occupational therapists as healthcare team members: a review of the literature

Australian Occupational Therapy Journal ( 1996) 43,83-94

Occupa t iona l t h e r a p i s t s as hea l thca re team o f t h e l i t e r a t u r e A review members:

Susan Griffin School of Occupational Therapy, Faculty of Health Sciences, The University of Sydney, Lidcombe, Australia

The use of healthcare teams as a method of service delivery is widespread. Most occupational therapists work as part of a healthcare team. There has been a paucity of documented research that has investigated Australian occupational therapists’practice within the context of a healthcare team. The aim of this literature review is to develop a picture of occupational therapists’ practice within healthcare teams by considering what is known about healthcare teams and occupational therapists. This picture has been used to suggest the professional and personal characteristics of occupational therapists that influence their comfort within a healthcare team. Recommendations for future research are made.

K E Y W 0 R D S multidisciplinary, occupational therapy, professional practice, team work.

Healthcare work environments are characterized by the use of healthcare teams as a form of workforce organization for delivering healthcare services. Consequently, most occupational therapists work as part of a healthcare team. The effectiveness of occupational therapy services is therefore dependent on the ability of therapists to deliver their services efficiently and effectively within the context of a healthcare team. There has been a paucity of documented research that has investigated Australian occupational therapists’ practice within the context of a healthcare team. As a preliminary step to exploring therapists’ practice within healthcare teams, a conceptual and reflective review of the literature on healthcare teams and occupational therapists’ practice within healthcare teams was undertaken. This article reports the findings of that review, which suggest that the professional and personal characteristics of occupational therapists influence their comfort in a healthcare team.

METHODS

Books and journal articles were reviewed. English language occupational therapy journals including the Australian Occupational Therapy Journal (1980-1996), the Canadian Journal of Occupational Therapy (1980-1994), the American Journal of Occupational Therapy (1980-1994), the Occupational Therapy Journal of Research (1981-1994) and the Journal of the New Zealand Association of Occupational Therapists (1975-1994) were searched for both discussion and research articles that considered aspects of practice that may relate to working in teams. These included articles on learning needs, job satisfaction, professional characteristics and issues, and relationships with other health professionals. The indexing tools Cinahl, Sociological Abstracts, Psychological Abstracts, Index Medicus and Medline were used to search for articles on healthcare teams from 1980 onwards. In addition, reference lists of key articles were reviewed,

Susan Griffin BAppSc(OT), GradDipAppBehSc, MA(Hons1; Lecturer. Correspondence: Susan Griffin, PO Box 170, Lidcombe, NSW 2141, Australia. Email: [email protected] Accepted for publication September 1996.

S. Griffin 84

Professional image 4 * Understanding team colleagues

HEALTHCARE T E A M

Decision making

Norms and values

Beliefs a bout colleagues’ views of your profession 4 Personal image

t

t t

Figure 1. Healthcare teams context.

and key articles and authors were searched for in citation abstracts. The computer index of the Faculty of Health Sciences, University of Sydney library was used to search for relevant books.

RESULTS

The results of the review indicate that the healthcare team is shaped by several factors, as represented in Fig. 1. Healthcare teams are made up of a number of healthcare professionals who bring particular personal characteristics (such as assertiveness) into, and disclose specific professional images of, themselves (such as being a competent professional) within the healthcare team. They also have expectations of their team colleagues (Horwitz, 1970). These characteristics, images and expectations affect, and

in turn are affected by, the way the healthcare team functions.

The healthcare team’s function is affected by the way it develops as a small group, including its norms and values, role expectations, leadership, communication,and decision making processes (Brill, 1976; Ducanis & Golin, 1979; Payne, 1982). The development of the team over time, through a number of stages, also influences how the team will work (Blechert, Christiansen, & Kari, 1987; McPher- son, Wittemann, & Hasbrouck, 1984). The power relationships operating between individual members also influence team functioning (Ducanis & Golin, 1979).

