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Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20
"I Beg to Differ" a
b
Roberta G. Sands PhD , Judith Stafford MSW, PhD & Marleen McClelland MS
c
a
Associate Professor, College of Social Work, Ohio State University, Columbus, OH 43210 b
Assistant Professor, Department of Sociology, Social Work, and Corrections, Moorehead State University, Moorehead, KY 40351 c
Staff Physical Therapist, Riverside Hospital, Columbus, OH Published online: 26 Oct 2008.
To cite this article: Roberta G. Sands PhD , Judith Stafford MSW, PhD & Marleen McClelland MS (1990) "I Beg to Differ", Social Work in Health Care, 14:3, 55-72, DOI: 10.1300/J010v14n03_04 To link to this article: http://dx.doi.org/10.1300/J010v14n03_04
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'I Beg to Differ': Conflict in the Interdisciplinary Team
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Roberta G. Sands, MSW, PhD Judith Stafford, MSW, P h D Marleen McClelland, MS
ABSTRACT. Three cases in which interdisciplinary teams experienced conflict were examined in depth. Disagreement within the team was expressed covertly and overtly. In the face of conflicting perceptions, team members attempted to influence others to agree with them, changed their own recommendations, or tried to find an area of compromise. Team members did not fully address differences across disciplines. Interactions during these cases suggest that team members see themselves primarily as representatives of their own discipline rather than as members of a team. Different values and theoretical perspectives seem to influence divergence of opinion. A need for a common value base, language, and conceptual framework was evident. Conflict is a natural and inevitable development of interdiscipli-
nary team life (Kane, 1983; Margolis & Fiorelli, 1984; Sampson & Marthas,
1981). Like anger, conflict m a y be experienced a s dis-
Roberta G. Sands is Associate Professor at The Ohio State University, College of Social Work, 1947 College Road, Columbus, OH 43210. Judith Stafford is Assistant Professor at Moorehead State University, Department of Sociology, Social Work, and Corrections, UP0 947, Moorehead, KY 40351. Marleen McClelland is Staff Physical Therapist, Riverside Hospital, Columbus, OH and is a PhD candidate, The Ohio State University, College of Education, Columbus, OH 43210.
The authors gratefully acknowledge the cooperation of the team members and families observed in this study. Funding provided by The Ohio State University is also appreciated. This article is based on a paper presented at the Interdisciplinary Health Care Conference, Toledo, OH, September 1988. Social Work in Health Care, Vol. 14(3) 1990 The Haworth Press, Inc. All rights reserved.
O 1990 by
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turbing or threatening, but from the perspective of group decisionmaking, conflict is desirable (Margolis & Fiorelli, 1984). When differences of opinion surface, team members are able to examine issues from a variety of perspectives, distinguish substantive from interpersonal issues, and identify and address underlying tensions within the team. In the process of negotiation that ensues, the conflict becomes a catalyst for growth. Conflict in teams reflects more than a clash of perspectives among team members. Sometimes the conflict mirrors the emotions experienced by clients and their families or contradictions at the systems level (Nason, 1981, 1983). By looking at its own emotional reactions, the team can diagnose and clarify client issues, provider issues, institutional practices, and societal impediments that underlie the conflict (Nason, 1983). "Disagreements that are internal can be negotiated within the team: disagreements that are a reflection of institYutiona~priorities requirk efforts at system changes, not interprofessional blaming and name calling" (p. 38). The emotions that surface in the team may be related to its own dcvelopmental process. Lowe and Herranen (1981) describe stages in which the team moves from a posture of emotional repression and turf guarding to conflict avoidance to a stage in which overt conflict emerges, to a point in which the group becomes committed to working together as a unit. Germain (1984) describes similar stages of interdisciplinary collaboration in which team members progress from "fragmented thinking about the patient-and context, based on disciplinary specialization, to a holistic or systemic view of patient-environment relationships bearing on health and illness" (p. 203). Teams that achieve higher levels of development have fluid boundaries and flexible roles (Lowe & Herranen, 1981). Decisions are driven by client needs rather than professional rivalries. Conflict in interdisciplinary teams is associated with a number of sources. Disciplines that have overlapping functions may perceive each other as competitors (Lister, 1980; Lowe & Herranen, 1978, 1981). Differences in professional values, professional socialization, philosophy, or theoretical perspective are other sources of conflict (Mizrahi & Abramson, 1985; Mailick & Ashley, 1981). In this respect, some disciplines see themselves as advocates for the client whereas others are concerned with producing factual evi-
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dence of the existence of clinical syndromes. Another source of conflict lies in the status differences between disciplines (Wikler, 1980). Teams that are run by a discipline that views others as ancillary may arouse resentment and run counter to the democratic ideal of team functioning (Kane, 1983). More democratically run teams are in keeping with a collaborative or consensus model of team functioning (Mailick & Ashley, 1981; Mailick & Jordan, 1977). Such teams emphasize egalitarianism, cohesion, group problem-solving, and shared responsibility. Nevertheless, "the pressure for consensus does not fall equally on all of the participants" (Mailick & Ashley, 1981, p. 132). Authority within the interdisciplinary team is related to the status of the profession, legally sanctioned powers, demographic characteristics, and personality traits (Mailick & Ashley, 1981). Accordingly professions with a lower status may feel more compelled to conform to group norms than more autonomous, higher status groups. Furthermore, the split between caring and technical professions and an externally supported technical bias have complicated interdisciplinary collaboration (Nason, 1983).
