How can we learn from the Norwegian rehabilitation sector (health industry) to create an environment for interdisciplinary collaborative among different disciplines?

How can we learn from the Norwegian rehabilitation sector (health industry) to create an environment for interdisciplinary collaborative among different disciplines?

As a changed specialist with focus on strategic management and development I would like to lift up the Norwegian Rehabilitation sector as an examples on how one can create an environment for interdisciplinary collaborative among different disciplines. There are learnings from this industry thatis compliance for other industries. Other industries should look to the rehabilitation sector to see and learn on how to build an interdisciplinary collaboration environment inside their industries.

Through one of the main federation in Norway, Virke, the Virke Rehabilitation sector has managed to standardize on a new term in rehabilitation. The industry has managed to work together towards a common understanding of rehabilitation, and established a new term in the field of rehabilitation. We are talking about Interdisciplinary Specialized Rehabilitation, ISR in Norwegian (TSR). This is a common and recognized term designation that the industry has established. This implies interdisciplinary collaboration between different professions inside the industry. The rehabilitations industry has managed todisregard from the traditional silo mentality where each profession submits its evaluation, assessment. We are talking about an interdisciplinary team work cross boarder the professions for the benefit of the patient.

Several industries should learn from this interdisciplinary collaboration, not least the rest of the Norwegian health sector. We read daily in the news about major challenges associated with collaboration across disciplines within the hospital sector.

Some months ago I had a discussion with one of the executive directors of one of Norway’s largest hospitals. Over a whole decade the hospital had having challenged with the cooperation’s within a department. Several heads of the departments had been replaced of the departments. Changing head of the departments was almost equal to the numbers of years for the hospital. Then it is not necessary the challenges lie with the head of the department. And examples from another industry, in a 15 years’ period there had been changing of 11 CEO. As a changed specialist this tells me that here a more fundamentally changed that need to be done then only change the CEO or a Head of the department.

Let’s go back to the health sector that I have been working within the latest years. As a change specialist I believe that the future of the Norwegian health system is dependent on health professionals re-tooling the way they practice together.  No longer can a multi-disciplinary model support the complex health needs of many patients nor can anyone-health profession have all the knowledge needed to provide total patient-centered care.  However, todays education and health systems are structured around a multidisciplinary model of practice with physicians or nurse practitioners as decision-makers and rarely are clients included in care planning. The health sector should learn from lean thinking where the customer (patient) is in the middle. Examples the Interdisciplinary Specialized Rehabilitation than I have been working in the last years has defined as a partnership between a team consist examples of health professionals within the following fields; psychologist, occupational therapy, physiotherapy, nursing, doctors, labor consultants etc. Through this interdisciplinary work process, the rehabilitations sector has found a way of collaborating, coordinating the approach to shared decision-making around health issues, this should be used for a revamping of how the future health professionals should be educated and how the system should accommodate a shared decision-making within the health sector. Through interdisciplinary collaborative professional practice model that are patient-centered one can facilitate the culture for change that is in needed to have more efficient hospitals.

By taking learnings from the Interdisciplinary Specialized Rehabilitation sector I would like to raises the recommendation for teamwork in the hospital sector to transform the traditional multidisciplinary approach to health care delivery in favour of a more interdisciplinary approach that recognizes and values the expertise and perspectives of a variety of different health care disciplines. Experience from theInterdisciplinary Specialized Rehabilitation has showed that one can enables a partnership between a team of health professionals and the patient in a participatory, collaborative and coordinated approach to share decision-making around his or her health issues.

The hospital sector can use Lean thinking to move towards a patient-centred interdisciplinary collaborative process, this will require a fundamental shift in health professionals’ attitudes towards such an approach.  A change to interdisciplinary collaborative process requires alterations in existing health professionals’ values, socialization patterns, and workplace organizational structures.  In order to facilitate such a change there is a need to create a new culture in the hospital sector that supports trust, a willingness to share in patient care decision-making, and meaningful inclusion of patients and/or family members in discussions about their care (according to one of the medical doctors of one of the rehabilitations institutions in Norway, believe that the next major patients groups are the relatives).   Medicine makes the distinction between intraprofessional and interprofessional teams and argues that within the discipline there are a number of specialties and therefore to address cross-professional work the latter term should be adopted.

