The importance of teamwork, collaboration

Expressing goals authoritatively with other professionals

by Howard M. Notgarnie, RDH, EdD

An emerging philosophy in the health care industry is that of professionals embracing collaboration. This article will examine collaboration by dental hygienists in the health care industry, and propose a meaning of collaboration that is relevant to modern dental hygiene practice.

Terada emphasized the importance of demonstrating professional expertise by recognizing and applying relevant information to create a logical conclusion consistent with reality.1 This view of professionalism is existentialist. The professional rejects dogma and does not accept conclusions drawn from another person until that professional verifies those conclusions. This existential attitude is consistent with the philosophy of evidence-based care, which Chichester, Mann, Wilder, and Neal regarded as applying scientific evidence and personal resources to each patient’s needs and expectations.2 Thus, a collaborative practice must have practitioners who appraise one another’s diagnoses and treatment plans for the purpose of either corroborating or improving those decisions.

Collaboration involves a team that provides a diverse set of skills, thereby providing ideal care for clients. Nevertheless, for most health conditions, appropriate team composition or protocol between team members is < (Best, 2010).3 A recent collaborative practice model enacted in South Dakota shows promise for improving access to and quality of care. In South Dakota, dental hygienists have the authority to work in public institutions or schools.4 This model can be collaborative because dental hygienists might work with other health professionals or educators. However, the "collaborative supervision" by which a dentist must consent to the care a dental hygienist provides evinces permission rather than authority.

The distinction between supervised collaboration and interdisciplinary collaboration highlights the potential for inequity to consumers and practitioners. The legal restrictions on dental hygiene practice settings create a dependency of dental hygienists on institutional operators and dentists, thereby reducing autonomy and their ability to offer care most suited to their clients. Alternatively, practitioners drawn together in order to benefit a client’s holistic needs, rather than by a desire to overcome legal obstacles, are likely to support one another’s recommendations. Support between practitioners arises from mutually consistent goals and trust based on data and experience rather than capitulation to authority. Mutually supportive practitioners can create synergistic case management plans by identifying risks, preventing disease, and addressing disorders early, thereby reducing the need for expensive remedies.

Dental hygienists provide a unique perspective to the comprehensive condition of clients. The Health Resources and Services Administration (HRSA) emphasizes that dental hygienists’ role as collaborators in patients’ total health care will be more effective as states remove restrictions on dental hygiene scope and settings of practice. Furthermore, HRSA noted, these broader responsibilities require more sophisticated decision-making skills than the historical model of dental hygienists as obligate employees of dentists.5

The American Dental Hygienists’ Association (ADHA) noted that the traditional model of dental hygiene education as a short behavioral training process fosters a limited expectation of dental hygienists’ role as clinicians working for dentists and following dentists’ orders.6 Yet dental hygienists must distinguish their diagnoses and treatment plans from those of dentists. While dentists might provide a periodontal diagnosis and treatment plan comparable to one a dental hygienist provides, the dental hygiene diagnosis and plan should address more specific risks to a client’s periodontal health – those diagnostic elements for which a dental hygienist’s expertise is most applicable.

The dental hygiene treatment plan should also include responses to a client’s questions and behavior. To accept these advanced clinical challenges, dental hygienists require greater cognitive skills than required merely to "clean teeth" upon orders of a dentist. Dental hygiene schools stimulate dental hygienists’ expression of the profession’s unique perspective by nurturing the cognitive skills required of diagnosticians. Chichester et al. indicated that these cognitive skills include lifelong learning developed through problem solving, identifying relevant questions regarding a client’s condition, finding the best research to answer those questions, and determining the relevance of scientific evidence to the client’s condition.

Jaecks found that dental hygienists recognize the need for collaboration among professionals.7 Yet Wilder, Thomas, and Jared demonstrated that there is little interdisciplinary education in dental hygiene schools.8 As a result, Hague and Kovacich noted, collaboration between professionals is difficult because of poor understanding of one anothers’ practice.9 Indeed, Haas and Sheehan found that health professional students who learn in interdisciplinary environments are more comfortable with collaborative work environments.10 Likewise, Mabry and Mosca found collaborative learning environments foster dental hygiene students’ effective assessment of patients with complex special needs, a competency expected by the Commission on Dental Accreditation.11

In a survey by Wilder et al., dental professionals considered collaboration with other health professionals to be a management activity.12 Mann and Finkel added that case management occurs when dental hygienists coordinate their wellness perspective into the integrated diagnoses and treatment plans of clients shared by members of a health care team.13 Collaborative management by dental hygienists includes organizing practitioners’ limited time, interaction with coworkers, and accepting responsibility for office effectiveness (Turbyne, 2007).14

Although collaboration is interdependent, autonomy of each professional is essential. Darby and Walsh said that autonomy provides dental hygienists the capacity to share specialized knowledge that other participants in a collaborative diagnosis might not be interested in offering to clients.15 Thus, the autonomy of each member of a collaborative team provides the opportunity of those members to ensure the team addresses all client concerns. Accordingly, collaboration that includes dental hygiene decisions generally improves quality and access to health care for consumers.

