MULTIDISCIPLINARY COLLABORATION
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Multidisciplinary Collaboration
Anette Tronvik, Greta Strikulyte, Lúcia Almeida, Reimar Vink, Yvonne Simpson
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Integrated care for adults with mental health disorders and co-morbidity conditions – a
transcultural nursing approach
1
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INDEX
1.
INTRODUCTION ................................................................................................................. 3
2.
BACKGROUND .................................................................................................................... 3
2.1.
Definitions: ....................................................................................................................... 3
2.2.
Research articles ............................................................................................................... 4
2.2.1.
“Multidisciplinarity, interdisciplinarity and transdisciplinarity in health research,
services, education and policy”................................................................................................... 4
2.2.1.1.
Part 1: “Definitions, objectives, and evidence of effectiveness” .............................. 4
2.2.1.2.
Part 2: “Promotors, barriers, and strategies of enhancement .................................... 5
2.2.2.
2.3.
3.
“Studying Multidisciplinary Teams in the Irish Republic: The Conceptual Wrangle” 5
Participating countries perspectives ................................................................................. 6
DISCUSSION OF DIFFERENT PERSPECTIVES ON MULTIDISCIPLINARY
COLLABORATION..................................................................................................................... 8
3.1.
Law and guidelines........................................................................................................... 8
3.2.
The application of multidisciplinary collaboration .......................................................... 9
4.
CONCLUSION .................................................................................................................... 10
5.
REFERENCES .................................................................................................................... 11
6.
APPENDIX........................................................................................................................... 15
6.1.
Appendix 1 ..................................................................................................................... 15
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1. INTRODUCTION
“Multidisciplinary collaboration - a transcultural nursing approach” is the theme that we will
explore in our paper. As this is such a wide topic to explore, following a group discussion, we
decided to ask the question ‘what are the benefits of multidisciplinary collaboration in mental
health’? Deady (2011), highlights that the term multidisciplinary collaboration appears vague
and ambiguous. Therefore, we have chosen to use the terms multidisciplinary and
interdisciplinary, interchangeably, throughout our paper for this exact reasons.
Through the process of self-directed group work, supported by our group tutor, we will use
research articles to discuss the theme of our paper. The paper will focus on the multidisciplinary
collaboration aspect of the team, focusing less on the patient, due to limited time. To conclude,
we will identify key issues related to the provision of mental health nursing in Europe.
Additionally, from our group perspectives, we will contribute towards creating a visionary
“Golden Standard” of nursing care for multidisciplinary collaboration.
Following our literature research on the term multidisciplinary (Appendix 1) we have chosen to
use the term interdisciplinary, interchangeably with multidisciplinary throughout our
paper. Choi and Pak (2006) highlight that to varying degrees, multidisciplinary and
interdisciplinary, involves multiple disciplines working along the same continuum.
We used search terms specific to this subject using a PICO. PICO is a method of putting together
a search strategy. We used the databases Pubmed, Cinahl and Psychinfo to find the suited articles
(Appendix 1).
2. BACKGROUND
2.1. Definitions:
Mental health:
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Mental health or psychological well-being is an integral part of an individual’s capacity to lead a
fulfilling life (World Health Organization [WHO], 2013).
Multidisciplinary:
Multidisciplinary means working with several disciplines but with individual goals and where
the different disciplines work independently. It doesn’t challenge disciplinary boundaries and the
participants learn about each other (Choi & Pak, 2006).
Interdisciplinary:
Interdisciplinary occurs when others' boundaries are being blurred and the participants learn
about and from each other (Choi & Pak, 2006).
2.2. Research articles
2.2.1. “Multidisciplinarity, interdisciplinarity and transdisciplinarity in health research,
services, education and policy”
2.2.1.1.
Part 1: “Definitions, objectives, and evidence of effectiveness”
The article "Multidisciplinarity, interdisciplinarity and transdisciplinarity in health research,
services, education and policy, part 1 was published in Clinical and Investigative Medicine. It
discusses
the
definitions
of
the
terms
"multidisciplinary",
"interdisciplinary"
and
"transdisciplinary", objectives and the evidence of effectiveness of teamwork. The article
highlights that there is an increasing emphasis on multidisciplinary approach in health care and
that teamwork is valuable and beneficial towards a more holistic package of care. Teamwork for
collaborative care consists of people who share a common purpose and goal, with
complementary and overlapping skills. This common approach to work practice, has shown to
improve patient outcomes. The article emphasis the reasons for multiple disciplinarity is to
resolve problems, provide different perspectives on a problem and provide comprehensive
services, such as health care and health education. The benefits of teamwork are increased
learning, better utilization of resources and planning, minimization of unnecessary costs and
improving job performance and work quality. Other benefits are also discussions between
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professionals, networking, gaining new insights and skills. However, it also states that multiple
disciplinarity teams do not always work, that there is little documented evidence in literature
about the effectiveness (Choi & Pak, 2006).