To build an environment for Interdisciplinary Specialized disciplines one need to look at the goal of patient-centered collaborative process, organization structuralism, power relationships between health care professionals and between health care professionals and their patients and role socialization into health disciplines. Organizational structuralism is defined as the administrative organization and decision making processes adopted within institutions; power imbalances as the ability to exert pressure on another by virtue of formal or informal positions; and role socialization being development of behaviours, and attitudes deemed necessary to fit into a cultural group.

This can create a sense of powerlessness among some health professionals and patients. The power imbalance between health professionals due to professional socialization patterns can also leads to a lack of sharing in decision making around patients. Furthermore, the power imbalance within the health care system and between the health care system and the patient frequently excludes the patient from the planning for, implementation of, and evaluation of their health care. This leads to frustration amongst all parties who are not part of the decision making process. As an outcome, tests can be delayed, inappropriate medications or treatments may be ordered and administered, treatment appointments may be missed, and patients may feel frustrated that their needs are not heard. This would conflict with health care professionals’ social accountability† for the care they provide.

Transforming barriers into enablers is accomplished through a change process using four phases of change: sensitization, exploration, intervention, and evaluation.  These phases will create the environment for an interdisciplinary process culture as it has done within the rehabilitation sector.   Enablers include: role clarification which is gaining an understanding of both the roles assumed by each member of a group and their requisite knowledge in exercising the same; role valuing where respect is shown for each other based on of each members knowledge and contribution to the team; development of trusting relationships where each member trusts the knowledge, decision-making capacity and sense of ethics of each group associate; and power sharing where a willingness exists to facilitate joint power sharing within the group regardless of educational or professional preparation.

During the sensitization phase of the change process power imbalances and varying values are challenged.  Professionals explore the meaning of both their roles and decision-making processes thus creating an awareness of their current practice constructs.  Throughout the exploration phase health professionals explore their roles and seek clarification of the value they each bring to the collaboration.  For the duration of the intervention phase health professional collaborative teams work with their patients to gain an understanding of how both power can be shared and each member’s role can be valued.  In the final phase, evaluation, all participants assess the impact of their collaboration on patients’ satisfaction with their participation.

Sources of conflict within interprofessional healthcare teams can be the result of: ignorance to the conceptual basis for practice of other disciplines; poor communication among members of different disciplines; chauvinistic attitudes; distrust; and lack of confidence in other disciplines. Autonomous and specialized professional training and socialization lead many professionals to believe that their discipline is sovereign.  Few professionals are knowledgeable about the scope of practice, expertise, responsibilities, and competencies of other disciplines.  At the same time, collaboration, a relationship of interdependence, requires recognition of complementary roles and a respect for each discipline’s scope of knowledge and uniqueness of functions.

Teams operate within organizations that have their own rules, procedures and expectations.  As such, organizational cultures can create barriers to interdisciplinary collaborative practice. These larger systems may be less tolerant of innovative practice arrangements thus impeding creation of interdisciplinary teams.  Furthermore, interdisciplinary teams seldom choose their members, and it is common for individuals to leave and new members to join.  Turnover occurs because health care systems often encourage high staff turnover and rotation of health professionals. Potential barriers to interdisciplinary collaborative practice appear to cluster into three thematic groups:  organizational structuralism, power imbalances, and role socialization.

Organizational Structuralism 

Organizational structuralism is defined as the administrative organization and decision- making processes adopted within an institution to achieve mandates given by authority levels. These authorities include: Acts and statutes established at federal and provincial levels of government; provincial and national regulators of health professional practice, national health accreditation agencies, judicial system, and insurance carriers.  All of these authority’s place requirements on how health agencies manage operations and control employees and health professionals who function within.

