Perspectives

Rebuilding an Interdisciplinary Rehabilitation TeamKaren Blankenship, MA RN • Reneau Elsworth, BS PT

Team building, problem solving, and positive resolu-tion of conflicts that arise in the daily work environment can be a challenge even under the best circumstances. This is especially true when it involves an interdisciplin-ary team charged with providing physical rehabilitation services to patients and families who have recently ex-perienced a life-changing illness or injury (DeLisa, 2003). Effective, daily communication is an integral part of the process. Many healthcare professionals, especially those who have been practicing for some time, resist change. Not only do they resist participating in the change, but they may actively sabotage any attempts at implementa-tion. These behaviors are often fear based. This happened within the therapy department of a 25-bed hospital-based acute inpatient rehabilitation unit that is part of a large, level I trauma center in an urban area of southwest Texas. Patients on this unit commonly have spinal cord injury (SCI) or acquired brain injury (ABI), including stroke, transplant, orthopedic, multitrauma, or debility.

The interdisciplinary team on this rehabilitation unit is comprised of the patient, attending physician, resident, rehabilitation nurse, physical therapist, oc-cupational therapist, speech pathologist, dietitian, therapeutic recreational specialist, counselor, and rehabilitation case manager. This team takes a col-laborative approach to planning and implementing an individualized plan of care for each patient.

This team began to break down when a counselor, physical therapist, and occupational therapist aligned themselves against the rest of the team by question-ing most clinical decisions and became argumen-tative with other team members. Those three staff members resigned, but the effects on the remaining team members continued. Another issue facing the therapy team was a lack of confidence in the team leader, who proposed a change to the team conference process. The change involved having only patient-specific therapy staff present in the team conference rather than all therapy staff. The theory behind the change was that the patients’ therapy would not be delayed on meeting days, as therapists who were not in the team conference could be seeing patients, thus maintaining a higher level of productivity and better meeting the needs of the patients.

Most members of the therapy team were willing to try this new process as a pilot. However, one therapist felt left out of the decision-making and began to vo-

calize her displeasure to the rest of the team. Over time, the entire therapy team agreed that the new con-ference format was not working. The team began to ensure the new process would fail by coming late, not seeing patients during team conferences, and verbally lashing out at their supervisor.

These methods of sabotage were effective because the team required increased supervisory prompting to facilitate team conferences, resulting in decreased productivity. These behaviors led to complaints from physicians, nurses, and other interdisciplinary team members about the lack of cohesion in the therapy de-partment, which was disrupting the rest of the team’s cohesion and functionality. Communication within and from the therapy team disintegrated.

Other factors affecting the interdisciplinary team included a stressful work environment and decreased continuity in patient care. The therapy team split inter-nally because some members attempted to participate in the new process while others attempted to sabotage it. The therapist who initiated the disruption became vocal and insubordinate to the point of disciplinary action, which led to her resignation. This further fueled the fire of dissention, distrust, and disloyalty.

Due to inexperience and the strong personalities involved, the supervisor’s attempts to work through this problem were ineffective. It became evident to the director of therapy and the director of clinical op-erations that a more involved method of intervention was necessary. They decided to apply solution-focused therapy techniques, used in psychiatry and psychol-ogy, to help rebuild the team (deShazer, 1988). Their goal was to facilitate the therapy team’s recognition and resolution of the issues causing the dissention.

Solution-Focused Brief Therapy is an approach to counseling that is brief and effective. It can be brief because it is future focused and because it works with the strengths of those who come by making the best use of their resources, and it can bring about last-ing change precisely because it aims to build solutions rather than solve problems. (Brief Therapy Practice, 2003)

At the beginning of the first team meeting, facilitated by the director of therapy and the director of clinical op-

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erations, tension was high. The team was encouraged to speak honestly and identify the issues as they saw them. The team was assured that there would be no retaliation or negative consequences. The issues iden-tified by the staff included poor leadership, changes without the team’s input, poor communication, lack of team cohesion, and anger among the group.