2.2.1.2.
Part 2: “Promotors, barriers, and strategies of enhancement
The second part (of the above paper) examines the promoters and barriers for successful multiple
disciplinary teamwork.
Teamwork success is based on a good selection of team members, good team leaders, maturity,
flexibility of team members and a personal commitment. Additionally, a common goal, and
shared vision, clarity, rotation of roles and good communication are essential. Barriers to
successful teamwork include, the poor selection of disciplines and team members, poor process
of the team functioning and a lack of proper measures to evaluate success of interdisciplinary
work. Additionally, the lack of guidelines for multiple authorship in research publications,
language problems, insufficient time for the project, institutional constraints, discipline conflicts,
team conflicts, lack of communication between disciplines and unequal power among
disciplines. The paper highlights eight strategies to enhance multiple disciplinary teamwork,
which can be summarized in the acronym TEAMWORK - Team, Enthusiasm, Accessibility,
Motivation, Workplace, Objectives, Role and Kinship. However, Choi and Pak emphasise that
not every health project needs to involve multiple disciplines. Therefore, the pursue of a multiple
disciplinary approach has to be questioned (Choi & Pak, 2007).
2.2.2. “Studying Multidisciplinary Teams in the Irish Republic: The Conceptual
Wrangle”
The article “Studying Multidisciplinary Teams in the Irish Republic: The Conceptual Wrangle”
is a literature review paper written in 2011 and was published in Perspectives in Psychiatric
Care. It states that good teams are engaging in dialogue, which they do in an open and proactive
manner, whilst poor teams avoid dialogue that had potential for conflict. The article also argues
that interdisciplinary work directed towards improving patient outcomes, might not always
improve teamwork. It states that the common purpose, professional contribution, skills,
communication, coordination and joint thinking, appear to be key features in good teamwork.
When these common goals are not met, the likelihood for conflict and disagreement are more
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probable. The team leaders have to be cognizant of assuming that their own perception of team
membership are shared by the other members. The perspective of some of these members of the
multidisciplinary team may extend beyond the group, and be more inclusive or exclusive.
(Deady, 2012)
The above articles are complimentary to each other on many points, such as, professionality, the
use of effective communication and patient outcomes. The articles highlight the benefits of good
teamwork, but also emphasise that sometimes, to strive for good patient care, does not always
mean good teamwork. They also emphasise that poor teamwork, can at times cause arguments,
which the members of the team will avoid by not engaging in dialogue, as much as they are
supposed to. This can result in poor communication which you do not want, because the
communication is a key component of good teamwork.
2.3. Participating countries perspectives
Lithuania:
According to the Lithuanian Mental Health Care Act 1995, professionals who work in the field
of mental health, must work in collaboration. The Act emphasises that interdisciplinary
teamwork in essential within the various branches of science. All branches of science relating to
the care or treatment are parts of the team and contribute to the development of treatment,
evaluation and coordination (LR psichikos sveikatos priežiūros įstatymas 1995 m.). The mental
health sphere is a multidimensional phenomenon. Therefore, professionals who work in the area
of psychiatry, always work in interdisciplinary teams. However, the Lithuanian health care
system is still dominated by the medical model of working, which hinders all the possibilities of
interdisciplinary team (Alseikienė Z., 2005). According to Germanavičius (2004) traditionally
teamwork is “only on paper”, but in reality, it turns into “command execution” in hierarchical
structure, whilst those on top of the pyramid are “most competent”, i.e. psychiatrists.
Norway:
The Norwegian Government's focus is the importance of increasing health prevention, health
promotion and multidisciplinary collaboration (Helse- og omsorgsdepartementet, 2013-2014).
The municipal services are often fragmented, a patient can get new medical staff and new
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therapeutic regimens when he/she goes from out-patient clinics to subacute or to a day ward even within the same hospital. A major challenge is the trust between services and professions.