Def in i t ion of h e a l t h c a r e teams

The types of teams involved in the delivery of healthcare services have been described in a ,variety of ways such as multidisciplinary, interdisciplinary and transdisciplinary

Occupational Therapists in Healthcare Teams 85

(Edwards & Hanley, 1989; Maple, 1987; Qualls & Czirr, 1988). Authors and researchers have used different criteria to classify team types, and the terms multidisciplinary and interdisciplinary are often used to refer to the same type of team. The use of differing terminology to describe similar healthcare teams means that researchers need to be careful when reviewing research literature. For the pur- poses of the following discussion, the descriptions given by Maple (1987) will be used to define multidisciplinary, interdisciplinary and transdisciplinary healthcare teams.

Maple distinguished between the three types of healthcare teams (multidisciplinary, interdisciplinary and transdisciplinary) according to the nature of communication between members and the nature of the tasks they perform. She described a multidisciplinary team as one where the client was seen by more than one healthcare professional, but where communication generally and information exchange about clients between those professionals was minimal. Each professional worked largely independently, pursuing their own treatment plan with the client. An interdisciplinary team was described as one where there was communication between the health professionals involved and an attempt to co-ordinate treatment between them. A transdisciplinary team was used to describe a situation where similar work was carried out by each health professional and where activities did not conform to traditional discipline boundaries. In this type of team, Maple (1987) suggested that one healthcare professional often takes responsibility for a number of clients and an individual programme is designed for each client.

The individual as a t e a m member

Horwitz (1970) suggested that any individual who enters a team brings with them, and subsequently discloses, four images. These include the individual’s personal and professional image; the expectations she/he has of their own profession in the particular setting; an understanding of the skills and responsibilities of their team colleagues; and a perception of their colleagues’ image of them. These images are discussed further below.

The ind iv idua l ’ s personal image Brill (1976) suggested that a team member brings a self- image based on seven different frames of reference: (i) the individual’s personal values and attitudes; (ii) their behaviour patterns; (iii) their behaviour norms; (iv) their latent

characteristics; (v) their own reference group; (vi) generalist knowledge and skills; and (vii) specialist knowledge and skills. Apart from the frames of reference that include generalist and specialist knowledge, the research in this area generally addresses more personal characteristics.

The main barrier that student nurses perceived in relation to their ability to work well as a team member was a lack of personal assertiveness in participating in team interactions (Beatty, 1987, p. 26). In this study, respon- dents rated a 22-item Health Care Team Attitude Scale that was designed by the researcher and was a modified version of a scale previously used by Snyder (1981). Beatty (1987) noted that ‘comments such as “self doubt”, “shy- ness”, “ego vulnerability”, and “unassertiveness” were very frequent’ (p. 26). These self-perceptions may influence the nurses’ personal images that they present within the healthcare team. The exact nature of the healthcare team that was being referred to by Beatty was not clear, however, as she did not define what she meant by the term ‘interdisciplinary team’.

Raines (1988) used a model of six value systems developed by Adams (1986, cited in Raines, 1988) to demon- strate how an individual’s personal value system can affect the image that sheihe projects within a healthcare team. She suggested that individuals’ value systems influence their effectiveness as a team member. Their effectiveness depends on how the team is structured; whether the individuals’ value systems are congruent or at odds with the team’s goals and values or with those held by other individuals within the team. The six value systems mentioned by Raines are achievers, involvers, loyalists, loners, kinsmen and choice seekers.

Raines (1988) suggested that achievers are self- confident and good at making things happen. They are comfortable in authority positions. Involvers enjoy being part of a co-operative team, are good at collaborating, and tend to be sensitive to the feelings of others in the group. They do not deal well with authority. Loyalists generally stick with the status quo and are suspicious of any new ideas. They may view an involver as out of touch and ide- alistic. The loner has a value system that is individualistic and focuses on survival of the individual. The loner looks for chances to dominate and sees the world as hostile. Kinsmen are oriented to the survival of their family group. These values are usually found in people in nomadic tribes. Choice seekers value privacy, personal freedom and intellectual stimulation. There are fewer choice seekers

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than involvers, but they have a significant impact on work- places because of their competence. They are self- directing and tend to be intolerant of routine.

