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Interdisciplinary team work - can it work?

SUZANNE HARRIGAN, DEE DYAR and JAYNE INSCOE Nottingham Paediatric Cochlear Implant Group, Nottingham, UK

ABSTRACT In 1989 the first exclusiuely paediatric cochlear implant programme in the UK was established in Nottingham. As implant team speech and language therapists, this has enabled us to work collaboratiuely with colleagues from six to eight different backgrounds and to consider the importance and benefits of ejjec- tiue interdisciplinary teamwork. The Nottingham Paediatric Cochlear Implant Pro- gramme commitment is to a child-jamily-centred philosophy of seruice delivery. Its emphasis on sharing information and rehabilitation skills with parents and a range of professionals has led us to extend if not question more traditional models of ‘unidisciplinary’ programmes of care.

INTRODUCTION

The aims of this paper are to:

Outline the role of an implant team speech and language therapist. Describe four casework principles of rehabilitation and outreach support. Prioritise identified issues and concerns raised by speech and language thera- pists who work locally with deaf children selected for implantation. Outline the content and format of the outreach programme devised by the Not- tingham speech and language therapists.

THE ROLE OF AN IMPLANT TEAM SPEECH AND LANGUAGE THERAPIST

This is as follows:

To assess and describe the individual child’s communication skills and needs before implantation. To document the child’s rate of progress in communication after implantation. To investigate unforeseen or concomitant non-sensory difficulties.

As well as these essential duties, it is a vital part of our work to contribute, firstly, to training initiatives and, secondly, to measuring the benefits of cochlear implantation as part of the whole team. The amount of time and emphasis given to these areas de- pends on the business plan of the individual team.

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FOUR CASEWORK PRINCIPLES OF REHABILITATION

In order to fulfil our role, we try to adhere to the following principles:

Establish a child-centred relationship with families and local professionals - the child’s family and the local professionals are the experts regarding the indi- vidual child. We aim to help local professionals to set objectives that can be implemented by all the local team members, not just the speech and language therapists. Prouide information, guidance and reassurance from an interdisciplinary team perspectiue - as implant centre speech and language therapists we are the experts in the communication development of implanted children, so we can act as a specialist resource in order to reassure and guide local professionals. We can also ensure that goals set by the local team are appropriate, and reflect the findings of our other colleagues, such as audiological scientists. Maintain high standards of progress records - this enables us to easily evalu- ate the child’s use of the implant system, and contribute to both team-initiated measures of benefit, and in the future multicentre clinician-led trials. Contribute to local seruice policy o n request - on issues such as signing, and speech and language therapy provision. On outreach we are very much aware that we are visitors to local areas and it is our role to work with the local team, not against them by insisting on unachievable goals or levels of provision. How- ever, we do have the right to make independent recommendations based on the child’s needs as well as available resources. It is often a fine balancing act to fulfil both these roles.

On the Nottingham paediatric cochlear implant programme, of the 93 children who have been implanted up to 1 September 1995, 60% are supported by a speech and language therapist with specific responsibility for deaf people; 20% are supported by generalist speech and language therapists, and 20% receive no speech and language therapy input. But, what do these speech and language therapists need from us?

PRIORITISATION OF IDENTIFIED ISSUES AND CONCERNS

An informal investigation of need was carried out and therapists were asked the following questions:

If you had a child on your caseload who was going to receive a cochlear implant, what would be your main concerns? What would help you to support the child effectively? What would constitute ineffective support? Would you have any particular training requirements?

The main concerns were, firstly, lack of knowledge about implants, rehabilitation and prognosis and, secondly, lack of time. Some of the therapists believed that im- planted children require intensive speech and language therapy, and because of busy caseloads, they did not feel they would be able to manage. These two issues lead to the overriding concern that the therapist would be unable to support the parents/carers effectively.

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All therapists felt that for support to be effective it had to be accessible. Contact with the team-based speech and language therapist is essential, in particular in the early stages and, although telephone contact is good, face to face contact was felt to be crucial. Also, non-direct contact time to talk through assessment outcomes and discuss aims and objectives was felt to be important.

Inaccessibility was felt to be unsatisfactory, plus poor communication, when local professionals received mixed messages from different implant team members. Finally, all therapists requested more training on rehabilitation approaches for implanted chil- dren.

It is interesting to note that the issues that are pertinent to local speech and lan- guage therapists are very similar to those of implant centre speech and language thera- pists. Our main concerns are also lack of knowledge and time. We know very little about the individual child, or about the local service, and due to the nature of our work, we often have very little time to spend with the child.

Effective support, to us, means being able to access the child at vital assessment intervals, and we also need non-direct contact time with the child’s key worker in order to discuss findings. We find it frustrating when we receive mixed messages from local team members and our training needs change all the time as implants become more sophisticated.

On the Nottingham paediatric cochlear implant programme we try to ensure that we offer more visits in the early stages, and less as the child develops. This, we hope, allows for accessibility up to a point, although tight schedules make it impossible to be too accessible.

THE OUTREACH PROGRAMME

At outreach we aim to:

Provide a broad outline of aims and goals for a child, within a realistic timescale. Ensure objectives are appropriate, realistic and time effective. Ensure time is available for planned discussion. Provide informal written summaries of session outcomes.

In conclusion, we in Nottingham feel that working in an outreach capacity has helped to enhance not just our clinical skills but also our social and interpersonal skills. It has made us aware of the need to find new ways of sharing information, outcomes to a range of professionals not just speech and language therapists. It does take time. Time to talk to all those involved with a child, and time to liaise with members of our own team, which is not necessarily easy.

We continue to aim towards providing effective support for local teams and we look forward to working with you all in the future.