RESEARCH STUDY This paper derives from a larger ethnographic sociolinguistic research study of interdisciplinary communication in a center in which children are evaluated for possible mental retardationtdevelopmental disabilities. The two teams that were studied operated according to a consensus model. The disciplines that were represented on the teams were pediatrics, audiology, psychology, nursing, dentistry, social work, special education, physical therapy, occupational therapy, nutrition, communications, and adapted physical education. The conceptual framework ("constructivist") and research method are described in a previous paper (Sands, 1989). The organizational setting and disciplines that were observed were regarded as cultures that are characterized by a shared language, norms, values, and ways of perceiving. In keeping with the qualitative research paradigm that was employed, the researchers did not begin with a particular theory about teams that they wished to test empirically.
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Instead, hypotheses and theory emerged inductively from the data (Taylor & Bogdan, 1984). The research process entailed a year-long period of systematic observation of biweekly meetings of two clinical preliminary assessment teams. Data were in the form of audiotape recordings, field notes, and written documents on cases that were presented. In addition, complete interdisciplinary evaluations on five cases (approximately 14 hours per case) were videotaped and studied in depth. The teams followed a standard procedure in the cases that they evaluated. First the cases were formally presented by a case coordinator to the preliminary assessment team. The case coordinator could be a member of any discipline and frequently was a student. A student case coordinator worked under the supervision of a preceptor, who was a professional of another discipline. The initial case presentation took place after the case coordinator had gathered reports from professionals in the community and after contacts with the family and school were made. The presentation consisted of a description of what was known about the case, as well as the client's strengths and weaknesses. Team members interacted with each other in asking questions and raising concerns about the case and together developed an interdisciplinary assessment plan. In the next few weeks, the child was evaluated by team members or supervised students of the relevant disciplines in keeping with the plan. After these evaluations were completed, the team reconvened at a post-clinical meeting to discuss the results of the evaluations and to come to a conclusion about what to tell the family. Next the team met with the parents often together with a professional from their home community. One of the questions that emerged during the process of conducting this research was, "How are differences of opinion expressed on the teams? How, if at all, are they reconciled?" Over time the researchers became aware of recurring instances in which differences in perspective became part of team deliberations in the case studies. In the course of evaluating the data, the researchers found that social conflict theory was particularly relevant to this study.