An example of how individual value systems affect team functioning is illustrated by describing a team where the doctor in charge is an achiever and the team members are involvers. Raines (1988) suggested that the doctor would see the involvers as judgemental, unrealistic and subject to peer pressure. The members of the team would see the achiever as self-centred, impatient and insensitive. Such a combination of values within a team is likely to lead to conflict. She suggested that communication within a team can be improved if the value systems of individuals are appreciated and some compromise is possible in methods of communication and work approaches.

Expectations o f the ind iv idua l ’ s own profession (Pro fessiona I image) Maple (1987) states that ‘The primary frame of reference for each group of professionals differs and unless these differences are openly addressed and negotiated among members of the team efforts may be inconsistent and con- tradictory at times’ (p. 147). The frame of reference of each professional reflects their expectations of their own professional group in a given setting. Kane (1975) suggested that ‘professional allegiances as now developed in professional schools and professional associations are not conducive to producing effective teamwork’ (p. 2).

Qualls and Czirr (1988) identified different models of professional functioning among healthcare professionals. They claimed that ‘the values and behaviours that make up professionalism are not the same for all professions. In fact, some that are considered essential and highly valued by one profession may be considered luxuries or even weaknesses by another’ (p. 373). They described a continuum along four broad areas in which models of good health care held by various professional groups may differ. These are: (i) the logic of assessment; (ii) the focus of professional efforts; (iii) the locus of responsibility; and (iv) the pace of action.

(1) The logic of assessment relates to defining the clients’ problems. Physicians will rule out diagnoses by narrowing down possible causes of disease while an occupational therapist will go beyond a presenting problem to gather multiple data to get a broad picture of the issues and problems for any given client. Clearly, the expecta-

tions that each of these team members has of their own profession’s practice is different.

(2) The focus of professional efforts relates to intervention priorities. Physicians at the ruling-out end of the continuum will feel that their work is completed when an acute medical condition has been stabilized, while other professionals, including occupational therapists, will wish to continue the client’s hospitalization to look at func- tional tasks and the client’s home situation.

(3) The locus of responsibility relates to the extent to which the health professional expects to direct the patient to follow orders. At one end of the continuum is the professional who expects to be totally directive. At the other end is the professional who acts more as a consultant, with patients maintaining responsibility over the decisions affecting their own health.

(4) The last area on which professionals differ is the pace of action, or timetable, for change. They suggest that professionals at the biomedical end of this continuum are taught to work rapidly, often without patient consent in acute medical situations where patient status changes quickly. Other professionals are taught to work within a much longer time frame where determining problems and affecting change are much slower.

Qualls and Czirr (1988) believe that differences in each professional‘s model of practice along the four areas of the continua described above affect the functioning of a healthcare team.

A second set of continua described by Qualls and Czirr (1988) relate to the interactions of two or more professionals who are trying to function co-operatively. They suggested that ‘professionals can differ markedly in these implicit models for good behaviour in team settings. These models include beliefs along three continua: the focus of the group’s attention, expectations about decision making, and degree of interdisciplinary interdependence’ (p. 375). Professionals may differ in what they consider to be appropriate use of time and content in team meetings, with some wishing only to discuss medical facts and others wishing for a more broad discussion of the patient’s con- cerns. Professionals’ expectations about how decisions will be made may differ markedly. One extreme is the professional who expects one person to act as an executive and take decisions on behalf of the team. At the other end is the person who expects consensus decision making where all members have an equal voice. Beliefs about interdisciplinary interdependence relate to the distribution of


responsibility within the team. One extreme is autonomy of practice where, for example, the physician carries the legal responsibility for all decision making and directs other personnel accordingly. The other extreme of the continuum is where no one professional ever expects to assume all responsibility and is obliged to call on other professionals for their opinion and professional expertise.

