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TO AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE 11100 W.“ RELATIONSHIP COMPONENTS NEEDED FOR MARRIAGE AND FAMILY THERAPISTS TO WORK COLLABORATIVELY WITH HEALTH CARE PROFESSIONALS: A NATIONAL DELPHI STUDY By Laura Ann Myer-Mohr A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Family and Child Ecology 2000 l’.) T} ABSTRACT RELATIONSHIP COMPONENTS NEEDED FOR MARRIAGE AND FAMILY THERAPISTS To WORK COLLABORATIVELY WITH HEALTH CARE PROFESSIONALS: A NATIONAL DELPHI STUDY By Laura Ann Myer-Mohr The purpose of this study was to identify the relationship components needed for Marriage and Family Therapists (MFTs) to work collaboratively with Health Care Professionals (HCPS). The study focused on four major objectives: 1. to identify core components needed for MFTs to work collaboratively with HCPs; 2. to validate by obtaining consensus of MFI‘ practitioners working in collaborative practice (Delphi procedure) those components that are VERY IMPORTANT and IMPORTANT for collaborative work; 3. to identify demographic factors which difl‘erentially afl‘ect the reported significance of components; and 4. to propose a Collaboration Inventory (CI) for use in mm development of evaluative measures of collaborative practice. A four-phase methodology was used to attain the stated objectives. Phase 1 identified core components of the collaborative relationship fiom a review of literature relevant to collaboration. In phase 2 a Collaboration Inventory was constructed. The inventory consisted of three sections. 1. Background Information (four demographic variables and two qualitative items); 2. A list of Collaborative statements (99 items); and 3. Rank Order section (five general components and 26 sub-components questions). lese 3 pilot tested the instrument. The Delphi procedure for obtaining opinions of a panel of experts was used in phase 4 to empirically validate the CI by obtaining Laura A. Myer-Mohr consensus of therapists working collaboratively regarding VERY IMPORTANT and IMPORTANT components on the CI revised fiom phase 3. Marriage and Family Therapists who belong to the Collaborative Family Healthcare Coalition composed the panel. Opinions were obtained in two rounds, using two CIs: Round 1 response rate was 49% (42) and Round 2, 58% (23). Feedback fiom Round 1 was given as fiequencies of responses in each of the inventory items. Descriptive statistics included frequency, medians, and Leik’s Formula to report the findings. Panelists identified Domain Orientation and Interactive Process as VERY IMPORTANT with consensus rates of 58% and 63%, respectively. Components identified as IMPORTANT included Stakeholder and Shared Rules, Norms, and Structure with agreement levels of 55% and 75%. Finally, panelists agreed at a high level of consensus (80%) that Professional Autonomy was Not Important to the success of the collaborative relationship. In addition, panelists agreed at a high level of consensus (greater than 70%) that Mutual Respect, Common Purpose, and Frequency of Communication are VERY IMPORTANT, Orientation and Mode of Communication are IMPORTANT, and Action/Decision, Shared Support Staff, and Hierarchy within the Relationship are Not Important. Implications of this study are for improved skills for MPTS working with HCPs and for the initial steps towards the development of an instrument that will enable the further understanding and validation of the Collaborative Healthcare process. Copyright by LAURA ANN MYER-MOHR 2000 ACKNOWLEDGMENTS I would like to take this opportunity to express my deepest appreciation for all of the individuals who offered their support and assistance during my doctoral studies. To my husband, Tom, for your unwavering belief in my abilities. Thank you for your love, support, and affection. You once told me that anything is possible with enough hard work: now, I believe you. To my Doctoral Committee chairperson, Dr. Marsha Carolan, for your warmth, kindness, patience and support. You have guided my education and professional development with the appropriate balance of gentle support and encouragement. I am honored to be your ‘first.’ I hope someday I can be as helpfitl to my students as you have been to me. To my Doctoral dissertation co-chairperson, Dr. Norma Bobbitt, for your endless hours of work, guidance, and high standards. Your insight and understanding are an inspiration. You have taught me to appreciate the never-ending process of learning. To Dr. Marjorie Kostelnik, for teaching me about grace, integrity and professionalism. A doctoral student could not ask for a better role model. To Dr. Elizabeth Seagull, for your appreciation of the collaborative healthcare process and your straightforward input into my program. To the Department of Internal Medicine, for providing the space I needed to complete my studies. Finally, to all my family and fiiends, for your love, support, and patience during this hectic time in my life. TABLE OF CONTENTS Page LIST OF TABLES .................................................................................................... viii LIST OF FIGURES ..................................................................................................... x CHAPTER 1: Introduction Background Information ................................................................................... 2 Significance ...................................................................................................... 4 Purpose ............................................................................................................ 6 Research Questions .......................................................................................... 6 Collaborative Components ..................................................................... 7 Collaborative Sub-Components .............................................................. 7 Collaborative Items ................................................................................ 8 Demographic Factors ............................................................................ 8 Definition of Conceptual Terms ......................................................................... 8 Overview of Subsequent Chapters .................................................................. 10 CHAPTER 2: Literature Review Introduction. .................................................................................................... 1] Integration of Mental and Physical Health ....................................................... 12 Mental Illness in Medical Care ............................................................. 12 ThePrirmryCareClimateandManagedCare ..................................... 13 The Need for Psychotherapy in the Medical World .............................. 15 Empirical Support ........................................................................................... 15 CIT-Set Effect Research. ....................................................................... 15 Collaborative OfiT-Set Effect Research ................................................. 16 Collaborative Relationship Research. .................................................... 17 Collaborative Healthcare Models .................................................................... 18 The Medical Family Therapy Model .................................................... 18 The Levels of Collaboration Model ..................................................... 19 Collaborative Healthcare: The Rochester Model .................................. 21 Theoretical Perspectives and Models .............................................................. 25 The Ecological Perspective ................................................................. 25 The Biopsychosocial Model ................................................................ 26 The Concept of Collaboration ............................................................. 27 The Negotiated Order Theory ............................................................. 29 A Theory of Collaboration .................................................................. 30 The Integrated Model: Collaborative Relationship Components ............ 33 List and Definitions of Core Components for this Study ....................... 33 Use of the Survey and Delphi Methodologies .................................................. 37 The Survey Methodology ................................................................... 38 The Delphi Methodology ..................................................................... 41 Conclusion. ..................................................................................................... 46 Page CHAPTER 3: Methodology Objectives ...................................................................................................... 47 Research Questions #1-12 ............................................................................... 48 Research Questions #13-15 ............................................................................ 49 Research Objective 4 ....................................................................................... 50 Research Design ............................................................................................. 50 Sample ............................................................................................................ 55 Data Collection ............................................................................................... 56 Data Analysis .................................................................................................. 59 Conclusion. ..................................................................................................... 61 CHAPTER 4: Research Findings Response Rates - Round 1 and Round 2 .......................................................... 62 Use of Round 1 and Round 2 Data .................................................................. 63 Summary of Findings ...................................................................................... 64 Overview ............................................................................................. 64 Collaborative Components ................................................................... 65 Collaborative Sub-Components ............................................................ 67 Collaborative Items ............................................................................. 71 Demographics ..................................................................................... 75 Summary of Research Findings ........................................................................ 76 CHAPTER 5: Summary and Recommendations Summary ......................................................................................................... 84 Discussion. ...................................................................................................... 87 Research Objective #1 .......................................................................... 87 Research Objective #2 .......................................................................... 87 Research Objective #3 ........................................................................ 101 Research Objective #4 ........................................................................ 102 Implications ................................................................................................... 104 Potential Contributions to the field of Collaborative Healthcare ...................... 105 Researcher Observations ................................................................................ 106 Limitations of this Study ................................................................................ 108 Recommendations for future Research. .......................................................... 109 APPENDICES A. Identification of Components, Sub-Components and Items ................. 112 B. Pilot Study Correspondence ............................................................... 119 C. Survey Correspondence - Round 1 ..................................................... 135 D. Survey Correspondence - Round 2 ..................................................... 154 REFERENCES ......................................................................................................... 167 .11 Table 3.1 3.2 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 LIST OF TABLES Page Timetable for obtaining and analyzing the data ................................................. 58 Summary of Data Analysis ............................................................................... 60 Survey Response Rates ................................................................................... 62 Demographic Summary .................................................................................. 63 Collaborative Components Data. ..................................................................... 66 Sub-Components Ranked Very Important sorted by Degree of Consensus ........................................................................ 68 Sub-Components Component ranked Important sorted by Degree of Consensus ........................................................ 70 Number of Items sorted by Component ranked Very Important ................................................................................... 72 Number of Items ranked Very Important and Important sorted by Degree of Consensus ........................................................................ 73 Number of Items sorted by Component ranked as Important ................................................................................................... 74 Collaboration Components Research Question Summary ................................. 77 Collaboration Sub-Components Research Question Summary .......................... 78 Collaboration Items Research Question Surmnary ............................................ 81 5.1 5.2 5.3 5.4 5.5 5.6 Professional Autonomy and Sub-Components .................................................. 89 Shared Rules, Norms, and Structure and Sub-Components .............................. 91 Interactive Process and Sub-Components ......................................................... 94 Domain Orientation and Sub-Components ....................................................... 95 Stakeholder and Sub-Components ................................................................... 97 Level of Consensus reached by Percent of Inventory Questions ........................ 99 LIST OF FIGURES Figure Page 1 Collaborative Health Care: The Rochester Model ................................................ 23 2 A Theory of Collaboration. ................................................................................. 31 3 Relationship Components Needed for Marriage and Family Therapists to work collaboratively with Health Care Professionals ............................................................................ 34 4 Relationship Components Needed for Marriage and Family Therapists to work collaboratively with Health Care Professiomls - revised ..................................................................... 54 O! “I W I inc -"\1 L oen « ‘. (il'i .‘ I CHAPTER 1 Introduction The intention of this study is to identify the key components of a collaborative relationship among rmrriage and family therapists (MFTS) with health care professionals (HCPS). Over the last few decades, more WIs and HCPs have been working together, or collaborating, to better serve individuals and families. To successfully accomplish the work in this new dimension of healthcare, it has been necessary for mental and physical healthcare professionals to strengthen existing knowledge and skills plus learn new collaborative knowledge and skills. A comprehensive collaborative model that identifies the necessary components for working together would provide much needed information for these individuals who are forging a new professional path The findings from this study will assist individuals currently engaging in collaborative practices and provide a usefitl tool for emerging professionals with an interest in collaborative healthcare. A collaboration model would, in addition, allow for timber development of collaboration in healthcare by facilitating research about the impact of collaboration on patient care. This chapter will cover the need and significance of this study, the purpose and research questions, and definitions for this study. The next section presents a brief overview of the background on collaborative family healthcare and establishes the need for timber investigation of the key components of a collaborative relationship. Heaths Hakim grew . .45. ' ‘ “\LTEL‘; ~ mem d Gm Gar Baskermmdlnfcttuaficn Medical Emily therapy, or what is now known as Collaborative Family Healthcare, is a sub-speciality of marriage and Emily therapy. Collaborative Family Healthcare is considered by many as the ‘third wave’ of interest in this area. This sub- speciality is understood best within the context of its historical evolution. The first wave of interest occurred in the 1920's and 1930's which primarily began with a recognition of the importance of the Emily and social context in individual healthcare (Ransom, 1981). The second wave of collaborative Emily healthcare, occurring between the 1950's and the 1970's, included several significant developments. Primary developments included both Emily therapy and Emily medicine evolving as independent disciplines and the advent of community health centers (Seaburn, Lorenz, Gunn, Gawinski, and Mauksch, 1996). The third, and considered by some to be the most productive wave, has included several advancements. One of the most significant advancements of this time was the identification and explanation of the biopsychosocial model by George Engel (1977). This model provided a broader way of looking at individuals, acknowledging that biology, psychology, and social environment all contribute significantly to an individual’s well-being. This model moved the health care paradigm beyond the traditional reductionistic biomedical model. In addition, Emily focused professional organizations were integrating some of the previous developments into their professions. In medicine, the Society of Teachers of Family Medicine held the first “Family in Family Medicine” with: ‘ [km IX In 1983. ‘ represenli :lchr's mm Ht‘pRORI to it ideal: MIL i Curtis's ii Milli pit; ml. 10% missions mess a ‘n [climax In» «“515 to a c ,1” , Cl“. “336’. l L.“ conference in 1981 and identification of the ‘Emily as patient’ became a professional theme (Alper, 1994). The journal entitled “Family Systems Medicine” began publication in 1983. This journal, now called “Families, Systems, and Health” was a journal representing the “confluence of Emily therapy, systems theory, and modern medicine” (McDaniel, Hepworth, Doherty, 1992, p. 21). Within MFT, professionals began emplmsizing the integration of physical and mental well being. In 1992, McDaniel, Hepworth and Doherty coined the phrase ‘Medical Family Therapy’, which began a new, clearly identified sub-speciality within marriage and Emily therapy. Although more recent developments have been significant, a “new wave” has yet to be identified. These developments are represented by a notable shift in terminology. Although in 1992 ‘Medical Family Therapy’ was identified as a unique professional emphasis that joined medicine and therapy to better serve individuals and Emilies, the current phrase ‘Collaborative Family Healthcare’ was not proposed until 1996 (Seaburn et al., 1996). Collaborative Family Healthcare is a term that expands beyond joining two professions together and moves into a more integrative paradigm. This paradigm suggests a broader, more holistic perspective regarding health and wellness. Collaborative Family Healthcare also expands beyond the partnership of physicians and therapists to include other healthcare professionals as well as Emilies (Seaburn et al., 1996). Recently, several areas of research have been identified within the collaborative Emily healthcare movement as necessary to the advancement of the field. General research areas include “refining and operationalizing models of collaborative care, wmwu mad: ixswn mfifls ARMS ammfl meu Oiiflt‘ rm. Edmm Mm 3.": P0135“ conducting outcome research on collaborative approaches, expanding collaboration with medical specialities and sub-specialities beyond Emily medicine, and on influencing decision rmkers in health care policy and managed care “ (Bisehof, 1999, p. 7). This project is the first step in an effort to fitrther some of the objectives identified above. This project strives towards operationalizing a model of collaborative healthcare. A professionally validated Collaboration Inventory will help to refine and operationalize a comprehensive model of collaboration. It will begin the process of developing a tool for conducting outcome research on collaborative approaches and allow for application of the model to other medical specialities and sub-specialities. This inventory can be used in research outcome studies of collaborative healthcare to influence decision makers and to affect the growing potential of marriage and family therapy as a profession. 5° '6 The primary aim of this project is to identify key components of the collaborative relationship of MFTS with HCPs. As there is no standardized model of collaborative healthcare, there is tremendous variety in the way individuals engage in this process. Students in MFI‘ or health care training programs, professionals engaging in collaborative clinical practices, and university instructors have begun to incorporate collaborative healthcare into their respective programs. The presence of collaboration within both physical and mental health care is no longer a small sub-speciality but for many the inmge of tomorrow (McDaniel, 1993). Ex Ithiilashi gratin lath sen 1961 S mesh; film. I Hi m: ll. Wm her 10 ‘ dlchoz. i3 3L1. it“ War In FEET a it mili‘falfl Till: It‘r‘ field 1 l *" Milli 0 yd S“titer, 311 Trial In ‘9“ &"., g (u. in,“ t Existing literature emphasizes many concepts surrounding the collaborative relationship, however it is not focused on actually examining the relationship between practitioners. Research studies dating back to 1967 explored the impact of mental health services on patient well being and health care utilization (F ollette and Cummings, 1967). Some of the impetus for interest in the mental and physical health care partnership comes fiom the visibility of mental health problems in medical care practices (Shemo, 1985; 1986). A further discussion of cost off-set studies and the connection with mental health problems in medical settings is developed in Chapter 2. More recent studies have begun to examine collaboration and its impact on patient health care. Collaboration in these ofllset effect studies, however, is still limited to a dichotomous variable, present or absent (Belar, 1995). Much descriptive writing has also been done in order to share difl’erent collaborative models in difl'erent settings, however little empirical research has been conducted around this professional arena. Finally, a few qualitative studies have begun to explore the complexity of the collaborative relationship (Bischofl‘, 1999; Bischof, in press). This project utilizes the Delphi methodology. This methodology allows experts in the field to identify and validate components and sub-components considered very important or important to the success of a collaborative relationship. These components and sub-components will form a model of collaboration. This model of collaboration will result in an inventory for firture use in measuring the impact of collaboration on patient and Emily well being. mm: Em Lit Seconi t. to} N CH Blames: The intent of this project is twofold. First, this project will identify the very important and important components of collaborative practice among marriage and family therapists with health care professionals as perceived by practicing experts. Second, this verification process will result in a more comprehensive collaboration model that can be used to develop an inventory in the firture to evaluate collaborative practice. The following objectives will be accomplished by this study: 1. To identify core components needed for MFTs to work collaboratively with HCPs. 2. To validate by obtaining consensus of MFT practitioners working in collaborative practice (Delphi procedure) those components that are VERY IMPORTANT and IMPORTANT for collaborative work. 3. To identify demographic Ectors which diflerentEfly afl"ect the reported significance of components. 4. To propose a Collaboration Inventory (CI) for use in finther development of evaluative measures of collaborative practice. Rsssarshfinssticns The following research questions were developed to accomplish the identified objectives and achieve the project purpose. The questions are divided by subject category. Wants (Objectives 1 and 2) 1. What are the VERY IMPORTANT components of a collaborative relationship of an MFT with an HCP? 2. What is the degree of consensus regarding VERY IMPORTANT components of collaborative practice? 3. What are the IMPORTANT components of a collaborative relationship of an MFT with an HCP? 4. What is the degree of consensus regarding IMPORTANT components of collaborative practice? WW (Objectives 1 and 2) 5. What are the VERY IMPORTANT sub-components of a collaborative relationship of an MFT with an HCP? 6. What is the degree of consensus regarding VERY IMPORTANT sub- components of collaborative practice? 7. What are the IMPORTANT sub—components of a collaborative relationship of an MFI‘ with an HCP? 8. What is the degree of consensus regarding IMPORTANT sub-components of collaborative practice? ((3:55 W (Objectives 1 and 2) 9. What are the VERY IMPORTANT items of core components of a collaborative relationship of an MFT with an HCP? 10. What is the degree of consensus regarding VERY IMPORTANT elements of core components of collaborative practice? 11. What are the IMPORTANT items of core components of a collaborative relationship of an MFT with an HCP? 12. What is the degree of consensus regarding IMPORTANT elements of core components of collaborative practice? W915 (Objective 3) 13. What demographic Ectors are associated with consensus regarding VERY IMPORTANT and IMPORTANT components? 14. What demographic Ectors are associated with consensus regarding VERY IMPORTANT and IMPORTANT su b-components? 15. What demographic Ectors are associated with consensus regarding VERY IMPORTANT and IMPORTANT items of core components? 11 [i . . E C 1 I mm and Eamrly' Iheraprst' 5: includes members of the mental health care profession self-identified as primarily practicing therapy fiom a systemic paradigm Health Care Professm' pals: includes physicians, nurses, nurse practitioners, and physicians assistants Wham: includes members of the mental health and physical health care professions working together regarding patient wellness Components: broad categories of relationship characteristics identified as relevant to the process of collaboration Wm: dimensions of components firrther identified for clarification When: individual Ectors that contribute to the understanding and definition of the sub-component Wm: a list of items identified by practicing Marriage and Family Therapy experts as important or very important to the success of collaborative practice with Health Care Professionals Minimum: those items ranked by panelists as Very Important on the Collaboration Inventory Important: those items ranked by panelists as Important on the Collaboration Inventory Delphifimdy: methodology used to produce convergence of group consensus through a series of questionnaires regarding a topic of interest Consensus: the extent panelists concur in their ranking per inventory question is considered degree of consensus Wm: includes gender, primary work Enction, current employment setting and years in collaborative practice For a more thorough discussion of terms and for operational definitions, see Chapter 3 Methodology. WW Chapter one has described the need and significance of this study. It has identified the purpose of this study and defined relevant research questions. Chapter two provides a review of the relevant literattn'e regarding the integration of mental and physical health, empirical support for this partnership, collaborative healthcare models, the theoretical perspectives and models for this project and a review of the research methodology and its appropriateness for this project. Chapter four reviews the findings of the study and Chapter five provides a summary of the project, discussion of the findings, implications, researcher observations, limitations, and recommendations for future research. 