Conflicts arise about knowledge, treatment and power in the treatment system (Almvik & Borge,
2006). "Lov om helsepersonell", § 4 requires professionals to interact and collaborate with each
other (Helsepersonelloven, 1999). The reform "Samhandlingsreformen" states that patients will
get the right treatment, at the right time and at the right place, through comprehensive and
coordinated health care services (Stortingsmelding 47, (2008-2009), 2009) "Lov om pasient- og
brukerrettigheter", § 2-5 gives patients the right to have an Individual Plan (Pasient- og
brukerettighetsloven, 1999). The Individual Plan is a tool and a method of cooperation between
patients and between the various service providers, to ensure comprehensive, coordinated and
individualized services (Helsedirektoratet, 2012).
Netherlands:
In the Netherlands they incorporate multidisciplinary guidelines to improve collaboration.
However, studies show that not all healthcare professionals use these guidelines in mental
healthcare (Sinnema, Franx, van't Land, 2010). The consequence is, that the available knowledge
in these guidelines about diagnostics, treatment and guidance of patience with anxiety,
depression, schizophrenia, eating disorders and many other mental issues, isn't used as much as
they should be. In the Netherlands the mental healthcare professionals strive towards more
healthcare professionals will use these guidelines, which will result in better knowledge in how
to treat a patient across multiple disciplines (Sinnema et. al, 2010). It is also important that they
revisit and alter these guidelines. The reason for this is, to implement any changes following
research on one of these illnesses which may improve the way the patient is treated, which again
results in better and faster recovery. Communication between the disciplines is of utmost
importance (Aarts & van Woerkom, 2008).
Portugal:
The Portuguese "Lei da Saúde Mental" (1999) states that external consultation and intervention
in the community, including home support and development programs for health promotion and
disease prevention, should be provided in each geo-demographic sector by multidisciplinary
teams (Diário da Republica- I Serie - A, 1999). In Portugal the access to mental health care is
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limited by the lack of specialists in public mental health services, presenting a huge barrier to
integrated interdisciplinary collaboration. It’s also important to mention the low development in
community services, resulting in a high rate of hospitalization and preferential use of the
emergency services caused by the difficulties of making appointments with physicians.
Additionally, the interval between discharge and subsequent consultation associated with the
proportion of re-admissions occurs without any contact with outpatients, suggesting the existence
of problems of continuity of care. However, integrated care programs and family health units are
being developed and units of psychiatry and mental health in general hospitals is a project in
construction (Plano Nacional de Saúde Mental, 2008).
Scotland:
In Scotland multidisciplinary collaboration means that services providing care, treatment and
support for adults with mental health disorders and comorbidity conditions must share common
health goals with other health care professionals. The Scottish Government (2011) emphasise
that multidisciplinary collaboration in mental health services produces a more effective and
person centred service and wants local authorities to ensure that there is equality in the provision
of mental and physical health across health, social care and other local services. The
implementation of the Mental Health (Care and Treatment) (Scotland) Act 2003 placed the rights
and treatment of mental health at the center of mental health services. Whilst the Scottish
Government’s mental health strategy 2012-2015, reinforces partnership working as an essential
role in supporting people with mental illness (The Scottish Government, 2011). The
implementation of such laws, ensures that multidisciplinary collaboration is the practice,
throughout the healthcare system in Scotland.
3. DISCUSSION OF DIFFERENT PERSPECTIVES ON MULTIDISCIPLINARY
COLLABORATION
3.1. Law and guidelines
According to the Lithuanian Mental Health Care Act 1995, professionals who work in the field
of mental health, must work in collaboration. The Portuguese Law on Mental Health (1999) also
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emphasises that external consultation and intervention in the community, should be provided in
each geo-demographic sector by multidisciplinary teams (Diário da Republica- I Serie - A,
1999). Norway have several laws pertaining to collaboration and coordinated care: "The
Healthpersonel Law", § 4 requires professionals to interact and collaborate with each other (The
Healthpersonel Law, 2011). Additionally, "The Coordination Reform" states that patients will
get the right treatment, at the right time and at the right place, through comprehensive and
coordinated health care services (St.Meld. 47, 2008-2009). However, in the Netherlands there are
no governmental laws that stipulate multidisciplinary collaboration in mental health
services. Multidisciplinary guidelines are incorporated into practice within some services to
improve collaboration. However, studies suggest that not all healthcare professionals use these
guidelines in mental healthcare (Sinnema, Franx, van't Land, 2010). Scotland appears to have
several
laws
that
promote
multidisciplinary
collaboration
in
mental
health
services. Additionally, the Scottish Government’s mental health strategy 2012-2015, reinforces
partnership working as an essential role in supporting people with mental illness (The Scottish
Government, 2011).
