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Teamwork in Medical Rehabilitation

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Abstract

Good teamwork ensures the close collaboration and coordination between professions and across disciplinary boundaries which is particularly important in medical centres and departments admitting complicated patient cases. But contrary to what many health care organisations seem to believe, effective teamwork does not come about automatically. It has to be well prepared and trained, like every other practical, clinical skill. Furthermore, the management need to provide the professionals with working conditions that allow for good team work. Medical Rehabilitation in Sweden is a discipline crowded by not only doctors and nurses, but also physiotherapists, occupational therapists, psychologists, social workers, speech therapists, dieticians and others. Teamwork in Medical Rehabilitation – the Swedish way provides basic know-how for those who want their health care business to develop well-functioning teamwork. The book describes how to create, develop, nourish, and organise a team. It pin-points factors that need to be handled in the process, how to distribute tasks and responsibilities and it anchors them in a theoretical understanding of teamwork, rehabilitation and communication. The book contains many practical examples and patient cases from different rehabilitation care areas. The authors have considerable experience from teamwork in medical rehabilitation in a wide variety of settings, and combine this with theoretical knowledge on organisational theory. No doubt, the book should be useful for many other health care disciplines where effective collaboration is essential to good clinical outcomes. Teamwork in Medical Rehabilitation – the Swedish way was written primarily for professionals who work or would like to work in multi-professional teams, but also for students in these professions as well as managers in the health care organisations.
Teamwork in Medical
Rehabilitation
Good teamwork ensures the close collaboration and coordination between
professional groups and across disciplinary boundaries. This is particularly
important in healthcare centres and clinics admitting complicated patient
cases, but contrary to what many healthcare organisations seem to believe,
effective teamwork does not happen automatically. It needs to be successfully
trained and practiced.
Teamwork in Medical Rehabilitation provides a guide to efcient teamwork
in professional healthcare. Showcasing the practice of medical rehabilitation
in Sweden, the book describes how to create, develop, nourish and organise
a team. Medical rehabilitation in Sweden is a discipline lled by not only
doctors and nurses, but also physiotherapists, occupational therapists, psy-
chologists, social workers, speech therapists and dieticians. Using these multi-
professional teams as clinical case studies, the book contains many practical
examples from different rehabilitation care areas.
This book will prove to be invaluable to healthcare professionals and
students as effective collaboration is essential to good clinical outcomes.
Managers will also nd this a worthy read thanks to its understanding of
howworking conditions affect good teamwork.
Charlotte Lundgren is a Senior Lecturer at the Department of Culture and
Communication, Linköping University, Linköping, Sweden. Lundgren has
worked with the development of professional communication and teamwork
in a wide variety of clinical settings, including rehabilitation medicine.
Carl Molander is presently a Senior Consultant of Rehabilitation Medicine,
working in a multi-professional team at Rehabakademin in Stockholm,
Sweden. Molander has been the head of several Swedish clinics for rehabil-
itation medicine and has extensive experience in managing team efforts in
chronic pain and mental stress disorder rehabilitation.
Teamwork in Medical
Rehabilitation
Charlotte Lundgren
Carl Molander
First published 2017
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
711 Third Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2017 Taylor & Francis Group
The right of Charlotte Lundgren and Carl Molander to be identied
as author of this work has been asserted by him/her in accordance with
sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced
or utilised in any form or by any electronic, mechanical, or other means,
now known or hereafter invented, including photocopying and recording,
or in any information storage or retrieval system, without permission in
writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or
registered trademarks, and are used only for identication and explanation
without intent to infringe.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
Names: Lundgren, Charlotte, 1974- author. | Molander, Carl, author.
Title: Teamwork in medical rehabilitation / Charlotte Lundgren and Carl
Molander.
Description: Abingdon, Oxon ; New York, NY : Routledge, 2017. |
Includes bibliographical references and index.
Identiers: LCCN 2016057610| ISBN 9781138035034 (hardback) | ISBN
9781498725439 (pbk.) | ISBN 9781498725446 (ebook)
Subjects: | MESH: Rehabilitation--organization & administration | Patient
Care Team--organization & administration | Interdisciplinary
Communication | Physical and Rehabilitation Medicine--organization &
administration | Sweden
Classication: LCC RM930 | NLM WB 320 | DDC 617.03068--dc23
LC record available at https://lccn.loc.gov/2016057610
ISBN: 978-1-138-03503-4 (hbk)
ISBN: 978-1-4987-2543-9 (pbk)
ISBN: 978-1-4987-2544-6 (ebk)
Typeset in Times New Roman
by Datapage India (Pvt.) Ltd.