10 CHAPTER 2 Literature Review Intmdusticn A major initiative in the Marriage and Family Therapy field is the development of alliances with health care professionals as a means of improving client well-being and reducing healthcare costs (Rinaldi, 1985). This association has come about for a variety of reasons. The afliliation first began as a result of the recognition of the integration of physical and mental health. Research studies followed the recognition and explored the impact of psychotherapy services provided within the medical arena. Present day health care services often provide some level of collaborative care between physical and mental health care professionals. This care is the result of the previous initiatives in research andpracticeaswellasaproduct ofthirdpartymanaged care. This project is an efl‘ort, in keeping with the evolution of health care, to further explore the relationship of Marriage and Family Therapists collaborating with Health Care Professionals. The following discussion expands upon the empirical and theoretical components relevant to the development of this study. The review begins with an exploration of the integration of mental and physical health, including the presenceofmentalillnessinmedicalcare. Theliteratureonthechangingprirnarycare climate and the nwd for psychotherapy in the medical world provides some of the backgrotmd on this integration. Next, a review of empirical studies provides insight into the evolution of research in the field of collaborative health care. This section looks at traditional ofllset efl‘ect studies as well as collaborative ofllset efiea studies, including 11 that} 1-I ifl’. CK": l0? I. .4‘ ul the few existing studies that explore the complexity of the collaborative relationship. The next section focuses on the development of Collaborative Healthcare models including the most recent and influential model to date. Following that section is a discussion of the theoretical paradigms that influence this study. The conceptual model for this study is then presented. This model evolved from an integration of Colhborative Healthcare models with Wood and Gray’s (1991) Theory of Collaboration. Finally, a review of the literature on the research methodology used for this study is included. Individuals with mental illnesses have always required assistance fi'om the medical field. Years ago, mental illness was considered an illness only if a neurological disorder was present (Engel, 1977). As time passed, psychiatrists, psychologists and other professionals within the mental health field began recognizing the full realm of psychosocial disorders that existed. Despite the Ect that professionals both in and outside the medical field were recognizing a distinction between neurological and psychosocial disorders individuals struggling with various mental illnesses continued to be treated predominately within the medical field (Baughman, 1994; Mauksch & Leahy, 1993; Shemo, 1985). In a survey conducted in 1975 by the National Institute of Mental Health, for example "800,000 patients with mental illness were treated in mental hospitals while 900,000 were treated in general hospitals, 300,000 in VA Ecilities, 200,000 in nursing homes, and 13,000,000 (emphasis added) in the offices of 12 non-psychiatric physicians." (Shemo, 1985, p. 21). Although these figures are twenty years old, mental health treatment is still prinmrily provided by physicians through the use of psychotropic medications (Baughman, 1994; Mauksch & Leahy, 1993). Healthcarehaschangedinthelasttwo decades. Healthcarehasmoved fioman era of medical specialization to an emphasis on preventative general health care (Belar, 1995). This lms afl’ected the role of the general practitioner who has become increasingly important (Alper, 1994). In 1985, 67% of hospitalized patients had diagnosable mental illnesses (Shemo, 1985). Currently, the percentage of Indrvrduals within hospitals who are diagnostically mentally ill has decreased, but mental illness diagnoses has surged within primary care Ecilities (Baughman, 1994). As recently as 1994 "77% of all mental health visits are to primary care physicians." (Baughman, 1994, p. 374). Mental illness has shifted to predominantly presenting in primary care instead of within hospitals. This shift reflects the current change in healthcare. Health care managed by a third party payor (e.g. insurance companies) is increasingly becoming the form of healthcare delivery (Alper, 1994). Managed health care is quickly changing the role of primary care (Sandy, 1995). Primary care physicians are heavily relied on to treat larger, more varied populations in shorter spans of time (Emanuel & Duhler, 1995). Primary care physicians are expected to manage the total health of their patients, including physical and psychosocial ”wellness" (Glasser & Stems, 1994). Time constraints make it diflicult for these physicians to spend quality time with their patients. Communication and rapport building are not reimbursable acts 13 a: it 23360 :99“, w._-I and consequently diflicult for the physician to accomplish (Emanuel & Duhler, 1995; Glasser & Stems, 1994). Primary care physicians have become "gatekeepers" to their patients' health care, therefore most medical care needs, regardless of the illness, must be funneled through the prirmry care physician (Alper, 1994; Emanuel & Duhler, 1995). Today, mental illness is highly present in primary care practice but not well addressed (Fogel, 1993; Glasser & Stems, 1994; VonKorfl‘, 1992). According to Miranda et a1. (1991) 40-60% of individuals presenting for primary care visits present symptom with no biomdical issue, 5-34% have actual mental health diagnoses. The change in the management of health care necessitates patients viewing their primary care physician as an overall "wellness" doctor, ultimately placing too heavy a burden on the primary care physician (Marcus, 1989). Primary care physicians struggling to balance the high demands of managed care companies with quality patient care sometimes results in the neglect of psychosocial disorders. Recognizing and/or treating psychosocial issues is diflicult for primary care physicians due to limited training and time constraints (Fogel, 1993; Russell & Roter, 1993; Hepworth & Jackson, 1985; Katon, et al., 1990; Tomson, 1990). Prirmry care physicians manage to accurately recognize patients with mental illnesses and/or psychosocial disorders only about 50% of the time (Glasser & Stems, 1994; Mauksch & Leahy, 1993). These changes in health care open up a variety of opportunities for mental health specialists, especially for marriage and Emily therapists (Patterson & Scherger, 1995; Crane, 1995a; Crane, 1995b). 14 lik’ ‘5 \\ .iC ' l W The face of health care is changing. Preventative care and wellness are becoming common themes (Alper, 1994; Emmanuel, 1995). Alternative and holistic medicine are more commonplace domains in medical school (Marcus, 1989). The recognition of the mind/body connection is an obvious step in the direction of holistic medicine. An integration of psychiatric care can occur within primary care (Belar, 1995; Shemo, 1985). According to Fogel (1993), a very complex relationship exists between physical and psychological illness. To distinguish between the physical and psychological, especially in primary care, is arbitrary (Glasser & Stems, 1994). Within the range of “normality,” there is an association for most individuals between physical complaints and emotional well-being (Dworkin, VonKorfl’, & LeResche, 1990). E . . l 5 There have been various empirical studies relevant to the union of the mental and physical health care fields. These can be categorized into three groups: traditional ofll set efl’ect research, collaborative ofl-set research and the most recent research on the collaborative relationship. The following sections will explore further these time groups. Wasatch The strongpresenceofmentalillnessinprirnarycare settingshasinitiated studies exploring the impact of a referral by a physician to psychotherapy on health care utilization. A few studies have been conducted regarding the efieaivemss of therapy or counseling on medical care utilization. This research has been called ‘ofl‘set’ effect 15 [0 501 research, defined as “an ofiset effect occurs when the use of mental health services leads to a reduction in the use of other health or social services, thereby potentially defraying some portion of the cost of the provision of the mental health services by the savings realized in other components of the health care system” (Shemo, 1985 p. 19-20). Off-set efl‘ect research began with Follette and Cummings’ (1967) ground breaking study suggesting that a medical care utilization decrease would follow psychotherapeutic services. Recent studies continue to demonstrate a decrease in utilimtion of medical care following psychotherapy (Budman, Demby, & Randall, 1982; Katon, et al., 1990; Mumford, et al., 1984; Shemo, 1985). Forester, Kornfeld, Fleiss, and Thompson (1993) studied the effects of psychotherapy and recognized a decrease in both emotional and physical symptoms. W A few research studies lmve begun to look at, or at least label, the physician/therapist relationship as a collaborative effort (V onKorfl‘, et al., 1998). Collaborative care, however, is more often than not identified as a dichotomous variable, present or absent. VonKorfl‘, et a1. (1998) found that a model of collaborative care that includes either physician care accompanied by a psychiatric visit, or physician care accompanied by brief psychotherapy reduced health care utilization for patients diagnosed with major depression. The findings included a greater decrease in utilization than patients treated only by their primary care physician (VonKorfl‘, et al., 1998). Finally “the cost per patient successfully treated was lower for Collaborative Care than 16 d at... “‘0: N\ sgkp C . I\ "s for Usual Care patients” (V onKorff, 1998, p. 143). This study is one of the few to date that examines the complexity of collaborative care. C ll 1 . B l . l . B 1 Most studies of collaborative health care are outcome studies that focus on cost and psychotherapy benefit to the patient. A few studies (Bischof, 1999; Bischofl' & Brooks, 1999) have emerged that take a qualitative look at the dynamics of the collaborative relationship. Recently, Bischof(1999) conducted a phenomenological study exploring the experiences of several mental health providers working collaboratively in non-academic health care settings. This study qualitatively identified perceived pros and cons of working collaboratively, ethical and reciprocal issues of working collaboratively and colhboration in rural settings. Bischof (1999) also included recommendations for mental health providers interested in working collaboratively. A second qualitative project (Bischofl' & Brooks, 1999) is exploring issues arotmd training and education of individuals interested in mdical Emily therapy. This ongoing study utilizes a Delphi methodology with a data collection method using open ended questions. These authors are seeking “to determine the knowledge— and skill- based competencies tlmt mental health practitioners med for successfirl collaborative practice” (Bischofl‘ and Brooks, 1999). Bischofl‘ and Brooks (1999) are focused on constructing a training model for mental health practitioners. This dissertation project is timely in tint it takes the much meded step of quantitatively explicating the collaborative relationship to the next level. 17 [’- WW Understanding and exploration of the collaborative health care relationship has evolved in several different ways, from emphasis on oflT-set eflect studies to initial exploration into the collaborative relationship. This evolution has also produced an abundance of literature, much of which is anecdotal in nature, describing collaborations throughout the country. While many marriage and Emily therapists are working collaboratively with physicians, and sharing this experience within the field, very little is empirically based. A few models have been put forth in an attempt to capture the dynamics of this relationship. Three of the most influential models will be discussed in this section, including: The Medical Family Therapy Model, The Level of Collaboration Model, and The Collaborative Healthcare Model. These models are progressive models as each builds on the previous one, and are presented chronologically. Illll'lE .11] “ll This first attempt at categorizing types of collaboration provided many necessary tools, including introducing the phrase Medical Family Therapy and introducing the concept of ‘bump-in-the—hall’ conversations. Medical Family Therapy as the first of these models suggested three types of collaboration: indirect consultation, co-therapy, and limited referral (Hepworth & Jackson, 1985). Indirect consultation involves brief interactions between physician and therapist offering “suggestions, support, or supervision” (Hepwlo & Jackson, 1985, p. 124). This type of collaboration categorized the “in-the-hallway” interaction common in the medical profession (McDaniel, Hepworth, & Doherty; 1992). The second type of collaboration, 18 co-therapy, is the least common and involves both physician and therapist present during a Emily consultation (Hepworth, 1985). Finally, limited referral is said to be the most common form of collaboration, even today (Seaburn et al., 1996). Limited referral involves the process of one professional referring patients to another professional. This model is often used when professionals are physically separate in location, and usually results in each professional providing “parallel” services (Hepworth & Jackson, 1985). The contributing Ectors of this model would be the recognition of Medical Family Therapy as a speciality within Marriage and Family Therapy, and suggesting difl‘erent types of relationships between physician and therapist. IhelsxclmflflcllahomichQdel At the first annual conference of the Collaborative Family Healthcare Coalition in July 1995, William Doherty introduced a model that highlighted the new concept of collaboration. This concept focusing on collaboration, broadened the understanding of the relationship between physician and therapist in several ways. One of the most significant ways that was identified was to include a variety of health care professionals, no longer limited to physicians, encompassing nurses and other health care workers. Doherty’s model (1995) suggests different levels for working collaboratively, “the levels refer both to the extent to which collaboration occurs and to the capacity for collaboration in a given health setting as a whole” (p. 277). Five different levels of collaboration that increase hierarchically are part of this model fi'om minimal collaboration at level one to greater systemic collaboration at level five. 19 ‘YJ / J! ft. W. This level is characterized by professionals working at separate sites providing separate services with little to no interaction regarding patient care. This form of collaboration is most often seen in private practice and is similar to the limited referral model above. Wage. This level is similar to Level 1 in that professionals practice at separate locations however communicate occasionally regarding patient care. Active referrals occur and recognition of the other professional as a resource is present at Level 2. Wigwam This level is distinguished Primarily by proximity; professionals are often located in the same physical location. Professionals nuintain separate management systems, such as charting, billing, and so forth. The two professionals, however, experience regular communication via phone/letter or ‘burnps- in-the-hall’ due to their physical location W This level is characterized by the beginnings of an allegiance to a biopsychosocial paradigm; professionals engage in regular Ece-to-Ece meetings, coordirmte treatment plans, and develop the beginnings of an understanding of each other’s culture. Finally, some systemsareshared, suchaschartingandscheduling. Levels3 and4aresirnilarto the indirect type of collaboration mentioned previously. W. This level is rare, however a suggested “vision for the firture” (,Doherty, 1995, p. 279). Physical and mental health professionals share a biopsychosocial vision of shared services, systems 20 and treatment plans. Mutual conscious efl‘ort is made to attend to professional relationship issues such as balance of power and influence based upon professional expertise. Level 5 is similar to the co-therapy type of collaboration initiated by Hepworth and Jackson (1985). Doherty (1995) acknowledges this level as rare in actual practice, but providing a goal for future collaborators. Doherty’s levels of collaboration provided much need expansion into the complex relationship of collaborative healthcare. These groundbreaking levels of collaboration remain one of the most predominant collaborative models in the field of collaborative healthcare. Doherty’s levels of collaboration were the foundation for the most recent and thoroughly developed model of collaboration to date, described below. The relationship components that Doherty identifies as key include: physical location, physical Ecilities, communication patterns, professional culture, paradigm, and attention to the professional relationship. The most recent model, Collaborative Health Care, is based upon Doherty’s key components (Seaburn et aL, 1996). WWW One of the rrrost visible and published groups that work collaboratively in mental/physical health care is the Rochester group, located at the University of Rochester, New York. This group published a text “Models of Collaboration; A Guide for Mental Health Professionals Working with Health Care Practitioners” (Seaburn et al., 1996) that reveals their comprehensive model of collaboration. The breadth and depth of collaborative relationships is presented similar to Doherty’s (1995) levels with significant additional Ectors relevant to collaborating. Seaburn et aL (1996) firrther 21 define health care professionals and include patient/Emily into their definition of collaboration. Relevant to this study, the text also includes the “best current thinking” (Seabtn'n, et al., 1996, p. 92) elucidating what this group considers to be the core components of a collaborative relationship. This text reviews much of the existing literatme and identifies six core components of a successful collaborative relationship. The components are communication, common purpose, paradigm, relationship, location of services, and business arrangement, see Figure l (Seabm'n, et al., 1996). The following are summaries of the ingredients of these components with breakdowns according to areas of emphasis. 0 W191}. Understanding of cultural norms regarding rules for and forms of communication (e.g. mode, fiequency, confidentiality, language, content) Mode: the method for commtmication (phone calls, e-mail, letters, Ece- to-Ece meetings) Frequency: how often Therapist and Health Care Professional communicate regarding patient care Confidentialion clarified understanding of professionally dictated code of ethics around confidentiality Language: degree of shared jargon/language; breakdown of communication/lack of understanding Content: development of an understanding regarding what inforrmtion will be shared 0 W Professionals unite around comnron goal; at the heart of collaboration is the desire or need to solve a problem, create or discover something; short term goals may differ, however each contributes to overarching collaboration goal 0 Paradigm, Respective paradigm may not be shared, however cannot be mutually exclusive; may evolve or shift as time passes (biomedical/psychosocial to biopsychosocial) 22 .. N Oh 3 “5% Ra; _ as: 4 as: .3 8:98.. 38838 28 Lo Sfifiaz. .Vz 1.8? 302 .325 33m :eozfionazoo me £302.. 333 E 8 538m 3 vommsommu me move“: cofionoom. we Eaten“: mEoeoqeg v.50... 39:20:“ wow—:50 tease... sens? La 03.2.2.3. £658.59 ounce—EU SEE—om Erase—.5. a 2:5... 2.8.80. 3:2...— .=5 ate-=32... Bumps—am €8-93: Eek. Lobe—mam .3535... 33833— 5 Emma Scotti—m EEC-5 Bake—mam 832—0? 325:2. 09—2—0 "2.30 an: mono—58m; Engage—95G; we bee—E... :eEEeU wanna—=5... tiasg was; @Ewggwe—om Eammgeg $3558 55.32358 gas 3 5:83 3:82.58 28 fl Emmanm—Eoognoxmanw A _ Ammmmanm—Efigoaoxmaomm _ image 920855 Egan Ea owflbflz 28 FEES .33: .3853. 2: "28 5.8... 25232.8 an PEEK 23 0 Relationship, Basic relationship issues are relevant to collaboration. Specifically included are trust and mutual respect. The relationship is developmental in nature and individuals also value interpersonal processes. Developmental: building trust as relationship matures, increased personal communication Value Interpersonal Processes: professionals place value on the process of interaction with others Mutual Respect: respect validity of each participant’s perspective; value each participant’s expertise o W. geographic location of providers; close proximity enhances collaboration. Three models are proposed: Separate - separate locations, separate systems (oflice, charts, stafl‘, etc.) Together-but-Separate: shared location, separate systems Together: shared location, shared systems 0 WW Recognition of the financial arrangement is relevant as issues of hierarchy and power can impact a collaboration. Three types of business arrangements are suggested: Employer/Employee: includes one individual employed by another; hierarchy is often traditional and potentially impedes collaborative process; this situation is also rare Parallel: professionals have separate Ecilities and have parallel financial arrangements; currently the most common arrangement, expected to change as managed health care continues to evolve Colleague: professionals are part of a larger managed care system; financial differences may exist, however mismatch of power is not present as with employer/employee Seabtn'n et a1. (1996) suggest the aforementioned as key aspects ofa collaborative relationship. It is important to note that these are derived from their collective experiences and have not been validated through research. Seaburn et a1. (1996) call for fmtherresearchinthisarea. 24 I] . l E . 1 I I l 1 Several models and frameworks contribute to the integrated theory of collaboration for this research. The ecological and biopsychosocial perspectives serve as background theories. The theory of collaboration used in this study is partially based on aspects of negotiated order theory (Gray, 1989). All three theories, human ecology, biopsychosocial, and collaboration are integrated into the overall theoretical model guiding this project. These theories, as applied to collaborative health care, are reviewed in this section. Finally, an overview of the conceptualization of this project concludes this section. WW Several of the basic premises of the human ecology theory provide a background or macro theory of this project. Human Ecology theory (Buboltz & Sontag, 1993) looks at humans as biological as well as social beings in constant interaction with the environment; humans as a product of their environment and heredity. Early development of ecology theory recognized the importance of holistic and interdisciplimry approaches that linked science and theory to practice and the improvement of human lives (Buboltz & Sontag, 1993). Present day ecology brings with it an expansion of the scope of environment to include broader systems, such as health care (Buboltz & Sontag, 1993). Edgar Auserwald (1968) stated “Rather than starting with the perspective of separate disciplines or service agencies, an ecological perspective starts with the whole; thus it has the potential to avoid fiagmentation of knowledge, service, and support” (p. 424). 25 The collaborative health care movement emphasizes several points congruent with human ecology theory. Collaborative health care is based upon the premise that individuals are products of both physiological as well as psychological traits, or a biopsychosocial approach (see below for further discussion of the biopsychosocial model). As an interdisciplinary approach, collaborative healthcare strives to bring together members of the physical and mental health care professions both in theory as well as in practice. Finally, a key aspect of human ecology theory is the interaction between individual and environment; physical, social and cultural environment. This paradigm is congruent with the philosophy of both marriage and Emily therapy and Emily practice. It is no coincidence that the majority of providers who practice collaborative health care operate within these professions. Several Ectors influence our present day understanding of health and well being. These Ectors include human ecosystems theory, interdisciplinary approaches to problem solving and the evolved understanding of the interaction between individual and environment. The interplay of these Ectors is further articulated by George Engel in the biopsychosocial approach to healthcare. Bicpmhcscsialmdel The biopsychosocial model, first formalized by Engel in 1977, demonstrates the initial steps towards an integration of the mind/body paradigms. The biomedical model has been defined as ”a model of the workings of natural phenomena" and the biopsychosocial model as "a blueprint for how to think about natural phenomena" (Blount & Bayona, 1994, p. 174). It was originally thought that disease or physical 26 3.". -O i: ‘ . L "J /.; I, illness had only a biomedical root with molecular biology as its basic discipline. This perspeaiveassunwsmmflhmssarflwelhesscanbemrpactedpfimafilybynwdicafly treating deviations from the biological norm. This perspective does not allow for the impact of psychological, social or behavioral dimensions on physical well being. Engel (1977) in his groundbreaking paper, proposed a new paradigm; a new way of looking at physical wellness: “To provide a basis for tmderstanding the determinants of disease and arriving at rational treatments and patterns of health care, a medical model must also take into account the patient, the social context in which (the individual) lives, and the complementary system devised by society to deal with the disruptive effects of illness” (p. 132). Engel called this new medical perspective ‘biopsychosocial.’ The theory of human ecology and the biopsychosocial model provide broad background theories that contribute to present day attention to professional emphasis on pooling resources to manage increasingly diflicult problems, or collaborating. WW Collaboration, or the coming together of organizations or systems to address and/or resolve a problem, is a workable application of a dimension of an ecological perspective to explain human behavior. As the professional arenas in our society struggle with issues such as economic and technical change, declining productivity growth, increasing competitive pressures, and shrinking federal revenues for social problem (Sharfinan, Gray, & Yan, 1991), the notion of collaboration is becoming very popular. Research on this phenomenon, however, is in its infancy. The notion of collaboration has been investigated in many fields, including education, business, and 27 within the medical profession. One of the most recent developments in research and literature that transcends any one profession is attention to collaborative relationships. Collaboration is being examined and viewed as applicable to a wide variety of professions (Fishbaugh, 1997; Friend & Cook, 1992; Gray, 1989; Schrage, 1990; and Schrage, 1995). Barbara Gray (1989) has done some of the most notable research on the process of collaborating. Gray addresses the notion of collaboration in its broadest sense as applicable to many difl‘erent professional arenas in her book Collaborating (1989). In addition, Warren Bennis (1997) in his book discusses the “secrets of creative collaboration” primarily in business/management fields. Finally, Michael Schrage in his first book W (1990), (revised as W (1996)) also examines the collaborative process as applied to business/management environments. Some scholarly works recount the process of developing a collaborative relationship (Medalie & Cole- Kelly, 1993; Hepworth & Jackson, 1985). Some scholars speaks to the process of working collaboratively (Muchnick, Davis, Getzinger, Rosenberg, & Weiss, 1993). Some other work recognizes the need for developing a collaborative relationship (Blount & Bayona, 1994; McDaniel, 1995). Most of this work is individual and anecdotal with on-site descriptions. Individuals in healthcare and other professions are making more collaborative efforts yet an understanding and evaluation of this phenomenon remains unexplored. 28 |'/. C21 07; 5 (at all?” WW Several authors, with specialities ranging fiom organizational behavior to health care, have attempted to develop a full conceptualization of collaboration. Gray (1989) made one of the first attempts at developing a theory of collaboration, based upon the theory of negotiated order. Negotiated order theory examines the process by which individuals in organizations determine how things are accomplished (Day & Day 1977). Strauss, Scatzman, Bucher, Ehrlich, and Sabshin (1963) explored the relationship between doctors and nurses working in a psychiatric hospital setting. They found that many individuals did not adhere to company policies and manuals (rational bureaucratic theory), nor did they adhere to simply adhere to the writings of their individual professions (theory of individual professions). Rather “an informal structure emerges in which the involved parties develop tacit agreement and unoflicial arrangements that enable them to carry out their work” (Strauss et al., 1963, p. 130). These informal negotiations often supercede the formal structure of the organization. Day and Day (1977) firrther address the notions of negotiated order theory. In organizations individuals bring with them many difl‘erent aspects of themselves, including- but not limited to— training, professional socialization, experience, and personal backgrounds. Negotiated order was found to be a means of bringing together these differences to enable individuals to work together and resolve conflict- via informal, or negotiated, means. 