3.2. The application of multidisciplinary collaboration
The Lithuanian health care system is required to work collaboratively. However the health care
system continues to be dominated by the medical model of working, which hinders all the
possibilities of interdisciplinary team (Alseikienė Z., 2005). In contrast, the Norwegian
Government's focus is on the importance of increasing health prevention, health promotion and
multidisciplinary collaboration (Department of Healthcare, 2013-2014). In Portugal access to
mental health care, is limited by the lack of specialists in public mental health services,
presenting a huge barrier to integrated interdisciplinary collaboration (Plano Nacional de Saúde
Mental, 2008). However in Scotland, multidisciplinary collaboration enables all local authorities
to ensure that there is equality in the provision of mental and physical health across health, social
care and other local services (Scottish Government, 2011). In the Netherlands, mental healthcare
professionals strive towards the promotion of multidisciplinary guidelines (Sinnema et. al, 2010).
As the group reflected upon the individual laws, guidelines and application of multidisciplinary
collaboration there was much to discuss. It was agreed that having laws and guidelines to outline
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multidisciplinary collaboration in mental health services, benefits both the service and the
service user. We identified that the laws pertaining to multidisciplinary collaboration above
were noted to be similar. However, not all countries applied these laws to practice. In Lithuania,
a hierarchal communication existed which resulted in the lack of collaboration between
professionals. Whilst in Portugal a lack of finances, resulted in reduced staff levels which
impacts on multidisciplinary collaboration.
4. CONCLUSION
Throughout our paper we have explored the benefits of multidisciplinary collaboration from a
transcultural nursing perspective. From a group perspective, we believe that there are a great
number of benefits for this approach, within mental health servises. Therefore, in our conclusion,
we would like to propose our visionary “Golden Standard” of nursing care for multidisciplinary
collaboration, in mental health services.
Key benefits of a multidisciplinary collaborative approach:
-Incorporates team work, allowing for open discussions between professionals and a
sharing/ overlapping of skills (Choi & Pak, 2007).
-It envelops a holistic package of care (Choi & Pak, 2006).
-Improves patient outcomes (Deady, 2012).
Videbeck (2013) highlights that the nurse’s role in mental health is to provide a person centred,
holistic package of care and treatment. Therefore, as a group we believe that the above three key
benefits, would work towards creating a ‘Golden Standard’. It would also ensure that individuals
with a dual diagnosis and/ or comorbidity conditions recieved a package of care, inclusive of the
professional input from a multidisciplinary team.
To implement this we believe that there must be less ambiguity on the terms used for
collaborative care in mental health and agree that the term interdisciplinary, should be the
generic term used in Europe. To give a visual idea of what the difference is between
multidisciplinary and interdisciplinary, imagine two or more circles. Every circle represents a
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discipline. Multidisciplinary is represented by the circles seperated from each other whilst, in
interdisciplinary, the circles are partially overlapping. (Choi & Pak, 2006).
We also believe that by utilising the acronym TEAMWORK - Team, Enthusiasm, Accessibility,
Motivation, Workplace, Objectives, Role and Kinship (Choi & Pak, 2007), collaborative work
in interdiscipinary care would be enhanced. Teamwork and interdisciplinary collaboration have
been shown to shorten the patients hospital stay. Care models which include the patients
education, psychiatric and primary care co-management, improves the patients outcomes. For
example the patients that suffer from depression and panic disorders are more adherent to
medication, have decreased depression scores and have fewer symptomatic days. All this through
interdisciplinary collaboration (Choi & Pak, 2006).
As a group, we found that one of the most important parts of interdisciplinary collaboration is
good communication. Without communication no one within the interdisciplinary team will
know what the other one does. Deady (2012) emphasises that effective teams engage in dialogue.
Nurses are the eyes and ears for the rest of the team. If they do not communicate about what they
see and hear, how will the psychiatrist know if the medication is working? This also applies to
the rest of the team. They all have to work in an interdisciplinary way and not in a
multidisciplinary way.
The ‘Golden Standard’ should therefore be inclusive of; the acronym TEAMWORK - Team,
Enthusiasm, Accessibility, Motivation, Workplace, Objectives, Role and Kinship, incorporate
effective interdisciplinary teams, with good communications and work collaboratively, for the
good of the patient.
5. REFERENCES
Aarts, N. & Woerkom, van, C, (2008). Strategische communicatie (2nd ed.). Assen: Gorcum
B.V.
