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Collaborative Health Care Models and the Common Good
Collaborative Health Care Models and the Common Good
by Kay T. Roberts, EdD, FNPC, CS, FAAN
(This article was originally presented as a paper during the Human Values and Health Care online workshop hosted by the Wayne E. Oates Institute during March 2000.)
- Healthcare and the Common Good
- Professional Collaboration
- Meaning of Collaboration
- Healthcare Teams and Collaboration
- Collaboration in Primary Care
- Barriers to Collaboration
- Steps to Successful Collaboration
- Appendix A: Value Clarification Exercises
Values are deep and personal. Along with air, water, food, and rest, values are among our most prized, often undeclared, possessions. They are aged maps that lead to a hidden treasure chest containing priceless knowledge about our feelings and actions. Values reflect how we feel toward a person, object, or idea. They tell us what is important to us. Sometimes, values seem mysterious. They may reside quietly within us only to arise sporadically like a thunderstorm to arouse strong emotions. Powerfully, values shape our actions. Despite their seemingly amorphous quality, values can be extricated and made explicit. It is important to do so. The more that we remove the mystery from our values, the more we can be true to ourselves.
Personal and professional values lie at the heart of why and how we participate in the healthcare system. This Institute is an opportunity for participants to disentangle their personal and professional values and to determine how these values guide their vision of an ideal, future, healthcare system. The purpose of this paper is to assist healing professionals in clarifying their beliefs and values about two principles that are proposed to improve the healthcare system. These principles are: (1) healthcare should be structured toward the common good and (2) professional collaboration is a key factor in improving the quality of and access to healthcare (Doughtery, 1997; Hamric, Spross, & Hanson, 1996).
Healthcare for the common good consists of a delivery system that promotes the health of all members of a community. Through responsible stewardship, it balances the moral value of dignity of the individual with the moral value of service to the common good. Excessive individualism is avoided. Social roots of the healthcare system are recognized; there is greater emphasis on public health and preventive measures and more opportunities for the public to help shape the healthcare system (Doughtery, 1997; Deblois & O'Rourke, 1995; Simmons, 1999).
At least two distinct belief systems underlie this value. Both belief systems recognize the connectedness of life. First, there is the belief that providing healthcare for the common good is the moral thing to do. All individuals possess innate dignity and therefore have a right to healthcare. It is the moral duty of the members of society who have the necessary resources to provide responsible stewardship for the common good. According to Dr. Simmons (1999), healthcare is more than a commodity; loss of health induces human suffering. He eloquently stated, "The society that knows that we all suffer together and cultivates ways to bear one another's burden is one that has a claim to being moral" (p. 13).
The second belief system is more egocentric and based on self-interest. This system recognizes that none of us are truly alone. Nationally and internationally, we are bound inextricably through a web of reverberating interactions. In other words, "What goes around, comes around." Poor health in one social sector haunts the more affluent members of society through ripples of unemployment, welfare, crime, and a cycle of poverty. Therefore, it is in one's self-interest to attend to the healthcare needs of those who cannot provide for themselves. The author's position is that providing healthcare for the common good is both the moral and the selfish thing to do.
Achieving healthcare for all persons has been an extremely difficult task. Because of the increasing healthcare costs, there are growing numbers of underinsured persons in the USA (American Nurse, 1999; News & Notes, 2000). About 44 million persons under age 65 (18%) in the US population had no health insurance in 1998. There was a significant increase in persons earning >200% of the US poverty level who were unable to afford health insurance. Women age 45-64 now have higher uninsured rates than men do and the number of persons covered by Medicaid is decreasing. It is estimated that by 2008, one in four, or 55-60 million, nonelderly persons could be uninsured. Many Americans only seek care when they experience catastrophic illness or major trauma. Once accepted into the healthcare system, patients face many quality care issues. They continue to experience lack of access, fragmentation of care, and excessive healthcare costs. They do not receive important healthcare information, preventive care, or achieve maximum control of chronic health problems. A frightening report by the Institute of Medicine revealed that healthcare errors kill a startling 44,000 to 98,000 people each year. Professionals struggle to harness the speed and complexity of new information in order to make good therapeutic decisions.