Contents
Preface viii
1 Introduction 1
References 4
2 Historical background 5
Organization theory and organizational change 5
Taylorism 6
Autonomous work groups 7
Quality management 8
The emergence of teamwork 8
Contemporary trends 10
The development of teamwork in healthcare organizations 12
Development of rehabilitation medicine 13
History of rehabilitation medicine 13
Contemporary trends 13
References 15
3 Teamwork in theory 17
Disciplines, professions, and modalities 17
Discipline—an area of scientic knowledge 17
Profession—an area of work-related rights and responsibilities 18
Modality—a type of intervention 19
Interprofessional, transdisciplinary, or multimodal? 19
The rationale for structured teamwork 20
Professional, overlapping, andshared knowledge 24
Profession-specic knowledge 24
Partially overlapping knowledge 28
Shared knowledge 31
vi Contents
Team denitions 34
Groups at work 35
Classical team denitions 36
Shared responsibility 36
The tasks of the team 37
Organizational belonging 39
A new team denition 40
Team types 41
Team structures 41
Multidisciplinary, interdisciplinary, and transdisciplinary teams
in rehabilitation 41
Different tasks require different kinds of teams 50
Factors affecting team performance 50
Economic conditions 50
Ideological conditions 52
Other organizational conditions 52
Team leadership 54
Team maturity 54
Roles and status 56
Disputes within the team 57
Shared values 59
Effects of advanced teamwork in rehabilitation medicine 60
References 61
4 Teamwork in practice 62
Building a team 62
Preparatory work 62
Recruiting team members 63
Production and documentation planning 64
Several teams operating in parallel 65
Improving an existing team 66
Mission 66
New members of the team 67
Phases in team development 68
Team mentors 70
Crisis management in team 71
Supporting processes 72
Documentation 72
Coordination with stakeholders 73
Evaluating the work process 74
Stand-ins 75
Psychosocial support 75
The legal responsibility related to teamwork 78
References 82
Contents vii
5 Clinical teamwork 83
Patient investigation and evaluation 83
Normal team investigation phase 83
Premature evaluation 84
Initial goal setting 85
Rehabilitation phase 88
Discharge phase 89
Team meetings 90
Workplace staff meetings 91
Team conferences 92
Planning days 92
Meeting formalities 94
Should the patient be present at the team conference? 95
References 96
6 Team communication 97
Team communication in theory 97
The mug metaphor 100
Team communication in practice 102
Common problems and how to avoid them 103
Daring to disagree 105
References 107
7 Examples of team rehabilitation settings 108
Primary care 108
Occupational health service 108
Community care and at-home rehabilitation 110
Spinal cord injuries 110
Brain injuries and multitrauma 110
Stress-related disorders 112
Diabetes 112
8 Concluding discussion: Advantages and disadvantages of
advanced teamwork 113
Is advanced multiprofessional teamwork necessary? 113
Disadvantages of advanced teamworkin medical rehabilitation 114
Advantages of advanced teamworkin medical rehabilitation 116
Key issues for the future 117
Index 119
Preface
To you, who are thinking of reading this book!
This book has been written to provide a theoretical and practical over-
view of teamwork as well as a hands-on guide for implementing and
improving it to those interested in well-functioning teamwork in medical
rehabilitation. Our aim was to write something that will provide food for
thought for a variety of readers, regardless of why they have chosen to read
what we write.
Are you a student who has been assigned this book as part of your cur-
riculum? Then, this book will teach you the basics of teamwork, a form
of organization that you are very likely to come across in your future
jobs. At the same time, you will learn some basic theoretical concepts
in organization history, which you are likely to nd useful, regardless of
where you will work in the future.
Are you already working in medical rehabilitation and desire to enhance
your knowledge about teams and teamwork? Then this book will provide
you an opportunity to reect on what a team really means and on how to
understand teams and teamwork in a context wider than your personal
experiences.
Are you frustrated that your team is not functioning as well as it was
intended to? Then, this book will help you understand how to solve some
organizational knots so that you have the time and energy to focus on
patient work.
Are you the manager of a healthcare organization, considering creating a
team to improve the work with a particular group of patients? Then, this
book will support you in the process of setting up a new team, in helping
the team to improve their production process, and in nurturing an orga-
nization that can support the work of the team.
