Health care is increasingly provided by multidisciplinary teams. Psychiatrists are expected to work constructively within teams and to respect the skills and contributions of colleagues. In relation to collaborative practice, the RANZCP acknowledges the following:
- Clinical authority is vested in the psychiatrist by virtue of training and experience and can be enhanced by good teamwork.
- Psychiatrists working in a team remain accountable for their own professional conduct and the care they provide.
- Clinical responsibility, which relates to duty of care and standards of care, rests with every health care professional.
- The psychiatrist is an essential contributor to the multidisciplinary team.
- Collaborative practice assists in promoting better health outcomes for people experiencing mental illness and their carers.
- Effective mental health care requires collaboration between consumers, carers, mental health professionals (including psychiatrists), general practitioners, non-government and government agencies.
- Psychiatrists understand and value the expertise of the other mental health professionals.
- All mental health professionals need training in the principles and application of teamwork.
- Training programs need to give trainees a positive experience of collaborative work environments.
- Management of a multidisciplinary team is not necessarily the domain of the psychiatrist.
- Psychiatry trainees are responsible to their supervising psychiatrist.
Teamwork and psychiatric services
The advantages of teamwork include continuity of care, the capacity to take a comprehensive view of the consumer’s networks and problems, the availability of a range of skills, and mutual support and education. A well-functioning team with a shared sense of responsibility may be more than the sum of its parts: the team can produce more and better work than its individual members working as solo practitioners. However, working in clinical teams which are not functioning well can also be a source of professional dissatisfaction for psychiatrists and other mental health professionals, and can contribute to unsatisfactory care for consumers and families.
Effective teamwork requires:
- agreed goals, usually seen as consumer benefit
- an agreed approach, including a common understanding about the philosophy of care and a collaborative style between the consumer, family and clinicians
- effective communication styles, with agreements to aim for clear and open styles of communication through opportunities for all members to contribute to decisions, and adequate face-to-face meetings. In particular, this includes an attitude of openness in expressing disagreement and acknowledging the presence of conflict, together with agreed avenues for conflict exploration and resolution
- established ground rules which guide interpersonal behaviour within the team. An attitude of respect for the professionalism of every member when disagreement and conflict arise, will both enhance the possibility of conflict resolution and reduce destructive interactions
- clear team roles
- competent leadership.
Obstacles to effective teamwork include the following:
- ambiguity or conflict over roles
- conflict and confusion over leadership
- differing understandings of responsibility and accountability
- inter-professional misconceptions.
Leadership, management and clinical responsibility
It is important to distinguish between several critical overlapping aspects of team functioning. Teams will differ in the extent to which these functions may be performed by one or more individual team member. Psychiatrists may or may not have the desire, aptitude or skills to assume all of these functions.
Leadership is the process of influencing others to engage in the work behaviours necessary to reach organisational goals (Tobin and Edwards, 2002).
Management is the process of achieving organisational goals by the four major functions of planning, organising, leading and controlling (Tobin and Edwards, 2002). In many settings the term ‘team leader’ refers primarily to the operational and line management of the multidisciplinary team.
Each team member is the responsible for maintenance of their individual clinical skills and standards of care. Each team member has an individual duty of care. The concept of “ultimate” or “overall” responsibility for the actions of all team members is not applicable for this reason.
All teams should have clear lines of clinical responsibility, making explicit the roles and responsibilities of each team member. Where one team member has the responsibility for development of a management plan to guide and coordinate the actions of other team members, this should be unambiguously specified. In such situations the clinician developing the management plan has the responsibility for the adequacy of that plan and the systems for monitoring and review of that plan. Individual clinicians maintain responsibility for the skill and care with which they carry out individual components of that plan.
If a member of the team disagrees with the team’s decisions, they may be able to persuade other team members to change their minds. If not, and it is believed that the decision taken by the team would harm the patient, the team member should draw the matter to the attention of someone who can take action. As a last resort, the psychiatrist must take action his/herself to protect the patient’s safety or health.1
A more detailed discussion of these matters is presented in the document, The roles and relationships of psychiatrists and other service providers in mental health services, prepared by the Professional Liaison Committee (Australia) of the Board of Professional and Community Relations, August 1999, which is available from the College.
1 The duties of a doctor registered with the Medical Council of New Zealand