29 relatiorsh ubmnt a well as Colt-Kali; In Heretics! cam: cohbonii [“35 lmo mml‘hen GE} and I 5,311: r, M illt‘llld‘x (MOMMOM shared m 19: lit-00d and . This 2" ilit iti'] ‘ l. Negotiated order theory furthers the understanding of the collaborative relationship between MFT’S and HCP’S. Much of the literature suggests that collaborative relationships are both a formally and an informally negotiated relationship as well as far from permanent arrangements (Hepworth & Jackson, 1985; Medalie & Cole-Kelly, 1993; Seaburn, et al., 1996). Wan In the development of a theory of collaboration, Gray states that “no single theoretical perspective provides an adequate foundation for a general theory of collaboration” (Gray & Wood, 1991 p. 3). In 1991, Gray and associates explored collaboration to develop “a deeper, nrore systematic understanding of the theoretical issues involved in forming and maintaining collaborative alliances” (p. 4). A comprehensive review of case research and theoretical analysis to date is provided by Gray and Wood (1991) in their paper in the special issue ofthe W W on collaborative alliances. The result is a definition of collaboration that includes suggested core components: “Collaboration occurs when a group of autonomous stakeholders of a problem domain engage in an interactive process, using shared rules, norms, and structure, to act or decide on issues related to that domain ” (Wood and Gray, 1991 p. 146). This broad definition of collaboration includes several components (see Figure 2). The following are summaries of these concepts (Wood & Gray, 1991). 30 >..u..mv 1:: :33; *——nv._~—w--Avh~:-avrVi~Av \IILAVLJ~\.~ < MN Qihzufir‘ 93a .52 4 ea: 3 Reese boos Sfisfiaoe Sega. .879: E R. 883 save < .«e 3:58. dens—Baas me .082: 03330588 a @333. .233 .35 a. ace? E @8383 8 been“ 5:823:00... tease Ba 0296 .88 85 80595 3888 m5 9:296 n"Edges... 83:33.8 889E «Sumac ES... .385 m a a gem “Seamfimfiw 8% 33. a sage sea emu-mmfi as Smfie ease... . .83 «on 9 mm mafia—Ugh mg 58 8—3.: . . w =<§ a 8% «8—595 5 av .8 Seuss... age.» a .295. BEE o 5:6... 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Esmeofitwceflom o>tfionm=oo me 35:85 a. a s. aaofixsm v 522235 ”.255th eosficoto 52:09 52:5 30 Es e83 203832—00 me @022. < "N «Earn 31 0 Stakeholders: groups or organizations with an interest in the problem domain both may have common or difl'ering interests in beginning, however they may evolve or be redefined as time, and the life of the collaboration, pass - Autonomy stakeholders retain their autonomous, independent decision making capabilities - Interactive: a process; change-oriented relationship; all participants take part in the change - WW: can be implied in collaboration; usually, however stakeholders explicitly agree in rules and norms that govern interactions; shared structures; evolving 0 Wu. participants intend to act or decide, as a collaboration is directed toward an objective 0 W participants orient processes, decision, and actions toward issues relating to the problem area that brought them together These components will provide the structure and foundation for measuring and evaluating the collaborative relationship between health care professionals and marriage and family therapists. These components will be integrated with terms relevant to the health care setting using collaborative health care literature. The identification of this theory is central to being able to operationalize a study of collaborative relationships. The components provided in the collaboration literature, although not empirically based, are similar in nature to those suggested in the collaborative health care literature. This facilitates a smoother translation fi'om broad, organizational terminology into relevant health care terminology. 32 The conceptualization of this study includes a background of both human ecology and biopsychosocial theory. The prominent, or foreground, theories for this study are a negotiated order based Theory of Collaboration put forth by Wood and Gray (1991) integrated with the Collaborative Health Care model put forth by Seaburn et a1. (1996). Collaborative theory (Wood & Gray 1991) subsumes the core components of the collaborative health care model (Seaburn et al., 1996). The core components used in this study are: 0 Stakeholder - Professional Autonomy - Interactive Process 0 Shared Rules, Norms, and Structure . Action or Decision 0 Domain Orientation The following section provides definitions for this study of the integrated core components and breaks the components down fiu'ther into sub-components. An illustration of these components can be found on the conceptual map (Figure 3). 1' 1116" EC [2 E 1.51 0 Core Component: Stakeholder: The extent to which individuals have a stake in the patient care issues. Sub-components: 1. Stake: Groups or organizations with an interest (stake) in the problem domain 2. 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Relationship that develops: -deveIopmental: building trust as relationship matures, increased personal communication (see communication: professional) -communication content: professional relationship begins with initial self disclosure (prirmrily indirect and through discussion of cases); discussion turns more often toward what is going on with the providers Core Component: Professional Autonomy: The skills and knowledge related to maintaining professional autonomy within the relationship. Sub-Components: 1. WW: Stakeholders retain their autonomy 2. ElengHieramhy - Differential sharing of power, fluid hierarchy; patient focus: professional with most expertise given the situation exerts most influence professional focus: professional arrangement; one is employee of another, versus shared, equal power Core Component: Interactive Page“ The skills and knowledge related to the interaction between professionals. Sub-Components: 1.9hangeQfiemafiQn; Relationship exists as participants intend to engage in some change 2. Wm: Professionals place value on the process of mteraction with others 3. Relationship Mutual Respect. respect validity of each participants perspective; value each participants expertise 4. WW5; Process of negotiating a variety of perspectives Core Component: mm: The extent to which individuals understand cultural rules and norms and the structure of the collaboration. Sub-Components: l. Explicitflmpligit: Can be explicit or implicit; usually explicitly agree on rules and norms that govern their behavior Structure is usually temporary and evolving 35 2. W: Understanding of cultural norms regarding rules for and forms of communication (e. g. mode, fi'equency, confidentiality, language, content - patient focus) Mode: the method for communication (phone calls, e-mail, letters, face-to-face meetings) Frequency: how often Therapist and Health Care Professional communicate regarding patient care Confidentialioz: clarified understanding of professionally dictated code of ethics around confidentiality Language: degree of shared jargon/language; breakdown of communication/lack of understanding Content- panent focus developed norm for communicating about individual patients’ care; communication includes conversation regarding professional relationship dynamics 3. W: Therapist and Health care professional provide services together or apart; separate services to joint comprehensive care 4. W: Geographic location of providers 5. W: Shared facilities (charts, support staff) Core Component: Action or Deck ion: The extent to which professionals intent to act or decide Sub-component l. W: process of collaboration is engaged in with the intent of resulting in an action or decision Core Component: Domain Qriengtign: Actions and decisions are oriented toward the patient’s health care. Sub-Components: 1. W: Participants orient processes, decisions, and actions toward issues relating to the problem area that brought them together 2. W Professionals unite around common goal; short term goals may difler, however each contributes to overarching collaboration goal 36 O 3! dc EV m 31E ., k DEX sem- These are the components suggested throughout the healthcare and organizational behavior literature (Seaburn, et al., 1996, Wood & Gray, 1991) as facilitating a successful collaborative relationship between health care professionals and marriage and family therapists. It has been suggested that “explorations of possible answers (to what the core components are) through experimentation with rigorous designs, both qualitative and quantitative, need to continue” (Seabm'n, et al ., 1996, p. 92). This project will examine each of these collaborative relationship components. Experts practicing in the field of collaborative health care will evaluate a collaborative inventory that itemizes each of the above components and sub-components. It is through feedback fiom practicing experts that the final product will emerge. As this is a new field with many individuals in collaborative practice but little existing research, the most appropriate methods for further examination into the core components are the Survey and Delphi methodologies. Literature discussing these methodologies is presented in the next section. UMWWMMQW A review of the methodologies appropriate for this project is included in this section. The primary method of research is the Delphi Technique. The Delphi Technique involves obtaining a consensus of opinions about a topic fi'om experts in the field (Stone Fish & Busby, 1996). the technique involves surveying panelists to obtain the consensus, a brief review of survey methodology is included. 37 The following is a discussion of both Survey research and Delphi research methodologies. Each topic address such issues as a general overview, historical roots, research questions appropriate, validity and reliability issues, and strengths/wealmesses of the methodology. Finally, the appropriateness of fit with this particular project will be included throughout the discussion. As this project primarily uses the Delphi methodology, a more developed discussion of this methodology will be provided. WW. Warwick and Lininger (1975) define survey as “a method of collecting information about a human population in which direct contact is made with the units of the study (individuals, organizations, communities, etc.) through such systematic means as questionnaires and interview schedules” (p. 2). Survey research is a method of collecting data from or about a group of peOple, asking questions for the purpose of generalizing to a population represented by the group or sample. The sample is a subset of a population thought to represent the population. The variables for survey research are those areas of interest to the researcher. The questionnaire or survey is a list of questions that are given to individuals in the sample. Warwick and Lininger (1975) noted that survey research is the most appropriate and usefirl methodology under the following three conditions: 38 1. When the data that are necessary to meet for the project objective is quantitative 2. When information is reasonably specific and familiar to respondents 3. When the researcher has considerable knowledge regarding the t0pic of interest and potential responses from participants Babbie (1983) stated that survey research is probably the best method available to the social scientist interested in collecting data on a population too large to observe directly. Further, survey instruments provide mechanisms for additional data analyses later on (Babbie, 1983). In the case of this project, the inventory is created with the intention of further development into a survey instrument for use in firture research projects. HistgdgaLmQts. Survey research is one of the oldest and most commonly used methods of research known. The 1930's and 1940's saw the beginning of survey research and sampling in the social sciences (Warwick & Lininger, 1975). Early scientist Rensis Likert was one of the individuals pioneering survey research into areas such as individuals’ attitudes, beliefs, and behaviors (Likert, 1932). Likert is the scientist who originated the Likert scale so commonly used in research today. Wm. Research questions appropriate for survey research include inquiring about characteristics or descriptions of a certain population as well as questions related to behavior, beliefs, influences on behaviors or beliefs, attitudes, values, and/or the relationship between the variables. This project will inquire into opinions regarding influences on collaborative behavior. Survey research can move 39 to a higher level of investigation. Ofien when modes of inquiry are complex, a survey can be coupled with additional surveys or research methods to draw inferences or additional information. As this project’s objectives include an examination of the complex relationship between two professionals, a sophisticated survey style, the Delphi Technique, was implemented. W. A discussion of reliability and validity issues is warranted with the survey methodology. Kerlinger (1996) recommends using statistical means to determine survey data’s reliability. This project used statistical methods appropriate with the Delphi Technique (see Chapter 3 for a further discussion of the data analyses). Methods for enhancing reliability include clear, unambiguous questions and a good number of questions for all sub-sets of the questionnaire. The most significant factor regarding validity is that the questions are asking what the researcher is attempting to learn about (face validity). As mentioned, unambiguous, clear questions can impact this. Finally, response rates affect validity. The presence of systematic bias affecting which individuals do not respond, as well as individual factors among respondents such as mood, time of day, and so forth can impact the responses received. W The greatest strength of survey research is the ability to gather large amounts of data fiom a large population (Nelson, 1996). Survey research, however, has significant weaknesses. The most significant weakness is that through each step of the process, error can be made thus resulting in invalid data. Researchers must cautiously and carefully conduct survey research. In addition, survey research is diflicult to replicate, as there are many unknowns. Finally, survey research 40 ofien yields a good amount of data regarding statistical information, descriptions, distribution, and so forth, however, it is often up to the researcher, and/or reader to assign meaning to the findings. This is a significant area to proceed into with caution. DelphiMethadaler The Delphi method is an opportunity to obtain the opinions and/or thoughts of individuals considered experts in a particular field (StoneFish & Busby, 1996). The Delphi method takes surveying to a higher level. This is done by not only surveying for opinions, but then sharing responses in a recursive manner, until hopefully some consensus is reached among the experts. The process involves providing a forum of communication where experts respond with their opinion and/or knowledge regarding the topic of interest. The panelists are then provided feedback from other panelists, anonymously, and given an opportrmity to adjust their viewpoints. The goal is to come to a group consensus regarding the topic of inquiry. W The primary assumption of the Delphi method is that “n heads are better than one” (Dalkey, 1972). This is evident in the distinction between basic surveys and the Delphi method. This process allows for more interaction and, ideally a consensus, whereas a survey of opinions might result in individual thoughts without the richness of the reciprocal process. The second assumption of the Delphi method is that of a greater concern with “the application of useful knowledge than with the attempt to define the truth” 41 (StoneFish & Busby, p. 470). This is the perspective that the Delphi method takes on the positivist versus post positivist argument. The Delphi method recognizes the changing realities as panelists adjust their thoughts, opinions, or realities, throughout the process, however is primarily interested in providing knowledge that is useable rather thantaking astance onthe issue. 11mm The Delphi method has a rich and interesting history. Initially, the word Delphi was taken from the name of the site of the famous Greek oracle and is rich with Greek mythology. Initially intended to predict the future, the Delphi method was used for either research in horse racing (Quade, 1967) or defense and military issues (Dalkey & Hemler, 1963). More recently, the Delphi method has been used in a variety of fields, including health, enviromnent, education, and transportation. The Delphi method has also been used throughout the social sciences including psychology, sociology and political science. The Delphi method began emerging in the field of family therapy in the early 1980's, yet very little research has been conducted utilizing this method. In fact, StoneFish and Busby (1996) suggest as few as five separate studies in MFT have implemented the Delphi method for research. The level of interest in the methodology is increasing, as evidenced by a resurgence of projects currently underway (Bischofl; in progress, Mamalakis, in progress). Researchguestignslpnmses; The Delphi method is useful for questions that can be addressed by obtaining a consensus of opinions from experts in the field. As the collaborative healthcare is a field wrought with unanswered questions and unchartered 42 waters, the Delphi provides a natural fit. The Delphi method can also be useful in developing policies or regulation in a new field or with relatively new phenomena (StoneFish & Busby, 1996). Finally, the Delphi method can often simplify or bring to consensus those thoughts or opinions that are somewhat scattered throughout the literature, so as to make them more user friendly for the readers. A review of these aforementioned purposes of the Delphi Technique suggest a fit with firrther research into the field of collaborative healthcare. WSampflng fortheDelphimethodisprimarilybaseduponthe individuals’ expertise in the area of interest. Individual expertise is the best method of obtaining a quality outcome with the Delphi Technique (Dalkey, 1972). Randomly selecting individuals as panelists is therefore not the ideal process. Criteria that the researcher utilizes to identify experts can vary. Some criteria may include publications, clinical experience, teaching experience, national convention participation, and/or degrees earned. It is up to the researcher to identify methods for identifying erqaerts for the panel. Obtaining demographic information regarding panelists may be useful for future reference. W191]. The collection of data for the Delphi method generally consists of a questionnaire with approximately two to three rormds. Questionnaires are sent out several times (often about three), first for initial responses and thereafter for changes and/or alterations based upon others panelists’ responses. Hemler (1976) descn’bes the following steps in collecting data. First, the researchers inquire of the panelists and 43 allow expression of thoughts ideas and/or information regarding the subject. Second, the researchers pull together the information so as to get an image of how the group views the topic. The third phase involves any differing opinions expressed by the individual panelists; (this is the phase where panelists receive anonymous information received by the research team and are given opportunities to adjust their own responses). The final phase involves the gathering of general consensus, this occurs after the team receives final revisions of responses from the panelists. This project will include two mailings of the inventory, one for general response and feedback, the second a feedback of initial responses to panelists for re-response. Traditional means of assessing reliability and validity are diflicult to apply to the Delphi method. Specifically, the test- retest reliability measure could possibly be reconstructed with the same panelists regarding the same topic, however it is unlikely that, if the panelists took time to participate, they will be very tolerant of participating again, for testing reliability (StoneFish & Busby, 1996). Validity is directly related to the selection of the panelists. ItishnpoflMtocarefifllysebctthepanefistsusmgclearlyspecifiedcrheria. Asitis expert opinions that are being sought, the individuals answering the questionnaires have often thought a great deal on the subject and can include information in the open ended questions that do not really address the topic at hand. a . Strengths of the Delphi model include its usefulness for new, unexplored areas, and for developing a consensus among a panel of experts. “Anonymity in the Delphi technique reduces the effect of dominant individuals, controlled feedback reduces irrelevant communication, and the use of statistical procedures reduces group pressure for conformity” (Dalkey, 1972). These are often considered drawbacks of traditional pooling of opinions. Several potential weaknesses do exist. One potential weakness is that panelists, repeatedly asked questions, may tend to provide answers that move closer and closer to the mean. Stone Fish and Busby (1996) recommend providing the panelists information regarding the mean only on the last questionnaire. A second potential weakness is tlmt diversity may be sacrificed to the desired outcome of consensus. A third potential weakness may be thatasthepanelistsareexpertsinsomearea,theirtimeisprobablyindemandandthe questionnaires for the Delphi project may be quite lengthy. The required time commitment can be a potential problem. Fourth, consensus may be difficult to obtain as the panelists are experts within their respective field, and have often developed very specialized, narrow perspectives. Finally, as the goal is to reach a consensus, the categories may be broadened so that all parties agree, however the categories are so broad that the information is useless. 45 Mien. Chapter two has reviewed the relevant literature exploring the evolution of collaborative health care. The literature review included the integration of mental and physical health, empirical studies, the most current Collaborative Healthcare model, a discussion of human ecology theory, biopsychosocial model, and the theory of collaboration, the conceptual model for this study, and concluded with a review of the literature on Delphi research methodology. The new model ofhealth care is ‘collaborative health care.’ It stands to reason that the exploration of the collaborative relationship would be crucial to the successful marriage of the mental and physical health care fields, yet minimal research examining this particular relationship Ins been conducted. Gray and Wood (1991) suggest specific elements of a successful collaborative relationship. Seaburn et a]. (1996) aid us in translating these broad concepts into terminology applicable to the health care field. Missing fi'om the literature is an identification of specific collaborative components, sub- components and operationalized statements and an empirical validation of their significance. This study will address this missing dimension. Chapter three will delineate the research methodology specific to this study. 46 CHAPTER 3 Methodology The purpose of this study is to verify the levels of importance of components in a collaborative relationship of an MFT with an HCP as perceived by practicing experts. This chapter introduces the methodology used to fulfill the purpose by including a reiteration of the project objectives, related research questions, the research design, including the four phases of the methodology, sample, and the data collection and analysis procedures. Images in this dissertation are presented in color. Q] . . The following are the objectives of this study: 1. To identify core components needed for MFI‘s to work collaboratively with HCPs. 2. To validate by obtaining consensus of MFT practitioners working in collaborative practice (Delphi procedure) those components that are VERY IMPORTANT and IMPORTANT for collaborative work. 3. To identify demographic factors associated with the reported significance of components. 4. To propose a Collaboration Inventory (CI) to use in the future to evaluate collaborative practice. The following research questions were generated fiom these objectives. This study is guided by research questions rather than hypotheses. This is due to two reasons: one, the nature of this study is exploratory. Secondly, the data analysis is primarily descriptive. Research questions are presented in the order of the objectives. Operational definitions that apply to each research question follow by section. 47 Ct ' #-12 Caflalxzratiyefiommmnts (Objectives 1 and 2) 1. What are the VERY IMPORTANT components of a collaborative relationship of an MFT with an HCP? 2. What is the degree of consensus regarding VERY IMPORTANT components of collaborative practice? 3. What are the IMPORTANT components of a collaborative relationship of an MFT with an HCP? 4. What is the degree of consensus regarding IMPORTANT components of collaborative practice? QallaharativeSulLQQmmnents (Objectives 1 and 2) 5. What are the VERY IMPORTANT sub-components of a collaborative relationship of an MFT with an HCP? 6. What is the degree of consensus regarding VERY IMPORTANT su b- components of collaborative practice? 7. What are the IMPORTANT sub-components ofa collaborative relationship of an MFT with an HCP? 8. What is the degree of consensus regarding IMPORTANT sub-components of collaborative practice? Qaflaharatixeltems (Objectives 1 and 2) 9. What are the VERY IMPORTANT items of core components of a collaborative relationship of an MFT with an HCP? 10. What is the degree of consensus regarding VERY IMPORTANT items of core components of collaborative practice? 11. What are the IMPORTANT items of core components of a collaborative relationship of an MFT with an HCP? 12. What is the degree of consensus regarding IMPORTANT items of core components of collaborative practice? 48 D . ”15.. For the purposes of this study, VERY IMPORTANT will be the median score of questions identified by panelists as essential or absolutely essential (3.5 - 5). The numbers indicate a ranking on the response scale in the Collaboration Inventory. For the purposes of this study, IMPORTANT will be those questions identified by panelists as somewhat or minimally essential (1.5 -3.4). The numbers indicate a ranking on the response scale in the Collaboration Inventory. For the purposes of this study, consensus will be defined as the extent panelists concur in their ranking per inventory question Consensus will be measured using Leik’s formula for Ordinal consensus ranging from a score of 0 (no consensus or 0%) to 1 (perfect or 100% consensus). Consensus will be reported in this study as degree of consensus or a percentage range of consensus. Ranges will be broken down into three groups: less than 50% commence (< 50%), between 50 and 74% commence (50 - 74%), and greater than or equal to 75% commence (>75%) per inventory question. Researchfluesticnailfli W (Objective 3) 13. What demographic factors are associated with the ranking of VERY IMPORTANT and IMPORTANT components? 14. What demographic factors are associated with the ranking of VERY IMPORTANT and IMPORTANT sub-components? 15. What demographic factors are associated with the ranking of VERY IMPORTANT and IMPORTANT items of core components? W: The demographic variables that describe the panelists are identified in the following four categories: 1. Gender: 3. Current Employment Setting: 1 = Female 1 = Academic setting 2 = Male 2 = Clinical, inpatient 3 = Clinical, outpatient 2. him Work Fumtion: 1 = Physician 4. Years in Collaborative Setting: 2 = Physician Assistant 1 = 5 years and less 3=Nurse 2=6-10years 4=MarriageandFami1yTherapist 3=1l-15years 5 = Other 49 Researahflbjesfixfl Research objective 4: to propose 3 Collaboration Inventory (CI) to use in the future to evaluate collaborative practice, does not warrant any research questions. As discussed, this project will identify a list of questions based on the literature review as descriptive of a collaborative relationship (Objective 1). Following this list, confirmation of the importance of the inventory questions will be explored (Objective 2). Final analysis of the Collaboration Inventory will include a list of this inventory items or subjects more or less important to the success of a collaborative relationship. This information may then be used for firrther exploration and analysis (eg. factor analysis) in the continued development of more empirical tools for future research studies. Reseamhllesign A four-phase Delphi methodology was used to accomplish the objectives of this study and address the research questions. Each phase and the relevant objectives are described below. PM: (Objective 1: Identify components) The purpose of this phase was to identify core components of collaboration. This was accomplished by reviewing literature relevant to collaboration. Writings on collaboration included literature fiom business (Schrage, 1995), collaborative healthcare (Seaburn, et al., 1996), education (Fishbaugh, 1997), human services (Dluhy, 1990) and organizational behavior (Wood & Gray, 1991). The review of literature is described in chapter 2. The identification of the core components and breakdown of components into sub-components is fiirther discussed in chapter 2. A list of identified Core components and sub-components can be found in Appendix A. 50 Phase}: (Objective 1, 4: Develop components and inventory) The purpose of this phase of the research was to construct an inventory of core components of collaboration. This process involved developing questions exploring the various aspects of the collaborative relationship and identifying the importance of each aspect. The Collaboration Inventory consists of three parts: components, sub— components, and individual items. As developed in phase two, collaborative components address five broad categories of the relationship. On the inventory, panelists are asked to rank the importame of each component relative to the other components (rank 1-5). Collaborative sub-components are smaller categories under each of the components. The five components each have a number of sub-components, ranging in size flour for example three sub-components (for the Domain Orientation component) to ten (for the Shared Rules, Norms, and Structure component). On the inventory, panelists are again asked to rank the importame of the sub-components relative to the other sub-components within the same component (ranking ranges fi'om 1-3 for Domain Orientation sub—components to 1-10 for Shared Rules, Norms and Structure sub- components). Inventory items were then generated from the collaboration literature. Once components were broken down into sub-components, individual questions were developed regarding each sub-component inquiring about the various aspects of the sub- component. The majority of item derivation developed out of the collaborative healthcare literature. As reviewed in chapter 2, several collaborative healthcare models included various aspects relevant to the collaboration process. These difl‘ering aspects 51 were incorporated into the inventory under the appropriate sub-component as individual questions. Panelists were asked to rank the importance of each item (1-3; Very Important, Important, Not Important) to the success of the collaborative relationship. The list of items generated fi'om the review of literature is included in Appendix A. The inventory is designed with the inventory items listed first. Inventory items are the most specific questions and an inverted funnel sequeme was thought to be clearer for panelists. Headings that include the appropriate descriptive component and sub-component are provided with the items. The last section of the inventory includes the ranking questions; first, ranking of the general components followed by ranking of the individual sub-components. Finally, at the end of each section, panelists are provided space to write in any additional compomnts, sub—components or items thought absent fiom the existing inventory. This is in keeping with the Delphi methodology. Phase}: (Objective 1, 4: Pilot test the inventory) The purpose of this phase was to pilot test the instrument. A copy of the original Collaboration Inventory can be formd in Appendix B. The pilot test included three Michigan therapists practicing collaboratively who evaluated the instrument and offered suggestions for thoroughness, clarity, and specificity (breath and depth). A copy of correspondence for the pilot phase can be found in Appendix B. Pilot panelists were not included in the research sample. Several significant changes resulted fiom the pilot study. Pilot participants unanimously agreed on the following points: 52 1. Components ‘Act or Decide’ and ‘Domain Orientation’ should be collapsed into one category. 