Are you frustrated because your unit is not working as a team to your
liking? Are you considering bringing in a consultant to set the house
in order? Then this book will help you understand the actual problems
and provide the help you might need. You will thus become a more
informed seeker of outside help and more competent in your dealings
Preface ix
with the consultant. This will, in turn, save you and the rest of the orga-
nization from further frustration and probably also save large amounts
of money.
Have you already worked for a long time in various types of teams? Or,
have you just begun working in a team? Regardless, this book will help
you untangle the many thoughts and worries which teamwork can give
rise to.
Are you a patient under treatment in a rehabilitation team? Then you
will nd that this book is not directed at you, although it may give you
a rewarding glimpse of the work “behind the scenes.” We consciously
decided to focus this book on the collaboration between the profession-
als in the team and the work they carry out together in order to help you
get back the independence and well-being you may have lost because of
illness or injury.
There are two reasons why we have written this book. The rst reason is
that most people who have chosen to work in healthcare sooner or later will
work in a team of some kind. The other reason is that, although there appears
to be consensus on the fact that teamwork is rewarding to patients and pro-
fessionals alike, it can also be difcult and time-consuming. Webelieve that a
book on teamwork in medical rehabilitation can be of help to those aiming to
reduce these problems and to contribute to effective and fruitful teamwork.
Now, you might opine that there are already far too many books on teams
and teamwork. If this were true, why would we write this book? Our answer
isthat there are not many books focusing on teamwork in healthcare, partic-
ularly there are very few books written by people with personal experience
of teamwork in healthcare. Since this book is based on our own experience,
it scrutinizes the concept of teams and teamwork from various angles, to
show how they can be understood and used in everyday practical work in
different clinical settings. Because of this, we relatively rarely write norma-
tively of how something absolutely must be done. However, when we do so,
it is because we rmly believe that certain solutions are of considerable help
to achieve well-functioning teamwork in medical rehabilitation. Obviously,
we do have experience of teams that did not work as well as we would have
wished—conicts; lack of resources; and old, deep-rooted ways of thinking
are just some of the things that can throw a spanner in the works. But more
importantly, we have experienced good teamwork. This means that we can
give advice on what to aim for when you try to make your teamwork well,
as well as on how some of the problems that may occur can be handled, if
not avoided.
We have chosen to focus on how teamwork can be supported and facili-
tated and how you as a team member or leader of a team-oriented organiza-
tion may think in order to get the team to work as well as possible. This book
will give you the tools needed to set up well-functioning teams by making the
most of the opportunities you have in a given organization at a particular
x Preface
point in time. After reading this book, you will be better equipped to get the
best out of your team, regardless of whether you work in a team, if you are
the team leader, if the team already exists, or if you are considering creating
a new team. Here you might observe that teamwork does not solve all prob-
lems, and it is absolutely true. However, it is our conviction that teamwork,
in most cases, is impossible to avoid if you want to reach success in practical
medical rehabilitation.
Much of the content of this book was published in Swedish by Liber, back
in 2008. Since then, we have been asked several times to publish an English
version for the international audience. It is natural that most of what we
say is based on Swedish conditions, because this is where we live and where
our experience comes from. We are fully aware that there are big differences
between countries in terms of how healthcare systems are organized, culture
and traditions, and how the political and economic conditions inuence the
larger context in which the healthcare system is a part. We also know that this
lays the fundamentals for introducing or developing teamwork in rehabilita-
tion very differently in one country compared to another. Even so, we think
that much of what we say can be generalized and rather easily adjusted to
tthe many contexts of medical rehabilitation worldwide.
The following individuals have provided important feedback on the rst
book published in Swedish (in alphabetical order): Eva Allemark, speech
therapist; Elisabeth Ekman, occupational therapist; Marcelo Rivano
Fischer PhD, psychologist; Malin Hallgren, psychologist; Ruth Kusek-
Fredriksson, social worker; Åsa Olsenmyr, physiotherapist; and Ingrid
Sanner, psychologist. For all your help, which is of great relevance even for
the present edition of this book, we are ever so grateful!
We wish to thank the two anonymous reviewers, who assured us that the
book would be a welcome addition to the existing literature, and our rst
editor, commissioning editor Naomi Wilkinson, at CRC Press, for accept-
ing this suggestion. Furthermore, we also wish to thank the editorial team
at Routledge, senior editor Grace McInnes and editorial assistant Carolina
Antunes, for their invaluable help throughout the production of this book.