It can be seen that the model of practice that each professional considers desirable, as a result of their education, and which they bring into the team will affect the way a healthcare team functions. There is the potential for both conflict and collaboration, depending on whether any differences that might exist are resolved. The effect of educa- tional socialization on expectations of team work is also stressed by Blechert, Christiansen and Kari (1987) who stated that ‘the education of professionals in any discipline can promote learned attitudes that make it difficult for students to participate in team work’ (p. 577).

Role identity and security are also considered important for effective participation in a team (Liddell, 1981). It is necessary at times for a team member to do aspects of another’s role in the best interests of the patient. ‘If one is secure in one’s role as a professional, one will see the need for this to happen. If one is insecure in one’s role one will become professionally jealous or professionally offended, demarcation disputes will follow’ (Liddell, 1981, p. 5). Role security is thought to be enhanced by a strong ideology or view of one’s professional role. ‘A strong ideology can serve as a bulwark against excessive vulnerability to envi- ronmental demands - it becomes a position of power from which the practitioner can negotiate or build his or her role. On the other hand, a lack of strong ideology may lead to identity confusion for clinicians’ (Barris, 1985, p. 73).

In addition to having a distinctive and important role, it has been suggested that it is necessary for team members to know their own limitations and to recognise the strengths of others (Downie & Calman, 1987), and that an important part of role definition is the articulation of com- petencies that are operationalized as skills and tasks.

Kane (1975) suggested that ‘there is a continuous interplay between the ideal of a professional responsibility to maintain a unique and specific position for one’s own profession on the team and the professional responsibility to work with others’ (p. 16). Role perception is clearly important since a lack of clarity or agreement may lead to role conflict or ambiguity. This may in turn affect the pro-

fessional’s ability to work in an organization where there are professionals functioning in various capacities.

Understanding t h e ski l ls a n d responsibi l i t ies o f t e a m col leagues Health professionals may have an inaccurate understanding of their team colleagues’ skills and responsibilities because of the influence of stereotypes. Westbrook (1978) described stereotypes as ‘pictures in the head’ that people have of various groups. Such stereotypes affect the way healthcare teams interact. They may be ‘causes of interdisciplinary ignorance, competition and jealousy’ (p. 12). Considerable differences may exist between a group’s perception of itself and the perception of outsiders; in this instance, other team members.

Nurses and occupational therapists have been found to hold significantly different stereotypes about their own and each other’s professions. ‘Occupational therapists saw themselves as being more interested in people, more sensitive in evaluating a medical problem and having more sense of humour and being less impersonal than nurses, whereas nurses perceived the reverse state of affairs’ (Westbrook, 1978, p. 14). Generally, however, each professional group had a positive image of the other group, sug- gesting that stereotypes held by these particular groups do not lead to poor team work. Westbrook (1987) reported sampling difficulties during the study, which could have resulted in a biased sample. The results of this study must therefore be interpreted with caution. One would not be able to assume that these attitudes are representative of the nursing and occupational therapy populations.

Administrators in Canada have been found to have a good knowledge of what occupational therapists do, but seem to have little appreciation of the therapist’s role in client evaluation, treatment and monitoring treatment effects (Brintnell, Madill, & Wood, 1981). They were unclear about the therapist’s rationale behind their actions. Rural occupational therapists in a study in the US rated a poor awareness of occupational therapy as the first and second major problems (across two different rural samples) encountered by them in their practice (Kohler & Mayberry, 1993). This lack of knowledge, if shared by other healthcare team members, may affect the other professionals’ respect or acknowledgment of the role of the occupational therapist.

Bassoff (1983) conducted a series of interviews with twelve practitioners from five health disciplines to deter-

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mine the factors that they saw as important in facilitating good team work. The results of these interviews revealed that attitude was the most important factor. One of the attitude areas that was identified was the need to value and respect professionals from other disciplines. This concept was composed of achieving competence and security in one’s own role, maintaining a focus on optimal patient care and who can best provide which parts, and approach- ing and responding to others without threat. They also found that it was important for roles to overlap at times.

