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NeuroRehabilitation 8 (1997) 21-29

Fostering effective team cooperation and communication: Developing community standards within interdisciplinary cognitive rehabilitation settings Daniel Holland*, John Hogg, Janet Farmer University of Missouri-Columbia School of Medicine, DepaT1ment of Physical Medicine and Rehabilitation, One Hospital Drive, Columbia, Missouri 65212, USA

Abstract Cognitive rehabilitation is a promising and necessary component of interdisciplinary treatment for brain injured patients, but it remains an area that lacks universal definitions, empirically validated constructs, or standards of practice. This situation leads to difficulties for interdisciplinary teams in cognitive rehabilitation settings, since definitions, conceptions, and labels of cognitive constructs can differ across team members and disciplines. In order to implement effective cognitive rehabilitation in a given setting, it is necessary to establish a set of 'community standards' that will compensate for the lack of universal standards in the broader cognitive rehabilitation landscape. These community standards will improve team functioning by facilitating communication between disciplines and identifying the team's preferred treatment strategies. Such a project was undertaken by a task force at the University of Missouri-Columbia School of Medicine, Rusk Rehabilitation Center. The process of establishing such a task force and the need for establishing community standards are described and outlined. Copyright © 1997 Elsevier Science Ireland Ltd.

Keywords: Cognitive rehabilitation; Interdisciplinary team; Treatment planning

1. Introduction Exploring the current landscape of cognitive rehabilitation is similar to a hike before dawn. There appear to be many paths, though no single one seems well travelled, and most disappear

* Corresponding author. Tel.: + 1 573 8828847; fax: 8844540; e-mail: [email protected].

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quickly into the pre-dawn fog, suggesting one must rely to some extent on faith rather than topography in order to proceed. At times, the immediate terrain appears friendly and manageable, with appealing theoretical approaches and promising comprehensive computer programs or treatment kits. Sudden pitfalls occur even in the seemingly most friendly terrain, however, and many of the most straightforward cognitive rehabilitation routes, frequently those that promise

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D. Holland et at. / NeuroRehabilitation 8 (1997) 21-29

a comprehensive treatment in one package, meander far afield from the destination of functional relevance. Given this confusing state of affairs in the broader cognitive rehabilitation landscape, the need exists for enhanced coordination and communication within each rehabilitation setting, so that individual treatment settings do not simply become microcosms of the frequent disharmony occurring in the larger scene. One of the first steps in achieving this coordination within settings involves establishing a consensus regarding what the team is targeting for treatment, what to label these constructs, and what kind of remediation or compensatory approaches the team is most likely to utilize in treatment. 2. A problem of definitions A particularly salient obstacle in the area of cognitive rehabilitation is that of definition. Essentially identical constructs are called different things by different clinicians, researchers, and disciplines, and the same terms (e.g. 'attention') are employed to refer to a host of different concepts [1]. This lack of unitary definitions for cognitive constructs is evident in neuropsychological assessment as well as cognitive rehabilitation treatment. A long recognized problem in neuropsychological assessment is that a measure used by one clinician or researcher as an index of, for example, 'cognitive flexibility' may be used by another as an index of attention or executive function [2]. This lack of unity in the definition of cognitive constructs in ass~ssment then persists into the cognitive rehabilitation process, with potentially deleterious effects. If assessment is to dictate appropriate and specific treatment in cognitive rehabilitation settings, then accuracy and agreement in terminology becomes crucial in choosing the proper treatment protocol. Otherwise, a rehabilitation team may be targeting a cognitive construct for treatment with, unwittingly, differing conceptions among team members as to what that construct is and how best to conduct a treatment approach. One of the greatest assets of the team approach to rehabilitation, coordinated interdisciplinary treatment planning,

