2006) and a similar one by Karjalainen et al (2007) (focused on rehabilitation for neck and shoulder pain among working-age adults), found no differences in clinical outcomes, including deaths, or discernible differences in mental and social wellbeing, and no differences in hospital admissions or repeat admissions pointing to little by way of cost savings. Similarly the studies cited by Moorin (2005:43–44) on cost savings are not conclusive, although Moorin notes that one of the key findings of the Australian National Cancer Demonstration Projects was that costs associated with multidisciplinary team meetings reduce as they become better established. The exception to this is a study done by Ettner et al (2006) who were able to demonstrate that it was cheaper to care for the patients in an intervention (multidisciplinary) group than patients who received ‘usual’ care.
Box 6.4
Sandra: For a child with a medulloblastoma, maybe, on a good day, there might be a 15% chance of survival without any treatment. But these stats are old, and might well be confounded by misdiagnosis or other error. There are no good recent stats on survival without treatment – the study design problems are obvious. So, we are left with old, probably unreliable evidence of a 15% survival rate without treatment.
With each step in treatment there are benefits, but there are also enormous risks. For a child with a medulloblastoma, following neurosurgery alone there may be approximately 45% survival depending on the site, extent and type of tumour. Setting aside those risks associated with any surgery, neurosurgery for cancer risks permanent brain damage (motor control, memory, sensory, cognitive) and hormonal system damage (growth, hunger, diuresis, sexual maturity, etc).
Add radiotherapy to the surgery and survival increases from 45% to around 55 or 60% – survival for two or three more children out of every 20. However, with that improved survival comes more treatment-related risks and side effects: cognitive defects, sensory deficits, secondary cellular dysplasia or cancers, radiation burns, nausea and vomiting. Keown said, ‘Throwing up, Mum. Don’t forget throwing up.’
Chemotherapy. Add 48 weeks of triple therapy and survival increases to maybe 65 or 70% – another two or three kids out of every 20 who get to survive. Additional side effects and risks include death from ordinary childhood illnesses (chicken pox, viruses), renal damage, major hearing loss, sterility, cardiac damage, vomiting and hair loss. The cumulative effects of treatment – a 70% chance of survival and certainty of complications.
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