2. Additional questions, such as ‘Did this Occur?’ should proceed the ranking of Importance for clarity. 3. A 3-point scale, rather than a 5-point scale, would be clearer. Figure 4 is the final conceptual map illustrating the collapse of the previous component ‘Act or Decide’ into the ‘Domain Orientation’ component. Questions such as “Did or Did Not Occur” and “Which most accurately describes your experieme?” were added prior to the ranking questions in the inventory for clarity. The most complicated change was the shift in the scale fiom S-points to 3-points. As a result of the scale change, operational definitions had to be changed. Operational definitions could no longer be based upon a 5 point scale. In order to maintain consistency throughout the survey analysis, with scales of differing ranks (all items with 3 point scale, components with a 5 point scale and sub- components ranging from 3 levels to 10 levels), operational definitions were converted to percentage form fiom point form. Three categories (Very Important, Important, and Not Important) will be identified. In chapter four, each research question will specify the point breakdown congruent with the percentage definition. Revised Operational definitions are as follows: Pre-Pilot Study: For the purposes of this study, VERY IMPORTANT will be those questions identified by panelists as essential or absolutely essential (3.5 - 5). The numbers indicate a ranking on the response scale in the Collaboration Inventory. Post-Pilot Study: For the purposes of this study, VERY IMPORTANT will be those questions identified by panelists in the top one third (< .333) of their ranking category. 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The numbers indicate a ranking on the response scale in the Collaboration Inventory. Post-Pilot Study: For the purposes of this study, IMPORTANT will be those questions identified by panelists in the middle one third (.34 - .70) of their ranking category. The ranking categories appear on the response scale in the Collaboration Inventory. The shift to percentage allows all Components, Sub-components, and items to be analyzed on a similar scale (t0p one third = Very Important, middle one third = Important, lower one third = Not Important). A copy of the revised Collaboration Inventory (CI) can be found in Appendix C. Bhasefi: (Objective 2, 3, and 4: validate by obtaining consensus, identify demographics, and derive Collaboration Inventory) The purpose of this phase was to empirically validate the C1 by obtaining consensus of therapists working collaboratively regarding VERY IMPORTANT and IMPORTANT components on the CI revised from phase two. The Delphi methodology was used. Two rounds were used to survey therapists. A copy of correspondence with the sample and the revised CI can be found in Appendix C. Sample Panelists for a Delphi study are chosen based upon expertise rather than via a random process (Dalkey, 1969). The membership of the Collaborative Family HealthCare Coalition was chosen as an appropriate group to invite to participate in the Delphi process. The Coalition has 500 subscribed members. 55 pi I\ mi of: ”'3 dev “The Collaborative Family Healthcare Coalition, founded in 1993, is a diverse group of physicians, nurses, psychologists, social workers, family therapists, and other healthcare workers .......... .who study, implement, and advocate for the collaborative family healthcare paradigm.” (Mission Statement, CFHcC, 1993). Members of the Coalition are dedicated to the advancement of the collaborative paradigm. Additional selection criteria included: individuals who are currently, or have within the last calendar year, practiced collaboratively; physical healthcare workers; and mental healthcare specialists who identify themelves as Marriage and Family Therapists, either by training, license or primary practice. Mental Health care providers who did not claim to engage in any form ofrmrriageand familytherapywere not includedinthepanel. Thesecriteriaarein place to ensure that respondents are individuals with an interest in the further development of collaborative healthcare and its integration into MFT. W The Collaboration Inventory (CI) consists of three sections. The first section, CI-l: Background Information includes four demographic variables and two qualitative items regarding collaborative experiences. The second section, CI-2: Collaborative Experiences includes an Explanation and Definition sheet, and 99 collaboration items (ranked Very Important, Important and Not Important). The third section, CI-3: Rank Order includes two sections asking panelists to rank order the general components (rank 1-5) and sub-components (depending on the size of the sub—component, rank 1-3, 1-4, 1-5, or 1-10). The survey form is a total of 11 pages, one page is informational. A copy ofthesurveycanbefoundinAppendixC. 56 Parrl'm regardii them A Likert-type rating scale of 1 to 3 was be used to score inventory items CI-2. Panelists responded to the items based upon the following statement: “Respond regarding yom‘ most successful MFT/HCP professional collaborative relationship within the past five calendar years (1995 - 2000).” The rankings are as follows: 1 - Very Important 2 - Important 3 - Not Important A rank order scale was used to identify which of the different components and sub-components was more or less Important. Section 3 of the CI includes the rank order questions. Panelists were asked to rank order each component and sub- component based upon the total number possible. For example, for the Components: ‘Rank the following five Components in order of Importance (1-5)” and for the component Professional Autonomy (that has 3 sub-components) “Rank the following three Sub-components in order of Importance (1-3).” The inventory was sent to all members of the CFHcC, together with a cover letter requesting each eligible person to be a panelist and complete the CI. Eligibility was finally determined by including those individuals who were identified as Marriage and Family Therapists either in the CFHcC directory or self-identified. From the eligible panelists, 42 responses were returned (49%) in Round 1 and 23 responses were returned (58%) in Round 2. The Collaboration Inventory for Round 2 was similar to the CI fiom Round 1. In order to simplify and clarify for the second round, the questionnaire demographic and descriptive (Did it occur? Which most accurately describes your experience?) questions that did not require consensus along with those that did reach consensus at more than 57 75% were removed In accordance with the Delphi methodology, feedback was provided to the panelists regarding the frequency of each response. The section of the inventory with the items, CI-2 included percentage breakdowns of the frequency of responses in Round 1. Due to the complexity ofthe data gathered in CI—3, the ranking of Components and Sub-Components, bar graphs were provided to report frequency of responses from Round 1. A cover letter was included with Round 2. A sample of the cover letter and CI for Round 2 can be found in Appendix D. Follow-up e-mails were sent to the CFHcC Listserv for both rounds. Each was done approximately two weeks after the mailing of the surveys. A return postage paid envelope was included in both rounds to encourage completion of the CI. Round 1 was mailed on July 13, 2000; Round 2 was mailed on August 26, 2000 (see Table 3.1). Table 3.1. Timetable for obtainin and ana in the data. Amiga DaLe Pilot testing April 2000 Round 1 Mailed July 13, 2000 Follow-up E-xmils sent August 7, 2000 Round 1 Analyzed August 2000 Round 2 Maibd August 26, 2000 Follow-up e-mails sent September 1 1, 2000 Round 2 fl SLmber 2000 58 CL D l COR of r: indi; Com 0% c. Sud}. 5%. 90mm 51m m limb to Maia Delphi data are primarily concerned with obtaining consensus, therefore are primarily analyzed using medians and interquartile ranges (Stone Fish & Busby, 1996) or other measures of Ordinal consensus (Leik, 1966). This study utilized median scores as they are most accurate when describing ordinal data and Leik’s (1966) measure of ordinal dispersion to determine consensus. This formula allows the data to be analyzed free from limitation based upon sample size, choice options, central tendency (bell curve) and assumptions about intervals between choice options. The following formula provides an appropriate measure of ordinal consensus. 13:22.51. '1 m - 1 D is a percentage, a measure of ordinal dispersion; when subtracted fiom 1 (complete consensus) it becomes a percentage of consensus. 2 (1l equals the cumulative frequency of responses; m equals the number of options in the scale. Convergence to consensus indicates the degree to which the respondents reach unanimity on a given item. Complete consensus would be 1.0 (or 100% consensus), according to Leik, and 0 (or 0% consensus) would be complete dispersion of responses. For the purposes of this study, degree of consensus will be reported in ranges: less than 50% concurrence (< 50%), between 50 and 74% commence (50 - 74%), and greater than or equal to 75% concurrence (>75%) per inventory item. For both Round 1 and 2 Collaboration Inventories, data were entered into a survey software program. Random checking by the researcher and an assistant was done to maintain accuracy. Frequency distributions were provided to panelists in 59 Tl // 5,? Round 2 as it is a statistical measure easily understood by those reading the inventory. Medians were used to report the identified levels of importance for components, sub- components, and items. Frequency was provided to describe demographic characteristics. Chi-square tables were done to determine difference between group means on all the CI elements. Table 3.2 illustrates the statistical tools used for the data analysis. Table 3.2: Summary of Data Analysis Exploratory Variable Scale of Data Survey Items Analysis Measurement Used Feedback to Panelists Ordinal Round 1 all items Frequency Level of Importance for Ordinal Round 1 S3: 1- 5 Median, Components Frequency Level of Importance for Ordinal Round 1 S3: 6 - 30 Median, Sub - Components Frequency Level of Importance for Ordinal Round 1 $2: 1 - 50 Median, Survey Items Frequency Convergence to Ordinal Round 1 all items Leik’s Consemus and 2 Formula Describe Demographics Nominal Round 1 SI: 1, 4-7 Frequency Amociation of Nominal Round 1 SI: 1, 4-7 Chi-Square Demographic fictors on and 2 Consensus 6O cl fit I {Ch Conchsign This chapter has delineated the research methodology specific to this study. The chapter has included research objectives identified by this project and related research questions. An explanation of the Delphi procedure was presented. How the sample was recruited, how data was collected and how data was analyzed were then addressed. Chapter 4 will present the findings of the study. 61 T85 of: CHAPTER 4 Research Findings This chapter contains the results of the analysis of the responses from the panelists who participated in this study. The objectives of this study were accomplished in four phases. Phase one consisted of identifying core components of collaboration by reviewing the literature relevant to collaboration. A list of the core components and sub-components identified can be found in Appendix A. Phase two consisted of constructing an inventory of components, sub-components and items of collaboration. The list of items generated for the inventory can be found in Appendix A. Phase three consisted of pilot testing the Collaboration Inventory (CI) and making the appropriate changes as recormnended by the pilot participants. A complete discussion of results and changes can be found in chapter 3. A copy of the revised Collaboration Inventory can be fmmd in Appendix C. Phase four included the data analysis. In this chapter the research findings will be given for each research question. WW2 Table 4.1 contains a sumrnaryofthe rate ofresponse to each ofthe two rounds of survey. Table 4.1: Survey Response Rates Surveys Eligible Surveys Returned Response Rate Round 1 85 42 49% Round 2 40 23 58% 62 I'tl' .L- =t. mm Survey eligibility was determined by the sample inclusion criteria reviewed in chapter 3. Based upon insufficient response rates for HCPs, data analysis was conducted only on data for Marriage and Family Therapists. Health care professionals numbers (n=1 1) were too low for analysis. Seven panelists returned incomplete surveys with notes stating they were ineligible and were dropped fiom the eligible list. Two responses returned in Round 1 were unidentifiable as no mme or postage information allowed for identification and therefore were not re-surveyed. The demographic data which describesthecharacteristicsofthesamplewhichrespondedto Round 1 isgivenin Table 4.2. __ Dex; ' hie Summ- __ ___ Total Respondents Employment Setting” 7 MFT r HCP Academic Clinical I Inpatient I Outpatient 42 I 11 31 40 I 4 I 36 Years in Colhborative Practice* i Gender" 0 - 5 I 6—10 I ll - 15 Male I Female 1 1 13 16 W The Delphi technique was employed in two rounds. This technique encourages participative decision making by allowing input and re-evaluation on the inventory items. Round 1 included demographic and ranking questiOns. Participants were invited to contribute any additional items thought missing. No additional items were provided. As required by the methodology, response rates were provided to panelists in Round 2. 63 Due to the nature of the questions, most items could have been ranked Very Important, oratthehighendofthescale. Thisrankingcompromisestheparametric assumptions of interval and normal distributions. Therefore, non-parametric measures were used throughout the analysis. Leik’s measure of ordiml consensus was used to determine the level of consensus of each item. Since minimal change was noted in the overall ratings of the items from Round 1 to Round 2, data from Round 1 was used as the principal source of information for determining which Collaborative components, sub-components, and items were considered Very Important and/or Important. Round 1 provided the demographic informtion. Winding: Qxentim The following discussion is structured in order of the research questions. Research questions are grouped by Components, Sub-Components, and Items. Three generaltypesofquestionswerepositedthroughoutthisstudy. Thefirst isaseriesof questions regarding the ranking of each inventory question (VERY IMPORTANT and IMPORTANT). These ranking questions are Research Questions #1, 3, 5, 7, 9, and 11. The second is a series of questions regarding consensus, or the degree to which panelists agree with the respective ranking. Consensus questions are Research Questions #2, 4, 6, 8, 10, and 12. Finally, a series of questions is posed regarding demographic association with ranking and consensus. Demographic questions include Research Questions #13-15. Wong, Median scores were utilized to determine level of importance for all inventory questions. The scales used for analyzing the median scores for each inventory question vary based upon the size of the category (component, sub- component, item all have different category sizes). Scales are depicted below within each category. The VERY IMPORTANT components, sub-components and items are those questions identified by panelists within the top one third (< .33) of their ranking category. The IMPORTANT components, sub-components, and items are those questions identified by panelists in the middle third (.34 - .70) of their ranking category. mm For the purposes of this study, consensus is defined as the extent panelists concm' in their ranking per inventory question. Consensus is measured using Leik’s formula for Ordinal consensus ranging fi'om a score of 0 (no or 0% consensus) to 1 (perfect or 100% consensus). Leik’s formula provides a percentage of agreement in decimal form for each inventory question. Consensus is reported in this study as degree of consensus or a percentile range of consensus. Ranges are divided into three groups: less than 50% commence (< 50%), between 50 and 74% commence (50 - 74%), and greater than or equal to 75% concurrence (>75%) per inventory question. Coflahorafixcficmpcnems Table 4.3 summarizes findings related to Collaborative Components. Median scores for both Round 1 and Round 2 are provided. Median scores fi'om Round 1 are used to determine level of importance using the following scale: 65 Very Important: 1.00-2.33 Important: 2.34-3.67 Not Important: 3.68-5.00 Components are listed in order of score on Leiks formula of consensus, beginning with the component with the highest degree of consensus. A discussion of individual research questions and respective findings follows the table. " : 'v Collaborative Degree of Leik’s Level of R1 R2 Components Consensus formula Importance Median Median Professional > 75% range 0.805 Not 4.4 4.86 Autonomy Important Shared Rules, > 75% range .75 Important 3.33 3.06 Norms, and Structure Interactive 50-74% range 0.6385 Very 2.07 1.5 Process Important Domain 50-74% range 0.583 Very 2.04 1.93 Orientation Important Stakeholder 50—74% range 0.5555 Important 3.25 3.64 W: What are the VERY IMPORTANT components of a collaborative relationship of an MFT with an HCP? Eind'mgs: Two components were found to be Very Important. These components include: 1. Interactive Process and 2. Domain Orientation. Winn #2: What is the degree of consensus regarding VERY IMPORTANT components of collaborative practice? 66 d: Endings; Both Interactive Process and Domain Orientation reached consensus in the 50-74% range. Interactive Process reached 63.8% consensus and Domain Orientation reached 58.3% consensus. W What are the IMPORTANT components of a collaborative relationship of an MFT with an HCP? Findings: There are two components that have rmdian scores within the Important range. These components include: 1. Shared Rules, Norms, and Structure and 2. Stakeholder. Researchflnestjgmfl; What is the degree of consensus regarding IMPORTANT components of collaborative practice? Ejmfings; Shared Rules, Norms, and Structure reached 75% consensus or within the >75% range. Stakeholder reached 55.5% consensus or within the 50-74% range. W Due to the extensive nature of the information for sub-components, tables for sub-components are provided in two difierent forms. Table 4.10, provided at the end of the chapter, summarizes all of the data related to Collaborative Sub-Components. This chart is similar in structure to Table 4.3 (Collaborative Components Data, above). Table 4.10 includes median scores for both Round 1 and Round 2, level of importance determined using Round 1 medians, scores on Leik’s formula of Ordinal consensus, and degree of consensus. 67 hi Tables 4.4 and 4.5 are included within the text. These tables summarize sub- cornponcnts’ levels of importance and degrees of consensus, including scores on Leik’s formula for addressing research questions. Level of importance scales vary for each group of sub-components. Scores range from ranking 1-3 for Domain Orientation sub- components, to 1-10 for Shared Rules, Norms, and Structure sub-components. For analysis, all scales are then divided into thirds to determine the levels of importance. The breakdown of the individual scales is provided on Table 4.10, at the end of the chapter. Sub-Components are listed in order of the level of consensus achieved and are listed with their Collaborative Component heading. Respective Sub-Components ranked Degree of Leik’s Component Very Important Consensus Formula Domain Orientation Common Purpose > 75% range 0.952 Autonomy Hierarchy regarding patient >75% range 0.9 care _ _____ Interactive process Mutual Respect > 75% range 0.8195 Shared Rules, Commrmication frequency > 75% range 0.7502 Norms and Strnture , , Communication content 50-74% range 0.7222 Communication language 50—74% range 0.542 Stakeholder Stake < 50% range 0.474 Total 7 of 25 (28%) W What are the VERY IMPORTANT sub-components of a collaborative relationship of an MFT with an HCP? 68 Eindims; A total of seven of the possible 25 sub-components (28%) ranked within the Very Important range. Table 4.4 lists the sub—components that ranked within the Very Important range. Table 4.10 includes median scores and scale ranges for each sub-component. Reseamhflnestionfi 6: What is the degree of consensus regarding VERY IMPORTANT su b—com ponents of collaborative practice? Bindings; There are four sub—components ranking as Very Important that reached consensus in the >75% range; Common Purpose reached 95.2% consensus, Hierarchy Regarding Patient Care reached 90% consensus, Mutual Respect reached 82% consensu,; and Communication Frequency reached 75% consensus. Two sub- components ranking as Very Important reached a consensus in the 50-74% range. Communication Content reached 72.2% consensus and Communication Language reached 54.2% consensus. One sub—component Location of Services ranking Very Important, did not reach consensus of 50%. It reached only a 26.4% consensus. 69 Respective Component Sub-Component Degree of Leik’s ranked Important Consensus formula ‘- ‘t' 3 Domain Orientation Orientation 50-74% range 0.714 _ ....... E Shared Rules, Norms and Communication mode 50-74% range 0.7084 Structure ‘ 5 Professional Autonomy Independent Decision 50-74% range 0.65 Making ‘ Interactive Process Value Interpersonal 50-74% range 0.647 - Process ‘ 5 Shared Rules, Norms and Communication 50.74% range 0.6111 Structure confidentiality ‘ Stakeholder Shift m Paradigm 50-74% range 0.5787 Interactive Process Negotiate Multiple 5074% range 0.559 Perspectives ‘ Shared Rules, Norms, and Provision of Services 50-74% range 0.5416 Structure ‘ Stakeholder E Relationship: Trust 50-74% range 0.5087 Shared Rules, Norms and Location of Services . < 50% range 0.2638 Structure Total 10 of 25 (40%) W What are the IMPORTANT sub-components of a collaborative relationship of an MFT with an HCP? Eimlings; A total of 10 sub-components fiom a possrble 25 sub-components (40%) ranked within the Important range. Table 4.5 lists the sub-components that ranked within the Important range. Table 4.10 includes median scores and scale ranges for each sub—component. 70 WES; What is the degree of consensus regarding IMPORTANT sub-components of collaborative practice? Bindings; There are nine sub-components ranking as Important that reached consensus in the 50-74% range. These include: Orientation at 71.4% consensus; Communication Mode at 70.8% consensus; Independent Decision Making at 65% consensus; Valuing Interpersonal Processes at 69.6% consensus; Communication Confidentiality at 61.1% consensus; Shifi in Paradigm at 57.9% consensus; Negotiate Multiple Perspectives at 55.9% consensus; Provision of Services at 54.2% consensus; and Relationship: Trust at 50.9% consensus. One sub-component ranking Important did not reach consensus of 50%. Location of Services reached only 26.4% consensus. Qcflahcratixeltems As with collaborative sub-components, tables for collaborative items are provided in several different forms. Table 4.11, provided at the end of the chapter, summarizes all of the findings related to Collaborative Items. This clmrt is similar in structure to Table 4.3 (Collaborative Components Data, above). Table 4.11 includes mdian scores for both Round 1 and Round 2, level of importance determined using Round 1 medians, scores on Leik’s formula of Ordinal consensus, and degree of consensus. 71 Tables 4.6 and 4.8 are included within the text. These tables summarize collaborative items’ level of importance for addressing research questions. Median scores fi'om Round 1 are used to determine level of importance using the following scale: Very Important: 1.00-1.66 Important: 1 .67-2.33 Not Important: 2.34-3.00 Tables 4.7 is also included within the text. This table sumrmrize the degree of consensus for Collaborative Items ranked both as Very Important and Important. Collaborative Items are grouped by the respective Collaborative Component heading. Due to the large number of Collaboration items reported findings of items will be limited to summary statistics. Individual Item rankings can be found on Table 4.11. W _rankedlealmportant Respective Component Items ranked Very Important Professional Autonomy 3 of 4 (75%) Shared Rules, Norms, and Structure ............ 9 of 15 (60%) museum... ....................... 5.245959% ............................ Domain Orientation ..... 3 of 4 (75%) Stakeholder 15 of 21 (71%) Total 34 of 50 (68%) 72 Degree of Number of Items Number of Items Total Items by Consensus ranked Very ranked Degree of Important Important Consensus > 75% range 11 _ _0 ll 50 - 74% range 12 _ 12 24 < 50% range 11 4 15 Total 34 16 50 W: What are the VERY IMPORTANT items of core components of a collaborative relationship of an MFT with an HCP? Eingfings; A total of 34 items from a possrble 50 items (68%) ranked within the Very Important range. Table 4.6 lists the number of items by their respective Component, that ranked within the Very Important range. Table 4.11 includes median scores and scale ranges for each item. WW Wlmt is the degree of consensus regarding VERY IMPORTANT items of core components of collaborative practice? Findings; There are eleven items ranking as Very Important that reached consensus in the >75% range. There are twelve items ranking as Very Important that reached a consensus in the 50-74% range. Eleven items ranking Very Important did not reach consensus of 50%. Table 4.11 includes Leik’s formula scores with individual consensus percentage for each item. 73 ofa that lit} Respective Component Items ranked Important Domain Orientation 1 of 4 (25%) Interactive Process 2 of 6 (33%) Stakeholder 6 of 21 (29%) Shared Rules, Norms, and Structure 6 of 15 (40%) Professional Autonomy l of 4 (25%) Total 16 of 50 (32%) WWII: What are the IMPORTANT items of core components of a collaborative relationship of an MFT with an HCP? Eimfings; A total of 16 items fiom a possible 50 items (32%) ranked within the Important range. Table 4.8 lists the number of items by their respective Component, that ranked within the Important range. Table 4.11 includes median scores for each item W What is the degree of consensus regarding IMPORTANT items of core components of collaborative practice? Findings; None ofthe items making as Important reached consensus in the >75% range. There are twelve items ranking as Important that reached consensus in the 50-74% range. Four items ranking Important did not reach consensus of 50%. Table 4.11 includes Leik’s formula scores with individual consensus percentage for each item. 74 rem off tabu com I633 cons cOns COIN COmI Dmmnhiss The demographic questions seek to determine if additional variables, such as gender or years in practice, play a significant role in how individuals rank the importance of Collaborative components, sub-components and/or items. Chi-square ( x2 ) cross tabulations were selected as the statistical approach to use used to analyze this data. In consultation with a statistical consultant, chi-square tables were selected for two reasons. First, the data in this project required non-parametric analyses, as it does not meet the assumption of normal distribution required of parametric measures. Ordinal data in this study are positively skewed. Second, Chi-square analysis was selected over analysis of variance as Chi-square analyses compare entire distributions of variables rather than the means. In the case of this survey several of the scales are three points, making comparison of means less discriminating than comparison of entire distributions. The significant value was set at p < .05. Will; Wlmt demographic factors are associated with consensus regarding VERY IMPORTANT and IMPORTANT components? W What demographic factors are associated with consensus regarding VERY IMPORTANT and IMPORTANT sub-components? WE; What demographic factors are associated with consensus regarding VERY IMPORTANT and IMPORTANT items of core components? 