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Geriatric Teamwork: Keys to Successful Collaboration and Cooperation
Phillip G. Clark, Sc.D.
Professor, Human Development and Family Studies,
Director, URI Program in Gerontology and Rhode Island Geriatric Education Center

Introduction
The multifaceted, chronic health care problems of older adults frequently demand an integrated, teamwork approach to care. "Two heads are better than one" is a common expression that captures this intuitive insight. As geriatric health care increasingly focuses more on the quality--than the quantity--of life, it is natural that we will need the input and expertise of several different health care professions in working with older adults. Indeed, the basic premise of the Rhode Island Geriatric Education Center is that there is a fundamental need for interdisciplinary education and training in geriatrics.

However, as most health care providers well know, teamwork is frequently more difficult and challenging than they thought. You cannot just put nice people together, tell them they are a team, and expect that they will work together as a highly functioning unit. As its name suggests, "teamwork" means working hard to make a team!

Several factors are related to effective teamwork, and these are summarized below under the headings of (1) turf and territoriality, (2) communication and language, (3) conflict management, (4) cognitive and value maps, and (5) mission dominance.

Turf and Territoriality
It is human nature to want to protect our own little world, our turf or territory. In health care professional circles, this may refer both to our own unique perspectives--based on our training and education--and to our own particular agency's budget and resources; community visibility; and social, political, and economic considerations. All these factors may reduce our willingness to work together in clinical programs out of fear of losing our identity, power, or resources. In reality, turf issues simply become another excuse for not working together, out of fear of change.

Communication and Language
As in any relationship, communication is essential to a healthy partnership. "Keep the lines of communication open" is a good way of expressing both the importance of sharing with others and the necessity of working at establishing and maintaining the conduits that make good and open communication possible. Yet, frequently personality and professional differences can make such communication difficult and challenging. However, it is only by effective communication that collaborative groups and teams of health care providers can create the kinds of programs that make the best use of their respective disciplines, perspectives, and experiences.

Any group will have individuals embodying varied personality types, which may make communication more difficult. Those with more extroverted and controlling personality characteristics may dominate group interaction and discussion. Those with more introverted and submissive personalities may find it easy to simply "sit back" and let others control the direction and style of a collaborative effort, perhaps complaining secretly about the powerful figures that are imposing their wishes and goals on the group. Under these circumstances, the more passive members of the group should be empowered to "step forward" with their contributions. To help, the group must establish an accepting environment in which each member's role and contribution is respected and valued. Arriving at this point in group development takes time and effort, however.

Another basis for communication problems is differences among different professions with regard to models and modes of practice and functioning. These include the logic of assessment, the focus of professional efforts, the locus of responsibility, and the pace of action [see S. Qualls and R. Czirr (1988). Geriatric health teams: Classifying models of professional and team functioning. The Gerontologist, 28, 372-376].

1. The logic of assessment represents the method of defining the problem. In particular, this hinges on the extent to which some professions systematically "rule out" aspects of a problem until only one possible definition and solution remain. Others are taught to "rule in" possible dimensions and interpretations, thereby expanding the range of potential factors that may account for a particular problem, and introducing potential solutions that were originally not recognized.

2. The focus of professional efforts may range from a narrow concentration on biomedical aspects, to a much broader concentration on the functional and social issues. A group that cannot understand the implications of different foci, and is constantly mixing them up, may have difficulty collaborating in achieving its mission.

3. The locus of responsibility deals with differing styles of group participation and leadership, ranging from the "executive professional" who dictates to everyone else what they must do, to the individual who feels that they are simply a consultant to the participant or client. Similarly, differing styles of group process and decision making can help or cripple a group if they are not fully examined and understood. For example, should a group arrive at a consensus, vote formally, or allow one leader to make the final decision?

4. The pace of action refers to the time frames within which different professions are trained to work. For example, some problems have to be addressed immediately and require aggressive, short-term treatments to solve. Others may be more long-term and need extended attention over several months or even years.

Finally, language in general--and specifically jargon in particular--can be a real barrier to effective collaboration among different health care professionals working on geriatric teams. For example, the word "assessment" can mean very different things to nurses, social workers, and physicians. Yet, the use of the term is seldom clarified: people may be using the same word but actually mean very different things!

