Strategies to Encourage the
Multidisciplinary-Team Care Model
Caring for HIV-infected patients is more effective when there is a comprehensive approach that includes medical, nursing, and psychosocial services as well as community resources. Different members of the care team have different educational backgrounds, experiences, and skills that are important in meeting the needs of patients and their families. Regular and organized communication among all these team members is crucial to the provision of optimal patient care. Teaching this concept, however, can be quite challenging. In many settings, staff members feel overwhelmed and feel that “one more meeting” just takes time away from their work. Some settings operate in a very hierarchical way, with physicians making the decisions and the remaining staff implementing them without giving any of their own input. Below are several strategies mentors can use to encourage the multidisciplinary-team model.
On arrival, ask how, or whether, health care workers from different disciplines (and ranks) usually communicate and collaborate: If possible, spend time observing patient flow and health care worker interactions as well as the care provided by individual providers. When applicable, reinforce that you are there to observe and learn, not to judge or evaluate, so that health care workers are comfortable with your presence. Tailor your subsequent interventions to the existing professional culture.
Explain the benefits of multidisciplinary collaboration: Caring for HIV-infected patients is challenging and at times can be overwhelming for staff. Collaboration can actually make work easier—all team members have unique “pieces of the puzzle,” and non-clinical staff have critically important information that clinicians do not. Not only can this model provide the best care for patients but it can also provide informal support for all those caring for patients.
Conduct training sessions together: While this may be a new concept in some places, this gives the immediate message that all cadres are important in the care of patients. Initially some team members may feel uncomfortable offering comments, but the trainer can encourage discussion from all members attending, and those attending can see the importance of contributions from others. Ideally, cases that encourage participation of different disciplines can be presented.
The trainers should ideally be a multidisciplinary group as well, and they can actually model collaboration. They can also show that disagreement can be a healthy part of determining what is best for patients. A case could be presented in which trainers have a disagreement about how a particular problem should be managed. The participants can be asked for their input on how the problem should be resolved.
Conduct team-building activities: Team-building activities and exercises can help to build relationships among people who do not typically work together. An example of a team-building exercise is provided below.
Exercise: Guided Visualization
Ask participants close their eyes. Ask them to imagine that they show up for work at their facility one morning, and nobody else is there—no physicians, clinical officers, nurses, pharmacists, cleaners, clerks, data manager, or receptionists. Imagine the roles of other people working at the facility and their contributions to the care and treatment of patients as they think about all the tasks they will need to carry out that day, starting from the arrival of a patient.
Ask the participants to open their eyes. Lead a discussion, focusing on one individual at a time. Ask all of the other people in the group to talk about one thing that they really value about this individual’s work, why they think that individual’s job is essential to the team approach to care for patients, and one challenge they see in this person’s job.
Encourage multidisciplinary rounds: Quite often, clinic or hospital rounds are conducted in a single-discipline model. Physicians have their own rounds while nurses and counselors have theirs. It is helpful to integrate rounds whenever possible, or at least for each team to have representation from the other disciplines present. These representatives would contribute important perspectives, get clarification of treatment and care plans, and communicate information to other members of their groups.
Schedule regular multidisciplinary team meetings: Weekly meetings are an ideal way to communicate, exchange information, and formulate plans. A block of time should be set aside weekly in which no patients are scheduled so that all can attend. It is crucial for all members of the team to attend these meetings—both clinicians (clinical officers, nurses, physicians) and non-clinicians (counselors, outreach workers, pharmacists, health care educators). The meetings should have a designated leader who will develop the agenda, chair the meeting, and identify cases to be discussed. It is useful to use nurses or counselors in this role to encourage others to see their importance to the team.
A format should be agreed upon for the meetings. For example, the chair could ask clinic staff during the week which patients they would like to discuss at the meeting. Another method is to review the patients that were seen in the clinic that week, giving a brief update, and discussing any key issues. Input should be solicited from all team members, and discussion should be encouraged. At times these meetings can become “venting sessions” for staff, so the chair should monitor the time and keep discussions focused on key issues.
Notes can be written during the meeting and can become part of the record.
Clarify the difference between punitive and supportive discussions: In some settings, discussion of cases (whether interdisciplinary or not) occurs only for the purpose of exposing errors, with attendant humiliation of the person thought responsible. If you find yourself working in such an environment, the most helpful first steps may be to conduct your initial case discussions without naming any of the involved health care professionals (unless of course they have been exemplary) and to acknowledge errors that you have made personally. Emphasize the importance of using case discussions to generate suggestions for system improvement and to disseminate knowledge, rather than for shaming and punishment.
Giving and receiving feedback is generally challenging in clinical settings where feedback tends to be only punitive. In those cases, it can be helpful to arrange a small in-service that focuses on how to give and receive feedback constructively. A session on providing constructive feedback, including handouts and PowerPoint presentations, can be found in the training and curricula section of the toolkit.
Where the health care system is extremely hierarchical, define boundaries: In the more rigid health care systems, junior-level health care personnel (including women) may be reprimanded for disagreeing with their superiors (or with men) or for speaking out of turn. If you push the customary boundaries too far, the reprimands may occur during your mentorship period or after you leave, and lower-level staff may be terrified. At times it is helpful to have a frank, private conversation with lower-ranking health personnel in order to solicit their opinions on safe limits for your interventions.
Multidisciplinary Team Care Model Page PAGE 3 of NUMPAGES 3
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