75 Findings: Contingency tables were developed for all of the demographic relationships with the variables (components, sub-components, and items). Due to the limited size of the sample, N = 42, contingency tables could not be completed. A basic assumption of Chi-square tables is the continuity of expected frequencies (a continuous increase/decrease in the number of expected fiequencies). When expected frequencies of any of the cells is srmll (less than 5 cases), the distribution departs fiom continuity and the distribution of the x2 poorly fits the data (Hinkle, Wiersrna, & Jurs, 1994). The recommended method addressing the problem of cells expected size < 5 is to collapse or eliminate individual rows (variables) to increase the size of the cell. This suggestion is not recommendedwiththisdataset, astherowsarelirnitedto onlytwo orthree. Due to the size of the sample, Research Questions 13 - 15 cannot be addressed. W This chapter has included the research findings to each of the research questions presented. Table 4.9 provides a summary of the results and research questions #1-4 for Collaborative Components. Table 4.10 provides a summary of the results and research questions #5-8 for Collaborative Sub-Components. 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Es. . 55.85. ro> 822$ 6 8583 once. $8 v , . was. $8 v , mumsucfl “5.3258550 9cm. $3. . on 003.2603 .wctoE. to; ._I.=2 ecu no: 232:5 u..- eenoz 60.3... tee-Em 83 CHAPTER 5 Summary and Recommendations This chapter presents the overall summary of the study, a discussion of the findings, the implications of the findings, the contribution this study has made to the field of Collaborative Healthcare, researcher observations, the limitations of this study, and recommendations for firture research. Summary A change in how our society defines health and well being has precipitated a shift in how helping professionals view themselves. Mental and physical health care workers have begun forging professional relationships in efforts to better serve individuals. Marriage and Family Therapy, as a field, embraces the notion of synergy among people: thewholeofgroupsisnnreusefillandvaluablethanthesumofthe individuals. This respect and appreciation for the impact of working with others has motivated MFTs to look beyond the scope of traditional mental health private practice. Marriage and Family Therapists have begun developing professional relationships with health care professionals. Many health care professionals have welcomed the opportunity to better serve patients with the inclusion of mental health services as part of routine care. An examination into the various aspects of this new collaborative relationship is warranted as the occurrence of such partnerships increases in number. The intention of this study was to identify the relationship components needed for marriage and family therapists (MFTs) to work collaboratively with health care professionals (HCPS). Presently, several professional writings exist illustrating the various different collaborative relationships of MFTs working with HCPs. A few studies have begun to 84 qualitatively explore this new phenomenon The present study is an attempt to move the current research in collaborative healthcare in a more quantitative direction. The following objectives were identified for this study: 1. To identify core components needed for MFTs to work collaboratively with HCPs. 2. To validate by obtaining consensus of MFT practitioners working in collaborative practice (Delphi procedure) those components that are VERY IMPORTANT and IMPORTANT for collaborative work. 3. To identify demographic factors which differentially affect the reported significance of components. 4. To propose a Collaboration Inventory (CI) for use in fiirther development of evaluative measures of collaborative practice. A four-phase methodology was used to accomplish these objectives. Phase 1 was to identify core components of the collaborative relationship. This was accomplished by reviewing literature relevant to collaboration. This review of literature is described in chapter 2. The identification of the core components and breakdown of components into sub-components is firrther discussed in chapter 2. A list of identified Core components and sub-components can be found in Appendix A. The purpose of phase 2 was to construct an inventory of core components of collaboration. This process involved developing questions exploring the various aspects of the collaborative relationship. Broad relationship components, then components further divided into sub-components, and finally individual items were generated for the inventory. Panelists were then asked to rank the importance of each aspect of the 85 collaborative relationship. A list of items generated from the review of literature is included in Appendix A. The purpose of phase 3 was to pilot test the instrument. A copy of the original Collaboration Inventory can be found in Appendix B. The pilot test included three Michigan therapists practicing collaboratively who evaluated the instrument and offered suggestions for thoroughness, clarity, and specificity (breath and depth). A few significant changes resulted from the pilot study. A copy of the revised Collaboration Inventory (CI) can be found in Appendix C. Finally, the purpose of phase 4 was to empirically validate the inventory by obtaining consensus of therapists working collaboratively regarding VERY IMPORTANT and IMPORTANT components on the CI revised from phase 3. The Delphi methodology was used. Two rounds were used to survey therapists. A copy of correspondence with the sample and the revised CI can be found in Appendix C. The inventory was sent to members of the Collaborative Family Healthcare Coalition (CFHcC), together with a cover letter requesting each eligible person participate as a panelist and complete the CI. Eligibility was finally determined by including those individuals who were identified as Marriage and Family Therapists either in the CFHcC directory or self-identified. From the eligible panelists, 42 responses were returned (49%) in Round 1 and 23 responses were returned (58%) in Round 2. The time needed for completing data collection was three months. Follow-up e-mails were distributed approximately two weeks following initial mailings. 86 Data was analyzed focusing on 15 research questions. Descriptive and nonparametric testing was used in the analysis. The primary goal of the study was to describe what collaborating experts reported. In adhering to the Delphi methodology, no attempt to generalize findings to a population was made. Depiction of levels of importance for various inventory items employed descriptive statistics. Since the nature of the scaling for level of importance did not adhere to parametric assumptions, the Leik formula was incorporated into this study to measure ordinal consensus among respondents on their response to items. Descriptive statistics were also utilized to describe the degree of consensus panelists reached regarding each inventory item Disamsion A discussion of the findings for each of the four research objectives follows. E l D] . . I To identify core components needed for MFTs to work collaboratively with HCPs. B l D] . . 2 To validate by obtaining consensus of MFT practitioners working in collaborative practice (Delphi procedure) those components tint are VERY IMPORTANT and IMPORTANT for collaborative work. Five collaborative components were identified in the literature. These broad components were derived fiom the general collaboration literature, Gray’s (1989) most recent effort at defining the process of collaboration. Collaborative healthcare literature aided in the explanation and application of these components to the healthcare field. These explanations took on the forrm of both elucidation of the components and further clarification of the categories in the form of sub-components. The following discussion 87 is in regards to objectives one and two: identification core components and validation by obtaining consensus and will examine each of the five collaborative component with the corresponding sub-components. The components will be discussed in the order of degree of consensus reached: the extent panelists agreed upon the ranking of the inventory question. The discussion will begin with the component reaching the highest level of consensus. hofessjonalAutonomy, Professional Autonomy was the components to reach the highest level of consensus at 80% agreement, and the only component ranked Not Important. This component is best understood by further examining the respective sub- components. Professional Autonomy includes the following sub-components: 1. Patient Focused Hierarchy: the professional with the most expertise given the situation exerts the most influence; 2. Relationship Focused Hierarchy: the professional or business arrangement; and 3. Independent Decision Making: professionals retain their independent decision making capabilities. Professional Autonomy ranked Not Important with a very high level of consensus: 80% of panelists agreed that this component was not important to the success of the collaborative relationship. The level of consensus for the sub—components is high relative to other sub-components. Two of the three sub- components reached consensus at a high level. Hierarchy around patient care issues ranked Very Important with 90% agreement, Hierarchy around the professioml relationship ranked Not important with 75% agreement, and Independent Decision Making ranked Important with 65% agreement. Table 5.1 represents the relevant findings of this component and corresponding sub-components. 88 Table 5.1: Professional Autonom and Sub-Com onents ——4 . Name Leik’s Degree of Level of Importance 1 Formula Consensus ‘ l Professional Autonomy 0.805 > 75% range Not Important ! Hierarchy: Patient focus 0.9 > 75% range Very Important ‘ I Hierarchy: Relationship focus 0.75 > 75% range Not Important I Indgndent Decision m 0.65 50 - 74% range Important The high level of consensus lends validity to the ranking of Not Important for this component. The high levels of consensus for the sub-components lend further validity to panelists’ agreement on this particular subject area and it’s importance to collaboration. The rankings of the sub-components corresponding to Professional Autonomy are in keeping with one of the common threads of this study. This theme defies the tenor of the predominant collaborative healthcare relationship literature. Panelists have agreed that aspects of the professional relationship, care and treatment of patients are most important, and personal aspects of the professional relationship, those aspects independent of the patient are less, or not important. Findings in this component are incongruent with the dominant literature regarding another aspect of collaborative writings. The existing literature suggests that collaborations that occur primarily around individual patients are lower, or lesser, levels of care. Current writings also suggest that as collaborative care continues, independent relationships between professionals often characterized by emphasis on professional hierarchy become increasingly more important. It is possible that collaborations between MFT and HCP that remain at the level of converging around a particular 89 patient are most effective. Further examination is needed of the assrnnption that higher levels of collaboration, including increased professional intimacy between collaborators, means better care for patients. W The largest of the components, Shared Rules, Norms, and Structure is the extent to which individuals understand cultural rules and norrm, and the structure of the professionals involved. Shared Rules, Norms, and Structure reached consensus at 75% and ranked Important. This indicates a high level of consensus regarding the level of importance of this item: 75% of panelists agreed that this component is Important relative to the other components. Shared Rules, Norms, and Structure includes ten sub-components. Only one, Communication Frequency, reached consensus at a high rate of 75%. Frequency of communication is a subject ofien addressed within the Collaborative literature; It is recognized as significant, but is perhaps not imperative, to the success of collaboration. Panelists agreed with moderate levels of consensus that Communication Content, and Language (72% and 54%, respectively), ranked Very Important. Panelists also agreed with moderate levels of consensus that Mode of Communication (71% agreement), issues of Confidentiality (61% agreement), and Provision of Services, or who is providing what services (54% agreement), are Important to the collaborative process. Finally, Sharing of Support Stafi‘ and Sharing of Records ranked Not Important with moderate levels of consensus (73% and 51%, respectively). 90 Location of Services provided ranked Important, however with only 26% agreement. Rules and Norms being explicitly stated ranked Not Important with 45% agreement. Table 5.2 represents the relevant findings of this component and corresponding sub—components. Table 5.2: Shared Rules Norms and Structure and Sub—Com onents _g Name Leik’s Degree of Level of Formula Consensus Importance Shared Rules, Norms, and 0.75 > 75% range Important Structure f Cormnunication: Frequency 0.7502 > 75% range Very Important , Shared Support Staff 0.7322 50 - 74% range Not Important Communication: Content 0.7222 50 - 74% range Very Important l Cormnunication: Mode 0.7084 50 - 74% range Important [ Communication: Confidentiality 0.6111 50 - 74% range Important . Communication: Language 0.542 50 - 74% range Very Important ‘ Provision of Services 0.5416 50 - 74% range Important [ Shared Record Keeping 0.5104 50 - 74% range Not Important [Explicit/Implicit Rules and Norms 0.4569 50 - 74% range Not Important _ ee mam __ _30-268 = :o _ Some of the most interesting findings of this study are within this component. Several of the findings are congruent with the Collaborative Healthcare literature, including Doherty’s Levels of Collaboration (1995) and the Rochester Model (Seaburn, et al., 1996). Doherty suggests that a few of the aforementioned communication sub- components are positively correlated with the level of collaboration; as communication frequency, mode, language and content increase, the extent of the collaboration increases. In this study, panelists have agreed that these sub—components are all either 91 Very Important or Important. In addition, Issues of Confidentiality, and Provision of Services are considered significant relationship ingredients within the existing literature. In this study, panelists agreed with moderate levels of consensus ( 61% and 54%) that these items are also Important. Several other sub-components within this component are also dominant themes in both Doherty’s (1995) and Seaburn et al.’s (1996) writings. A unique finding ofthis study is that Shared Support Staff ranked Not Important with a relatively high rate of consensus (73% agreement). Shared Record Keeping also ranked Not Important, yet with slightly less agreement (51%). Much of the collaborative healthcare literature encourages sharing of support staff and records, whenever possible (Bischofl‘ & Brooks, 1999). The low ranking of these sub-components may have several explanations. First, these are some of the more rare circumstances that occur in collaborative relationships between MFTs and HCPs. Panelists may not have ranked these as important as they may not occur within their respective settings. Panelists were, however, encouraged to respond to questions that had components that did occur in their individual settings. It is possible that panelists ranked these sub-components as Not Important as they did not appear to contribute to the success of the collaborative relationship. One of the more interesting findings of this component is the final sub- component ranked Not Important. Explicit/Implicit Rules and Norms, defined as the extent to which rules and norms are overtly discussed, ranked Not Important, with agreement of 46%. This finding is congruent with the theory of Negotiated Order. Day and Day ( 1977) suggest that it is the unwritten, covert rules and norms that most significantly influence behavior. The theory of Negotiated Order states that “an informal 92 structure emerges in which the involved parties develop tacit agreement and unoflicial arrangements that enable them to carry out their wor ” (Strauss et al., 1963, p. 130). Finally, Location of Services while ranking Important, was agreed upon by only 26% of panelists. This may suggest that panelists are ambiguous about the role physical location plays in the success of the collaborative relationship. Sharing physical space with HCPs is reported throughout the literature as one of the more rare circumstances. This finding may be attributed to the low rate of occurrence for this sub-component. Doherty (1995) suggests shared Location of Services is also positively correlated with higher levels of collaboration. Further investigation into this subject is warranted. mm This component, defined as the skills and knowledge related to the process of interacting between professionals, ranked Very Important with a 64% rate of consensus. One of the sub-components of Interactive Process, Mutual Respect was the only sub-component in the entire inventory to reach a high level of consensus in the first round. More than 80% of respondents agreed in the first round that this sub-component is Very Important to the success of collaborative relationships. The remaining subcomponents reached consensus at moderate levels. Two sub- components: Valuing Interpersonal Processes and Negotiating Multiple Perspectives were ranked as Important, with 65% and 56% levels of agreement, respectively. The remaining two sub-components of Interactive process are a Change Orientation during the Ongoing Interaction and during the Initial Interaction. Panelists agreed that both Change Orientation during the Ongoing Interaction (69% agreement), and during the Initial Interaction (62% agreement), were Not Important. Table 5.3 represents the relevant findings of this component and corresponding sub-components. 93 _ Table 5.3: Interactive Process and Sub-Com. nents Name Leik’s Degree of Level of . Formula Consensus Importance : 1 Interactive Process 0.6385 50 - 74% range Very Important 1 I Mutual Respect 0.8195 > 75% range Very Important I Change Orientation: Ongoing 0.6875 50 - 74% range Not Important l Value Interpersonal Process 0.647 50 - 74% range Important . Change Orientation: Initial 0.618 50 - 74% range Not Important '_ e Multi ole P . -— tives 0.559 50 - 74% rang-=1 Important These inventory questions all reached consensus at a reasonably high level. At least 50% of respondents concurred with the rankings. This component has a more pragmatic quality as it emphasizes the back-and-forth nature of the relationship; a common characteristic of many relationships. The common nature of this component may explain the high ranking. Individuals may have recognized these terms more easily. Also, the respondents are Marriage and Family Therapists who, in many cases, emphasize process over content. This may further explain the high ranking of this component. Finally, it is important to note the high concurrence of ranking mutual respect as very important. As professionals dedicated to the advancement of successful relationships, MFTs are likely to place a high level of importance on a sub-component such as Mutual Respect. Bischofl' and Brooks (1999) recognize the necessity of mutual respect in order for collaborations to exist. 94 Wm This component, defined as ‘actions and decisions between individuals are oriented toward patient health care’ ranked the highest of the five components for level of importance, with an agreement rate of 58%. Three sub- components were identified as further characterizing this component: Common purpose, Orientation, and Act or Decide. Common purpose, or professionals uniting around a common goal, was agreed upon by panelists at a very high rate. Panelists reached 95% consensus regarding the ranking of Common Purpose as most important of these three sub-components. Orientation: professionals orient processes, decisions and actions around patient care issues, was ranked Important, with 76% agreement, and Act or Decide: interaction results in an action or decision, was ranked Not Important, with 71% agreement. Table 5.4 represents the relevant findings of this component and corresponding sub-components. Table 5.4: Domain Orientation and Sub-Com I tnents Name Leik’s Degree of Level of Importance Formula Consensus -1 Domain Orientation 0.583 50 - 74% range Very Important : Common Purpose 0.952 > 75% range Very Important , I Act or Decide 0.762 > 75% range Not Important L_ Orientation 0.714 50 - 74% range Important __ _ These inventory questions all reached a relatively high level of consensus regarding the rankings. At least half of individuals surveyed agreed that this collaborative component, Domain Orientation, was the most important aspect of the relationship. This is a less pragmatic, more paradigmatic component than some of the others. This can be interpreted in several ways. This my be due to the complex nature 95 of the subject nutter, several pilot study participants found this particular category complex. It may be, however, that one of the more crucial aspects of a successful collaborative relationship is the intent of each participant in the forming and maintaining the relationship. This finding is in keeping with recommendations by Bischof (1999) to support an action-oriented approach to collaboration. The rank of Domain Orientation is supported by the ranking of the sub- component Common Purpose. A very high consensus (95%) was reached regarding the importance of individuals engaging in a relationship united around a common goal. All sub-components of Domain Orientation reached a high level of consensus. This supports the congruence of thoughts regarding these relationship characteristics. Stakeholder, This component, defined as the extent to which an individual, or individuals have a stake or investment in patient care issues, ranked Important at a moderately high level of consensus, 55%. This component acquires the lowest level of consensus among panelists. The namesake of this component» sub-component Stake-- ranked Very Important, but with rather low consensus (47%). Trust in the relationship and Shift in Paradigm ranked Important with reasonable consensus (51% and 48% respectively). Finally, also with at least 50% consensus, Personal communication within the rehtionship was ranked Not Important. Table 5.5 represents the relative findings of this component and corresponding sub-components. 96 Table 5.5: Stakehold r and Sub-Co n nts Name Leik’s Degree of Level of Importance . Formula Consensus ~ Stakeholder ' ' ' 0.5555 '_ ’ so -_ 74% range ' ‘ . Important _ Relationship: Personal 0.6487 50 - 74% range Not Important Communication Relationship: Trust 0.5087 50 - 74% range Important Shift in Paradigm 0.4787 50 - 74% range Important L—fl—A 0.474 - »»W — . —- - ~ This component, identified as a stakeholder, is a term that is used throughout the Collaborative Healthcare field as well as the Organizational behavior field. Individuals engaging in a professional relationship with common goals are often referred to as ‘stakeholders.’ This component ranls as Important, however with a low level of consensus. As this is a term that is often used as a label to describe individuals, participants may not place value on the role of stakeholder as much as the processes that occur when one becomes a stakeholder. Within the component--sub-component Stake-- which bears a similar definition, ranks Very Important, yet panelists are also ambiguous about the ranking. Consensus is low (47%), which may be due to some of the same reasons Stakeholder does not get a higher rating. Panelists agree at a relatively high level of consensus (65%) that Personal Communication is Not Important. Panelists moderately agree that Trust within the relationship (51% agreement) and Paradigm shift, or a change in one’s conceptualization of patient wellness/illness to include both physical and psychosocial issues (48% agreement), are important to the relationship. 97 Professional conceptual and relational issues are ranked Important, and are consistent with findings in the previous components. While various relationship aspects are Important or Very Important, such as Trust, Respect, and Valuing Interpersonal Processes, the prevailing theme is that the emphasis is on the professional interactions. Personal interactions are not, according to panelists, important in the success of collaborations. WW. Collaboration inventory items provided several interesting findings. Inventory items were all ranked on the same three point scale: Very Important, Important, Not Important. One of the more notable findings is that none of the inventory items were ranked as Not Important. This finding can be interpreted to mean several things. First, panelists may not be discerning regarding individual items. The components and sub-components included forced ranking; rankings relative to each other. Inventory items were not ranked relative to each other, rather ranked separately on a three point scale. Secondly, inventory items demonstrate this data as being positively skewed, therefore not meeting assumptions of normal distributions. Finally, the scale is only three points so that the distinction between responses is minimal, which suggests the need for a larger number of categories. This point will be further discussed in the Limitations section of this chapter. Another relevant finding of the inventory items data is the relatively low level of consensus. The assumption would be that with fewer options to choose fiom (a three point scale) that consensus would occur at a higher rate. As demonstrated in Table 5.6, the percent of inventory items (30%) that reached consensus at a low level is higher than for Components or Sub-components (0% and 8% respectively). Table 5.6 demonstrates 98 the percent of inventory questions divided by style (component, sub-component, item) reaching consensus at high, moderate, or low levels. Table 5.6: Levels of Consensus reached by Percent of Inventory Questions High Consensus Moderate Consensus Low Consensus ( > 75%) (50 - 74%) ( < 50%) Components 40% 60% 0% Sub-Components 24% 68% 8% Items 22% 48% 30% The significant diversity regarding consensus of inventory items may be attributed to several points. First, consensus may be more difficult to reach when the questions at hand are more specific in nature. There is a difference between agreeing on how important the role of Mutual Respect is to the success of a relationship and how important is the role of a phone call. Second, it may be more than just the nature of the questions. This finding may confirm one of the gaps within the collaborative healthcare field mentioned earlier in this study: the lack of converging ideas within the field. As mentioned, several individuals in areas of the United States contribute to the literature by sharing their respective collaborative experiences. What is missing, however, may still be a merging of thoughts and experiences into a collective model. This study suggests that individuals with an interest in the field of collaboration may not be working together to maximize the understanding and facilitation of collaborative healthcare. This project is the first of, hopefully many, that begins to pull together thoughts, experiences, successes, and failures, to benefit professionals beyond their current location. 99 A closer look into the content of the inventory items is also warranted. One of the most significant findings is that, as illustrated on Table 4.12, several inventory items delineating Paradigm (part of Stakeholder component) reached a high level of consensus in Round 1. More than 75% of panelists agreed that both collaborative parties’ (MFTs and HCPS) concern with physical and psychosocial well being of patients is Very Important. Theseweretheonlyitemsthatobtained suchhighconsensusinRound 1. The overall sub-component, Shift in Paradigm, ranked only Important with moderate consensus (48%). Inventory items portraying mutual respect ranked Very Inrportant with high levels of consensus. This is in keeping with the rank of the sub-component Mutual Respect. The inventory items regarding Corrnnon Pin-pose and Orientation both ranked Very Important with high levels of consensus (82% for both). This is congruent with sub-component findings. Finally, panelists are ambiguous regarding how professionals initiate contact. Most inventory items examining initial contact reached minimal levels ofconsensus. This is also in keeping with some ofthe significant findings regarding communication of this study which have been incongruent with the dominant literature. Finally, it is important to recognize that panelists provided no additional questions to the inventory in either round, suggesting the inventory included an exhaustive list of collaborative dimensions. A significant goal of this project was to facilitate the move of Collaborative Healthcare research in a quantitative direction, eventually producing for a Collaborative measurement tool. This project is the first attempt to itemize relationship characteristics. The lack of additions from ‘experts’ suggests that this project is timely in that the vast majority of relationship characteristics 100 considered important to the success of the relationship is discussed in the literature, however few have been empirically tested. This project attempts to provide additional groundwork for future studies of relationships of MFTs working collaboratively with HCPs. The recommendations section will further this discussion. B l D! . . 