Power Imbalances 

Power imbalances cluster into two broad categories: role conflict and goal conflict.  The former results from overlapping competencies and responsibilities, preconceptions that professionals have of their own role, and stereotypic perceptions that professionals hold of members of other disciplines. In contrast goal conflict relates to value differences arising from dissimilar philosophies or professional socialization. Unequal exercising of power occurs in situations, between the health professionals and others in the health system and among different groups of health professionals.

Although health professionals would likely report that they work in teams, in reality team members identify with their own professional group and this blocks their ability to consider the opinions and perspectives of others. Turf wars, weak leadership, and confusion regarding levels of autonomy and authority can have negative effects on abilities of team members to work together and produce results. The downfall to the continued delivery of health care services within the existing system is that these power imbalances can lead to conflict within and between health professionals and lead to higher health costs through energy expended from the frustration within teams and potentially leading to patient safety problems.

A further power imbalance exists between the health care system and the patient who is generally excluded from the planning for, implementation of, and evaluation of their health care. At the same time patients’ complex care requirements necessitate use of collaborative approaches by health professionals.

One of the major hospital in Norway has changed their head of a department too often due to challenges within the department of cooperation’s. Here we have the nurse-doctor relationship that has been fraught with conflict and an unequal exercise of power among health professionals within the health system is leading to barriers for interdisciplinary collaborative practice.  Termed turf issues this imbalance is a legacy of our current system that provides a narrow gate for patients accessing the system.

Collaboration based on a relationship of interdependence, built on respect, trust and understanding of the unique and complementary perspectives of each profession cannot occur without resolution of this power imbalance. Moreover, an acceptance of patient’s views must also be respected.  Even though health professionals verbally support patient entered care territorial issues regarding who should be in charge interferes. Hence, both a systemic structure, physician decision-making, and disciplinary practice isolation seem to be primary reasons for the failure of healthcare teams to commit themselves to an interdisciplinary process and relinquishing perceived independent decision-making.

Role Socialization 

The development of both an identity and pattern of practice in health professions is based on a process of socialization in which knowledge, skills, values, roles and attitudes associated with the particular professionals’ practice are acquired. One again look to the Norwegian rehabilitation sector on how this has been done.  Each discipline has its unique way of thinking and acting; its own culture. Disciplinary cultures are founded on prevailing assumptions about appropriate epistemological, behavioural and normative bases of action.  Thus, each member of a health discipline brings a different set of values about teamwork based on professional socialization, personal experiences and beliefs.

Upon entering collaborative process, health professionals must learn to accept a blurring of process boundaries and trust other discipline members in sharing patient care processes as in the rehabilitation sector. Consequently, role socialization must be expanded to include collaboration with other health professional colleagues. Hence, a cultural shift in re-socializing health professionals, administrators and educators is required for interdisciplinary collaborative practice to occur. Obviously, interdisciplinary collaborative process does not preclude strong disciplinary socialization but this is enhanced with an understanding of the complementary skills and expertise that all health professionals can bring to patient care process.   Effective interdisciplinary collaboration depends upon establishing an understanding that respects differences in values and beliefs.

Enablers to interdisciplinary collaborative practice is based on gaining both an understanding of all roles assumed by members of a disciplinary group and their knowledge in exercising these roles.

Each health professional discipline will need to discuss and acquire:

–          A clear understanding of their own roles and expertise

–          Confidence in their own abilities

–          Recognition of boundaries of their own discipline

–          Commitment to values and ethics of their own profession

–          Knowledge of their own disciplinary practice standards. 

Movement towards role clarification requires discussion around the constructs, in particular beliefs and values that underlie disciplinary boundaries of each discipline.

Role clarification also necessitates discussion around patients’ participation within the health care team.  Health professionals and patients initially need to explore their views towards full participation of patients as members of interdisciplinary teams.  The crux to role clarification is acceptance of a less dogmatic boundary between health disciplines. Hence, during the sensitization process it is important that all participants accept that each member of a profession has both the right and ultimate responsibility to argue about the truth and usefulness of ideas within his or her professional domain.  Allowing group members to share their frustrations and challenge each other for a change in practice fosters open dialogue that is respectful, but at the same time honest and open.  It is from this base of understandings that new modes of practice can emerge.  The outcome is clarification of the roles of each professional group.