Ducanis and Golin (1979) developed an interprofessional perception scale to examine how professionals view themselves, view other professions and think that other professions view them. The scale requires individuals to use two questionnaires. The first looks at their views of their own profession, how they feel other health professionals view their profession, and the congruence they see between the two views. The second is answered in relation to another profession where the individual indicates their views of that other profession, how sheihe thinks the profession views itself, and the congruence that exists between these views. Preliminary studies using these scales have shown that there are areas of misunderstanding between allied health professionals and nurses and doctors. The areas of misunderstanding include encroach- ing on another’s professional territory, lack of understanding of the capabilities of other professionals, defensiveness about professional prerogatives, and underutilization of the capabilities of other professionals. This perception scale also addresses how professionals feel others view them within the healthcare team.

The indiv idual ’s bel iefs about their colleagues’ views o f them The doctor-nurse relationship has been perceived by nurses to create a bamer for them when trying to work in teams (Beatty, 1987). The nurses felt that there was a problem with the acceptance and respect for the nurses’ role from both doctors and other healthteam members.

A similar difficulty was expressed by occupational therapists, who felt that resident doctors and medical con- sultants in a particular hospital showed a lack of interest or understanding of the role of the occupational therapist (Smith, 1986). However, these results need careful inter- pretation due to a very small sample size (n=8) and lack of validity and reliability of the survey instrument, which was

not trialled and was developed specifically for one institu- tional context.

In a study by Parker and Chan (1986) occupational therapists and physical therapists (physiotherapists) rated themselves and each other on the Allied Health Profes- sions Prestige Rating Scale. Physical therapists were ranked higher than occupational therapists by both groups. However, the occupational therapists ranked themselves in fourth position while the physical therapists ranked the occupational therapists in fifth position. This indicates that there is a difference between the occupational therapists’ perception of themselves and that held by physical therapists, which may have consequences for team function. For example, the occupational therapists may feel less valued in a healthcare team that has physiotherapists as team members. This may in turn affect their own perceptions and levels of confidence within the team.

Shortell (1974) found that a medical specialty’s prestige was related to the degree of control that it exerted over a patient’s fate. Those specialties where the nature of the relationship between the doctor and the patient could be described as ‘activity-passivity’ (with the doctor being active and the patient being passive) received the highest prestige ratings from patients, students and medical practitioners themselves. Specialties whose relationships could be described as ‘mutual participation’ received the lowest prestige ratings while those described as ‘guidance- cooperation’ received middle ratings. Similar variables may operate in relation to other allied health disciplines. This activity-passivity dimension is akin to the locus of responsibility continuum described by Qualls and Czirr (1988). Medical practitioners whose relationships are characterized as active-passive may not view other professionals whose orientation is mutual participation or guidance-co-operation very highly. This may in turn lead to problems with team work, which may be the case for occupational therapists who tend towards the mutual participation model of interaction.

Other factors affecting team functioning

In the area of team dynamics, Ducanis and Golin (1979) defined a team as a small group. The team is defined such that ‘the members of the group are in interaction with one another. They share a common goal and set of norms which give direction and limits to their activity. They also develop a set of roles and a network of interpersonal


attraction, which serve to differentiate them from other groups’ (Hare, 1976, p. 5, cited in Ducanis & Golin, 1979, p. 119).

When reviewing team functioning, various characteristics of teams have been considered. These have included the team’s norms (Downie & Calman, 1987; Ducanis & Golin, 1979; Payne, 1982), conformity to the norms, and the extent to which sanctions apply for non-conformity. It is suggested that the goals of the team must be explicit and that when this does not occur, conflict may arise (Downie & Calman, 1987). Goals of specific professionals in the team may be ones that are not explicit (Maple, 1987); such as particular professionals’ goal to clarify their own role within the team. If these types of goals are not recognized and accepted by the team, a feeling of frustration and that one’s role is not understood may develop. Evers (1982) investigated team practice in geriatric teams and proposed that difficulties arose when common patient goals could not be agreed on. It was found that where this occurred the medical view predominated and dissent was expressed by other health professionals. This relates to the different focus of various health professionals discussed by Qualls and Czirr (1988).