As with providing dental hygiene’s unique perspective, intellectual development fosters professional autonomy. Chichester et al. emphasized that critical analysis of research helps dental hygienists make appropriate clinical decisions. According to Cuypers and Haji, this is a hallmark of intellectual development, and decisions offer authentic responses to clients’ individual conditions rather than behaviorally trained responses.16 Treatment is not standardized to a schedule or the whims of a supervisor. The autonomous practitioner is accountable to his or her clients for decisions and actions.

Bourgeault and Darling describe the boundaries between health professionals as a potential impediment to collaboration. The traditional form of health care delivery exhibits isolation of professions, each of which protects its professional scope, and a hierarchy, which exacerbates jealousy that creates isolation. Low-status members of the health care team don’t get to participate in decision-making. Factors influencing collaboration include experience working with teams, personal relationships between team members, structure of the workplace, regulations, and salary structure.

Health professionals with different status usually agree on consumers’ needs for increased access to care, but disagree on how to address that care. The contrast is often evident as supporting wellness in a democratic environment versus attacking pathology in an authoritarian environment. In addition, health professionals receive payment through different mechanisms from third-party payers, and gain privileges in clinics based on status rather than work outcome. These discrepancies discourage practitioners from sharing cases.17

Breaking the boundaries between professions is valuable to a team’s effectiveness. Körner defined the difference between interdisciplinary and multidisciplinary approaches to health care. Interdisciplinary teams encourage members to solve problems together. Members of interdisciplinary teams share a link in the chain of command. Each member of a multidisciplinary team contributes expertise individually to create a comprehensive plan. The multidisciplinary team has multiple, parallel links in the chain of command organized by a leader. Körner found the interdisciplinary approach provided better teamwork than did the multidisciplinary approach.18

Bourgeault and Mulvale pointed out that physicians have traditionally had leadership status in health care.19 However, instituting the preventive orientation of dental hygienists has the opportunity to foster community wellness and increased access to care (Cheng, Huang, and Hsieh),20 thereby minimizing the need for expensive correction of ailments. O’Neil reflected on the traditional leadership philosophy in health care by responding to changes in the social environment, and suggested that physicians align with people who take an active role in their health care. Leaders in the health care industry should promote partnerships among organizations. Physicians’ leadership in the health care system would therefore be in the form of managing change.21

Conversely, Beyers recognized the growing scope of practice enjoyed by health professionals who are focused on client-centered care, as they align with more educated clients who actively participate in their health care. Modern health care consumers seek wellness more frequently than disease intervention, and seek care in nontraditional settings. Beyers stressed that nurses should educate clients and manage complex care needs through a collaborative team. Managing care and the team requires knowledge of the disciplines and communication skills.22

In comparison, ADHA evinced Byers’ philosophy of leadership by client-centered practitioners through collaboration. ADHA emphasized that dental hygienists’ authoritative participation in the interdisciplinary health care team results in optimum client outcomes. Darby indicated that dental hygienists should take on a leadership role in the health care industry by applying the profession’s specialized knowledge and collaborating with other professionals.23

Collaboration is effective when participation among team members is active. Selle, Salamon, Boarmon, and Sauer indicated successful collaboration occurs when members comprehend one another’s disciplines and support the roles of each profession toward client health. Participants must have mutual confidence and shared authority. Collaborative team members set aside egos and communicate in order to learn from one another and create a model of diagnosis.24

Selle et al. defined collaboration as working together toward goals that no single member of the team can solve individually. Team participants working in parallel lack the connections of those who share problem solving. Interdisciplinary collaborative teams thus create integrated diagnoses and treatment plans. The increasing recognition of links between oral and systemic health substantiates the importance of dental hygienists providing care, performing research, and learning their professional roles in a variety of settings. Dental hygienists will improve their integration in the health care system by expressing themselves authoritatively and with professionals who share their goals.

Howard M Notgarnie, RDH, EdD, practices dental hygiene in Colorado. He has eight years of experience in professional association leadership and five years of teaching experience.