Role valuing is based on showing respect for one another based on the knowledge and contribution that each member brings to the group.  Respect develops once all members of an interdisciplinary collaborative practice team gain clear understandings of the unique contributions that each can bring to the care process.  Role valuing among health professionals facilitates sharing of self, ideas, responsibility, aspirations, and disagreement. Valuing the contribution of each health professional will create a climate of openness and respect with a guarantee for safe expression of opinions and feelings without retaliation. An outcome is trusting relationships.

Trust evolves when there is respect for each other’s values.  Values believed to be essential for collaborative teamwork are – mutual respect, trust, and synergy. Mutual respect means team members have a commitment to values and ethics of their own profession, recognize the expertise of colleagues, and the interdependency of practice. Trust is an important element in effective collaborative practice and when it is lacking team effectiveness can be undermined.  Trust not only influences commitment to group goals, but influences group attachment and support of group decision-making.  Trust in a collaborative effort not only influences commitment to group goals, but influences group attachment and support of group decisions and is prerequisite for developing collaborative cultures.  Fostering trusting relationships among collaborative groups creates synergy and a tolerance of assertiveness, enhanced communication, cooperation, and shared decision-making around coordination of care.

 Trusting relationships will be evident:

–          When there is shared responsibility for patients’ care

–          Care is a cooperative shared venture

–          A team approach is adopted with willing participation, shared planning and decision making,

–          Contributions of expertise and shared responsibility allocated through non-hierarchical relationships

–          Power is shared based on knowledge and expertise versus role or title.   

The process of development and change is achieved through power sharing.  Creating an interdisciplinary collaborative process.

Thus, moving from the current care delivery process to interdisciplinary collaborative process will require a significant change in the way health professionals are educated and socialized into their roles, in how the health system operates, and in how patients participate in their care. This shift will require health professionals and patients to participate in change processes from the previously identified barriers to adopt enablers.

The change process starting with sensitization where a developing awareness about issues affecting members in different health disciplines occurs as they work across disciplines.  A similar but independent process follows with health professionals’ sensitization with patients who are encouraged to frankly share their issues in receiving care, this is how it is done within the rehabilitation industry.  This change process moves on to exploration which provides a means for establishing a model for collaborative working relationships across disciplines and with patients; then to intervention where the agreed upon model of interdisciplinary collaborative practice is tested with patient groups; and finally evaluation when outcomes of the interdisciplinary collaborative practice models are determined.

Sensitization – Initially the focus is on creating awareness for the need to change from current practice models.  During the sensitization process the three barriers to establishing interdisciplinary collaborative practice, organizational structuralism, power imbalances, and professional socialization discussed previously are brought forward by group members.  Participants share issues they have about each other and the myths that abound relating to knowledge and skill capabilities of other disciplines.  All viewpoints are respected allowing for full disclosure of issues that can interfere with collaboration.  Members then assist each other in clarifying misperceptions about each other’s knowledge and practice. A repeat of this process occurs with a selected group of patients.  These patients also share their frustrations in interacting with various health professionals and clarify the role they wish to have in future collaborative care processes.

Exploration focuses on a clarification of roles and a valuing of the contributions that each team member brings to the interdisciplinary collaborative process.  Members then consider where overlapping skills exist among the group.  Patients then share the role they wish to have within the interdisciplinary collaborative care process.  Members finally agree upon unique and collaborative contributions that each member can have in the care process. The former is termed role clarification and the latter role valuing. Initially role clarification is explored within each health professional discipline by having members focus on their unique knowledge and skills and then across the health professional disciplines.  Team members gain an understanding of role overlaps and begin to develop role valuing of each other, discussed previously.

Once the team of health professionals has discussed the values and beliefs related to how they wish to work together, they can begin to develop their shared vision for collaborative practice.   An antecedent to formulating this shared vision is establishment of what members’ expectations will be from each other and clarifying what each other’s beliefs are about interdisciplinary collaboration and teamwork. Operating as an interdisciplinary team will require resources.