The acceptance of a common goal of commitment to comprehensive patient care has been identified as a key component for effective team work (Bassoff, 1983). Included in this are beliefs that the team is essential to the delivery of good patient care, the requirements of personal investment to make the team work, the ability to make one’s own needs subservient to the team purpose, inclusion in the decision making of all concerned and an expectation that one will work collaboratively. As a strat- egy to emphasize the similarities between team members, without diluting the uniqueness of each, Ivey, Strauch Brown, Teske, and Silverman (1988) supported a common orientation to the client/patient as the primary unit of attention. In turn, they suggested that this facilitated good team work and minimized conflict.

The handling of conflict within the team is another key factor affecting team functioning (Brill, 1976). Groups with interdependent tasks but differing goals, such as a multidisciplinary healthcare team, may encounter conflict (Wexley & Yukl, 1977, cited in Lynch & Rogers, 1986). A lack of clarity concerning which individual has responsibility for which particular tasks is described as jurisdictional ambiguity and may lead to conflict (Walton, Dutton, & Cafferty, 1969, cited in Lynch & Rogers, 1986).

Another key area of team functioning is the development of leadership roles and processes of decision making (Ducanis & Golin, 1979; Payne, 1982; Qualls & Czirr, 1988). Some professionals may expect to be in leadership positions and make decisions on behalf of the rest of the team, while others expect to participate in consensus decision making (Qualls & Czirr, 1988).

The effect of status on role development and power issues within the team has been considered by some authors (Ducanis & Golin, 1979). Kane (1975) felt that the extent to which a member would conform to team norms was influenced by their status in the group, which in turn may be influenced by their professional affiliation.

The highest ranked and most secure members feel most free to express their disagreement with the group both privately and in public; the lowest ranked members are more likely to disagree privately but conform in public; and the average members are more likely to agree both privately and in public (p. 36).

Communication within the team is highlighted as an important team process that affects its functioning. This includes the levels and type of interaction within the team, the effects of various personal characteristics of team members on its functioning, the level of cohesion amongst members of the team, and coalitions that may develop (Ducanis & Golin, 1979). The extent to which communication between team members is direct has also been discussed. Smith (1986) cited a situation where doctors communicated with occupational therapists through nursing staff and that this contributed to a lack of understanding by the doctors of the occupational therapy role. She suggested the need for expanded channels of communication if the team is to work in practice. This is consistent with the continuum of interdisciplinary practice developed by Ivey, Strauch Brown, Teske, and Silverman (1988).

Openness of communication is considered an important norm for good team work (Miller, 1989). Team process discussions are necessary to achieve a balance between task functions of the team and the monitoring of the team process (Downie & Calman, 1987; Miller, 1989). Maple (1987) discussed the differing priorities that health professionals may place on process goals such as open communication and the fact that these goals may remain implicit rather than being discussed. She saw that this may lead to conflict within the team. Bassoff (1983) found that an attitude of openness and receptivity to the ideas of

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others was important for good team work. This includes the ability and desire to relate to others, approachability, and a view of team colleagues as people. Dienst and By1 (1981) included communication as a core topic in an edu- cational programme on healthcare teams.

The internal and external expectations of, and influences on, the team are also important (Maple, 1987; Payne, 1982). Maple suggested that differing frames of reference held by team members may be reinforced adminis- tratively when individuals are responsible not only to the team but also to a discipline-specific unit such as a professional department. She also suggested that there is stated support for the concept of the team but that the reward structures (promotion, recognition etc.) may be controlled by a discipline-specific unit.

Edwards and Hanley (1989) investigated the interprofessional activity between speech pathologists and occupational therapists. Factors limiting this type of activity were similar for both groups and included staff shortage, finan- cial constraints imposed by the employment institution, physical barriers or diverse physical location, all of which imposed constraints on the freedom to engage in meaning- ful and frequent interdisciplinary activity. The physical environment in which the teams function, and its influence on the way it works, has been highlighted by Payne (1982).

A study addressing the preparation of nursing students for work within healthcare teams found that the most use- ful content area for students was group dynamics (Beatty, 1987). Areas within group dynamics that were seen as problematic included communication, decision-making, authority and role conflicts.