would then be compromised for the neurocognitively impaired patient requiring cognitive rehabilitation. This problem of achieving universal definitions is not a new one and is by no means specific to medicine, neuropsychology, or cognitive rehabilitation [3]. The importance of definition has been a central tenet throughout the Western history of debate, science, and philosophical thought, and the early Greek philosophers, Plato, Socrates, and Aristotle each struggled with the importance of definition as a function of logical thought. Aristotle [4] ventured to define the very term 'definition' itself. A successful definition, he argued, is able to elucidate qualities that distinguish the object from other objects, while at the same time capturing its very essence. This process of definition becomes particularly challenging when one is attempting to achieve an essentialist definition, a conceptual definition that captures the very nature of that to which the word refers [5]. In the more simple lexical definition, or definition of word meanings, the concept is concrete enough that one can literally rely, for example, on pointing and still achieve something [5]: 'What is a dog?', 'What is a coin?'. In the second type or level of definition, essentialist definition, pointing is likely impossible, much less a resolution to the problem: 'What is truth?', 'What is profit?', and along the same lines, 'What is abstract, non-verbal problem-solving?'. Thus stems the lack of shared definitions or unitary constructs in cognitive rehabilitation. The motivation to define is to remove ambiguity, yet when the constructs involved are highly abstract, frequently overlap with other related constructs [6], and appear sometimes to have more than one essence, the resulting definitions are likely to be more personal than universal. Furthermore, variables other than complexity also complicate the process of achieving a set of unitary definitions for cognitive rehabilitation. 'Cognition' or 'brain function' are expansive constructs in themselves. How these constructs get carved up and their various parts defined can end up being driven as much by taste as by science. In approaching a broad construct of any kind, there are various preferences and orientations of those doing the

D. Holland et al. / NeuroRehabilitation 8 (1997) 21-29

carving up and defining. 'Lumpers,' for example, tend to see and carve up the larger construct into fewer, bigger sub-constructs; while 'splitters' tend to see more distinctions, more unique essences, and thus smaller parts within the larger whole [7]. For example, some clinicians prefer to use single, global concepts like 'executive functioning' to describe behaviors such as initiation, persistence, and planning/organization, while others parse such global concepts into the specific subtypes [2]. Even reliance on quantitative solutions does not eliminate this problem. This is evident in factor analytic techniques, where different approaches to classification can be applied to the same data [8].

The problem for cognitive rehabilitation, then, is two-fold: not only do taxonomies differ with regards to number of cognitive categories or domains, but how these various domains are named and defined is highly individualistic. If a working taxonomy and unitary definitions are not established, the potential result is a virtual Tower of Babel even within a single treatment setting when it comes to communicating evaluation results and rehabilitation planning. 3. The validity of cognitive constructs Within psychology there is a classic body of literature addressing constructs, both their definitions [9] and their validation [10]. Of particular importance, Meehl [11] well describes the conceptual problems encountered with such psychological constructs or open concepts. He detailed the need to specify operational criteria and to refine these criteria empirically via a matrix of convergent and discriminative validities [12]. Indeed, the need to be functionally oriented and prescriptive in cognitive rehabilitation settings is complicated by the dependence upon abstract, or implicit, constructs that have not been operationalized or validated. In physical rehabilitation, for example, achieving a functional treatment focus is much less complicated by theoretical target constructs since assessment and treatment domains are frequently observable and more clearly defined (e.g. range of motion, postural responses, etc.) [13]. On the other hand, the often

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difficult identification of functional cognitive deficits (e.g. impaired visual-organizational abilities), is the essential starting point for cognitive rehabilitation efforts. The problem of construct validity of cognitive domains has been identified by numerous researchers [14-16]. Both the multi-dimensional nature of cognitive constructs and how these broad constructs are labelled continue to give rise to differing views among researchers and clinicians. For example, Sohlberg and Mateer [17] made a distinction between various attentional processes (focused, sustained, selected, etc.) while Shum et al. [18] argued that there is no empirical support for a multi-domain taxonomy of attention. Or, as Johnstone and Frank [14] pointed out, the Wechsler Memory Scale-Revised (WMS-R) Attention Index is a dependable measure and is clearly represented in factor analytic studies of the entire test, but it remains unclear whether its designation as a measure of attention is accurate. Along the same lines, there are a number of examples of very similar tests measuring what is likely a similar cognitive construct, but the construct receives different labels. For example, the Number/Letter Memory subtest on the Wide Range Assessment of Memory and Learning (WRAML) is very similar in form and content to the Digit Span subtest of the Wechsler Memory Scale-Revised (WMS-R). Yet, the Number/Letter Memory subtest purports to measure 'verbal memory' and the Digit Span subtest purports to measure 'attention' [14). The discrepancy in what constructs are called, if not corrected, could complicate the treatment process if the treatment plan for, say, impaired verbal memory is in fact different than the treatment plan for impaired attention. This problem of construct validity is not unique to cognitive constructs and has been grappled with in the realm of psychiatric diagnostic categories and definitions of mental health [19]. Strupp and Hadley [20] made the point that 'If conceptions of mental health are fuzzier than ever, how can we determine whether a particular intervention has led to improvement, deterioration, or no change?' This question is precisely that which is now being posed in the field of rehabilitation with regards to cognitive constructs and cognitive re-

