Team working in Rehabilitation for neurological problems

1. Team working in Rehabilitation for neurological problems …..a European perspective Vera Neumann

2. 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?

3. Are teams really needed? Potential disadvantages: • Patients may feel overwhelmed • Time-wasting • Increased use of (scarce) resources • Increased costs

5. 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

6. 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? .

7. Evidence for teams in rehabilitation • From scientific literature – searched Medline & other databases 1996-2008 • Musculoskeletal rehabilitation • Cardio-respiratory .. • Neurological .. • Personal experience

8. Multidisciplinary teams in musculoskeletal rehabilitation

9. Multidisciplinary teams in cardio-respiratory rehabilitation

10. Multidisciplinary teams in neurological rehabilitation

11. MDTs in Spinal cord injury rehabilitation? • Very little published evidence…

12. 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

13. European position paper JRM 42 ; 2010

14. 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

15. How our team works - 1 • Team decision on acceptance based on • patient’s needs • potential for improvement • resources • Rehabilitation goals set with patient

16. How our team works - 2 • Assessment – recorded against standardised measures at weekly meetings • Multi-, inter- or trans-disciplinary input to address these

17. 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

18. Centre for the Rehabilitation of the Paralysed – CRP

19. What CRP does

20. physiotherapy

21. Making own equipment

22. Getting ready for home

23. Returning to work

24. 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?

25. ESPRM congress workshop on teamwork Vilnius, Lithuania. Sept 2011

26. Our task To define each MDT member’s role Core competencies Contribution to team in 3 situations:

27. Mobilisation in the acute setting following trauma

28. training communication skills in the post-acute setting

29. Community reintegration for those with long-term needs

30. Results?

31. 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

32. 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

33. 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

34. What makes a good team? Evidence from elsewhere

35. 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

36. 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)

37. agreed aims and direction

38. good communication, avoiding jargon Tower of Babel - Breugel

39. appropriate range of knowledge & skills for the agreed task • Strimmer for haircut?

40. mutual trust & willingness to share information

41. Leadership??? a thorny question!

42. 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

43. 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?

44. 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!

45. Thank you For further information please contact • vera.neumann@leedsth.nhs.uk