Almvik, A. & Borge, L. (Red.). (2006). Psykisk helsearbeid i nye sko. Bergen: Fagbokforlaget.
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Alseikienė, Z. (2005) Komandos vaidmuo medicinoje. Gydymo menas. 2005, p. 35-36.
Choi, B. C. K. & Pak, A.W. P. (2006). Multidisciplinarity, interdisciplinarity and
transdisciplinarity in health research, services, education and policy: 1. Definitions,
objectives, and evidence of effectiveness. Clinical and Investigative Medicine, 29(6), 351364.
Choi, B. C. K. & Pak, A. W. P. (2007). Multidisciplinarity, interdisciplinarity, and
transdisciplinarity in health research, services, education and policy: 2. Promotors, barriers,
and strategies of enhancement. Clinical and Investigative Medicine, 30(6), 224-232.
Deady, R. (2012). Studying Multidisciplinary Teams in the Irish Republic: The Conceptual
Wrangle. Perspectives in Psychiatric Care, 48, 176-182. doi: 10.1111/j.17446163.2011.00326.x
Germanavičius, A. (2004) Komandinis darbas medicinoje ir psichiatrijoje. Slauga. Mokslas ir
praktika. Retrieved from: http://www.elibrary.lt/resursai/Ziniasklaida/Slauga/MP/2004/slauga_2004_12.pdf
Helse- og omsorgsdepartementet (2013-2014). [Ministry of Healthcare] Kap. 764 Psykisk helse.
Retrieved from: http://www.regjeringen.no/nb/dep/hod/dok/regpubl/prop/2013-2014/prop-1-s20132014/4/6/4.html?id=739866
Helsepersonelloven. (1999). Lov om helsepersonell (helsepersonelloven).[The Healthpersonel
Law]. Retrieved from:
http://www.lovdata.no/all/tl- 19990702-063-002.html
Helsedirektoratet (2012). Individuell plan og koordinator [Individual Plan]. Retrieved from:
http://helsedirektoratet.no/helse-og-omsorgstjenester/habilitering-rehabilitering/individuellplan/Sider/default.aspx
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Lietuvos respublikos psichikos sveikatos priežiūros įstatymas (1995) Nr. I-924[Lithuanian
Mental Health Care Act], p. 4-5.
Mental Health (Care and Treatment) (Scotland) Act 2003. asp 13. Retrieved from:
http://www.legislation.gov.uk/asp/2003/13/contents.
Ministério da Saúde (1999). Diário da República, Lei nº 35.
Ministério da Saúde, Alto Comissariado da Saúde (2008). Plano Nacional de Saúde Mental:
2007-2016.
Pasient- og brukerrettighetsloven. (1999). Lov om pasient- og brukerrettigheter (pasient- og
brukerettightesloven. [Patient and User Rights Act]. Retrieved from:
http://www.lovdata.no/all/tl- 19990702-063-002.html
Sinnema, H., Franx, G., & Van't Land, H. (2010). Multidisciplinaire richtlijnen in de ggz .
Utrecht: Trimbos-instituut.
St.meld. nr. 47 (2008-2009). (2009) [White Paper, no. 47] Samhandlingsreformen-rett
behandling-på rett sted-til rett tid. Retrieved from:
http://www.regjeringen.no/nb/dep/hod/dok/regpubl/stmeld/2008-2009/stmeld-nr-47-20082009-.html?id=567201
The Scottish Government (2011). The Scottish Government’s mental health strategy 2012- 2015.
Retrieved from: http://www.scotland.gov.uk/Publications/2012/08/9714/0.
Videbeck, S. (2013) Psychiatric-mental Health Nursing. (6th ed.). Philadelphia: Lippincott
Williams & Wilkins.
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World Health Organization. (2013). Risks in mental health: an overview of vulnerabilities and
risk factors.
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6. APPENDIX
6.1. Appendix 1
Date
Database
Search words
Limits
Hits and
selection
04-03- Cinahl with
(MH "Collaboration") AND (MH "Mental
Full
28 hits
2014
fulltext via
Health") OR (MH "Research, Mental Health")
text
1 chosen
EBSCO
OR (MH "Mental Health Personnel")
(MH "Research, Interdisciplinary") OR (MH
"Multidisciplinary Care Team+")
04-03- Pubmed via
"Multidisciplinarity" AND "Interdisciplinarity"
Full
4 hits
2014
AND "Transdisciplinarity"
text
2 chosen
bib.hva.nl