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Social Conflict Theory The sociologist Georg Simmel was one of the earliest theorists to discuss conflict. To Simmel (1904) conflict is pervasive, built into the social structure, and productive of social unity. During a conflictual situation, disputing parties achieve consciousness, solidarity, and unity and become connected to the social order (Abramson, 1981). Expanding on Simmel's ideas and integrating them with functionalism, Lewis Coser (1956) outlined the ways in which conflict contributes to the maintenance of the social order. So long as the social system is flexibly organized (i.e., open) and the issues under consideration are not central to the existence of the group, conflict can contribute to the maintenance of relationships, revitalization of social norms, development of new norms, release of tension, and an adjustment of the balance of power within the social system. A flexible system allows for "realistic" conflict, that is, conflict that arises from specific issues. In addressing these issues, the organization achieves unity. When a social system is rigid, however, expression of conflict is inhibited and conflicts that challenge basic values and goals arise. Although these conflicts provide a mechanism for tension release, they threaten the basis for consensus in a social system (Coser, 1956). Conflict was evident in three of the five cases that were videotaped. Two of the cases involved pre-school age boys about whom school placement for the following year was at issue. The other case was a child with a speech impediment for whom the recommendation for an alternative communication system aroused conflict. These cases will be described and analyzed separately with special attention to the expression of differences of opinion among proiessionals in the post-clinic team meetings. After the three cases are discussed, theoretical implications will be identified. CASE STUDIES
Case 1: Nicholas Nicholas is a six-year-old boy who was referred to the center by his teacher, who was concerned about his school performance. This
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child was repeating kindergarten and doing poorly at letterlnumber recognition, visual-motor skills, following directions, and completing tasks. In addition to these general cognitive concerns, Nicholas' parents had identified communication as a problem. His communication was largely nonverbal, and his verbal attempts were unclear. Lastly, Nicholas exhibited motor problems, which were initially described as "clumsiness." During the preliminary assessment meeting, the team identified four problems-communication, unknown cognitive status, motor concerns, health issues (wax build up in his ears), and family issues (dual career family). The psychologist observed that according to the information they already had, Nicholas had strength in the cognitive area. When his sensori-motor skills were discussed, someone described Nicholas as "clumsy" whereupon the adapted physical educator remarked, "We don't like the word 'clumsy'-it's a label." The team agreed that the child should be evaluated by audiology, communications, psychology, occupational therapy, adapted education, .pediatrics, nutrition, and social work. .physical During the post-clinic meeting, when the professionals who had performed evaluations gave their reports, there were several issues of conflict. The main point of contention was over the degree of delay exhibited by the child and the resulting recommendation for placement in a developmentally handicapped (DH) classroom. The recommendation was introduced by a psychology intern and was based on IQ test scores of below 50. Two other disciplines, adapted physical education and occupational therapy, found inconsistent responses in their evaluations, and communication said that Nicholas' non-verbal behavior indicated that he had higher capabilities than that which was demonstrated in the psychology examination. The team's disagreement was, at times, vocal and overt. The most salient issue of conflict centered on terminology and the effect of its use to accomplish the team's purpose. In the course of the discussion, terms for the child's assessment included mental retardation (MR), developmentally handicapped (DH), learning disabled (LD), and cerebral palsy (CP). Concern over "labeling" was reflected in the statement, "Once we stick him in that DH class. . . ." A debate over terms is reflected in a discussion among three disciplines:
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Communication: To see that kid in an MR class . . . Psychology: Nobody said MR. Adapted physical education: That's what DH is. The team was aware that its evaluation would be utilized for school placement, but there was concern that the decision would rely solely on the "numbers" reported on psychological tests. As one participant said, "You can't argue with numbers, but I want to, and obviously you're going to say, well, this is the number. . ." In fact, the team coordinator reminded the team of the external demands when she said, "Unfortunately the way, in the state of XXX, that they categorize these kids is by the number." The team spent considerable time and asked repeated questions about the tests themselves. Team members asked which tests were or were not done and challenged the reliability of the tests, the boundaries for scoring, and the capacity of the tests to consider nonverbal as well as verbal responses. In the course of this discussion, another psychologist was called into the room to assist the psychology intern in interpreting scoring techniques. Another topic of intense debate was the evaluation results found to be inconsistent within a discipline or in conflict with the results of another discipline. Testing by occupational therapy yielded different results on the two separate days in which the child was evaluated. Adapted physical education saw "splintered skills." One member stated, "I wonder if there's some inconsistent things going on, something we didn't see that particular day that happens on another day." Despite the disagreements and even upon questioning the reliability of the tests given, the psychology member asserted, "I'm pretty confident in these results." The outcome of the team discussion remained to recommend a developmentally handicapped (DH) placement. There was, however, concurrence to also recommend that Nicholas be reevaluated in one year, even though by law he does not have to be retested for three years. There was some expression of optimism that Nicholas' strengths could be developed within a smaller DH classroom setting and that a year of such programming would yield significant changes in his performance.