The current healthcare system is like a tangled, gnarled car that has been hit full-force by a run-away train. Where does one start to "de-tangle" and repair the remaining structure? The nation must commit itself to finding a way to provide healthcare for the common good. New insights and skills are also needed in order to find the hidden pathways of repair. An honest examination of one's values is a first step to commitment. Do you value healthcare for the common good? Do you value healthcare for the common good as much or more than your personal career/vocational goals? Are there different values that dictate your participation in the healthcare system? What is the "bottom-line" in your commitment to the future healthcare system? Exercises in the appendix are intended to help you in this self-analysis.
New skills are found by looking beyond one's usual sphere of comfort. Professional collaboration is a skill that extends and unites the boundaries of many different professional communities, thereby increasing the likelihood of finding hidden paths of repair. Professional collaboration is like a handshake - prior to the joining of hands, two individuals stand separately, but then the handshake joins and extends both parties. The character of the handshake influences the interaction - a handshake lightly given indicates limited penetration of mutual boundaries while a firm handshake sets the stage more intense interaction. Futurist Dr. Jeffrey Bauer recently advised the American Medical Association that collaboration is the key to an effective future healthcare system (Booth, 2000). Collaboration among professionals has also been advocated by several leading, policy-making organizations, e.g., the American Nurses' Association, Pew Foundation, Robert Wood Johnson Foundation, and Kellogg Foundation. Despite the popularity of the term, people often misunderstand the meaning of collaboration. The expectation to collaborate is often a source anxiety and uncertainty. It is important to decipher the meaning of collaboration and accurately apply that concept to practice. According to Hamric, Spross, & Hanson (1996), client dissatisfaction, unsatisfactory clinical outcomes, and clinician frustration can often be traced to failure to collaborate. The remainder of this paper will examine the meaning of collaboration, present common barriers to collaboration, and suggest ways that healing professionals can enhance collaboration.
The Meaning of Collaboration
To "collaborate" means to work together, act jointly, and cooperate. To collaborate also means to conspire, connive, and cooperate treacherously with the enemy, which is not the intended meaning in this paper (Fowler & Fowler, 1964). When examined within the context of the healthcare system, the meaning of collaboration is more complex than either of the above definitions. Hamric, Spross, & Hanson (1996) defined collaboration as:
An interpersonal process in which two or more individuals make a commitment to interact constructively to solve problems and accomplish identified goals, purposes, or outcomes. The individuals recognize and articulate the shared values that make this commitment possible. The definition implies shared values, commitment, and goals and yet allows for differences in opinions and approaches (p.230).
Collaboration is not supervision, which implies a hierarchical relationship. According to Hamric, Spross, & Hanson (1996), collaboration also is not:
Parallel communication where professionals interact separately with the client with no expectation of joint interactions.
Parallel functioning where professionals address the same problem but do not engage in joint planning.
Information exchange with one or two-sided communication with no joint decision-making.
Coordination involving construction of structures that minimize duplication and maximize resources.
Consultation where one professional seeks advice but retains primary responsibility for the patient.
Co-management as in a process where two or more professionals each provide care within a defined aspect of the total care, but another clinician retains responsibility for the majority of care.
Referral by which one professional directs the client to another professional for management of a problem that is beyond his or her expertise.
Intraprofessional collaboration occurs between two or more professionals from the same discipline. Interprofessional collaboration occurs between two or more professionals from different disciplines. While both types of collaboration are important, the focus in this paper is primarily on interprofessional collaboration. Characteristics of effective collaboration include a common purpose, professional competence, interpersonal skills, and a sense of humor. Trust, respect, and valuing each other's knowledge and skills reflect an interpersonal process.