3 To identify demographic factors which differentially affect the reported significance of components. Research questions regarding demographic factors were generated. Specifically, demographic factors that were examined included gender, employment setting and years of collaborative practice. This project was not able to examine in a meaningful way the demographic factors in relation to the data Chapter 4 addresses the statistical limitations of analyzing these questions. Statistically, limitations were due primarily to an inadequate sample size (N = 42) and potential cell size in regards to the demographic factors. A look at the inability to explore these questions conceptually is also warranted. The first demographic factor, gender, is included to inquire about any differences between males and females regarding the perceived value of relationship characteristics. Currently, the literature in collaborative Healthcare does not include any gender-related findings. It should be noted that similar to most mental health professions, Marriage and Family therapy is predominately female. The sample for this study, limited to MFTs, in terms of gender as a demographic, is congruent with the MFT population in that it is predominately female. Due to this limited diversity, rigorous analysis and correlation are not possible. 101 Employment setting is a demographic factor that is peripherally addressed in the collaborative literature. Throughout collaborative healthcare writings there is a recognition of the difi’erent ‘work settings’ and the influence on collaborative practices (Seaburn et a1, 1996). For the purposes of this project, employment settings included academic, clinical, inpatient and outpatient. One interesting finding is the significant overlap of individuals working in several different contexts. Marriage and Family therapy is applicable in such a broad range of contexts, few practicing MFTs work in any one setting. This may contribute to the difficulty in addressing this objective. Statistically, the limitation is due primarily to the inadequate sample size. This, along with potential reasons for the limited sample size, will be further addressed in the Limitations section of this chapter. Remhflbiecfiyfl To propose a Collaboration Inventory (CI) for use in further development of evaluative measures of collaborative practice. A list of inventory items, broad characteristics and sub-characteristics provided in the form of the Collaboration Inventory in Appendix C. Panelists added no additional items, components or sub-components suggesting that at this stage, the CI is reasonably thorough in exploring various relationship elements. The existing inventory is timely in that it takes the initial steps towards bringing together thoughts and opinions of many different practicing ‘experts’ in the field of collaborative healthcare. Pilot participant suggestions were incorporated into the final inventory improving the quality and potential for future developments. 102 Future research is required to continue the development of the CI. Findings of this study will contribute to the further development of a quantitative instrument available for individuals to examine the extent of collaborative relationships in various settings. Several strategies exist as a result of this study for consideration in fixture developments. First, it is clear that components, sub—components, and even inventory items are more or less important in the process. Future developments should take into consideration the varying degrees of importance, and include this into the measurement process. The difference between the presence of one component, sub—component, or item, over another may be significant and scoring should be weighted accordingly. Second, as sub-components and inventory items are embedded within broader groupings, firrther exploration into the relationship between components and sub- components, sub-components and items, and finally items and components is warranted. There is potential for scores on inventory items to infer information regarding the corresponding sub-component, and the corresponding component, as well as scores of sub-components being utilized to make inferences about collaborative components. These additional developments rely heavily on statistical processes, primarily factor analysis. Factor analysis involves “classifying large numbers of interrelated variables into a limited number of dimensions or factors” (Frankfort-Nachmias and Nachmias, 1992, p. 442). Factor analysis includes exploring the relationships between inventory items (factor loading) as well as determining the ‘weight’ of each inventory item, to most accurately represent what the author hopes to identify or explain. 103 The Collaboration Inventory requires firrther development in the aforementioned areas. These areas are primarily quantitative in nature. It is equally important to firrther the understanding of the subject areas included within the inventory. Interpretation of the various relationship characteristics by panelists, and future participants, is key to the usefulness of the inventory. Qualitative studies, including interviews, focus groups and additional Delphi studies can strive towards developing terminology with shared meaning throughout the field, thereby enhancing the validity of reported answers. I l. . As Marriage and Family Therapy is a clinical practice, and Collaborative Healthcare is something individuals engage in, practical implications of these findings are relevant. The findings of this study can be applied to three broad areas: 1. training, 2. initiating collaborative relationships, and 3. further facilitating collaborative relationships. Efforts and energies should be placed in areas that practicing experts recognize as more important to the success to the relationship. This study found that the professional orientation (Domain Orientation) was very important to panelists. In interacting or initiating interactions with health care professionals, MFTs should emphasize their orientation towards patient care, discussing it overtly with the HCP. Clearly identifying specific goals related to patient care to HCP may further facilitate collaborative practice. Acknowledging the importance of mutual respect, and modeling the respectfirl behavior may go a long way in furthering collaborative relationships. Recognizing the importance of the process of interacting with the HCP (Negotiating Multiple Perspectives, Valuing Interpersonal Processes) and how HCPs are in a way clients as much as the patients. Some communication 104 characteristics, such as frequency of communication appear important as opposed to others such as formal meetings or sharing of patient charts or support staff, which may not be as useful. Overt, explicit discussions around daily tasks may be unnecessary as they will often evolve out of the process. The development of a personal relationship with the HCP may be beneficial, but is certainly not required for successful collaboration. Finally, the professional structure or hierarchy, may not warrant a great deal of attention. These implications are primarily drawn fi'om the findings around the rankings of components, sub—components, and items. Marriage and Family Therapists bone and practice many skills with clients. It is often the case, however that those skills are limited to the therapy room. It may also be the case that professionals are limiting their application of collaborative skills to collaborations with on-site professionals. The low levels of consensus suggest that MFTs are not working on collaboration with each other in ways that maximize potential for collaborative efforts. It may be helpfirl to examine skills utilized within both the therapy room and within the healthcare setting and consider the greater impact those skills may lnve on the field of Collaborative Healthcare as well as Marriage and Family Therapy. The current state of collaborative healthcare research was discussed in chapter 2. Many individuals contribute to the collaborative healthcare literature in a more anecdotal form based upon their clinical experiences. Several models or spectrums have been suggested to aid professionals in their conceptualization of this process. A few studies have begun to take a more empirical view of the collaborative relationship. This study 105 has attempted to make two significant contributions. The first of these contributions is to bring together ideas and concepts fiom a variety of origins into a more comprehensive collaborative model. Second, this study has made an attempt to quantify the relationship components. The goal is to firrther this process and allow for more specific and rigorous ways and means of looking at this process of providing care. The profession should continue to explore collaborative healthcare both qualitatively and quantitatively. The field has made enormous strides in the development of the journal, WM and the establishment of the Collaborative Family Healthcare Coalition. Both of these advances are resources with great potential for firrther use in this ongoing process of understanding, measuring, and defining Collaborative Healthcare. ResearcheLthemations This sections provides the opportunity to include information that does not belong in any of the existing areas. This section includes information potentially helpful for future projects and general information relevant to this study. The process of completing the survey deserves some attention. Several panelists commented that the survey was long, complicated or confirsing. Individuals were often confused by the ranking portions of the survey. Several had either incomplete or incorrect responses to this section and were dropped from the study. Future surveys may need to explore other ways of gathering this information. This supports recommendations for future research, discussed below. Several panelists commented on how the standing relationship with the HCP made several questions moot. Panelists felt that some questions were ‘obvious’ for their respective situation. It would behoove 106 future surveys to take into further consideration the length of time individuals have been participating in the collaborative relationship. A few interesting points surfaced when exploring the data. Significant diversity in what kind of work MFTs do was very present. Work settings had tremendous diversity and should be firrther explored. In addition, while few HCPs responded to the survey, levels of consensus did not change regardless of the inclusion of the HCP. Data including the HCPs was not included for this study, however some analyses were run for curiosities sake. It would stand to reason that members of a single profession, such as MFT, would tend to agree more around a particular topic, than if professions were combined. This study did not find this to be the case. Perhaps the distinction by paradigm (biopsychosocial or not) is more significant than the title of the profession. Finally, this researcher had the opportunity to work in a new collaborative setting throughout the duration of this project. Several relationship characteristics identified in this study as Very Important, however incongruent with the dominant literature, were observed in the clinical setting. Location of Services was thought, per the dominant literature, to be of extreme importance. Clinical work was done within a particular HCP’s omce. Referrals and collaboration, however, were greater fi'om HCP’s beyond the physical ofice of the MFT clinical work. The findings of this study suggest that paradigm, primarily through inventory items, and not the sub-component, is a Very Important component. This finding is congruent with the experience of the researcher. HCPs who embrace a biopsychosocial paradigm engage in collaboration far more fi'equently than those who do not. General findings of this study suggest paradigmatic relationship components as more important than pragmatic components. 107 This researcher’s clinical experience in collaborative healthcare is congruent with this finding. While more diflicult to observe and measure, it may be of significance for the field to take a closer look at these abstract relationship components over those that are more easily quantified. This project has several limitations. The most significant limitation is the sample size. This study included a sarrrple size of 42 of a possible 85 panelists. This was 49% of the eligible panelists. The response rate was limited for many reasons. Potential reasons may have included the time of year the surveys were mailed. As many of the members of the CFHcC work in an academic environment, many may have been on summer leave during the mailing of Round 1 (July). Round 2 was rmiled in August. This time of year is also difficult for professionals affiliated with academic settings as it is the beginning of the academic year. Efforts were made to increase response rate. Two weeks following each of the rmilings, follow up e-mails were sent to respondents to encourage completion of the survey. Finally, one halfof the collaborative relationship includes health care providers, often physicians who are fiequently the target of many individuals seeking to gain some of their time. This culture may have contributed to a low response rate for physicians. Another limitation includes the respondent perspective. Several issues are relevant. Respondents were asked to complete the survey based upon their ‘most successfirl collaborative relationship around a particular patient within the past five years.’ If respondents experienced a successful collaborative relationship between rounds, the second round may have been completed based upon a difi’erent experience 108 than the first. In addition, it is possible that different relationship characteristics are important depending upon the presenting patient. A look into different types of patients warrants fiu‘ther investigation. An additioml limitation was the three point scale provided to panelists for ranking the importance of inventory items. Pilot participants unanimously agreed that a three point scale was more conducive to responding to the questions, however a five point scale would have provided richer data. A five point scale may have provided more discrimination among inventory items. The inventory was constructed by a therapist and therefore may include a strong therapist focus. The respondents for the survey were therapists and therefore may be in keeping with a ‘therapist’ perspective. Further exploration into use of the inventory with Health Care providers is warranted. Finally, the terminology for the inventory may be cumbersome and terms may not have had shared meaning. This could alter the interpretation and subsequent response of participants. Rmmmendafiensforflrfiuekesearch Research into the field of Collaborative Healthcare is new and therefore full of future opportunities. Based upon this study and the existing literature a need for a plethora of future research exists. Demographic findings in this study, or lack of findings, suggests further qualitative studies are warranted. A close examination into how employment settings, managed care contexts, and particular collaborative partners all bear significance in firrthering this process. Focus groups exploring additional relationship characteristics would be beneficial. Issues of consensus and the level of importance would warrant focus groups. Finally the nesting structure of the inventory 109 deserves a closer look. As demonstrated by Shift in Paradigm (sub-component ranked Important with moderate consensus, yet, inventory items ranked Very Important with high consensus), often inventory items lend a different ranking than the sub-component they attempt to clarify. Quantitative research studies are also merited. Further development of the Collaboration Inventory, including factor analysis, bears significant potential for future research. An instrument equipped to measure the extent of collaborative practice would allow for examination of maximizing collaborations and care for patients. In addition, an instrument of this nature would allow for communication of the benefit of collaborative healthcare to managed care companies interested in efficiently and cost- effectively managing patient care. Enormous potential exists for increased qualitative understanding of the process, practice and impact of collaborative healthcare. As mentioned previously, qualitative examination of the terminology and development of shared meaning would make significant contributions to the development of the instrument. Exploration into the impact different patients have on the relationship, and perceived importance of corresponding relationship characteristics warrants closer examination. In addition, this study explored successful collaborative relationships. Results may vary significantly if MFTs considered an unsuccessful relationship. Finally, inventory content areas worth exploring rose from this study. A closer look into the assumption that increased collaboration means better patient care should be explored. Increased collaboration in the literature is characterized by high levels of shared record keeping, shared staff; and relationship between MFT and HCP independent of the patient. Findings in this study 110 are incongruent with these characteristics. Further investigation into these areas might prove fi'uitfirl. Practical application of the qualitative understanding of this relationship into quantitative studies can lead to improved patient care, cost savings and job satisfaction for practitioners. As a field specializing in interactive processes and relationship dynamics, it is appropriate that Marriage and Family Therapy lead the way in forging collaborations with other helping professionals to create a new definition of health and well being. 111 Appendix A: Identification of components, sub-components and items I A-l: Components and Sub-Components I A-2: Item Derivation 112 Appendix A-l Commnemsmmmm Component #1: Shared rules, norms, and structure: Definition: The extent to which individuals understand cultural rules and norms and the structure of the collaboration Sub-components include: communication location of services provided provision of services physical facilities utilized rules and norms are implicit or explicit Component #2: Interactive Process: Definition: The skills and knowledge related to the interaction between professionals. Sub—components include: individuals value interpersonal processes mutual respect within the relationship relationship has a change orientation individuals negotiate multiple perspectives Component #3: Professional Autonomy: Definition: The skills and knowledge related to maintaining professional autonomy within the relationship Sub-components include: independent decision making capabilities flexible hierarchy Component #4: Stakeholder: Definition: The extent to which individuals have a stake in the patient care issues Sub-components include: Paradigm shift development of trust in the relationship content of communication individuals with a stake in services provided Component #5: Action or Decision: Definition: The extent to which professionals intent to act or decide Sub-component includes: The extent to which professionals intent to act or decide Component #6: Domain Orientation: Definition: Actions and decisions are oriented toward the patients health care. Sub-components includes: common purpose and action orientation 113 Appendix A-2 I D . . HCP: Health Care Professional (Physician, Nurse, Physician Assistant) MFT: Marriage and Family Therapist 1. Component: Shared Rn Norms and Structure Sub-Component: Communication: (mode): 1. HCP sent letter/e-mail to MFT regarding patient 2. MFT sent Ietter/e-mail to HCP regarding patient 3. HCP phoned MFT regarding patient 4. MFT phoned HCP regarding patient 5. HCP and MFT had an informal face to face (bump in the hallway) meeting regarding patient 6. HCP and MFT had formal arranged meeting regarding patient Sub-Component: Communication: (fi'equency): 1. On average, how often did the HCP communicate with the MFT regarding patient issues. 2. On average, how often did the MFT communicate with the HCP regarding patient issues. Sub-Component: Commoniootion: (confidentiality): 1. Issues of confidentiality were not discussed nor implied between MFT and HCP ' 2. Issues of confidentiality differences not discussed, MFT and HCP 3. Issues of confidentiality differences were discussed and were explicit between MFT and HCP Sub-Component: Communioaiion: (language): 1. MFT had little/no understanding of medical terminology which led to some communication breakdown 2. HCP had little/no understanding of therapeutic terminology which led to some communication breakdown 3. WT and HCP shared some medical and therapeutic terminology, however some communication breakdown still occurred 4. MFT and HCP developed a shared language (a basic understanding of medical and therapeutic termmology) which minimized communication breakdowns. 114 Sub-Component: Commioation: (content): 1. Interaction between MFT and HCP focused on patient issues only 2. Interaction between MFT and HCP focused primarily on patient issues, however included some relationship dynamics 3. Interactions between MFT and HCP included a mixture of patient care and relationship dynamic issues. Sub-Component: Brougionofifiomioen: 1. The MFT and HCP provided separate care and treatment 2. The MFT and HCP provided primarily separate care and treatment, with occasional joint comprehensive care and treatment 3. MFT and HCP provided consistent joint comprehensive care and treatment. Sub-Component: W: l. The MFT and the HCP had separate support stafi‘ 2. The MFT and the HCP shared some support staff 3. The MFT and the HCP shared most support staff Sub-component: W: 1. The MFT and the HCP kept patient records separately 2. The MFT and the HCP kept primarily separate but occasionally shared patient records. 3. The HCP and the MFT share patient records. Sub-Component: LmafionnflSemices: l. MFT and HCP provide services in separate locations (separate buildings) 2. The MFT and HCP provided services in shared location with separate offices. 3. MFT and HCP worked in the same office Sub-Component: Exnlicitllmplieit: 1. The majority of rules and norms for behavior between MFT and HCP were implied, but not explicitly discussed. 2. Some of the rules and norms for behavior between MFT and HCP were explicitly identified while others remained implied. 3. Most rules and norms for behavior between MFT and HCP were explicitly identified. 115 2- Componentdnterastjmm Sub-Component: Rolafionship: (Mutual Respect): 1. MFI‘ had little/no regard for HCP perspective or expertise 2. HCP had little/no regard for MFT perspective or expertise 3. MFT demonstrated some regard for HCP perspective or expertise 4. HCP demonstrated some regard for MFT perspective or expertise 5. MFT showed clear regard for HCP perspective and expertise 6. HCP showed clear regard for MFT perspective and expertise Sub-Component: WW1 1. MFT/HCP interactions indicated that patient treatment outcome was dependent on separate efforts of either the MFT or HCP 2. MFT/HCP interactions indicated that patient treatment outcome was dependent on parallel efforts of the MFT and HCP 3. MFT/HCP interactions indicated that patient treatment outcome was dependent on joint/shared efforts between MFT and HCP Sub-Component: WM}; (initial interaction): 1. MFT/HCP relationship developed with no intent to modify existing patient care 2. MFT/HCP relationship developed with clear intent to modify existing patient care Sub-Component: Changofliientation; (ongoing interaction): 1. Ongoing interactiom between MFI‘ and HCP indicate no intent to modify existing patient care 2. Ongoing interactions between MFT and HCP indicate clear intent to modify existing patient care Sub-Component: WW: 1. HCP trained perspective of patient was shared with MFT 2. MFT trained perspective of patient shared with HCP 3. HCP and MFT dialogued about both professional perspectives 4. HCP and MFT negotiate a mutual (shared) professional perspective about patient 3- Component: Merriam! Sub-Component: Hiemmm (patient focus): 1. HCP/MFT interactions regarding patient care reflect HCP as dominant; regardless of the situation 2. HCP/MFT interactions regarding patient care reflect MFI‘ as dominant; regardless of the situation. 3. HCP/MFT interactions regarding patient care reflect flexible shifts in professional roles, depending on the situation. 116 Sub-Component: Hiemmhy (relationship focus): 1. HCP is supervisor ofthe MFT. 2. MFT is supervisor of the HCP. 3. MFT and HCP are peers/colleagues. Sub-Component: WM: 1. HCP reports to MF'I‘ regarding patient treatment 2. MFT reports to HCP regarding patient treatment 3. HCP does not report to MFT regarding patient treatment 4. MFT does not report to HCP regarding patient treatment 5. HCP dialogued with MFT regarding patient treatment 6. MFT dialogued with HCP regarding patient treatment 7. HCP provided suggestions to MFI‘ regarding therapeutic treatment of patient 8. MFT provided suggestions to HCP regarding physical treatment of patient 4. Component: W2 Sub-Component: Relationship: (developmental/trust): 1. Initially, the MFT - HCP providers shared personal and professional information 2. As the collaboration progressed, the MFT - HCP providers disclosed more personal and professional information 3. As the collaboration evolved, the MFT - HCP providers exchanged personal and professional informtion 4. As the collaboration matured, the MFT - HCP providers developed a trusting relationship. Sub-Component: Relationship; (personal communication): 1. Personal disclosure shared between MFT and HCP is indirect, through patient care. 2. Some personal disclosure shared between MFT and HCP occurs directly, and some occurs through patient care. 3. Personal disclosure is shared openly between MFT and HCP in clear and direct ways. Sub-Component: Stake: 1. TheHCP referred patient fortherapy 2. The MFT referred patient to HCP 3. The HCP contacted the MFT regarding the referral 4. The MFT contacted the HCP regarding the referral 5. The HCP provided care/treatment for the patient 6. The MFT provided care/treatment for the patient 7. The HCP continued care after referring patient for therapy 8. The MFT continued care after referring patient to the HCP. 117 Sub-Component: Shifijnflamdigm. (biopsychosocial): 1. The HCP was initially concerned with only the physical well-being 2. The MFT was initially concerned with only the psychosocial well being 3. The HCP was initially concerned with physical and psychosocial well being 4. The MFT was initially concerned with physical and psychosocial well being 5. With the progression of the collaboration, the HCP was concerned with only the physical well-being of patient 6. With the progression of the collaboration, the MFT was concerned with only the psychosocial well being of the patient 7. With the progression of the collaboration, the HCP was concerned with physical and psychosocial well being of the patient 8. With the progression of the collaboration, the MFT was concermd with physical and psychosocial well being of patient 5. Component: Action or Dooision Sub-Component: Aotflleoide; l. MFT never shared with HCP any decision or plan of action regarding patient care, as a result of the collaboration. 2. HCP never shared with MFT any decision or plan of action regarding patient care, as a result of the collaboration. 3. MFT shared with HCP a vague decision or plan of action regarding patient care, as a result of the collaboration. 4. HCP shared with MFT a vague decision or plan of action regarding patient care, as a result of the collaboration. 5. MFT expressly stated to HCP a decision or plan of action regarding patient care, as a result of the collaboration. 6. HCP expressly stated to MFT a decision or plan of action regarding patient care, as a result of the collaboration. 6. Component: Domain Og’entotion Sub-Component: Comm: 1. The goal of collaboration between MFT and HCP was not stated, nor made clear 2. The goal of collaboration between MFT and HCP was implied, vague understanding 3. The goal of collaboration between MFT and HCP was explicitly stated and understood by both HCP and MFT Sub-Component: Qn'entafion: 1. MFT - HCP collaborative processes, decisions, and actions are general with little focus on general patient care and health promotion 2. MFT - HCP collaborative processes, decisions, and actions include some focus on general patient care and health promotion. 3. NIFI‘ - HCP collaborative processes, decisions and actions are primarily focused on generalized patient care and health promotion. 