To you, the reader, we say: Welcome to our experiences and thoughts! If,
after reading the book, you feel inclined to share your comments and your
own experiences and thoughts about teamwork, feel free to contact us. Your
views will be of great help for future editions.
Charlotte Lundgren
Linköping University, Linköping, Sweden
Carl Molander
Rehabakademin, Stockholm, Sweden
In medical rehabilitation, there has been a long-standing tradition of collabo-
ration between different professions and disciplines. Today, this work is often
organized in teams, and there are good reasons for this. The most important
reason is that teamwork has proven to give good results in terms of treatment
outcomes. Another important reason is that teamwork is a form of organiz-
ing work that provides a sense of coherence to team members.
A classical text on teamwork in rehabilitation medicine (King et al. 1998)
stated that much of the work which was previously mentioned via text is now
a matter of eye-to-eye communication. Traditionally, healthcare systems have
depended on written communication, with referrals, opinions, and prescrip-
tions of various kinds sent back and forth between professionals, departments,
and organizations, with the professionals involved in a patient’s care rarely
meeting in person. Before teams were introduced, physicians in outpatient
organizations worked primarily in solitude in their ofces, physiotherapists
were gathered in a specic part of the building, and medical social workers had
their ofces somewhere on the perimeter of the hospital. Unlike in inpatient
wards, they never or very rarely met in person to discuss their respective inter-
ventions (with some obvious exceptions such as when performing a surgery).
Of course, as everyone who works in the modern healthcare systems know,
these conditions are changing in many places. It is becoming increasingly more
common to organize the care around the patient and his or her needs, instead
of around the historically understandable, yet progressively obsolete, organi-
zations that saw the light in the post-WWII attempts at organizing hospitals
in the same way as industries organized their production lines (Iedema 2007).
The distance between hospital-based care providers and other institutions
such as community-based social services and job centers has been, and to a
large extent still is, even greater. Numerous projects and reorganizations have
been implemented to minimize the difculties created by these divisions. Most
of them seem to have failed. Others have succeeded as temporary projects,
but, due to a lack of support needed to become a part of the ordinary orga-
nizational structure, they are seldom persisted with.
It is fair to say that the healthcare sector at large still wrestles with seri-
ous problems relating to communication and collaboration across borders of
Introduction1
2 Teamwork in medical rehabilitation
various kinds: between professions and disciplines as well as between organiza-
tional units such as clinics or across divisions between primary and secondary
care (Iedema 2008). This does not mean that no such communication and col-
laboration takes place. It does. But the sub-optimized support for everyday com-
munication and collaboration remains a problem in today’s healthcare systems,
in spite of many attempts at improving the problems. According to the U.S.
Agency for Healthcare Research and Quality, over 60% of all adverse events can
be explained by decit communication. However, it is important to note that it
is normally not the individual care provider’s will to communicate and collabo-
rate that is lacking, but rather the organizational will to allocate resources for
developing procedures and protocols that do not swiftly return improvements
in the balance sheet for the unit allocating the resources. The silo organization
that characterizes most healthcare systems today simply does not support the
kind of cross-boundary improvement projects necessary to improve this situa-
tion. And so, the enduring lack of dialogue between professions and disciplines
continues to lead to sub-optimized solutions to problems that have not been
understood in all their complexity—not because the people in the system do
not understand that the problems are complex, but because the organizational
support for collaborating and communicating across borders is lacking.
It is our experience that lack of well-developed collaboration and commu-
nication tends to increase feelings of meaninglessness, fatigue, and unneces-
sary antagonism in and between healthcare professionals. In the long run, it
may also contribute to the growing numbers of long-term sick leave among
healthcare personnel. When it comes to rehabilitation, several studies have
shown that employers in rehabilitation teams with managers who support
good teamwork have higher job satisfaction (Cartmill et al. 2010; Körner etal.
2010, 2015; Lundgren 2009).
This book is about teamwork within the eld of rehabilitation medicine,
which can in many ways be described as the discipline that rst introduced
qualied teamwork. Now, you may suggest that surgery surely was the rst
discipline to introduce teamwork, and in this you are partly right. But the
purpose of this book is to present and discuss the kind of teamwork that is
largely a matter of inventorying problems and possible solutions, reaching a
shared understanding of both, and coordinating future actions. Teamwork
in rehabilitation medicine is a way of overcoming the difculties stemming
from not communicating properly and in time about the problems the patient
is facing and the possible solutions, and a way to adapt the care provided fol-
lowing the process of rehabilitation as it unfolds for the individual patient.
