There is so much out there about the value of teamwork.
We can likely all relate to the fact that being an expert in one specialty area does not always equal success if we are unable to work as part of a team. In every aspect of service provision - and business in general - the diverse skills of teams are needed for reaching successful outcomes.
This applies very much in the area of Postural care, Seating and Wheelchair provision. It has been my observation over the years that unfortunately there are many instances where decisions are made on behalf of an individual without considering input from key contributors, or key ‘holders of valuable information’, about the individual who is seeking solutions. In the absence of close collaboration and coordination between professions and across disciplinary boundaries, critical information may fall through the cracks and results negatively impacted.
Quite typically in the specialty area of Postural Care (sitting, standing and lying) and Wheelchair service provision in Europe, Occupational Therapists are often responsible for the provision of Seating and Wheelchairs while Physiotherapists have the Standing and Lying components within their scope of practice. In North America and Latin America, Physiotherapists appear to commonly have Seating also within their scope of practice but this varies from State to State, Province to Province and even within different rehabilitation services.
As a Physio, I need to tap in to the expertise of my allied health colleagues and consider the consequences, both positive and negative, of the proposed postural care plan on all aspects of this individual’s life. If I recommend a new wheelchair seating system, how will this impact the individuals pressure care program /pressure injury/ulcer management? How will my recommendation impact swallowing and respiratory function? How will it impact any communication work that is being done? How is the persons alternative positioning such as in lying down or standing program impacting their seating and vice versa? I also need to understand how and where this individual sits when NOT in this wheelchair because looking at the wheelchair and related seating only is leaving us open to failure or less than optimal outcomes. This involves communication and working together as opposed to operating in a silo.
Imagine if you will that you are an Occupational Therapist who has been asked to see a young person for the purposes of reviewing their wheelchair and seating because they keep sliding, their legs are not staying in the position that it is believed they should be in, they have had some redness on their back and on their buttock, they have had repeated chest infections, and their scoliosis is apparently getting worse over the past several months.
You schedule the appointment and your assessment of the person takes place. You identify the issues with their current wheelchair and seating and make necessary recommendations. The supplier is contacted and assistive technology is secured.
In the absence of linking in with the entire care team, like the Physiotherapist, for example, who would be likely to address the standing and lying down aspects of this persons postural care plan, or the Speech Language professional who might be working on communication, or the Tissue viability professional who might be aware of the skin issues, or the Respiratory professional who may be familiar with this persons respiratory history - a lot of very valuable information may be missing.
The individual needing the services and their carers may be frustrated as they may be getting direction and recommendations from multiple sources and may be unequipped to join the dots when needed.
It is fair to say that the healthcare sector still wrestles with challenges related to communication and collaboration across borders between professions. According to the U.S. Agency for Healthcare Research and Quality, over 60% of all adverse events can be explained by deficit communication. However, it is important to note that it is normally not the individual care provider’s will to communicate and collaborate that is lacking, but rather the organisational will to allocate resources for developing procedures and protocols that do not swiftly yield monetary return for the unit allocating the resources. I believe that here in Ireland there remains an element of silo organisation in several areas where there can be lack of dialogue between professions and disciplines within the provision of postural care and wheelchair services.
I have the privilege of working with many wonderful professionals in Ireland - those who’s primary function is to make clinical decisions, and those who’s primary function is to provide suitable Assistive Technology solutions, and all in the best interest of those we provide service to. When I first returned to Ireland it was important for me to become familiar and involved with professionals who shared my passion for postural care and wheelchair service provision. Looking back , this has been a great journey so far and communication as well as teamwork has been key.
One of my first consulting opportunities was working with an Assistive Technology Provider/Supplier to build upon their teams’ already solid foundation of knowledge with some coaching on how to effectively communicate with clinicians in postural care and wheelchair service provision.
I was so impressed with this company’s leader for recognising the need for this type of coaching - even after years of experience with providing excellent technology solutions to service users in Ireland. In the absence of being able to effectively communicate with clinicians, how does an assistive technology provider begin developing a fruitful partnership with the service user?
When I work with Assistive Technology Providers/ Seating and Wheelchair Specialists, I expect this person to be up-to-date on current trends and language related to this field of expertise. I also have an expectation that this person will be part of the assessment that I am doing, engaged and taking notes on relevant details that will make a difference when it comes to product selection. I expect them to know how the products they represent relate to clinical details and findings, and even beyond this, it is wonderful to work with this person who will also have knowledge about comparative products even if not in their portfolio of options, who can help me understand differences for my specific clients needs. Additionally, my expectation is that the supplier is involved in the collection and interpretation of outcomes, because we are all accountable as a team for our successes and failures.
When I have conducted training for supplier groups and clinical groups over the years, both together and separately, one of the top bones of contention within both groups is the feeling that the other group is not listening. When we all share what we know with sincerity as well as being open to questions and acknowledging when we DON’T know something, the person benefiting is our service user and their care team.