Blechert, Christiansen and Kari (1987) suggested that the most important factors for intraprofessional team work are in meeting three types of needs: (i) ministration or the desire to feel close to others in the work setting, feeling supported and safe; (ii) mastery, in terms of one’s own role, over the working environment and the team’s tasks; and (iii) maturation, which includes ‘renewing professional and personal goals, taking risks to achieve them, and empowering others in this process’ (p. 579). It may be that such needs are also important within interdisciplinary healthcare teams. This is supported by Champoux and Howard (1989)’ whose results suggested that the quality or the social context, including co-workers and relationships among co-workers, are important contributors to an employee’s general feelings of satisfaction.

The occupat ional therap is t as hea l thcare t e a m member

Nordholm and Westbrook (1986) found that the most strongly held belief by New South Wales occupational therapists about their profession was that ‘other groups of health professionals are confused about the role of my profession’ (p. 22). Occupational therapists were the least likely of the health professionals educated at Cumberland College of Health Sciences to agree with the statement that ‘members of my profession are clear about their role in the healthcare system’ (Nordholm and Westbrook, 1986, p. 22). Similar findings are reported for Canadian respon- dents, who questioned the validity or efficacy of the proce- dures they used and suggested that they may project this uncertainty in their associations with other professionals (Madill, Brintnell, Stewin, Fitzsimmons, & McNab, 1985). Likewise, in the US Cooperstein and Schwartz (1992) concluded that concern about the lack of awareness and respect from both the public and other health professionals was a concern for therapists.

This contrasts with findings for New Zealand occupational therapists where 59% of therapists sampled were clear about what they were required to do (Boyd, 1981). However, it was also found that there was a tendency for one-third of new graduates to be uncertain or unclear of their roles during the first twelve months of their practice. These newly graduated therapists may have difficulty in a healthcare team initially. There was also disagreement by 56% of the sample that others were clear about the role of the occupational therapist.

A number of authors have addressed the issue of lack of awareness in the American context. A study by Fleming and Piedmont (1989) found therapists to be concerned about the lack of visibility and recognition of occupational therapy by ‘third party payers’, ‘the general public’ and ‘other health professionals’ (p. 105). Kohler and Mayberry (1993) found that one of the major problems encountered by occupational therapists providing services in rural areas was a poor awareness of occupational therapy. Froehlich (1992) discussed what she called an ‘ongoing struggle within occupational therapy for personal and public recognition of the value and meaning of our work’ (p. 1042). This is consistent with Australian findings (Nordholm and Westbrook, 1986, p. 22) that five years after graduation occupational therapists placed greater value on the respect they received than they had 18 months after gradu-


ation. Respect for the profession and a sense of pride have been found to relate to Canadian occupational therapists’ job satisfaction (Canadian Mental Health Association, 1984; Krumboltz, 1979; Madill et al., 1985; Sabari, 1985). This lack of recognition, and hence status, may result in occupational therapists being unwilling to be outspoken in a team (Kane, 1975). Occupational therapists who are unwilling to be outspoken as a team member may be expected to be less comfortable in the team, due to feeling that they are less able to influence decision making, articulate their roles and communicate with their team colleagues generally.

In a number of US and Canadian studies interpersonal relations with co-workers have been found to influence the job satisfaction of occupational therapists (Brollier, 1985; Canadian Mental Health Association, 1984; Davis & Bordieri, 1988; Florian, Sheffer, & Saches, 1985; Herzberg, 1966). Interpersonal relations are seen as job incentives (Bordieri, 1988).

A British study (Rees & Smith, 1991) found that occupational therapists with high sickness absence rates scored low on scales measuring ‘satisfaction from personal relationships at work’ and high on ‘pressure from relationships at work’. These authors concluded that ‘one of the principal differences between occupational therapy staff and other professions allied to medicine ... in terms of sources of pressure was problems from relationships with other people’ (p. 293). In the Australian context (Nord- holm & Westbrook, 1986) it was found that therapists placed less emphasis on difficulties with other professionals 5 years after graduation than they had 18 months post graduation, although this area was still somewhat problematic. Occupational therapists who perceive that other professionals around them do not have a good understanding of their role or do not respect them will be less comfortable in a team than those who believe their colleagues views of them are more positive.