Decision-making that includes: explicit definition of problems; clarification of member roles and involvement in decisions; understanding of how to determine when sufficient and relevant data about the problem is achieved; willingness to generate many options and alternatives, shared testing of various options, and a built-in commitment to act with specified responsibilities.  Consensus in shared decision making need not be a unanimous decision, rather an equal opportunity for each member, including the patient, to influence the outcome.Leadership and handling of conflicts within healthcare teams are the most critical elements to their success. Leadership should reflect non-hierarchical relationship between the professions with an equitable distribution of work, authority, responsibility, and credit for success and allow for work across health professional’s disciplinary boundaries that are open and …remain open to the external environment. Interdisciplinary teamwork leadership is not constant as no single leader can provide all the leadership in any complex situation. The role of leaders in interdisciplinary collaborative practice models should be flexible depending on the unique patient situation. Members who are seen as either extremely competent clinicians or as extremely creative problem solvers are considered best in the leadership role because of their skills as process analysers. Development of interdisciplinary collaborative practice models requires health professional groups to consider the constructs of patient care practice.  These being: conceptualization of professional practice, re-conceptualization of patient care, vision of what service might be like and working with boundaries.

Conceptualization of professional practice is dependent on addressing:

–          Power relationships and sharing among members

–          Shared values between and among collaborative relationships

–          Role clarification of each group member

–          Development of collaborative working relationships.

Interdisciplinary healthcare teams are then organized around solving a common set of problems; working together closely, meeting regularly, and communicating frequently to optimize patient care.  Each member contributes his/her knowledge and skill set to augment and support the others contributions to achieve holistic management of patients’ complex health problems.

Re-conceptualizing patient care delivery requires that one overcome:

–          Poor communication between disciplinary members because of use of different language sets and approaches to patient/client care

–          Duplication of services because of lack of understanding of other health professional’s expertise

–          Lack of a patient focus reflective of individualizing their distinct needs. 

Teams need to agree on common professional language to enhance communication.  The collaborative process of shared discussion with patients around care needs will, in itself, not just facilitate allocation of work to appropriate health professionals but also ensure all team members are aware of the basis of shared care planning. A patient-centred approach to interdisciplinary care involving the patient and/or family will make it difficult for health professionals to avoid individualizing care around patient’s needs.  At the same time bringing patients into the decision-making process will challenge patient’s socialization into the illness role. Initially health professionals may need to invite patients and their families to be active participants in the care process within their capabilities.  At the very least, patients and their families should be taught about what the team is, what to expect from it, and how the team members work together to share their expertise to improve patient outcomes.  Including the patient will, however, require some changes in the way health care responsibility and management is distributed. The patient will have, as a team player, to share responsibility about his/her health.

In interdisciplinary collaborative practice each health professional discipline will need to discuss and share knowledge about:

–          Their understanding of own roles and expertise

–          Confidence in their abilities

–          Recognition of discipline boundaries

–          Commitment to values and ethics of profession

–          Knowledge of disciplinary practice standards

–          Social accountability.

Team members then need to achieve agreement on where disciplinary boundaries are unique and where they can be shared.

Shared decision-making has following key components:

–          Assessment

–          Exploration of options

–          Selection of choices from among alternatives

–          Implementation of the selected plan 

Assessment begins with a clear definition of patients’ problem(s) with adequate and relevant data, and identification of sufficient information needed to provide clarity. Exploration of options is carried out at two levels. First, for patients’ care needs, and secondly, to determine which team member has the appropriate knowledge, skills, and abilities to deal with the patients’ problem(s). In the former all parties in the team, including patients and/or relatives participate in discussions related to potential meanings for problem elements.