We have a fantastic resource which is one of the nine components of ISO standard 16840: Wheelchair seating - Part 1: Vocabulary, reference axis convention and measures for body segments, posture and postural support surfaces. One of the values of this resource is that its provides a standardised method of communication and documentation to facilitate clear translation of clinical findings to technology solutions.
Imagine a world where manufacturers, suppliers, healthcare professionals, government agencies, carers and technology users all used the same language to describe postural presentations, seating support surfaces and their related linear and angular measurements.
This is possible, if we all become comfortable with using this fantastic body of knowledge that we have available to us. I dream of a world where this language is our normal and therefore integrated into every seating assessment form, manufacturer spec sheet and conversation related to postural care, seating and wheelchair service provision. New language is never easily adopted but when the value is obvious and we can see the direct link with improved documentation and communication across all team members, its a clear green light from my perspective.
We have incorporated the relevant measures from this document into our assessment forms over time. When I conduct postural/seating assessments with clinicians and suppliers present, I always strive to use the correct language and it is so rewarding to see this being adopted and implemented into daily practice. Unfortunately this is not common practice yet in Ireland but I am hopeful that we will see this transition as more and more assistive technology/wheelchair, seating suppliers and healthcare professionals take the time to become familiar and recognise the tremendous value all the way from initial assessment through to technology securement and outcome measurement with our service users.
It is my observation that there is an element of fear or hesitation with some clinicians related to working with suppliers of technology, or even with other clinicians.
Fear often stems from lack of confidence or knowledge. This becomes apparent when there is a clinician who perhaps does not have a lot of experience with seating/postural care and they are faced with having to make decisions around selection of the same for their patients/ service users. I have noted a hesitation on many occasions, such as when the clinician doesn’t question the logic behind a solution being proposed by the supplier. This is where using a common language and the art of communication can be critical.
I rely heavily on technology providers for their knowledge of technology by features first, and then by brand, as opposed to just jumping straight to the product name. This means I need to communicate clearly the features I need for the person I have assessed. This list may include language such as : Skin risk and related depth of immersion and moisture management requirements for the desired cushion : Postural presentation with the causes behind the symptoms clearly identified, therefore providing clarity to the supplier of necessary thigh to lower leg angle; thigh to pelvic angle , thigh to trunk angle and back support length.
Communication like this avoids common pitfalls and will in turn increase the odds of more sustainable outcomes. Not to mention, everyone’s knowledge base increases and team work enhances the overall experience for the individual we are working with.
Sometimes communication breaks down because not everyone on the team understands seating.
In this situation I think it is imperative that we share our knowledge - do some inter team/interdisciplinary education/training with the goal of bringing everyone involved in the care of this individual onto the same page.
Its amazing the difference it can make when everybody involved with the person you are working with understands why the individual sits with their legs supported to one side as opposed to in the more societal view of ‘symmetrical sitting”, for example.
Or why the persons head needs to be supported off to one side when their spine is not stacked and optimally aligned .
Or why when the individual is transferred with a hoist and a sling, there may need to be an additional final adjustment after the person lands on their new seating when your assessment revealed a hip limitation that is not respected by the sling.
In using our client-centered approach, we know that the individuals we are working with, along with their family and care team, hold the most valuable information related to that persons body.
If everyone who works with the individuals we are creating postural care solutions for understands the WHY behind this persons postural presentation, and understands how everything from transfers to personal hygiene to bathroom activities to transportation to play to work, etc. is impacted by the individual’s body structure and function limitations, small changes that make a huge differences during the 24 hour cycle can be made.
We experienced a perfect example of this in the UK when we spent a full day doing a comprehensive 24 hour postural care assessment, followed by a day of training and discussion with the care team. It was truly an ‘ah-ha’ moment for everyone to discover that one of the primary reasons why this young man was having so much difficulty with critical functions such as sitting, wearing his thoracolumbar spinal orthosis (TLSO), and breathing, was because he has an anteriorly dislocated hip joint resulting in less than 15 degrees of true hip flexion. Once everyone involved understood the WHY, 24 hour postural care became much more harmonised with more realistic expectations held by all. This information also provided his mother with some comfort that his scoliosis, which she had been told was deteriorating quickly, was in fact presenting worse in sitting due to his severe hip flexion limitation but when in supported lying , the changes were not nearly as significant.
We communicated our clinical findings in a meaningful and understandable way, and had numerous conversations throughout that time with the care team and family to better understand their experiences and expectations. By the end, everyone was on the same page about what must be done to protect this person’s body shape through 24 hour postural care, and the mother and care team had a new understanding of how to advocate for him - which is incredibly important as he will be using a wheelchair and require a postural care plan for the rest of his life.
Leave a comment below and tell us who you have on your team! What value do they bring?