Healthcare Teams and Collaboration
Healthcare teams are one way to decrease costs, improve quality, and increase patient satisfaction (Katon, 1995). An inherent assumption is that teams create a structure that facilitates collaboration among healthcare providers (Briti-Rossi, Adduci, Kaufman,Lipson, Totte, & Wasserman, 1996). Young (1998) defined a team as a group of professionals working toward a common purpose, in which a variety of disciplines may be represented (p. S138). There are three primary team models:
The multidisciplinary team consists of a group of professionals from different disciplines who work in cooperation, but are essentially separate. Goals are distinct for each discipline and treatment strategies follow individual lines. There is heavy dependence on the leader. In rehabilitation settings, professionals from different disciplines share the same physical space but function separately with separate roles and treatment goals. Many purport that this model does not create a holistic view of the patient, results in fragmentation of care and increases demands on the family and patient. (Mullins, Balderson, & Chaney, 1999; Young, 1998)
Interdisciplinary teams work more closely together. Members establish common goals and work to help the patient achieve these goals. They provide multidimensional assessment and input from multiple perspectives with the goal of providing comprehensive, coordinated care. Adequate communication and collaboration is essential to effectiveness. This team is more vulnerable than the multidisciplinary team to members who choose to follow solitary, different paths. Leadership may vary within the team according to situational needs.
The transdisciplinary team advances to a more integrated level. It requires members to be multi-skilled and to be prepared to engage skills learned from other disciplines. All members have equal status and power and should share all decision-making enterprises and work toward common goals. Mullins, Balderson, & Chaney (1999) found that although the model sounds ideal, it actually might lead to conflict and rivalry.
Collaboration in Primary Care
Doherty (1995) developed a model of collaboration that seems to merge the concepts of team structure and collaboration. The model was conceived within the context of primary care and is based on different intensities of interaction. Minimal collaboration (Level 1) is often seen in private practice where different providers are in separate facilities and professional disciplines. Providers are essentially autonomous and have little interaction with each other. In (Level 2) basic collaboration at a distance, providers make referrals to one another, but share little responsibility, power or understanding of each other's roles. Basic collaboration onsite (Level 3) occurs between providers who share the same facility, but work with separate systems. There is a fairly high level of communication between them, but a clear team is not defined. Shared facilities and systems characterize close collaboration in a partly integrated system (Level 4). Difficulties related to a team structure, hierarchy, and leadership still exist. Finally, in (Level 5) close collaboration in a fully integrated system different providers share a common site, vision, and system. This ideal team has a high level of communication, balance of power, and makes conscious efforts at enhancing team functioning and integrated patient treatment.
Professional collaboration is a complex process that involves mutual goals, trust, respect, self-esteem, interpersonal interaction, and competency of skills, supportive contexts, and altruism. Collaboration, particularly interprofessional collaboration, offers healing professionals an avenue for improving healthcare for all members of our society.
Barriers to Collaboration
A barrier is a fence preventing advance or access (Fowler & Fowler, 1964). The fences barring professional collaboration are legion. To imagine the potential number of barriers, consider the vast intricacies of human nature, society, and the current healthcare system. Some kind of conceptualization is necessary to understand potential ways to enhance collaborations. The following categories are intended to serve as a basis for analysis: (1) tradition, (2) excessive self-interest, (3) lack of knowledge, and (4) system barriers.
Tradition. Tradition is related to a sense of inertia. It is the tendency to do what one knows, to act in ways that are customary. Actions are based (without reflection or insight) upon adherence to beliefs or opinions that have been passed from one professional generation to another. Professionals accept outdated roles because "this is the way things have always been done." One barrier to collaboration is the AMA's (1995) official position to "encourage opposition to any attempt at empowering nonphysicians [e.g., nurses, optometrists, physical therapists, and pharmacists] to become unsupervised medical care providers." This policy stresses that physicians are responsible for the quality of all patient care. One has to wonder if tradition is not the underlying motive. If one assumes an altruistic motive for this position, then the question becomes, "Is it possible that any one profession can acquire sufficient knowledge to be capable of supervising several highly-educated, credible professions?" Given the information explosion, this is difficult to conceive. Professional sexism is also a product of tradition. Just as tradition influences our behavior of eating certain foods on special occasions, tradition influences expectations of acceptable professional behavior between men and women. In the past, men were the decision-makers. There is a tendency for male-dominated professions to assume the role of decision-maker over women-dominated professions (Hamric, Spross, & Hanson, 1996). This unfortunately spills into the arena of professional collaboration; it poses a great barrier to the authentic communication that is essential for effective collaboration. Finally, the socialized humility within women's professions emerges from tradition and limits the effectiveness of collaboration.