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habilitation. The fact that the abstract constructs involved in mental health and cognitive rehabilitation are difficult to define, clarify, and validate is a reflection of the level of abstraction in the subject matter addressed by these fields, and should selVe as an impetus to continue increasingly sophisticated empirical efforts. The conclusion of many researchers, however, is that there has not been sufficient attention paid to construct validity in neurobehavioral research [14,21,22]. Continued empirical efforts will eventually improve this situation, but in the meantime it is necessary to establish a working standard in clinical settings in order to foster interdisciplinary team efficiency. Cronbach [23] has emphasized that the process of construct validation is complex, creative, 'cannot be reduced to rules, and no interpretation can be considered the final word, established for all time'. During the fluid course of this empirical validation process then, a clinical model needs to be established for the immediate implementation of team-based cognitive rehabilitation. 4. The need for community standards Achieving a universal taxonomy in cognitive rehabilitation with unitary constructs and critical pathways for all treatment will be a protracted process, since it will be determined by cumulative empirical and theoretical advances over time. Nevertheless, in order to achieve efficiency within each cognitive rehabilitation setting, each team must arrive at a taxonomy and a set of working definitions in order to develop cognitive rehabilitation plans in a coordinated manner. Until a set of unitary constructs and critical pathways for treatment are achieved for all cognitive rehabilitation settings, each setting will need to develop its own set of 'community standards' for unified cognitive rehabilitation practice. Employment of community standards to achieve greater coordination and more efficient communication has been central to behavior modification settings, e.g. designing behavioral codes [24] and business settings e.g. making strategy, policy, structure, and systems explicit [25]. There are a number of reasons why implementation of explicit

community standards within settings for cognitive rehabilitation may have been slower to occur. One is that many rehabilitation settings continue to have a primary focus on physical rehabilitation with traumatically brain injured patients, targeting problems such as ambulation, swallowing, and toileting rather than cognitive or behavioral outcomes. Also, rehabilitation settings were initially more multi disciplinary than inter disciplinary, so that disciplines worked together in the same physical space, but treated the patient separately [26]. With the increased development of an interdisciplinary focus came greater coordination, but there has been a residual adherence to discipline specific goals, emphases, and jargon. Furthermore, health care disciplines have fostered a strong professional identity that is frequently disciplinespecific, and relinquishing traditions that are specific to the discipline in order to reach interdisciplinary community standards can be difficult. Finally, the hierarchical style that has been long established in health care settings involves a tradition of top-down administration. Interdisciplinary teams, while necessitating leadership, nevertheless rely on more horizontal communication patterns, which can be hard to achieve if any single discipline, whether medicine, psychology, nursing, etc., has traditionally dominated the team in a given setting. The goal of the interdisciplinary approach in cognitive rehabilitation is to offer input from multiple perspectives, with multi-faceted assessment, and comprehensive treatment [27]. To the extent that communication is incomplete or inefficient, this coordinated process will not occur and conflicts may arise [26]. The goal therefore is for each setting to establish its own set of community standards, consisting at least of a taxonomy of cognitive constructs to be targeted for assessment and treatment, clear definitions of these constructs, and a set of general guidelines for how the team will most likely approach the rehabilitation process for each construct. The intent is that such a set of standards will establish cognitive rehabilitation as a legitimate focus of treatment, foster more efficient and horizontal communication patterns among team members, and provide a general taxonomy for the team to use as guidance in assessment and treatment planning.

D. Holland et al. / NeuroRehabilitation 8 (J997) 21 -29 Table 1 Process of developing community standards in cognitive rehabilitation settings Assumptions: 1. Brain injury rehabilitation consists of more than physical rehabilitation and conditioning. Identifying and treating cognitive deficits is a significant aspect of comprehensive brain injury rehabilitation. 2. Establishment of a set of standards for the interdisciplinary team will result in more coordinated cognitive rehabilitation treatment within a given setting. Steps: 1. Establish a task force leader and team A designated leader gathers representatives from each rehabilitation discipline potentially involved in the cognitive rehabilitation program (occupational therapy, speech/language pathology, nursing, neuro/rehabilitation psychology) and outlines the purpose of the task force.