118 Appendix B: Pilot Study Correspondence Letter to Pilot Reviewers Original Collaboration Inventory Section 1: Background Information Section 2: Explanation, Inventory Items Section 3: Rank Order From Critique form for Pilot Reviewers 119 March 15, 2000 Department of Family and Child Ecology 107 Human Ecology East Lansing, MI 48824 Dear Colleagues: I am a doctoral student at Michigan State University and I have reached the dissertation stage. With a strong commitment to the growth and development of the ‘field of collaborative health care, I have chosen a dissertation topic which will contribute to this field. My topic is A Collaboration Inventory generated from a National Delphi Study of Collaborative Relationships of Marriage and Family Therapists and Health Care Professionals. The goal of my project is to develop an instrument for measuring the extent of collaboration between therapists and health care professionals to determine the collaborative practices necessary to maximize benefits to patients and professionals alike. The Inventory which rs included with this letter contains components whrch I have identified through a review of: 1. Seaburn et al, (1996) Models of Collaboration 2. Wood and Gray (1991) “A Theory of Collaboration” 3. Additional literature related to Collaborative Healthcare Based on your experience in working with physicians, I would appreciate it if you would review this survey instrument and offer any suggestions or comments. Please complete the survey and the additional Pilot review form. Based upon your response andthose ofotherslwiflnndifythequestionnaireandsend itto individualsregistered as members of the Collaborative Healthcare Coalition. Please return the survey to me by April 1, 2000. Thank you very much for your assistance in this important research project. Sincerely, Laura A. Mohr, M.S. Michigan State University 120 mm Section 1: Background Information Personal Data: please complete the following: Name: Gender: Female Male Primary Work Function: Physician Physician Assistant Nurse Marriage and Family Therapist Other (Please describe ) Current Employment Setting: Check one: Academic setting Non-Academic Check one: Inpatient Outpatient/Ambulatory Care Years in Collaborative Practice: 5 years and less 6 - 10 years 11 - 15 years Below, please describe how you initially began working in a collaborative health care setting. Please describe below your most successful collaborative experience (around a particular patient) in the past five (5) years. Please check on of the following: Iagreeto havemynameappearinthestudysummary Iwouldrathernot havemynameappearinthestudysummary. THANK YOU 121 Wm Section 2: Collaboration Experience Explanations and Definitions Collaboration Inventory: The goal of this inventory is to identify the elements of a collaborative relationship between health care professionals and mental health care professionals and determine the level of importance to collaboration. Panelists: W911): hldrviduals Who Pfimfily identify themselves as, and work as, a member of the medical health care profession (physicians, nurses, physician assistants) W individuals who primarily identify themelves as, and work as, marriage and family therapists Major Components to be Reviewed: There are six (6) mjor components identified as key to successful collaborative relationships. Each component includes sub-components which are identified in the explanation and throughout the inventory. Wm The extent to which individuals understand culturalrulesandnorrnsandthe structureofthe collaboration Sub-components include: communication, location of services provided, provision of services, physical facilities utilized, extent to which rules and norms are implicit or explicit. WWskfllsandkmwledgerehtedtothemtemcfionbetween professiomls. Sub-components include: individuals value interpersonal processes, mutual respect within the relationship, relationship has a change orientation, individuals negotiate multiple perspectives. Wm The skills and knowledge related to maintaining professional autonomy within the relationship Sub-components include: independent decision making capabilities, flexible hierarchy Stakeholdon The extent to which individuals have a level of investment in the patient care issues Sub-components include: Paradigm shift, development of trust in the relationship, content of communication and individuals with a stake in services provided. W: The extent to which professionals intend to act or decide Winn; Actions and decisions are oriented toward the patients care. Sub-components include: common purpose and action orientation 122 MW Section 2: Collaborative Experience Directions: Please read each statement and determine to what degree each statement was essential to the success of the most successful collaborative experience you have had around a particular patient within the past five calendar years (1995 - 2000). In other words, how important were the following items to the success of the collaboration. HCP: Health Care Professional (Physician, Nurse, Physician Assistant) MFT: Marriage and Family Therapist Please rank each of the statements according to this scale: s - Absolutely Essential (AB) 4 - Essential (E) 3 - Somewhat Essential (SE) 2 - Minimally Essential (ME) 1 - Useful, but not Essential (U) o - Not Applicable (NA) 1. Component Absolutely essential to the success of your collaborative experience Essential to the success of your collaborative experience Somewhat essential to the success of your collaborative experience Minimally essential to the success of your collaborative experience Use/ill, but not essentiaL to the success of your collaborative experience Not applicable, did not occur during the collaboration AE E SE ME U NA Wilming- Sub-Component: W: (mode): 1. HCP sent letter/email to MFT 1' . 2. MFT sent letter/email to HCP regarding patient 3. HCP phoned MFT regarding patient 5 4 3 2 0 4. MFI‘ phoned HCP regarding patient 5 4 3 2 1 0 5. HCP and MFT had an informal face 5 4 3 2 l 0 to face (bump in the hallway) meeting regarding patient 6. HCP and MFI’ had formal arranged 5 4 3 2 1 0 meeting regarding patient 123 AE Sub-Component: Communioation: (confidentiality): 1. Issues of confidentiality were not 5 discussed nor implied between MFT and HCP 2. Issues of confidentiality difi‘erences not 5 discussed, nor explicitly stated, but were implied between MFT and HCP 3. Issues of confidentiality differences were 5 discussed and were explicit between MFT and HCP Sub-Component: Skimmunmiion; (language): 1. MFT had little/no understanding of 5 medical terminology which led to some communication breakdown 2. HCP had little/no understanding of 5 therapeutic terminology which led to some communication breakdown 3. MFI‘ and HCP shared some medical 5 and therapeutic terminology, however some communication breakdown still occurred 4. MFT and HCP developed a shared 5 language (a basic understanding of medical and therapeutic terminology) which minimized commimication breakdowns. Sub-Component: Commmicmion: (content): 1.1nteractionbetweenMFTandHCP 5 focused on patient issues only 2. Interaction between MFT and HCP 5 focused primarily on patient issues, however included some relationship dynamics 3. Interactions between MFT and HCP 5 inchided a mixture of patient care and relationship dynamic issues. 124 SE ME NA AE Sub-Component: WW: 1. The MFT and HCP provided separate 5 care and treatment 2. The MFT and HCP provided primarily 5 separate care and treatment, with occasional joint comprehensive care and treatment 3. MFT and HCP provided consistent joint 5 comprehensive care and treatment. Sub-Component: SharedEacilities: l.TheMFTandtheHCPhadseparate 5 support stafl’ 2. The MFT and the HCP shared some 5 support staff 3. The MFI‘ and the HCP shared most 5 support staff Sub-component: RooonLKooping: 1.TheMFI‘andtheHCPkeptpatient 5 records separately 2. The MFT and the HCP kept primarily 5 separate but occasionally shared patient records. 3. The HCP and the MFT share patient 5 records. Sub-Component: Miriam: 1. MFT and HCP provide services in 5 separate locations(separate buildings) 2. The MFT and HCP provided services 5 in shared location with separate offices. 3. MFT and HCP worked in the same office 5 Sub-Component: Explicifllmplieit: l. The majority of rules and norms for 5 behavior between MFT and HCP were implied, but not explicitly discussed. 2. Some of the rules and norms for 5 4 behavior between MFT and HCP were explicitly identified while others rennined implied. 3. Most rules and norms for behavior 5 between MFT and HCP were explicitly identified. 125 SE ME NA AB 2. Component: Intomogiye Pmess Sub-Component: Rolafionship: (Mutual Respect): 1. MFT had little/no regard for HCP 5 perspective or expertise 2. HCP had little/no regard for MFT 5 perspective or expertise 3. MFT demonstrated some regard for 5 HCP perspective or expertise 4. HCP demonstrated some regard for 5 MFT perspective or expertise 5. MFT showed clear regard for HCP 5 perspective and expertise 6. HCP showed clear regard for MFT 5 perspective and expertise Sub-Component: MW: 1. MFT/HCP interactions indicated that 5 patient treatment outcome was dependent on separate efforts of either the MFT or HCP 2. MFT/HCP interactions indicated that 5 patient treatment outcome was dependent on parallel efforts of the MFT and HCP 3. MFT/HCP interactions indicated that 5 patient treatment outcome was dependent on joint/shared efforts between MFT and HCP Sub—Component: W (initial interaction): 1. MFT/HCP relationship developed with 5 no intent to modify existing patient care 2. MFT/HCP relationship developed with 5 clear intent to modify existing patient care SE Sub-Component: Win; (ongoing interaction): 1. Ongoing interactions between MFT and 5 HCP indicate no intent to modify existing patient care 2. Ongoing interactions between MFT and 5 HCP indicate clear intent to modify existing patient care 126 3 ME NA AE Sub—Component: II . l l l . l E . : 1. HCP trained perspective of patient was 5 shared with MFT 2. MFT trained perspective of patient 5 shared with HCP 3. HCP and MFT dialogued about both 5 professional perspectives 4. HCP and MFT negotiate a mutual 5 (shared) professional perspective about patient 3. Component: meogoionol Autonomy Sub-Component: Bimini (patient focus): 1. HCP/MFT interactions regarding patient 5 care reflect HCP as dominant; regardless of the situation 2. HCP/MFT interactions regarding patient 5 care reflect MFT as dominant; regardless of the situation. 3. HCP/MFT interactions regarding patient 5 care reflect flexible shifts in professional roles, depending on the situation. Sub-Component: Hiemrohy (relationship focus): 1. HCP is supervisor of the MFT. 5 2. MFI‘ is supervisor of the HCP. 5 3. MFI‘ and HCP are peers/colleagues. 5 Sub-Component: IndependentlhcisionMakina: 1. HCP reports to MFI‘ regarding 5 patient treatment 2. MFT reports to HCP regarding 5 patient treatment 3. HCP does not report to MFT 5 regarding patient treatment 4. MFT does not report to HCP regarding 5 patient treatment 5. HCP dialogued with MFT regarding 5 patient treatment 6. MFT dialogued with HCP regarding 5 patient treatment 127 Ahh SE WU) ME NNN NA OOO AE E 7. HCP provided suggestions to MFT 5 regarding therapeutic treatment of patient 8. MFT provided suggestions to HCP 5 regarding physical treatment of patient 4. Component: Stakeholder: Sub-Component: Relationship: (developmental/amt): 1. Initially, the MFT - HCP providers 5 shared personal and professional information 2. As the collaboration progressed, 5 the MFT - HCP providers disclosed more personal and professional information 3. As the collaboration evolved, the 5 WT - HCP providers exchanged personal and professional information 4. Asthecollaborationmatured,theMFl‘ 5 - HCP providers developed a trusting relationship. Sub-Component: Relationshm; (personal communication): 1. Personal disclosure shared between 5 MFT and HCP is indirect, through patient care. 2. Some persoml disclosure shared between 5 MFT and HCP occurs directly, and some occurs through patient care. 3. Personal disclosure is shared openly 5 betweenMFI‘andHCPinclearanddirectways. Sub-Component: Stake: 1. The HCP referred patient for therapy 2. The MFT referred patient to HCP 3. The HCP contacted the MFT regarding the referral 4. The MFT contacted the HCP regarding the referral MM'J’Q M 5. The HCP provided care/treatment 5 for the patient 6. The MFT provided care/treatment 5 for the patient 7. The HCP continued care after 5 referring patient for therapy 128 4 4 4 4 4 #«hs-h SE ME U 2 l 2 l 2 1 2 1 2 1 2 1 2 1 2 1 2 l 2 1 2 1 2 l 2 l 2 l 2 1 2 1 NA GOO AE E 8. The MFT continued care after 5 4 referring patient to the HCP. Sub-Component: W (biopsychosocial): l. The HCP was initially concerned 5 4 with only the physical well-being of patient 2. The MFT was initially concerned 5 4 with only the psyChosocial well being of patient 3. The HCP was initially concerned 5 4 with physical and psychosocial well being of patient 4. The MFT was initially concerned 5 4 with physical and psychosocial well being of patient 5. With the progression of the 5 4 collaboration, the HCP was concerned with only the physical well-being of patient 6. With the progression of the 5 4 collaboration, the MFT was concerned with only the psychosocial well being of the patient 7. With the progression of the 5 4 collaboration, the HCP was concerned with physical and psychosocial well being of the patient 8. With the progression of the 5 4 collaboration, the MFT was concerned with physical and psychosocial well being of patient 5. Component: M Sub-Component: We 1. MFT never shared with HCP any 5 4 decision or plan of action regarding patient care, as a result of the collaboration. 2. HCP never shared with MFT any 5 4 decision or plan of action regarding patient care, as a result of the collaboration. 3. MFT shared with HCP a vague 5 4 decision or plan of action regarding patient care, as a result of the collaboration. 129 SE ME U 2 1 2 1 2 1 2 1 2 1 2 l 2 1 2 1 2 l 2 1 2 1 2 1 NA AE 4. HCP shared with MFT a vague 5 decision or plan of action regarding patient care, as a result of the collaboration. 5. MFT expressly stated to HCP a decision 5 or plan of action regarding patient care, as a result of the collaboration. 6. HCP expressly stated to MFT a decision 5 or plan of action regarding patient care, as a result of the collaboration. 6. Component: Domain Orientation Sub-Component: Qammonfinmse: l. The goal of collaboration between 5 MFI‘ and HCP was not stated, nor made clear 2. The goal of collaboration between 5 MFT and HCP was implied, allowing for vague understanding 3. The goal of collaboration between 5 WT and HCP was explicitly stated andunderstoodbybothHCPandMF'l‘ Sub-Component: Qr'nntation: l. MFT - HCP collaborative processes, 5 decisions, and actions are general with little focus on general patient care and health promotion 2. MFI‘ - HCP collaborative processes, 5 decisions, and actions include some focus on general patient care and health promotion. 3. MFI‘ - HCP collaborative processes, 5 decisions and actions are primarily focused on generalized patient care and health promotion. 130 SE ME NA Directions: Please select the most accurate response regarding fi‘equency of communication during the most successful collaborative experience you have had around a particular patient within the past five calendar years (1995 - 2000). Winn: (frequency): 1. On average, how often did the HCP communicate with the MFT regarding patient issues. a. 0 - 2 times/month b. 3 - 5 times/month c. 6 - 10 times/month d. more that 11 times/month 2. On average, how often did the MFT communicate with the HCP regarding patient issues. a. 0 - 2 times/month b. 3 - 5 times/month c. 6 - 10 times/month d. more that 11 times/month 131 m Couaborotion Invontory Section 3: Rank Order of Importance Directions: Please rank order the following components in order of significance to a successful collaborative relationship. (1 = most significant 6 = least significant) Shared Rules, Norms, and Structure: the extent to which individuals understand cultural rules and norms and the structure of the collaboration Interactive Process: the skills and knowledge related to the interaction between professionals Professional Autonomy: the skills and knowledge related to maintaining professional autonomy within the relationship Stakeholder: the extent to which individuals have a stake in the patient care issues Action or Decision: the extent to which professionals intent to act or decide Domain Orientation: actions and decisions are oriented toward the patients healthcare. Please note below any additional components you believe should be added to the inventory: Directions: Please rank order the following sub-components in order of significance to a successful collaborative relationship. Note: Please do not rank order the components. (1 = most significant) Example: Professional Autonomy 3_Hierarchy: patient focus 1 Hierarchy: relationship focus 2_Independent Decision Making 1. Shared Rules, Norms, and Structure Communication: mode Communication: fiequency Communication: Confidentiality Communication: Language Communication: Content Provision of services Shared Facilities Record Keeping Location of Services Explicit/Implicit HHlll l 132 Example: Professional Autonomy 3_Hierarchy: patient focus 1 Hierarchy: relationship focus 2Jndependent Decision Making 2. Interactive Process Relationship: Mutual Respect Value Interpersonal Processes Change Orientation: initial interaction Change Orientation: ongoing interaction Negotiate Multiple Perspectives 3. Professional Autonomy Hierarchy: patient focus Hierarchy: relationship focus Independent Decision Making 4. Stakeholder Relationship: trust Relationship: personal communication Stake Shift in Paradigm 5. Action or Decision Act or Decide 6. Domain Orientation Common Purpose Orientation Please note below any sub-components you believe should be added to the inventory. Please include what component you feel it falls under. 133 Form for Critique of Colkbogtion Inyentory by Pilot Test Reviewers Directions: Please respond to these questions regarding the Collaboration Inventory. 1. How long did it take you to complete the inventory? less than 1 hour 1 - 1 1/2 hours 1 ‘/2 - 2 hours 2-3hours 2. Was the format easy to follow? very easy somewhat easy difficult: ifso, why: (please Specify) 3. Were the directions for responding to the inventory clear? yes no 4. Are there other demographic questions that should be asked? _ yes no If so, please list: 5. Is the terminology clear? yes no If no, please make suggestions below or on the survey form. General comments: Are there any other suggestions you would make to encourage participation in completion of this study? Are there any other suggestions you have for improving the understanding of the inventory? Any additional comments: 134 Appendix C: Survey Correspondence - Round 1 Invitation to Participate Revised Collaboration Inventory: Section 1: Background Informtion Section 2: Explanation, Inventory Items Section 3: Rank Order Form 135 July 12,2000 Department of Family and Child Ecology 107 Human Ecology East Lansing, MI 48824 Dear Colleagues: I am a doctoral student at Michigan State University and I have reached the dissertation stage. With a strong commitment to the growth and development of the field of collaborative health care, I have chosen a disSertation topic which will contribute to this field. My topic is A Collaboration Inventory generated from a National Delphi Study of Collaborative Relationships Between Marriage and Family Therapists and Health Care Professionals. The goal of my project is to develop an instrument for measuring the extent of collaboration between therapists and health care professionals to determine the collaborative practices necessary to maximize benefits to patients and professionals alike. The Collaboration Inventory contains components which I have identified through a review of literature related to Collaborative Relationships, including, but not limited to Seaburn, Lorenz, Gunn, et al, (1996) Models offlollahoration and Wood and Gray (1991) “A Theory of Collaboration.” In order to realize the contribution which this study will make to collaborative efforts between health care professionals and marriage and family therapists, I need your assistance. As a new field, the identification of these components will rely on expert opinion, such as yours. Since this rs a Delphi study which uses a panel of experts to provide opinions about specific items, I would like to invite you to accept the role as panelist. Eligible panelists include individuals who identify themselves as either health care providers or marriage and family therapists. You will receive two rounds of Collaboration Inventories. In Round One, panelists will give their opinions regarding the presence and the importance of each item based upon your most successfid collaborative professional collaborative relationship within the past five (5) calendar years (1995 - 2000) and add items or topics to the list. In Round Two, you will receive the revised inventory and havetheopportunityto ratetheitems again. The goalisto obtainconsensusonthe importance of components for successful collaboration. To summarize, you can assist me in the following ways: 1. Complete the Collaborative Healthcare Inventory by giving your opinion about the components importance and adding to the list 2. Completing the background information sheet 3. Returning the completed Inventory to me no later than July 25. 4. Repeating the Inventory in Round 2 which will be sent to you in August. 136 Please be assured that confidentiality will be maintained regarding your responses. Research findings will be reported in all write ups as averages and/or achievement of consensus, therefore no specific responses will be known. A list of all panelists will appear in the final study summary. Ifyou do not wish to have your name included, you can indicate so on the Background Information sheet. Your privacy will be protected to the maximum extent allowable by law. Please note that you indicate your voluntary agreement to participate by completing and returning this questionnaire. If you have any further questions, please feel flee to contact me at 517-699-1069 or Marsha T. Carolan at 517-432-3327. You may also contact David E. Wright at 517- 355-2180 for questions about your rights as a hurmn subject of research Thank you in advance for your support of this study and the advancement of the profession. Sincerely, Laura A. Mohr, M.S. Marsha Carolan, PhD Doctoral Student Dissertation Chairperson Michigan State University Michigan State University 137 Wham Section 2: Collaboration Experience Explanations and Definitions Collaboration Inventory: The goal of this inventory is to identify the elements of a collaborative relationship between health care professionals and mental health care professionals and determine the level of importance to collaboration. Panelists: I W: individuals who primarily identify themselves as, and work as, a member of the medical health care profession (physicians, nurses, physician assistants) l Mnmag’ e and Ennrrly' jlhemprsts’ (MEII):md1vrd' ' ' uals who pnmanly' ' identify themselves as, and work as, marriage and family therapists Major Components to he Reviewed: There are five (5) major components identified as key to successful collaborative relationships. Each component includes sub-components which are identified in the explanation and throughout the inventory. l W The extent to which individuals understand cultural rules and norrm and the structure ofthe collaboration Sub-components include: communication, location of services provided, provision of services, physical facilities utilized, extent to which rules and norms are implicit or explicit. I Interactiyoflrogessg The skills and knowledge related to the interaction between professionals. Sub-components include: individuals value interpersonal processes, mutual respect within the relationship, relationship has a change orientation, individuals negotiate multiple perspectives. I ProfessionalAurononmlheskfllsandknowledgerelatedtomaintaining professional autonomy within the relationship Sub-components include: independent decision making capabilities, flexible hierarchy l Stakeholder; The extent to which individuals have a level of investment in the patient care issues Sub-components include: Paradigm shift, development of trust in the relationship, content of communication and individuals with a stake in services provided. l W Actions and decisions are oriented toward the patients health care. Sub-components include: common purpose, action/decision and action orientation 138 Collaboration Inventog Section 1: Background Information Personal Data: Please complete the following: Name: Gender: Current Employment Setting: (check all that apply) Cl Female Cl Academic setting, university Cl Clinical, mental health Cl Male D Academic setting, residency inpatient training program CI Clinical mental health 0 Clinical, medical inpatient outpatient D Clinical, medical outpatient Age: Cl under 25 Primary Work Function: [326-35 DPhysician DMarraigeandFam'ly D 36 "5 E] Physician Assistant Them 046-55 Cl Nurse Cl 56 -65 Cl . Clover65 :flrer Ethnicity: Professional with whom you primarily collaborate with: Cl Caueasian Cl Physician Cl Manaige and Farrily Cl Hispanic Cl Physician Assistant Therapist 0 African Armn‘can 0 Nurse CI Asian Cl Other: C] Native American Years in Collaborative Practice: .................. Usyearsandless 06-10years D11-15years Below, please describe how you began working in a collaborative health care setting. How do you definfe a 'successful collaborative experience?‘ Describe your most successful collaborative experience (around patient care) in the past five (5) years. Please check one of the following: Diagreetohavemynameappearlnthestudysunmary. Dlwouldralhernothaverrrynameincludedinthesmdysumnary. 139 Collaboration Inventory Section 2: Collaborative Experience Please read each statement and respond regarding your most successful MFT/HCP orofessional collaborative relationship within the past five calendar years (1995 - 2000) around patient care. MFT: Marriage and Family Therapist HCP: Health Care Professional (physician, nurse, physician assistant, etc...) Section One: ireaions: - i ’- ‘ ' ' ‘ ' .Check the appropriate box to identijy 1 each activiQ Occurred during your collaborative . . ' elationship; ' , , . _ i If the activity Occurred, identifl theleve level at imQrtance to collaboration. s a Communication: Mode ___—_— s gee“ r. so 69:06 43 5’s a?“ a We HCP sent letter/e-mail to MFT [£6 [20‘ [3 Cr] Dr regarding patient care issues. ...... MFT sent letter/e-mail to HCP regarding patient care issues. ...... C] 1:] Cl E] El HCP phoned MFT regarding patient care issues. .................... D C] D D D MFT phoned HCP regarding patient care issues. .................... D C] D D D HCP and MFT had an informal face- to-face (bump in the hallway) meeting regarding patient care issues. ...... D D D D D HCP and MFT had formal arranged meeting regarding patient care issues. D D Cl Cl C] 140 Relationship: Develoomental/Trust Initially, the MFT - HCP providers shared personal and professional information ..................... As the collaboration progressed, the MFT - HCP providers disclosed more personal and professional information As the collaboration evolved, the MFT - HCP providers exchanged personal and professional information ....... As the collaboration matured, the MFT - HCP providers developed a trusting relationship ..................... Stakeholder The HCP referred patients to MFT . The MFT referred patients to HCP E1 The HCP contacted the MFT regarding the referrals ............ The MFT contacted the HCP regarding the referrals ............ The HCP provided care/treatment for the patients .................. The MFT provided care/treatment for the patients. ................. The HCP continued care after referring patient to the MFT ....... The MFT continued care after referring patients to the HCP. ...... s 6' e o‘" of"? @ét’flef 0‘56" 45‘s“)? if {if DD ODD CID DUO 00 ODD an DOD s e e 50‘" 6"er \‘ffs e‘e" «$609 if ill on ODD DD DOD 00 ODD an 000 DD 001:: CID ODD an ODD on our: 141 Shift in Paradim The HCP was in itally concerned with only the physical well-being of patients ........................ The MFT was initally concerned with only the psychosocial well-being of patients. ....................... The HCP was initially concerned with both physical and psychosocial well- being of patients. ................ The MFT was initally concerned with both psychosocial and physical well- being of patients. ................ With the progression of the collaboration, the HCP was concerned with only the physical well-being of the patients. .................... With the progression of the collaboration, the MFT was concerned with only the psychosocial well-being of patients. ..................... With the progression of the collaboration, the HCP was concerned with both physical and psychosocial well-being of patients. ............ With the progression of the collaboration, the MFT was concerned with both physical and psychosocial well being of patients. ............ 142 D Section two: .Please identify the statement that most accurately describes your MFT/HCP collaborative elationship, ,. ’ ' .ldentifl the levd of importance of that statement to collaboration ' Communication: Confidontiality Which statement most accurately describes your experience? Cl Issues of confidentiality were not discussed nor implied Cl Issues of confidentiality were not discussed nor explicitly stated, but were implied Cl Issues of confidentiality were discussed and were explicit How important was confidentiality to the collaboration? Cl Very Important Cl Important D Not Important Communication: 13mg; Which statement most accurately describes your experience? Cl MFT and HCP had littlelno understanding of medical/therapeutic terminology which led to some cormiunieation breakdown. Cl MFT and HCP shared some medical and therapeutic terminology. however some communiction breakdown still occurred. Cl MFT and HCP developed a shared language (a basic understainding of medical and therapeutic terminology) which m’ninu’zed communication breakdowns. How important was language to the collaboration? 