Excessive Self-Interest. Excessive self-interest is a second kind of barrier to professional collaboration. Collaboration is based on mutual trust and respect. Professionals who display excessive self-interest lack this respect. Solely because of personal interests, they fail to honor the knowledge and skills of other professionals and/or to seek resources that are available to the patient. Excessively selfish behavior is neither having a bad day, nor being a bit too tired to do one's best at a particular time, nor establishing reasonable limitations in order to be a whole healthy person. It is failing to be altruistic; it is consistently making decisions that fail to honor the responsibility to heal, to honor human dignity, and to put the needs of the patient first. Putting money before the best interests of a patient is an example of excessive self-interest. Political rivalry, power struggles, control issues, boundary conflicts and professional arrogance are all examples of excessive self-interest. These occur when the primary purpose is to advance one's profession and/or secure economic gains. Unwillingness to collaborate, i.e., to seek information that is in the best interests of the patient, is excessive self-interest.
The following headlines display a set of behaviors and attitudes that seem to erode a foundation for collaboration between physicians and nurses.
- Increasing professional tension limits NP opportunities (Edmunds, 1999)
- Physician finds extenders increase efficiency, but bring criticism as well (Physican Practice Options, 1999)
- Nursing leaders consider reactions to AMA policy, (Edmunds, 1999)
- Nonphysicians gain clout (Butler, 2000)
- Nurse practitioners: Growing competition for family physicians (Flanagan, 1998)
- They want my job, quote, p. 21, from Physicians' knowledge lets us land the plane (Anderson, 2000)
Political struggles obviously exist between medicine and nursing. However, perhaps less visible but nevertheless real, struggles erode the foundation for professional collaboration between other professionals.
Lack of knowledge. Lack of knowledge about effective collaboration skills is one area of concern. Limited knowledge about what other professions can offer to the client is another. Understanding the different perspectives, values and accompanying language of each profession is difficult. Even with the best intentions, the problems are difficult to transcend. We often don't understand each other even when we try very hard to do so. Words and images don't mean the same thing to everyone. Consider the following examples.
Four people view the sunset at the Florida Keys. One is a chemist, one is an artist, and two are newlyweds. The chemist sees molecules; the artist sees rich colors, and the newlyweds see a loving future together.
How do we convey unique discipline perspectives in a common language that all of us understand? In one interdisciplinary team meeting, I remember a lengthy conversation about what a "course" was. Believe it or not, a course has quite different meanings to different professions. Our group next attempted to discuss "assessment" only to learn that "assessment" also had a different meaning to medicine and nursing. To the nurses, assessment meant the gathering of information; to the physicians, assessment meant a conclusion or evaluative statement.
In addition to unique discipline perspectives, most of us were socialized to believe that there is only one right answer. A common assumption is that "our" discipline perspective is the correct worldview. In a wonderfully, creative book, A Whack on the Side of the Head, von Oech (1993) stressed the need to educate persons to look for multiple right answers. Each discipline holds different answers. When shared, these multiple views can lead to new unique perspectives and solutions. The key to finding the path to these new perspectives is interprofessional collaboration.