2. Provide preparatory education and review of assumptions Information-sharing and self-education may be necessary for those task force members less familiar with the cognitive sequelae of brain injury or in settings that have previously focused solely on physical rehabilitation. 3. Establish a taxonomy This step involves outlining a taxonomy of global cognitive constructs that represents a consensus among task force members (see Table 2). The global cognitive constructs identified should be those the team intends to treat in a coordinated manner, recognizing certain disciplines will be primarily responsible for the treatment of certain cognitive domains (e.g. speech/language pathology having primary responsibility for disorders of speech). 4. Determine lay definitions Definitions of cognitive constructs in lay terms can be developed to facilitate communication with patients and their families regarding cognitive rehabilitation process. 5. Develop general treatment guidelines General treatment strategies for each cognitive domain must be established. A general distinction might be made between remediation and compensatory approaches to cognitive rehabilitation (see Table 3). This step may be brief and consist of delineating cognitive treatment trends that already exist in a given setting, or protracted in settings where cognitive rehabilitation has not been previously introduced or maximized. 6. Disseminate results and receive feedback Once the task force arrives at a taxonomy and guidelines for treatment, a process of education is needed throughout the entire setting. This might be achieved through interdisciplinary inservices and discipline-specific training. Treatment staff throughout the setting should be encouraged to provide constructive feedback regarding the taxonomy and guidelines, so that inclusive input is gained and revisions of the working draft can be made.

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5. The Missouri model 5.1. The task force

A cogmtive rehabilitation task force was established at the University of Missouri-Columbia School of Medicine, Rusk Rehabilitation Center. The purpose of the task force was to establish a working taxonomy and set of treatment suggestions for interdisciplinary approaches to cognitive rehabilitation within Rusk Rehabilitation Center inpatient and outpatient settings. Table 1 describes the general progression and steps involved in the task force project. The task force consisted of representatives from occupational therapy, speech/language pathology, nursing, learning skills, rehabilitation psychology, and neuropsychology. The task force met weekly over a 8-week span to develop the set of community standards. The task force identified five broad areas of cognitive functioning that would constitute the taxonomy for use in rehabilitation (see Table 2). These five broad cognitive domains were deemed to be of the greatest functional relevance. The task force then broke down these broad domains into specific abilities that could be argued to represent relatively unitary cognitive constructs. For example, the domain of attention was broken down into three critical processes (focused attention, attention span, divided attention) and memory was identified as having specific modalities (verbal, visual, motor). These distinctions were made by the task force to address clinically significant facets within each Domain that would have implications for differential assessment and/or treatment strategies. In addition to providing a standard template and uniform set of definitions for use among therapists, the task force provided definitions of cognitive constructs in lay terms for use in communicating with patients and their families. The goal was to use these definitions to foster patient and family education regarding the cognitive rehabilitation process, and to enhance communication among rehabilitation personnel. Finally, general guidelines for treatment within each cognitive domain were clarified. A broad distinction was made between remediation versus

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Table 2 Domains identified for cognitive rehabilitation by the Missouri task force 1. Language A. Expressive (phonology, semantics, syntax, etc.) B. Receptive (reading comprehension, oral language comprehension) 2. Memory A. Verbal B. Visual C. Motor D. 3 phases of memory to consider (encode, consolidate, retrieve) 3. Visual spatial A. Input (figure/ground, depth perception, visualclosure, etc.) B. Output (construction, route finding, spatialorientation, etc.) 4. Attention A. Focused attention (ability to ignore distractions) B. Attention span (length of time able to attend) C. Divided attention (ability to process simultaneously presented material) 5. Problem solving A. Speed of processing B. Sequencing C. Flexibility D. Idea generation/task analysis E. Planning/organization F. Initiation O. Evaluation of strategies H. Attention to detail I. Self-awareness J. Time management

compensatory approaches to cognitive rehabilitation, realizing that these approaches are not dichotomous and that the techniques listed could not be exhaustive. Nevertheless, within the Rusk Rehabilitation Center,· trends existed in approaches to cognitive rehabilitation, and it was felt to be important to delineate these trends. Table 3 presents an example from the visual-spatial domain to illustrate the complete set of cognitive treatment guidelines. 5.2. The working model