The next step in the process was to use a tool called scaling, used to assess goals. On a scale of 0–10, 0 be-ing the worst possible situation and 10 being the best possible work environment, they were asked to score where the team was today. Scaling encourages a sense of progress, even if the score is 0 (Cottrell, 2000). Each team member individually scored their perceptions of the team. The team’s average was 5. This initial scal-ing tool gave the facilitators and the team a score to compare team progress at future meetings, when scal-ing would be repeated. Scaling questions are used to assess what is right about what the team is doing and to ascertain their preferred future (Cottrell, 2000).

The miracle question was the next tool used. It is a subjective verbal tool to facilitate input from clients and staff members. It helps the team focus on future direction and goals of the group. An example of a mir-acle question is, “Imagine that tonight, when you are sleeping, a miracle occurs. Your difficulties and prob-lems have somehow been resolved. What is the first thing that tells you that the miracle has taken place? What would you be doing? What would be different?” (Cottrell, 2000). The staff described open communica-tion, new leadership, less control, more freedom, and a more peaceful work environment as their miracle indicators. “For people so saturated with the problem, the person may need the concept of a miracle to enter-tain the notion of a cure” (Cottrell, 2000).

The next step in the process of solution-focused brief therapy is goaling, or identifying what it would take to get the inpatient rehabilitation therapy team to move from a 5 to 5.5. The goal increments are small, but that is necessary to make them attainable and en-sure the team’s success. The steps for improvement identified by the staff were more communication from the supervisor to the team, more team input regard-ing processes, and fewer negative comments directed at one another. The team agreed that each member would make an effort to address these behaviors.

Guidelines for facilitators during subsequent meetings were

• never return to discussion of problems• remain solution focused• scale at each meeting • identify areas of improvement

• identify successful strategies • continue with what worked and identify

additional steps toward improvement (Cottrell, 2000).

The final results of the process included more effec-tive communication, increased support for the leader, who had a better understanding of his job expectations; and more team cohesion due to improved understand-ing of each individual’s role on the team. The therapists began to work better with one another and all other disciplines. Complaints stopped and patient-care needs replaced the team’s dissention as the first priority. As a result, the final team scaling average was 7.91. This improvement was a result of the team’s implementa-tion of their own visions of what an improved work environment would be like. This resulted in improved communication and cooperation among the entire in-terdisciplinary team, which allowed the focus to return to the patients rather than the team.

The improvements are maintained by periodic meet-ings when new team members are added. These mem-bers are incorporated into the team and apprised of the team’s progress. When issues arise, they are addressed immediately using the solution-focused therapy tech-niques and tools. In each subsequent instance, all steps of the solution-focused therapy process should be used in the appropriate order. The process builds on itself. The focus is to identify what is working and do more of it, and identify what would work and implement it.

The application of solution-focused therapy tech-niques in a dysfunctional work team can be valuable and help the team determine solutions to issues they face. As Steven Cotrell said in his solution-focused therapy workshop notes, “The more you talk solu-tions, the more solutions you get” (Cottrell, 2000).

About the Authors

Karen Blankenship, MA RN, is director of clinical operations at the Reeves Rehabilitation Center, University Health Sys-tem. Address correspondence to her at Reeves Rehabilitation Center, University Health System, 4502 Medical Drive, San Antonio, TX 78229 or karen.blankenship@uhs-sa.com.

Reneau Elsworth, BS PT, is director of therapy programs and facility management at Reeves Rehabilitation Center, Univer-sity Health System, San Antonio, TX.

ReferencesdeShazer, S. (1988). Clues: Investigating solutions in brief thera-

py. New York: Norton.DeLisa, J. A., Gans, B., & Walsh, N. E. (Eds.).(2003)

Rehabilitation medicine: Principles and practice (4th ed.). (2003). Philadelphia: Lippencott.

Cottrell, S. (2000). Solution-focused therapy workshop. Retrieved March 11, 2004, from http://www.clinical-supervision.com/solution%20focused%20therapy%20workshop%20notes.htm

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