Conflict Management
Conflict in human relationships and teamwork is inevitable. What is important is how we as individuals or groups deal with this conflict; whether or not we have developed mature and productive ways to address conflict and to use it as a vehicle for greater growth and understanding is the issue.

Each of us has different ways of coping with conflict; most of us have one preferred method, though we may rely on others in different situations [see K. Thomas and R. Kilman (1974). Conflict mode instrument. Tuxedo, NY: Xicom]. One way of thinking about these styles is outlined below:

1. Competing. The competitive approach is used by persons who want to satisfy their own wishes or concerns at the expense of others. They may act in an aggressive and uncooperative manner and use attempts to dominate others.

2. Collaborating. In this method, persons want to satisfy both sides in a dispute, and they tend to exhibit highly assertive and cooperative behavior. They value mutual benefit, integration, and win-win solutions to problems.

3. Compromising. This style is sometimes thought of as a "middle of the road" approach, in which each side may have to give up a little to achieve a solution and achieve a partial gain--"give a little to get a little" is a phrase that embodies this thinking.

4. Avoiding. Persons who are avoiders seem indifferent to the concerns of both themselves and others. Non-assertive and uncooperative, they prefer apathy, isolation, and withdrawal to facing conflict. Distraction and ignoring are characteristics of avoiders.

5. Accommodating. Non-assertive and cooperative, accommodators are more concerned with pleasing others than with meeting their own needs. These individuals would rather sacrifice their own needs and desires in order to "keep the peace" and please others.

The conflict management styles of individuals may change as they become more aware of their own preferred methods and recognize their limitations. For example, when dealing with a person who uses a highly dominating method, an individual who prefers the accommodating style may have to practice or rehearse ways of avoiding being "railroaded" by the other's strong approach. Additionally, a group may have to sanction an individual who persists in imposing his or her will on others.

Cognitive and Value Maps
Another important dimension of collaboration--related both to communication and to conflict--is the importance of attaining an understanding of the cognitive and value maps of the different professions represented on the team. Unless individuals working together achieve a basic working knowledge of each other's maps, they will not achieve a level of interdisciplinary collaboration.

An interdisciplinary level of functioning entails the genuine integration of perspectives, not simply the "parallel lines" of communication typical of multidisciplinary groups. The latter situation is similar to the phenomenon of "parallel play" in children, where they play "together" without really interacting. In contrast, interdisciplinary collaboration entails the integration and modification of different contributing disciplines in light of the input from other professions. The hallmark of this level of cooperation is the kind of mental and behavioral change that occurs: participants understand the core principles and concepts of each contributing discipline, including the basic language and mindsets of the different professions represented in the group [see H. G. Petrie (1976). Do you see what I see? The epistemology of interdisciplinary inquiry. Journal of Aesthetic Education, 10, 29-43].

This achievement hinges on an understanding of the cognitive maps of other disciplines: the entire conceptual framework used by a profession, including its basic concepts, problem definitions, modes of inquiry, types of observation and explanation, and general ideas about what makes up a discipline.

Beyond cognitive maps, however, is another level of understanding based on the values and ethical principles that characterize different health professions--value maps. These give explicit recognition to the role that personal and professional values play in our lives, and the influence they wield in our relationships with other professionals and with our clients or patients. Members of an interdisciplinary geriatric team must come to understand and appreciate the value differences and directions that may distinguish different persons from differing backgrounds, and take these differences into consideration as they frame their own approaches to problems and their solutions.

Mission Dominance
Finally, the overall purpose for which a team is formed--and the extent to which this goal sustains it through periods of conflict--is another important factor in assuring the success of its cooperation. "Idea" or "mission" dominance refers to the shared goal or objective of the team--be it "patient welfare" or the "improved functioning" of the client.

Experts in collaborative group work have pointed out that a common mission to which all members of the group are committed can frequently help to overcome problems or pitfalls along the way--be they communication gaps, conflict, or personality clashes. Keeping the group's "eyes on the prize" can be the important glue in providing cohesion and coherence in an otherwise fragmented and disjointed effort that can be threatened by internal and external problems.

Summary
Collaborative, interdisciplinary teamwork efforts are challenging but rewarding, as participants unite in achieving a common goal whose attainment depends on the unique contributions of all of them. Although "two heads are better than one" can lead to situations of real headache, nevertheless such discomfort may be worth it if group members and those they work with are better off because of this collaboration--as is frequently the case in geriatric practice!

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