Boyd (1981) found, in relation to New Zealand, therapists that other healthcare professionals directly affected occupational therapists in determining what they did. Other occupational therapists most often influenced what a therapist did, followed by nurses, social workers, physiotherapists, physicians, surgeons, psychiatrists and psychol- ogists, in descending order. The extent to which others determine the role of the occupational therapist will influence their practice in the healthcare team. This contrasted with the findings of Graham and Timewell (1990) from a

small sample of occupational therapists in Australia who felt that their roles were most frequently set by their own conception, and that only infrequently were they dictated to by a superior occupational therapist, other professionals or administrators. The extent to which therapists feel they are able to determine the nature of their own practice will affect their confidence and clarity about their role. It may be expected that therapists with greater role confidence and clarity will be more comfortable in a team.

Graham and Timewell (1990) concluded that there is a false consciousness among occupational therapists in relation to their perceived status within the healthcare system. They suggested that the external indicator of prestige, namely salary, did not reflect a profession with high status. Furthermore, they felt that it was unrealistic for occupational therapists to feel that they were highly regarded by others in the healthcare sector when they freely admitted that others were unclear about what they did.

A factor that correlates positively to job satisfaction for American occupational therapists is perceived autonomy (Davis & Bordieri, 1988). A factor in the model of the professions within healthcare teams outlined by Quails and Czirr (1988) was the belief held by team members about interdisciplinary interdependence. Perhaps occupational therapists would be most satisfied and comfortable when working within a model that accepted the independence of different health professionals. The personality trait of desirability correlated with job satisfaction for Australian therapists (Peacock, 1984). Desirability is the need for social approval and acceptance and the belief that this can be accomplished through culturally accept- able and appropriate behaviour. This again highlights the occupational therapists’ need for acceptance and the importance that the view held of them by co-workers will hold for an occupational therapist.

Peacock (1984) also found that occupational therapists had high achievement scores, which reflected their need to accomplish difficult tasks, to maintain high standards, and a willingness to work towards difficult goals. This would positively influence their practice within a healthcare team.

CONCLUSION

Types of healthcare teams are distinguished according to the amount of communication and shared goals for patient

92 S. Griffin

treatment that they experienced. The way a healthcare team functions will depend on the images each individual professional brings to the team. These images include the individual’s personal and professional image, the expectations they have of their own profession in the context and their expectations of other team members, as well as the beliefs the individual has about how other professionals view them. The team can be viewed as a small group that will be affected by various dimensions of group dynamics. These include the team’s goals and norms, roles of team members, decision-making and conflict resolution prac- tices, leadership development and communication structures. The stage of development that the team has reached will also affect the way it functions.

Specific factors that may affect the comfort of the occupational therapists within the team environment include:

the knowledge of the occupational therapy role held by other team members; the value or respect that occupational therapists perceive from other team members; the extent to which the occupational therapists are able to value and respect the roles of their team colleagues; the role confidence and clarity experienced by occupational therapists; occupational therapists’ perceptions of their ability to influence the team’s decision-making; occupational therapists’ communication skills, including assertion, negotiation and conflict resolution skills; the extent to which they feel able to articulate their role to others on the team; the extent of interdisciplinary independence within the team. It may be expected that occupational therapists will

function most comfortably within a team environment when they are clear and confident in their role and able to articulate this role to others; are able to influence decision-making in their team; feel respected by and are able to respect the contributions of others in the team; and have good personal communication including assertion, conflict resolution and negotiation skills.

Further research is necessary to investigate more closely the experiences of occupational therapists in different types of heathcare teams and settings. Additionally, further research in both qualitative and quantitative forms is necessary to determine the personal and professional characteristics of occupational therapists that allow them

to function most comfortably and most effectively in healthcare teams.

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occupational therapists as healthcare team members: a review of the literature

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