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Analysis Conflict was aroused in this team over the inconsistency of evaluation results within a discipline and between disciplines. The internal consistency (between scores on the psychological tests) seemed to afford assurances to psychology that were not evidenced in other disciplines. Team members could not accept a single perspective that was not confirmed in their respective disciplines. They expressed this overtly by debating about terminology and the reliability of the psychological tests. However the team might feel about "numbers," they were constrained by the fact that scores on psychological tests are the basis for categorizing children. The team recognized this reality in accepting the recommendation of the psychology representative that the child be placed in a DH class. Nevertheless, the team compromised in agreeing to recommend retesting a year later; and in reiterating statements about the child's strengths. Case 2: Steve
Steve was four and a half years old at the time that he was evaluated by the team. The major presenting problems were (1) expressive language development difficulty; (2) short attention span; (3) lack of interest in learning; and (4) difficulty with sequencing. He was referred to the center by his family who requested advice on programming that would prepare Steve for kindergarten the following fall. This case was presented to the preliminary assessment team by a male psychology intern functioning as case coordinator with a female occupational therapist in the role of preceptor. The team discussion centered around whether or not Steve's behavior was due to hyperactivity or attention deficit problems or was age appropriate behavior about which the parents had unrealistic expectations. When the team was developing an outline of the problems, the preceptor said that there was a lack of information about Steve's health. One sub-topic was added-questionable visual activity and visual motor status-after which the pediatrician said that on the basis of the medical record, Steve does not have medical problems; that there was no need for a medical examination. The team, how-
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ever, prevailed upon the doctor to perform such an examination, as this would help assure the family that a complete evaluation had been conducted. The other problems identified were unknown cognitive status, communication difficulties, family issues, and behavioral concerns. The evaluations recommended by the team were to be performed by audiology, psychology, communication, occupational therapy, optometry, pediatrics, and social work. When the team reconvened at the post-clinic session, the pediatrician reported that Steve had no medical problems. On the basis of his evaluation, the psychology internlcase coordinator concluded that Steve's problems were due to emotional stress and that with appropriate structure, Steve would outgrow his difficulties. The other disciplines appeared to agree, except for the occupational therapist (the preceptor). She indicated that her screening tests showed that Steve was behind and was not ready for kindergarten. Because the occupational therapy and psychology test results were in conflict. the occu~ationalthera~istrecommended retestine. The psycholo& intern did not supPoit this suggestion, so afteysome discussion, the team coordinator (an administrator) asked further questions about the tests and reinterpreted the difficulty. Her conclusion was that although both professionals tested behaviors in the same area (sequencing skills), they actually were testing different levels of skills. This explanation seemed acceptable to the team, but it did not reduce the conflict about the recommendations the team would make to the parents. The occupational therapist felt that Steve needed practice and work in the areas in which he was weak. The psychologist offered the compromise of adding the word structured to his recommendation for a pre-school program, and that appeared to satisfy the occupational therapist. The team coordinator then asked how the team wanted to present its findings to the parents. The case coordinator said that he would emphasize the child's strengths and weaknesses. The focus would be on Steve's positive attributes and normal development. The team did spend some time discussing how they could present their findings in ways that would not imply that the parents were at fault, but it was not clear how they would accomplish this. When the team met with the parents, the case coordinator presented the following recommendations: (1) counseling for the par-
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ents; (2) a structured pre-school program; (3) more consistent discipline; (4) monitoring of Steve's progress; and (5) a book on normal development. When the occupational therapist presented her concerns, they were described as "minor, not real extreme difficulties." Just before the meeting ended, the team coordinator mentioned that Steve was not ready for kindergarten. The psychology intern, however, said that he was not comfortable "saying he was or was not; there was lots of time." Downloaded by [North Carolina State University] at 22:04 28 February 2015
Analysis
Although there were discrepancies in the findings of two disciplines who performed evaluations, in this case the team appeared to be avoiding conflict. Whereas in the previous case there was disagreement on the degree of delay, in this case one discipline viewed the child as normal and another said he was delayed. The team responded to the divergent opinions by asking themselves, "How do we reconcile this?" rather than "What does this mean? Have we missed something? Is the client performing differently in different environments?" In this case the team coordinator offered an interpretation that allowed each discipline's results to be correct; and the psychologist offered an acceptable compromise that the child go to a "structured pre-school" (combining his focus on structure with the occupational therapist's report that the child was behind). The compromise, however, was illusory. At the meeting with the parents, the occupational therapist minimized the problems she had identified at the team meeting. Moreover, it was not clear whether a "structured pre-school" would give Steve the kind of remedial help that the occupational therapist said he needed. In the end, when the psychologist indicated that the child may be ready for kindergarten, he seemed to be more aligned with his own recommendation than with the compromise arrived at by the team. The conflict here was not only between two disciplines (psychology and occupational therapy) but between findings of a female preceptor and a male student. The psychology student was older and more experienced than many of the student interns in this setting. Apparently he and the preceptor had not worked out their differences prior to the meeting. Even though the occupational thera-
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pistlpreceptor had a higher status than the student and functioned as his mentor for the case, the psychology student did not take the occupational therapist's recommendations seriously.