References

1. Terada R. (2008). Thinking for oneself: Realism and defiance in Arendt. Textual Practice, 22(1), 85-111.
2. Chichester SR, Mann GB, Wilder RS, Neal E. (2002). Incorporation of evidence-based principles in baccalaureate and nonbaccaluareate degree dental hygiene programs. Journal of Dental Hygiene, 76(1), 60-66.
3. Best H. (2010). Educational systems and the educational continuum for the older adult. Journal of Dental Education, 74(1), 7-12.
4. An Act to authorize dental hygienists to provide preventive and therapeutic services to more persons under certain circumstances. South Dakota HR 1045. (2011).
5. Health Resources and Services Administration. (2004). The professional practice environment of dental hygienists in the fifty states and the District of Columbia, 2001. Washington, DC: Author.
6. American Dental Hygienists’ Association. (2005). Focus on advancing the profession. Chicago:
7. Jaecks KMS. (2009). Current perceptions of the role of dental hygienists in interdisciplinary collaboration. Journal of Dental Hygiene, 83(2), 84-91.
8. Wilder RS, Thomas KM, Jared H. (2008). Periodontal-systemic disease education in United States dental hygiene programs. Journal of Dental Hygiene, 72(6), 669-679.
9. Hague A, Kovacich J. (2007). A needs assessment for health care professionals in the detection, intervention, and interdisciplinary treatment of bulimia nervosa using focus group methodology. International Electronic Journal of Health Education, 10, 114-125.
10. Haas BA, Sheehan JM. (2008). Developing and retaining a successful interdisciplinary law and ethics course for professional health care students. Journal of Nursing Law, 12(1), 38-41. doi: 10.1891/1073-7472.12.1.38
11. Mabry CC, Mosca NG. (2006). Interprofessional educational partnerships in school health for children with special needs. Journal of Dental Education, 70(8), 844-850.
12. Wilder RS, Iacopino AM, Feldman CA, et al. (2009). Periodontal-systemic disease education in U.S. and Canadian dental schools. Journal of Dental Education, 73(1), 38-52.
13. Mann NK, Finkel LM. (2007). A holistic approach to child psychiatric nursing: A new interdisciplinary collaboration. Journal of Child & Psychiatric Nursing, 20(1), 1-2. doi: 10.1111/j.1744-6171.2007.00082.x
14. Turbyne C. (2007). Clinical time management tips for every dental hygienist. Access, 21(1), 27-29.
15. Darby ML, Walsh MM. (2010). Dental hygiene: Theory and practice (3rd ed.). St. Louis, MO: Saunders.
16. Cuypers SE, Haji I. (2006). Education for critical thinking: Can it be non-indoctrinative? Educational Philosophy and Theory, 38(6), 723-743.
17. Bourgeault IL, Darling E. (2008). Collaborative care and professional boundaries: Maternity care in Canada (pp. 95-110). In E. Kuhlmann & M. Saks (Eds.).
18. Körner M. (2010). Interprofessional teamwork in medical rehabilitation: A comparison of multidisciplinary and interdisciplinary team approach. Clinical Rehabilitation, 24(8), 745-755. doi: 10.1177/0269215510367538 Rethinking professional governance: International directions in healthcare. Bristol, UK: Policy Press.
19. Bourgeault IL, Mulvale G. (2006). Collaborative health care teams in Canada and the U.S.: Confronting the structural embeddedness of medical dominance. Health Sociology Review, 15(5), 481-495.
20. Cheng YA, Huang ST, Hsieh ST. (2007). A predictive study on the role and function of dental hygienists in Taiwan. International Journal of Dental Hygiene, 5(2), 103-108. doi: 10.1111/j.1601-5037.2007.00236.x
21. 21. O’Neil E. (1999). Core competencies for physicians. In R. W. Gilkey (Ed.), The 21st century health care leader (pp. 209-215). San Francisco: John Wiley & Sons.
22. Beyers M. (1999). The future of nursing. In R. W. Gilkey (Ed.), The 21st century health care leader (pp. 216-224). San Francisco: John Wiley & Sons.
23. Darby ML (2009). The Advanced Dental Hygiene Practitioner at the master’s degree level: Is it necessary? Journal of Dental Hygiene, 83(2), 92-95.
24. Selle KM, Salamon K, Boarman R, Sauer J. (2008). Providing interprofessional learning through interdisciplinary collaboration: The role of "modeling." Journal of Interprofessional Care, 22(1), 85-92. doi: 10.1080/1356182070171475.

More RDH Articles
Past RDH Issues