Given the fluid nature of staff in most rehabilitation settings, the evolving status of most rehabilitation teams, and the accumulation of em-

pirical support or refutation of a clinically based taxonomy, any model should be assumed destined for change. This destiny does not hinder the immediate usefulness of a set of community standards, however. Indeed, articulating community standards will hopefully give rise to a focused development of progressively more sophisticated approaches to cognitive rehabilitation within each setting. The community standards established by the Missouri task force were arrived at on the basis of direct clinical experience of the task force members (Tables 2 and 3). Although knowledge of research in the areas of cognitive constructs, particularly in the area of construct validity, informed this process [2], the purpose of these standards was to coordinate clinical care in cognitive rehabilitation. Suggestions based on clinical knowledge and experience were given primary importance. 5.3. The need for team building in conjunction with community standards

The need for community standards extends beyond unitary definitions and coordinated treatment approaches. A protocol for developing a team itself is often necessary [28]. The difficulty of maintaining a productive and cooperative team in health care settings is a problem that must be addressed explicitly. To build a successful cognitive rehabilitation team, clinicians need to ask 'What are our goals?', followed by, 'How will we implement the key activities to reach our goals?' [25]. It is important for each team member to know what to do and to know what each one of the other team members is doing. Clearly, establishing a set of standards like that outlined in Tables 1 and 2 can provide the foundation of team building, since it affirms a process of communication, education, and mutual respect among team members. Ineffective and dysfunctional teams are characterized by a few rigid rules [29], a limited network of communication or interaction patterns [26], and an inability to change to accommodate new or unusual situational demands or treatment needs [30]. The effective cognitive rehabilitation

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Table 3 An example from the visual-spatial domain as an illustration of community standards for cognitive rehabilitation Visual-spatial ability

Treatment strategies Remediation

Compensation

Graded identification, repetition across settings (context specific)

Environmental restructuring (staff/family teaching)

2. Depth perception

Graded identification, repetition across settings (context specific)

Environmental restructing (staff/family teaching)

3. Visual-closure (part-hole relationships)

Graded identification, repetition across settings (context specific)

Environmental restructing (staff/family teaching)

A. Input 1. Figure/ground (discrimination of important visual details / objects)

Environmental restructing, cuing, mapping

4. Field cuts (inability to see certain areas) Red lines techniques, highlighting, grading of cues (muItimodaI), scanning positioning, environmental restructing (shaping attention to neglected side)

Mapping, cuing environmental restructuring

Repetition, copying, graded construction (assembly)

Note taking assistance, written/verbal cues

2. Route finding (finding one's way from place to place)

Repetition, graded cuing

Mapping, cuing, written directions, environmental cues, seek assistance (ask for directions)

3. Spatial orientation (where you are in relation to other things in the environment)

Graded environmental organization, estimation of distance with repetition

Environmental modifications, external cuing, activity restrictions

4. Body schema (recognizing body parts)

Sensory input with body part identification, positioning, continual cuing

Positioning, labeling, matching, external cuing

5. Neglect (unawareness/ inattention to spatial areas)

B. Output 1. Construction (ability to copy/draw /build)

team will have open channels of communication across disciplines, a willingness to depart from traditional rules or practices in order to solve unique problems, and an emphasis on building not only the team, but facilitating the individual goals of those members within the team. It is imperative that the establishment of community standards for the team serve to clarify goals and

enhance ·flexible, coordinated services without restricting innovation. 6. Conclusion Cognitive rehabilitation constitutes an area of rapid and promising advancement in neurobehavioral rehabilitation settings. The current environ-

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ment of differing theories and definitions can be viewed as ultimately constructive, if it reflects a natural stage in the maturation of the field. The need exists, however, to bring a pragmatic order to the implementation of cognitive rehabilitation within current treatment settings. The model for developing community standards offered here is intended to highlight one such effort at establishing local order. The task force approach to developing such a set of community standards, with equal input from representatives across disciplines and feedback subsequently encouraged from all treatment staff in the setting, is particularly amenable to change and development. The advantage of such a process based on increased horizontal communication and democratic input within the treatment setting is that mistakes are retrievable [31] and the team itself is strengthened. The intended result of such an endeavour is improved interdisciplinary functioning with regards to cognitive rehabilitation and, ultimately, enhanced patient care.

[7] [8] [9]

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[12]

[13]

[14]

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Acknowledgements [18]

The authors acknowledge the contribution of the following individuals as members of the Missouri task force: Brick Johnstone, Giuli Krug, Gale Rice, Lisa Scott, Richard Tollerton. References [1]

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