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Case 3: Jerry
Jerry, a 13-year-old, was referred to the clinic by a private psychologist who had been working with the boy and his family. Jerry had cerebral palsy and was in developmentally handicapped classes. Recently he had engaged in a number of aggressive behaviors at school and home. Other concerns were his drooling, unclear speech, and coordination. In view of Jerry's forthcoming change in schools (from a fourth grade developmentally handicapped class in an elementary school to a seventh grade DH class in a junior high), recommendations for programming, resources, and behavior management were requested. It was noted that Jerry was 5 ' 1 0 and weighed close to 130 pounds. The case was presented to a preliminary assessment team by a psychology intern working with a dentistlpreceptor. During this meeting a staff psychologist asked if an alternative communication system had ever been considered and continued to say that based on this child's intelligence scores, he would be a good candidate. He added there may be some physical problems that interfere with Jerry's ability to speak. This suggestion was followed by questions about the nature of these devices and how they are carried. Someone joked, "Maybe next year they'll be the size of a pack of cigarettes." Later the team decided to adopt an objective to determine the need for adaptive equipment. At this point the social worker argued that many people with cerebral palsy function socially without alternative communication devices. The psychologist insisted that the device was very important for a child in school. The social worker said that that was a good point, thus ending the discussion. A month later, after evaluations by various disciplines were made, the team reconvened to discuss the case. The communication specialist reported that Jerry did not drool during her evaluation and that he was almost 100% intelligible in structured tasks, 75% intelligible if the topic was understood, and 50% if the topic was unknown. The nutritionist and physical therapist reported some
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drooling in their sessions. On the basis of her evaluation the communication specialist remarked, "There's no way that I would recommend an alternative communicatipn system." The dentistJpreceptor, who had observed a number of the evaluations, concurred with the communication specialist but added that Jerry's speech was clearer during the communication evaluation than it was with other disciplines' assessments. The psychologists, nonetheless, pecommended an alternative communication device. They argue4 that Jerry had the ability to use one, it is frustrating for him to make himself understood by others, and that his teacher will not be willing to take the time to understand him. The communication specialist wondered whether using such a device would result in his having fewer opportunities to practice his language. The team coordinator wondered if the machine was a good model. The dentist said he is surrounded by good models and that computerized speech is not a better model. Someone wondered about the vocabulary the machine has and was told it had an unlimited one. The team discussed his using this to place an order at a fast food restaurant. There was a great deal of simultaneous talk during this discussion. Finally the team coordinator said, "The only thing to say at this point is that it is an option that is possible." She said that inasmuch as the team is having a hard time deciding, let the family and the child decide. The dentistlpreceptor concurred. After further discussion about Jerry's possibly becoming too dependent on the machine, the physical therapist said, "1 think that it could be a nice additive to the speech and language skills. . . ." The conclusion, stated by the preceptor, toward the end of the meeting was, "We're going to suggest that it's available if they want to pursue it." The child's private psychologist, who attended this meeting, however, remarked, "If you say that as a mild suggestion, it won't be followed up" (by the family). The team was not able to agree to anything beyond exploring this option with the family and offering to show the family one of the devices and demonstrate how it is used. The psychologist was asked to find a model device for the family. Ordinarily the team meets with the family immediately following
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the post-clinic team meeting, but on the day both sessions were scheduled, the family had an emergency and had to reschedule the meeting. Two weeks later, the team reconvened for a short meeting prior to session with the family. Before the formal beginning of this session, the preceptor told those who had arrived that he wished to. clarify the issue of the communication device. He asked the psychologist if she still wished to bring up this issue. The psychologist said that she did and that she had identified a place in the community in which a device could be seen. The communications person said that she was willing to go along with the recommendation but was concerned about Jerry's feelings. She then asked the psychologist to present her thinking on the subject. The psychologist said that it would help Jerry interact in certain situations (such as ordering food at a fast food restaurant) but it was not to be a substitute for speaking. She added that there was concern about Jerry's becoming dependent on the device; that Jerry needed to interact with other people; and therefore her recommendation would be that if the family wants this option, he should use the device as a supplement to ordinary speech. The communication person said that Jerry's feelings should be clarified, and the psychologist concurred. The physical therapist said that they had an obligation to present options to families and not to assess their value. The preceptor commented that the group had mixed feelings. The psychologist said that they were in agreement to leave it up to the family. The preceptor wondered how they could present ii as an option when the team did not have a sample to show the family. The team coordinator said that they could point the family in the right direction if they are interested; that clearly this was not a strong recommendation. During the session with the the psychologist recommended the communication device as an option. She said that it might give him mobility in social interactions so iong as he did not use it as a crutch. The communications specialist asked the family how they felt about it. The mother said that it would be like using a calculator instead of learning how to do math. The preceptorldentist admitted that the team had mixed feelings about it. The psychologist said that they can facilitate the family's getting one; that he can
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use it only in certain situations. The family did not pick up on this recommendation. The team went on to discuss other topics.