0 Very Important Cl Important D Not Important Communication: Content Which statement most accurately describes your experience? CI Interaction between MFT and HC P focused on patient issues only. Cl Interaction hem MFT and HCP focused primarily on patient Issues, however included some discussion of relationship dynamics. Clinteractionsbetween MFl'and HCP includedamixtureofpatientcareand relationship dynamic Issues. How important was the content of communication to the collaboration? Cl Very Important Cl Important CI Not Important 143 Provision of Services Which statement most accurately describes your experience? CI The MFT and HCP provided separate care and treatment. CI The MFT and HCP provided primarily separate care and treatment, with occasional joint sive care and treatment. CI The MFT and HCP provided consistent joint comprehensive care and treatment How important was the provision of services to the collaboration? Cl Very Important CI Important D Not Important Shared Snpmrt Staff Which statement most accurately describes your experience? CI The MFT and HCP had separate support staff C] The MFT and HCP shared some support staff. CI The MFT and HCP shared most support staff. How important was sharing support staff to the collaboration? Cl Very Important Cl Important D Not Important Record Ke_cging Which statement most accurately describes your experience? CI The MFT and HCP kept patient records separately. CI The MFI' and HCP kept primarily separate but occasionally shared patient records. 0 The MFT and HCP shared patient records. How important was shared record keeping to the collaboration? CI Very Important Cl Important 0 Not Important Location of Services Which statement most accurately describes your experience? 0 The MFT and HCP provided services in separate locations (separate buildings). 0 The MFT and HCP provided services in a shared location with separate offices. C] The MFT and HCP worked in the same office. How important was the location of services to the collaboration? 0 Very Important Cl Important Cl Not Important 144 Egg t/Implicit Rules and Norms Which statement most accurately describes your experience? DTheMajority ofmlesand normsforbehaviorbetween MFl'and HCPwere implied, butnot explicitly discussed. DSomeofthe rules and normsforbehaviorbetween MFl'and HCPwereepricltiy Identified while others remained inplied. CI Most rules and norms for behavior between MFT and HCP were explitily identified. How important were explicit mics and norms to the collaboration? C] Very Important 0 Important CI Not Important Relationship: Mutual Rm (m!) Which statement most accurately describes your experience? CI The MFT had Iittlelno regard for the HCP perspective or expertise. DTheMFTdemonstrated some regard forthe HCP perspectiveandexpertise. CI The MFT showed clear regard for the HCP perspective and expertise How important was the MFT's respect for the HCP to the collaboration? Cl Very Important Cl Important CI Not Important Relationship: Mutual Ram (flCP) Which statement most accurately describes your experience? 0 The HCP had littlelno regard for the MFI' perspective or expertise. CIThe HCP demonstrated some regard forther-‘l' perspectiveorexpertise. CI The HCP showed clear regard for the MFT perspective and expertise. How important was the HCP's respect for the MFT to the collaboration? 0 Very Important CI Important CI Not Important Value [Mme] Process Which statement most accurately describes your experience? 0 MFT/HCP interactions indicated that patientlreatrmntoutcomewasdependenton separate efforts of either MFI' or HCP. D MFT/HCP interactions indicated that patient treatrmnt outcome was demndent on parallel efforts of both MFI' and HCP. CI MFT/HCP interactions indicated that patient treatrmnt orrtcornewas dependent on jointlshared efforts between III-T and HCP. How important was valuing interpersonal processes to the collaboration? CI Very Important CI Important Cl Not Important 145 Change Orientation: Initial Interaction Which statement most accurately describes your experience? CIMFI'Il-ICP mlationshipdevelopedwith no intentto modify existing patientcare. D MFT/HCP relationshipdeveloped with clear intent to modify existing patient care. How important was a Change Orientation during the initial interaction to the collaboration? DVery Important CI Important 0 Not Important Chang; Orientation: Ongoing Interaction Which statement most accurately describes your experience? CIOngoing interactions between MFTend HCP indicated no intentto modify existing patient Cl Ongoing interactions between MFI' and HCP indicated clear Intent to modify existing patient care. How important was a Change Orientation during the ongoing interaction to the collaboration? CIVery Important C] Important CINotlmportant Egggtiate Multifle Peugeot—m Which statement most accurately describes your experience? CI MFT/HCP trained perspective of patient care was shared with HCP/MFT“. respectively. CI MFT and HCP dialogued about both perspectives. CI MFI‘ and HCP negotiated a mutual professional perspective regarding patient care. How important was negotiating multiple perspectives to the collaboration? 0 Very Important CI Important CI Not Important Hierarchy: Patient focus Which statement most accurately describes your experience? CI MFT/HCP interactions regarding patient are reflected HCP as dominant: regardless of the situation. 0 MFT/HCP interactions regarding patient care reflected MFT as dominant: regardless of the D MFTIHCP interactions regarding patient care reflected flexible shifts in professional roles, depending on the situation. How important was hierarchy around patient care issues to the collaboration? Ci Very Important CI Important D Not Important 146 Hierarchy: Relationship focus Which statement most accurately describes your experience? Cl MFT is the supervisor of the HOP. C] HCP isthesupervisoroftheMFT. U The MFI' and HCP are peerslcolleagues. How important was hierarchy around the relationship to the collaboration? 0 Very Important CI Important C] Not Important Indgmpdent Decision Makipg: MFI‘ Which statement most accurately describes your experience? CI The MFT reported to the HCP regarding patient treatment issues. CI The MFT did not report to the HCP regarding patient treatment Issues. CI The MFT dialogued with the HCP regarding patient treatment issues. CI The HCP provided suggestions to the MFT regarding therapeutic treatment issues How important was the MFT's independent decision making to the collaboration? CI Very Important CI Important CI Not Important Indemdent Decision mkim: HCP Which statement most accurately describes your experience? CI The HCP reported to the MFT regarding patient treatment issues. Ci The HCP did not report to the MFT regarding patient treatment issues. 0 The HCP dialogued with the MFT regarding patient treatment issues. 0 The MFT provided suggestions to the HCP regarding physical treatment issues. How important was the HCP's independent decision making to the collaboration? U Very Important CI Important Cl Not Important Relationship: Personal Communication Which statement most accurately describes yom' experience? DPersonaldisclosureshared betweentheMFi'and HCPwasIndirect,thrcugh patientcare issues. CI Some personal disclosure shared between the MFT and HCP occured directly. and some occured through patient care issues. CI Personal disclosure was shared openly between the MFT and HCP in clear and direct ways. How important was personal communication between MFT and HCP to the collaboration? CIVery Important Ulmportant DNot Important 147 Act/Decide: MFT Which statement most accurately describes your experience? DTheMl-‘l’neversharedwithtl'reHCPanydecisionsorplansofadion regardingpatient care. as a result of the collaboration. CIThe MFT shared with the HOP vague decisions or plans ofaction regarding patient we. as aresultofthecollaboration. DTheMFTexpresslystatedtotheHCPdeesionsorplansofaction regarding patientcareas aresultofthecollaboration. How important was the MFT stating explicitly any decisions and/or plans of action regarding patient care to the collaboration? CI Very Important [3 Important D Not Important Act/Decide: HCP Which statement most accurately describes your experience? DThe HCP neversharedwiththeMFT anydecisionsorplansofaction regarding patient cere,asaresultofthecollaboration. DThe HCP shared with the MFT vague decisionsorplans of action regarding patientcare, as aresultofthecollaboration. CITheHCPexpresst statedtotheMFTdecisionsorplansofactionregardingpatientcare, asaresultofthecollaboration. How important was the HCP stating explicitly any decisions or plans of action regarding patient care to the collaboration? Cl Very Important [:1 Important CI Not Important mmon Pam Which statement most accmately describes your experience? UThegoaldflrecoflabaafionbetweenmeMFdeHCPwasnotshtadmanadedear. CIThegoa/offhecollaborationbetwaentheMFTandI-iCPwasImplied.allowingforvague understanding. DThegoalofthecoIIaborationbetweentheMFtand HCPwasepricItIystatedand understoodbyboththeMFTandHCP. How important was a common purpose to the collaboration? CI Very Important CI Important 0 Not Important 148 Orientation Which statement most accurately describes your experience? 0 The MFT/HCP collaborative processes, decisions, and actions were general, with little focus on overall patient care and health promotion. 0 The MFT/HCP collaborative processes, decisions, and actions included some focus on overall patient care and health promotion. CI The MFFIHCP collaborative processes, decisions, and actions were primarily focused on overall patient care and health promotion. How important was an orientation focused on overall patient care and health promotion to the collaboration? CIVery Important Dimportant CINotlmportant Communication: _lj‘gggueng On average, how often did the MFT and HCP communicate regarding patient issues CI 0 - 2 times/month Cl 3 - 5 times/month E] 6 - 10 times/month C] More than 11 times/month How important was the frequency of communication to the collaboration? Cl Very Important D Important D Not Important 149 Collaboration Inventory Section 3: Rank Order of Components ecessfirll collaborative relationship. lease Rank order the followmg five Collaboration Components in Order of rmportance to a ' lace your ranking in the box to the right. 1== most important 5 f—"least important. ‘ Interactive Process: the skills and knowledge related to the process of interacting between professionals. ........................ [ Shared Rules, Norms, and Structure: the extent to which individuals understand cultural rules and norms and the structure of the professionals involved. ................................ [ Professional Autonomy: the skills and knowledge related to each individual maintaining professional autonomy within the relationship. ............................................ L Stakeholder: the extent to which an individual, or individuals, have a stake, or investment in patient care issues. ................... I Domain Orientation: actions and decisions between individuals are oriented toward patient health care. ......................... 1 Please note below any general components you believe should be added to the inventory. 150 mportance to a success/id collaborative relationship Note: Please do not rank order the , f ’- ii;- Erection Please rank order the jbllowing Collaborative Sub-components in order of mponents Place your mung tn the box to the right beginning with 1 = most warm; 5 Interactive Process: Rank the followingfrve sub-components l = most importgnt 5 = least impprtant: Relationship: Mutual Respect - individuals respect the validity of each participants perspective ............................... I 1 Value Interpersonal Processes - professionals place value on the process of interaction with others ........................... L I Change Orientation: initial interaction - the relationship is initiated as participants intend to engage in some change ......... I 1 Change Orientation: ongoing interaction - the relationship continues to exist as participants intend to engage in some change . I j Negotiate Multiple Perspectives - process of negotiating a variety of professional perspectives ................................ I I Shared Rules, Norms, and Structure Rank the following ten pub-component; (l = most important 10 = least important): Communication: Mode - the method used for communication (phone calls, e-mail, letters, face-to-face meetings) between professionals ........................................... I 1 Communication: Frequency: - how often the MFT and HCP communicate regarding patient care ......................... I I Communication: Confidentiality - the role of professionally dictated codes of ethics around confidentiality ................. I I Communication: Language - professional or technical jargon/language; mutual tmderstanding . .> ..................... I ] Communication: Content - norms for communicating about individual patients' care; as well as communication regarding professional relationship dynamics .......................... I I Provision of services - how care and treatment is provided (jointly, separately, combination) .................................. I I Shared support staff - sharing of receptionists, nurses, etc... . . . . . I j Record Keeping - sharing/keeping joint records ............... L I Location of Services - geographic location of providers ......... r 1 151 Explicit/1m plicit - extent to which rules and norms are overtly discussed .............................................. I Professional Autonomy Rank the following three sub-commnents (l = most impgrtant 3 = least immrtant): Hierarchy: patient focus - professional with most expertise given the situation exerts most influence ........................... I Hierarchy: relationship focus - professional arrangement; employer/employee, etc .................................... I Independent Decision Making - professionals retain their autonomy regarding decisions .............................. I Stakeholder Rank the following [our sub-componentsil =- most important 4 = least immrtant): Relationship: trust - building trust as relationship matures, increased personal communication .......................... I 1 Relationship: personal communication - discussion turns more often toward what is going on with the providers, indicating a relationship independent of patient care issues ................. I Stake - professionals have with an interest in the patient's care . . . . I Shift in Paradigm - conceptualization of patient wellness/illness (biomedical/psychosocial, biopsychosocial) ................... l Domain Orientation Rank the following three sub—component; (1 = most important 3 = least important): Common Purpose - professionals unite around common goal Act or Decide - interaction between participants result in an action or decision ............................................. L Orientation - professionals orient processes, decisions, and actions toward patient care issues ................................. I 152 Please note below any additional Collaborative Sub-com ponents you believe should be added to the inventory. Please include what component you feel it falls under. Additional General Comments 153 Appendix D: Survey Correspondence - Round 2 I D-l: Round 2: Letter I D-2: Round 2: Collaboration Inventory: 0 Section 2: Inventory Items 0 Section 3: Rank Order Form 154 August 25, 2000 Department of Family and Child Ecology 107 Human Ecology East Lansing, MI 48824 Dear Colleague: Thank you for completing the Collaboration Inventory in Round #1. I really appreciate your assistance with this project, knowing how busy you are. The return rate has been good for Marriage and Family Therapists and should supply valuable information to further our work in collaboration with Health Care professionals. Your final contribution will assist me in the completion of my doctoral program, but more importantly should yield lasting benefits for our profession. As I mentioned in my first letter, a second round is required by the research technique I am using - the Delphi methodology. Round #2 is an opportunity for panelists to see how other panelists rated the importance of each item and to rank each item again. The overall goal is to determine the consensus or agreement about the survey items. Please find enclosed a shorter version of the original survey; descriptive questions (demographics, did/did not occur) were excluded. The enclosed survey also contains responses from Round #1. Adjacentjosachmssjluhcckmgngmm rt 0. _ .u o u. n-_:.._ .140 you a. 0. as L-. 02.1 r-. 4° In tom 01° ..;.- ._.‘ . L O u . .n- o. z- --,c:. H, , ° ‘n Inordertowork within time constraints, please try to return the Collaboration Inventory m the envelope provided by September 8,2000. Please be assured that confidentiality will be maintained regarding all responses. Research findings will be reported in all write ups as averages and/or achievement of consensus, therefore no specific responses will be known. A list of all panelists will appear in the final study summary, unless you indicated otherwise previously on the Background Information sheet (Round #1). Your privacy will be protected to the maximum extent allowable by law. Please note that you indicate your voluntary agreement to participate by completing and returning this questionnaire. If you have any further questions, please feel free to contact me at 517-699-1069 or Marsha T. Carolan at 517-432-3327. You may also contact David E. Wright at 517-355-2180 for questions about your rights as a human subject of research. Thank you in advance for your support of this study which will promote the advancement of the profession. Sincerely, Laura A. Mohr, M.S. Marsha Carolan, Ph.D Doctoral Student Dissertation Chairperson Michigan State University Michigan State University 155 Collaboration Inventory - Round 2 Section 2: Collaborative Experience Please consider response rates from panelists in Round 1, re-read each statement and respond regarding your most successful MFI‘ZHCP professional collaborative relationship within the past five calendar years (1995 - 2000) around patient care. Name: (please include to match with Round 1 answers) irections: . Beneath each check box is the response rate (in percent form) from Round 1. Consider ow panelists responded in Round 1. , . Check the appropriate box to identify the g‘mgortance 0; each item to collaboration. , MFT: Marraige and Family Therapist 1;, HCP: Health Care Professional (physician, nurse, physician assistant, etcgot‘is x. (94+ 6 to“ <°«2° 06 690 0“ Communication: Mode (4 rx (9 HCP sent letter/e-mail to MFT regarding patient care issues. C] C] C] 33.3% 33.3% 33.3% MFT sent letter/e-mail to HCP regarding patient care issues. 1:] C1 CI 48.4% 35.5% 16.1% HCP phoned MFT regarding patient care issues. .......... D C] D 48.3% 24.1% 27.6% MFT phoned HCP regarding patient care issues. .......... D C] C] HCP and MFT had an informal face-to-face (bump in the 50% 193% 303% hallway) meeting regarding patient care issues. ........... C] [j C] 69.2% 25.6% 5.1% HCP and MFT had formal arranged meeting regarding patient care issues. .................................. D C] C] 55.6% 33.3% 11.1% 0‘ s» l h': vel mn rs Q0503. 9050 d4“ 06" 96‘ 4° «SQ 9° Initially, the MFT - HCP providers shared personal and I I I professional information ............................. [3 Cl D As the collaboration progressed, the MFT - HCP providers 44.7% 411% 132% disclosed more personal and professional information ..... C] D E] 0 0 0 As the collaboration evolved, the MFT - HCP providers 40") /° 42'9 /° 17'1 /° exchanged personal and professional informatior .......... C] C] C] 50% 30.6% 19.4% 156 6" Stakeholder \¢Q°€:3$‘ 690$ 06 $90“; \ f f f The HCP referred patients to MFT .................... C] C] C] 57.5% 37.5% 5.0% The MFT referred patients to HCP .................. D E] - D 54.3% 37.1% 8.6% The HCP contacted the MFT regarding the referrals ....... C] E] D 53.1% 40.6% 6.2% The MFT contacted the HCP regarding the referrals ....... D D D 64.9% 32.4% 2.7% The HCP provided care/treatment for the patients ....... C] D D 58.5% 41.5% 0.0% The MFT provided care/treatment for the patients. ....... D D D 66.7% 33.3% 0.0% The HCP continued care after referring patient to the MFT . D D D ~ 64.1% 35.9% 0.0% The MFT continued care after referring patients to the HCP. C] C] C] 64.7% 29.4% 5.9% 40.5 Shift in Paradigm ”69° 6&5; The HCP was initally concerned with only the physical well- I15} {‘3 being of patients .................................... C] C] C] The MFT was initally concerned with only the psychosocial 34 5% 41'4% 24'1% well-being of patients. ............................... C] [:1 CI The HCP was initially concerned with both physical and 407% 370% 222% psychosocial well-being of patients. .................... D D C] The MFT was initally concerned with both psychosocial and80‘5% 195% 00% physical well-being of patients. ........................ C] C] C] With the progression of the collaboration, the HCP was 850% 15.0% (10% concerned with only the physical well-being of the patients. . D C] C] With the progression of the collaboration, the MFT was 360% 44'0% 200% concerned with only the psychosocial well-being of patients. . C] D C] 36% 40% 24% 157 Part Two: iredio' us: I . Beneath each check box is the response rate (in percent fbrm) from Round 1. Consider how lists responded in Round 1. . Check the appropriate box to identifi' the importance of each item is to collaboration & of ‘i 9°" \ {0 s Shared Rulg, Normg, and Structure 06 43 Q 4 @ +° How important was the frequency of communication to I I I the collaboration? ................................. D C] D 42.9% 47.9% 9.5% How important was confidentiality to the collaboration? . . D D C] 31.0% 45.2% 23.8% How important was language to the collaboration? ....... C] D C] . . . . 61.9% 31.0% 7.1% How important was the content of communication (patient care/professional relationship) to the collaboration? ..... C] D D How important was the provision of services (care and 415% 512% 73% treatment) to the collaboration? ...................... D [j [3 41.5% 58.5% 0% How important was sharing support staff to the collaboration? .................................... D D D 22.5% 37.5% 40% How important was shared record keeping to the collaboration? .................................... C] D D How important was the location of services (geographic) to 452% 262% 235% the collaboration? ................................. D D a 54.8% 28.6% 16.7% How important were explicit rules and norms to the collaboration? .................................... D D D 1 1.9% 54.8% 33.3% 158 a» 3‘ e Interactive Process \¢f&&\‘§°‘o How important was valuing interpersonal processes to the I I I collaboration? .................................... I] D [3 How important was a change orientation (intent to 667% 333% 0% change) during the initial interaction to the collaboration? 0 D D How important was a change orientation (intent to 344% 517% 123% change) during the ongoing interaction to the collaboration? .................................... C] D E] 40% 55% 5% 6‘ e Professional Autonomy \eoétoé' 69°" 4‘3 \(°€ a) How important was negotiating multiple professional I I I perspectives to the collaboration‘. ..................... C] D D How important was the professional hierarchy to the 433% 463% 93% collaboration? .................................... 1:] a [J How important was hierarchy of professional expertise in 475% 453% 11% relation to patient care issues to the collaboration? ...... D [3 C1 How important was the MFT's independent decision 452% 405% 143% making to the collaboration? ........................ L] D Q How important was the HCP's independent decision 375% 55% 75% making to the collaboration? ........................ C] [j [3 41 .5% 53.7% 4.9% 159 a Stakeholder 9°" to A \o‘ e° How important was personal communication between I I I MFT and HCP to the collaboration? .................. E] D D 12.5% 62.5% 25% 6. Domain Orientation €50 & o How important was the MFT stating explicitly any {4 {‘6‘ r“ decisions and/or plans of action regarding patient care to the collaboration? ................................. 1;] D D How important was the HCP stating explicitly any 55% 40% 5% decisions and/or plans of action regarding patient care to the collaboration? ................................. C] D D How important was a common purpose between MFT and 452% 51.3% 245% HCP professionals to the collaboration? ............... 1;] CI 1:] 0 0 How important was an orientation focused on overall 58.5 /" 36M 49% patient care and health promotion to the collaboration? . D C] D 52.4% 45.2% 2.4% 160 <5 (s Collaboration Inventory - Round 2 Section 3: Rank Order of Components For ease of understanding, bar graphs (in the right column) have been provided which represents the frequency of response rates (in percentage form) from Round 1. Consider how panelists have responded and re-rank as appropriate. irections: ‘ lease rank order the items in each section box in relationship to the importance to achieving success/id collaborative relationship. There should only be _o__n_e number in each number box. lace your ranking in the box to the right: I= most impel-tam 5=least important. I Select 1, 2, 3, 4, or 5 I nteractive Process: the skills and owledge related to the process of 'nteracting between professionals. ..... ollaborative Com onents: Shared Rules, Norms, and Structure: the extent to which individuals understand cultural rules and norms and the structure of the professionals involved. ......................... I rofessional Autonomy: the skills and owledge related to each individual intaining professional autonomy 'thin the relationship. .............. I Stakeholder: the extent to which an individual, or individuals, have a stake, or investment in patient care issues. . . . . I Domain Orientation: actions and decisions between individuals are oriented toward patient health care. . . . . I 161 Lnteractive Process: The skills and knowledge related to the process of interacting between professionals. I Select 1, 2, 3, or 4 I alue Interpersonal Processes - rofessionals place value on the process f interaction with others ........... I hange Orientation: initial nteraction - the relationship is initiated participants intend to engage in some change .......................... I Change Orientation: ongoing interaction - the relationship continues to exist as participants intend to engage ' ‘ . insomechange ................... I 1 ° 2° 4° 00 00100 egotiate Multiple Perspectives - rocess of negotiating a variety of rofessional perspectives ........... I 162 Shared Rules, Norms, and Structure The extent to which individuals understand cultural rules and norms and the structure of the professionals involved. Select 1, 2, 3, 4, 59 69 79 89 99 or 10 M041 Rated 3 if; I Ruled 5 Communication: Mode - the method Mods used for communication (phone calls, e- m s mail, letters, face-to-face meetings) and ,0 between professionals ............. h J Communication: Frequency: - how often the MFT and HCP communicate regarding patient care .............. I Communication: Confidentiality - the role of professionally dictated codes of ethics around confidentiality ........ r Communication: Language - professional or technical jargon/language; mutual understanding r Communication: Content - norms for communicating about individual patients' care; as well as communication regarding professional relationship dynamics ....................... r , Continued on next gge... 163 Provision of services - how care and treatment is provided (jointly, separately, combination) ........... I: o 10 2b so 40 Frequency (96) hared support staff - sharing of receptionists, nurses, etc.... . . ........ ecord Keeping- sharing/keeping joint records .......... . .... Location of Services - geographic location of providers ..... . . . . . . . . . Explicit/Implicit - extent to which rules and norms are overtly discussed ..... e skills and knowledge related to each individual maintaining professional autonomy 'thin the relationship. ierarchy: patient focus - professional 'th most expertise given the situation xerts most influence ............... ierarchy: relationship focus - professional arrangement; employer/employee, etc ............... ndependent Decision Making - rofessionals retain their autonomy garding decisions ................ I Select 1, 2, or 3 I W1 W2 I laws Stakeholder The extent to which an individual, or individuals, have a stake or investment in patient care issues. elationship: trust- building trust as lationship matures, increased personal dicating a relationship independent of take - professionals have with an terest in the patient's care .......... I Select 1, 2, 3, M4 I 165 . . I Select 1,2, or3 I Common Purpose - professronals umte hround common goal Act or Decide - interaction between participants result in an action or decision ........................ Orientation - professionals orient processes, decisions, and actions toward patient care issues ................. I Please include additional general comments you would like to make. Return in the enclosed stamped envelope no later than September 8, 2000, if possible. THANK YOU!! 166 References 167 References Alper, P. R. (1994). Primary care in transition. JA_MA, 272(19), 1523-1527. Auerswald, E. H. (1968). 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