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Team working in Rehabilitation for neurological problems. …..a European perspective Vera Neumann. Scope of talk. Evidence concerning value of teams in rehabilitation: From scientific literature Personal experience What makes a good team? multidisciplinary team structure: Who does what?
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Team working in Rehabilitation for neurological problems …..a European perspective Vera Neumann
Scope of talk • Evidence concerning value of teams in rehabilitation: • From scientific literature • Personal experience • What makes a good team? • multidisciplinary team structure: • Who does what? • Who should lead?
Are teams really needed? Potential disadvantages: • Patients may feel overwhelmed • Time-wasting • Increased use of (scarce) resources • Increased costs
Clinical teams - rationale Clinical work needs a broad range of knowledge & skills: • selection of treatment options, often from a diverse range. Management of, for example, back pain may include medication, therapy and/or surgery. Which approach? • Co-ordination of varied interventions to achieve agreed goals • Critical evaluation & frequent revision of plans/goals
Website for this image • Singer/Songwriter, One-Man Band (and the world's oldest child prodigy) • oldstogie.com • Full-size image • 215 × 215 (Infinityx larger), 85KB • More sizes • Search by image • Similar imges Rationale for MDTs will any single team member have all skills needed? .
Evidence for teams in rehabilitation • From scientific literature – searched Medline & other databases 1996-2008 • Musculoskeletal rehabilitation • Cardio-respiratory .. • Neurological .. • Personal experience
Multidisciplinary teams in cardio-respiratory rehabilitation
MDTs in Spinal cord injury rehabilitation? • Very little published evidence…
MDTs in stroke – the evidence1 • 3249 patients in Sweden, Finland, Australia, Canada & UK randomised to stroke units with MDT working or routine care where only 277/1346 exposed to multidisciplinary rehabilitation. Stroke units (with MDTs) showed: • Better survival in 1st 4 weeks, especially in those with severe stroke – Barthel <15/100 on admission • fewer neurological, cardiovascular & immobility-related deaths. Not due to medication. • Less likely to need institutional care because less dependant. (attributable to more carer involvement in rehab?) 1. Stroke Unit Trialists' Collaboration. Stroke 1997
European position paper JRM 42 ; 2010
Personal experience Chapel Allerton Hospital, Leeds, UK • post-acute rehabilitation following acquired neurological (brain) injury. • 20 beds, ~140 patients/year. MDT including: • Nurses • doctors • Psychologists • Physiotherapists • Occupational therapists • Speech & Language Therapists • social workers
How our team works - 1 • Team decision on acceptance based on • patient’s needs • potential for improvement • resources • Rehabilitation goals set with patient
How our team works - 2 • Assessment – recorded against standardised measures at weekly meetings • Multi-, inter- or trans-disciplinary input to address these
How our team works - 3 • MDT meets patient & family to • review progress • plan further rehabilitation • plan hospital discharge • Referred on to community services such as Community Brain Injury, Stroke or Multiple sclerosis teams
Scope of talk • Evidence concerning value of teams in rehabilitation • What makes a good team? • Outcome of ESPRM multidisciplinary workshop • From psychology & management literature • multidisciplinary team structure: • Who does what? • Who should lead?
ESPRM congress workshop on teamwork Vilnius, Lithuania. Sept 2011
Our task To define each MDT member’s role Core competencies Contribution to team in 3 situations:
What makes a team successful? physiotherapists’ views Communication Cooperation Common goals members want to work in a team listen to each other respect and trust each other speak a common language That each team member take the responsibility for their own professional competence and implement it
Occupational therapists’ views Leader ship Size of the team Organization support the team Clear roles, responsibilities and functions Time structure Values shared Communication Competences needed Skills to be able to solve conflicts Time for team building Effective documentation routines Attitudes towards teamwork
Doctors’ views Agreed aims Agreement & understanding on how best to achieve these [avoiding jargon unique to a particular profession] Appropriate range of knowledge & skills for the agreed task Mutual trust & respect Willingness to share knowledge & expertise & speak openly
What can go wrong? Interdisciplinary working Semi-structured interviews with experienced rehabilitation nurses concerning their perceptions of physiotherapists (PTs): • PTs concerned with mobility only whereas nurses see themselves as concerned with patients’ general well-being • valued PT expertise in lifting & handling • Frustrated that expertise not shared with them • didn’t know why particular techniques had been selected • had difficulty getting patients to do things they had seen patients do with PTs • Couldn’t respond to patients’ & Drs’ questions • Therefore nurses didn’t continue mobility rehabilitation eg at weekends Dalley J. Clin Rehab 2001
Literature review • Literature review on teams & collaboration in paediatric rehabilitation in health & educational settings (Nijhuis. Clin Rehab 2007) • Working in Teams – report from British Psychological Society (2001)
good communication, avoiding jargon Tower of Babel - Breugel
appropriate range of knowledge & skills for the agreed task • Strimmer for haircut?
Leadership??? a thorny question!
Misconceptions about doctors’ roles in teams in UK Doctors think they • hold “ultimate responsibility” - can be sued if things go wrong! GMC perpetuated this belief in UK but • rejected by law courts (Montgomery 92) instead • have a duty to provide adequate information, training & support to others • Each professional has individual responsibility to uphold their profession’s standards
Doctors tend to have: Knowledge & skills to predict secondary problems & prognosis broad training & perspective training in critical analysis Examples: Is it safe to transfer patient to rehabilitation unit or to discharge home? Does patient need a different treatment modality? Is a new treatment evidence-based, effective & safe? Role of doctor in teams?
Team working in rehabilitation - summary • Reasonable evidence that MDTs achieve better results in low back pain, cardio-respiratory disorders & certain fields of neurological rehabilitation • Theoretical basis for good team-working well-described in other settings • limited evidence concerning key components of successful teams in rehabilitation • Leadership…open to debate!
Thank you For further information please contact • vera.neumann@leedsth.nhs.uk