Inadequate Personal and Social Systems. Finally, inadequate systems deter collaboration. On a personal system level, it takes more time and energy to collaborate with other professionals. It is often difficult to reach the other person and there are multiple technological and physical barriers along the way. The pace of life and the pressure to care for increasingly larger numbers of clients discourage the health professional from "one more discussion" in an already hectic day. Imperfect technological devices, such as computers, telephones, pagers, fax machines may create additional barriers. On a societal/system level, administrative and reimbursement policies fail to provide incentives for interprofessional collaboration.
Steps to Successful Collaboration
The current status of interprofessional healthcare collaboration is like my ten month-old granddaughter who wants very much to run with her big sister. Rachel slowly works her way to the side of the sofa, pulls her wobbling self to a standing position, smiles, casts her eyes toward freer territory, moves her hands away from the sofa, swerves in space, and then grabs the sofa again just as she almost falls. Each try seems to strengthen her. Sometime she is exuberant with her progress. Sometime she is wounded and cries in frustration at the body that won't quite cooperate. The path to interprofessional collaboration is wobbly and requires effort, but the potential rewards are enormous.
Education. Multidimensional steps are needed to place interprofessional collaboration on the list of common therapeutic interventions. First, there is a need for increased awareness of the need and benefits of professional collaboration. This can be achieved by education that is placed within the mainstream curricula, continuing education conferences, and public literature. The 1998 AAMC Report I Learning Objectives for Medical Student Education: Guidelines for Medical Schools stated,
Physicians must feel obligated to collaborate with other health professionals and use systematic approaches for promoting, maintaining, and improving the health of individuals and populations. They must be committed to working collaboratively with other physicians, other health care professionals, and individuals representing a wide variety of community agencies. As members of a team addressing individual or population-based healthcare issues, they must be willing both to provide leadership when appropriate and defer to the leadership of others when indicated. They must acknowledge and respect the roles of other health professionals, or communities.
This brings medical education into a greater consonance with the other major health professionals, which have included team collaboration as an integral part of their professional covenants. As this gets implemented it will surely be a major step forward in patient-centered comprehensive clinical care and will do more than almost anything else to sustain and restore interprofessional relationships
All disciplines would do well to emulate medicine in their efforts to incorporate collaboration within established curricula. To accomplish this kind of educational goal, educational programs first need to provide students with the skills they need to be successful within interprofessional teams. The process is far too complex to merely assign an article or make cursory statements about the need for collaboration. Learners need didactics and practice with real problems (Interdisciplinary Health Education Panel, 1997). Students need supervised practice with teams and one-to-one coaching on development of the necessary skills.
Win-Win Philosophy. Second, it is important to adopt a win-win philosophy. The purpose of collaboration is to improve the health of the patient. If our professional goals are directed toward this purpose, then all parties will succeed.
Establish Trust. Third, collaborating professionals must establish trust. They have the responsibility to earn trust by demonstrating clinical competency and acting trustworthy. Actions must be altruistic, patient-centered, timely, realistic, and affordable. Professional rivalry must be put aside. Headrick, Knapp, Neuhauser, Gelmon, Norman, Quinn, & Baker (1996) quoted a list of rules for effective collaboration. The rules were presented by Paul Batalden at the Inaugural Conference in Nashville, Tennessee in April 1994. An adapted summary follows.
Ground Rules for Effective Collaboration
No stealing, guard trust, share openly, and have fun together.
Protect each other's future. Go overboard in giving recognition when using each other's insights.
Honor your commitments when working together.
Keep focused on what can be done together to change the situations
Have shorter rather than longer meetings. Guard your common time.
Evaluate honestly what has gone well and what might be improved.
Practice creative thinking together.
Practice teaching each other something each time you meet.
Quality Leadership. Fourth, quality leaders need to correct an inadequate healthcare system that deters collaboration. This would require research about effective models and ways to eliminate barriers. There is a need for explicit models of collaboration that are workable and realistic.