Well-functioning teamwork in rehabilitation medicine can thus serve as an
inspiration to clinical settings, where the key to delivering high-quality care
is the need to understand the patient’s problems in all their physical, psycho-
logical, and social complexity, and being able to adapt the care provided in
accordance with the individual patient’s needs, as they change over time.
The complicated and complex cases faced by those working in medical
rehabilitation demand more dynamical and dialogical forms of collaboration
Introduction 3
than ever before. These days, the collaboration between different care provid-
ers does differ from the descriptions of King et al. cited earlier. An increas-
ingly qualied and close cooperation between caregivers, patients, employers,
social insurance ofces, and/or insurance companies is becoming more and
more common. Caregivers, not only in medical rehabilitation, do organize
the care they provide across teams of various kinds. To solve complicated
cases related to mental health issues or long-term pain, the efforts of highly
qualied teams like those in rehabilitation medicine have proved to be a suc-
cessful intervention. Qualied teamwork is benecial not just for patients suf-
fering from stress disorders or long-term pain that often cannot be cured by
unimodal interventions; however, we explicitly mention these patients as they
form a large part of the group who avail long-term sick leave in northern
Europe. A large amount of the costs for society, as well as the suffering of
individuals, is related to these problems. Other groups of patients also rely
on rehabilitation professionals to recover from serious disease and trauma.
Some of these groups have until quite recently not been provided with the
rehabilitation care they need, which has left many with complex problems
and functional decits. Many affected persons are young and many stand
a good chance to carry on with their lives normally if provided with proper
rehabilitation. Some examples are survivors of stroke, traumatic brain injury,
traumatic spinal injury, polytrauma, and cancer, including childhood cancer.
Even though we have come a long way, there is still a need for continu-
ing development of the collaboration when it comes to these groups of
patients. Much of the work related to these groups will be carried outside
of the specialized rehabilitation clinics, predominantly in primary care and
occupational care settings. Highly specialized rehabilitation clinics will only
be involved in the most complicated cases. The majority of the workload will
rest on primary care clinics and the occupational health services. Hence, this
is where qualied collaboration involving not only various care-providing
organizations but also care providers, the patient, and other involved par-
ties such as employers, social security providers, and/or insurance companies
must be developed. Another reason to emphasize these patients is that teams
working with them meet a number of challenges that illustrate more general
problems in teamwork, thus inviting more general discussions concerning
medical rehabilitation and teamwork.
In the kind of qualied teamwork necessary to solve the type of problems
mentioned above, the information the team needs to help a patient is gath-
ered with the individual patient in focus. This means that the investigations
carried out by each team member depart from a holistic perspective, where
the actions taken by each team member are coordinated, goal-oriented, and
individualized. But—and this is an important “but”—this type of organiza-
tion takes an effort from every professional participating in it, as it requires
not only a theoretical understanding of what a qualied teamwork is but also
a willingness to change the ways in which one has worked before. When an
organization commits to developing qualied teamwork, professionals who
4 Teamwork in medical rehabilitation
earlier hardly talked to each other except when they ran into each other in the
corridors will now nd themselves in meetings, face to face with colleagues
from other professions and from other disciplines.
This book aims at showing how one can improve professional communication
when discussing problems and solutions with colleagues who are not as familiar
as one may want to think. It is based on our experiences within the Swedish
healthcare system, where we have both worked with teams in a wide variety of
clinical settings. Sweden is a society well known for its egalitarian and tolerant
culture, and our understanding of what works and does not work in the realm
of teamwork in medical rehabilitation is to some extent born out of our experi-
ences in this context. We know that it is possible to prioritize information which
may further the work of the team, regardless of where or who that information
comes from. We also know that it pays off to endorse an atmosphere of active
collaboration, active listening, and active dialogue. But this is not a book about
how to become more Swedish. This is a book about the prerequisites for com-
munication across borders of various kinds (professional, disciplinary, organi-
zational) and the meetings that follow suit when teamwork is implemented in
an organization. This book is about how to meet the demands that follow from
implementing qualied teamwork, demands that have consequences for the
professionals, the leaders, and the organizations in the healthcare system. This
book is about teamwork in medical rehabilitation—the Swedish way.
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... The rest of the missing ICF categories mainly concerned physical function. Their absence was expected because these factors should primarily be addressed by other professions in the multi-disciplinary team such as physiotherapists and occupational therapists (Lundgren & Molander, 2017). ...
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