Selection of choice among alternatives involves a careful decision-making process where each option is weighed for its value in providing the means to resolve the problem coupled with willingness of the patient and/or relative to participate in planned interventions. Team members may also explore whether any other specialists should be consulted before finally selecting their care choices.    Implementation of the plan can only proceed if all who should be consulted and informed have been prior to deciding on the plan of care. Intervention – Throughout the intervention phase the developed interdisciplinary collaborative practice model is operationalized and tested with patient groups.  A number of authors suggest that testing interdisciplinary collaborative practice models should focus on structure, process, and outcomes. Structure has been a priority within the exploration phase. Process during this intervention phase and outcomes are addressed in the next phase, evaluation. Thus, this phase focuses on team processes, an area that has not been researched in health care.  Most of the reported research has focused on teamwork effectiveness.

Productive teams focus on both tasks to be undertaken delivery of care and inter-group communication.

Tasks needing agreements are:

–          Informal leadership

–          Goal setting

–          Influencing

–          Role negotiating

–          Trust building

–          Problem solving

–          Problem setting

–          Managing conflict

All requiring effective inter-group communications around:

–          Information about meetings

–          Other methods of communication

–          Reaction to decisions

–          Importance of leadership

A key to effective functioning is in how disagreements and conflicts are handled and specifically how to accept disagreement; identify issues that are likely to cause dissent; and develop methods for dealing with dissent. Thus, how groups problem solves together and handle conflicts are key areas in assessing their effectiveness in task accomplishment.

Team maintenance activities include:

–          Ability of all members to use power for decision making

–          Commitment to freedom of dissent

–          Willingness to resolve conflict

–          Commitment to evaluate and manage itself

–          Ability to teach leadership to new members  

Evaluation of the interdisciplinary collaborative process focuses on assessing team effectiveness.  Four foci are considered: team process, team member satisfaction with the process, patient outcomes, and patient and/or relative satisfaction with the process and their health outcomes.  Team development evolves through a change process and it is this process that is critical in establishing team effectiveness.  Therefore, both a formative and summative evaluation process must be adopted to measure how interdisciplinary healthcare teams work through their evolution.

Satisfaction with the interdisciplinary collaborative process relates to team members and patient’s perceptions of care effectiveness using this approach.  As with team process both quantitative and qualitative approaches can be adopted.  Quantitatively, measures include: satisfaction with collaboration and care decisions; interprofessional team effectiveness interdisciplinary team performance attitudes about team work, perceptions of interdisciplinary relationships, decisional conflict perceived organizational support, and trust and respect in workplace.  Qualitatively individual or group meaning of the following areas in the team process can be explored:

–          Mutual performance monitoring

–          Back-up behaviors

–          Adaptability

–          Team leadership

–          Team orientation 


By taking learnings from the rehabilitation sector one can build a new culture of interdisciplinary collaborative process within the hospital sector.  Interdisciplinary collaborative process involves a partnership between a team of health professionals and a patient in a participatory, collaborative and coordinated approach to share decision-making around health issues as the means to achieving improved health outcomes of patients.  The culture to support interdisciplinary collaboration interdisciplinary collaborative process has to be a patient-centred collaborative process. Barriers to this form of process are: organizational structuralism, power relationships between health care professionals and between health care professionals and their clients, creating imbalances, and role socialization into health disciplines and society’s expectations of sickness.

These factors are perceived to create a sense of disempowerment for some health professionals and clients.  The power imbalance between health professionals due to professional socialization also leads to a lack of sharing in decision making around clients.  Furthermore, the power imbalance between health care systems and clients frequently excludes them from planning for, implementation of, and evaluation of their health care. This leads to frustration amongst all parties who are not part of the decision-making process.

Transforming barriers into enablers can be accomplished through a change process using four phases of change: sensitization, exploration, intervention, and evaluation. Enablers include role clarification, role valuing and power sharing. Thus, during the change process power imbalances and value conflicts are challenged. It is believed that if these barriers are removed the outcome will be enhanced satisfaction with care provision by patients and care delivery by health professionals.  Such satisfaction is believed to lead to empowerment of all participants in the interdisciplinary healthcare team.

Empowerment through interdisciplinary collaborative process is believed to lead to a sharing of resources among members of the teams and a continuous desire to continue to collaborate. Clearly, interdisciplinary collaborative process is a sound approach to the future of health care.  Creating this type of culture among health professionals and their patients will inevitably result in heightened quality of care.

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