Go Ahead and Do It!. "Just do it!" is my final recommendation. In their national best-seller, Search for Excellence, Peters & Waterman (1982) described how great organizations just go ahead and try something, evaluate what they did, fix the problems, re-evaluate, try again, and so forth until they have a solution for a problem. Within the collaborative model, Batalden & Stolz (1996) referred to a similar process of Plan-Do-Check/Study-Act. There are many benefits that can be gained from the exercise of even imperfect collaboration. Despite the headlines that portray nurses and physicians as natural enemies, numerous research reports have shown that nurses and physicians who work together in collaborative relationships do not perceive problems with conflict and professional rivalry. Interprofessional collaboration is an active process that is affected by all of the potential joys and burdens of interpersonal relationships. We cannot resolve the problems surrounding interprofessional collaboration until we get involved. The evidence suggests that the benefits far exceed the costs. Professional collaboration is the key to repair a fragmented healthcare system, promote greater access for patients, create better interventions, and improve outcomes.
Value Clarification Exercises
5. Willingness to make values known to others.
6. Choices must precipitate action.
7.Values must be integrated into one's lifestyle.
Harmon, V., & Steele, W. (1979). Values clarification in nursing. New York: Appleton-Century-Crofts.
Value Clarification Exercises
Exercise # 1: Rank the following from the most important to you to the least important. .
Making a lot of money
Overcoming a challenge
Exercise # 2: You have space for one more appointment in your afternoon schedule. There are five new persons who have asked for an appointment. Assume all of their healthcare needs are acute, but not life- threatening. From the following list, which client would you agree to see? Rank the remaining clients in the order you would agree to see them (i.e., from first to last). What values directed your choices?
A 20 year-old mother of two. She is on welfare and you will not receive any money for the visit.
A 50 year-old man who you know is a leading community citizen.
A man who was recently released from a prison. No insurance.
An elderly woman who receives medicaid..
An unemployed 30 year-old male. No insurance.
Exercise # 3: Rate each of the following statements on a scale. Circle the number that most closely corresponds with your feelings about each of the following statements.
2. I do not like to care for a patient who is on welfare.
3. I do not like to care for a patient who is unemployed because of laziness.
4. Every health care provider has the responsibility to care for persons who cannot pay for their healthcare.
5. There should be a separate healthcare system for poor persons.
6. Healthcare should be operated like any other private business.
7. The USA should have a universal healthcare system.
8. Persons who cannot pay for their healthcare should not expect the same level of care as though who can pay.
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Booth, B. (2000). Collaboration seen as key to the future. American Medical News. February, 19-20.
Brita-Rossi, P., Adduci, D., Kaufman, J., Lipson, S.J., Totte, Wasserman, K. (1996). Improving the process of care: The cost-quality value of interdisciplinary collaboration. Journal of Nursing Care Quality, 10 (2), 10-16.
Butler, L. (2000). Nonphysicians gain clout. American Medical News. January, 1, 26
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Edmunds, M.W. (1999). Increasing professional tension limits NP opportunities. NP News. May, 101-104.
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New and notes. (2000). Percentage of uninsured Americans growing. Clinician News, February, 19.
von Oech, R. (1993). A whack on the side of the head. New York: Warner Books.
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Physician finds extenders increase efficiency, but bring criticism as well. (1999). Physician Practice Options, September, 1,8-9.
Simmons, P. D. (1999). The future of health care. Human Values and Health Care in the New Millenium Workshop. Ed. A. Christopher Hammon and Vicki L. Hollon. Louisville: Wayne E. Oates Institute, pp. 1-17. [On-line]. Available @ http://www.oates.org/conference_center/workshop99/ conf-center/workshop/simmons-01.html.
Mullins, L.L., Balderson, B. H.K., Chaney, J. M. (1999). Implementing team approaches in primary and tertiary care settings: Applications from the rehabilitation context. Families, Systems, & Health, 17 (4), 413-426.
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The author would like to thank John C. Wright II, MD, Professor Emeritus, Department of Family and Community Medicine, School of Medicine, University of Louisville for editing, reflecting about ideas, and providing selected references. Kirsten Schmall, Secretary II, University of Louisville School of Nursing also assisted with editing.