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Analysis The interdisciplinary team that evaluated Jerry was ambivalent about recommending an alternative communication device from the time the suggestion was raised by psychology at the preliminary assessment meeting. Differences of opinion were diffused among the members throughout the process. At the first post-clinic team meeting, the communication specialist expressed the opinion that, on the basis of her evaluation, there was no need for such a device. The psychologist, however, argued for the device, getting some support and some objections from others. Individuals on the team who had leadership roles recognized that the team had mixed feelings (the preceptor) and moved the team toward consensus (team coordinator). This resulted in the compromise that the team present the family with the option of the child's utilizing this device. When this mild recommendation was presented to the family, the family expressed a lack of interest. Interestingly, the preceptor told the family that the team was having difficulty coming to an agreement on this issue. It is significant that psychology and communications disagreed on this issue. The use of a communications device seems to be an issue relevant to the professional domains of both fields. Psychology views communication as a component of cognition. Communication sees verbal, non-verbal, and auxiliary communication as part of its domain. This case touched on the borderland between disciplines.
DISCUSSION The conflicts that occurred in all three cases were problematic for the team. The expectation was that the team come to a consensus so that when they would meet with the parents as a group, they could present a "united front." In all cases a compromise was reached, but in the case of Steve, this involved one discipline's minimizing
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areas of conflict, and in the case of Nicholas, the team introduced a recommendation to mitigate the recommendation (retest a year later). Team members did not seem to look at conflict as an opportunity for growth. Instead, they appeared to recognize three alternatives: (1).influence others to agree with them; (2) change their own recommendations; (3) find a middle ground or some area in which they can agree. In one case (Steve) an illusory compromise was reached. In another (Nicholas), one discipline's recommendation prevailed. In the third case (Jerry), the team agreed that it could not agree and passed the decision on to the parents. It mav be that the structure of the teamine orocess contributed to some o i the difficulties. Representatives orihe various disciplines presented their conclusions and recommendations at the post-clinic ieam meetings. By this time, they had already come to'decisions, which they defended. With the pressure of coming to a consensus within an hour (after which time the family arrived), the need for expedience influenced outcomes. Accordingly compromises that preserved a united front but did not explain or integrate differences occurred. Only in the case of Jerry, in which two post-clinic team meetings were held, did the team have time to air their concerns and at least agree that they disagreed. This case was unique, too, in that the family was told that the team was not of one opinion on the issue. Team members expressed their differences of opinion in a variety of ways. Disagreement seemed to be masked in pre-assessment planning meetings through questioning, joking, and commenting on the use of terminology. At the post-clinic team meetings differences were expressed through asking pointed questions, expressing diver.gent opinions, making affirmative statements, challenging, and arguing. At a number of these junctures, loud and simultaneous talk occurred. During the meetings with parents, differences of opinion were rarely expressed. In all three cases, the team grappled with inconsistencies. Some children performed well in one evaluation and poorly in another. The consistencies of test results and behaviors within a discipline's evaluation and across disciplines were discussed. The team's ap-
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proach to dealing with differences across disciplines and evaluation contexts varied. Sometimes they used the inconsistencies as a point of discussion to better understand the case and why differences occurred across contexts (e.g., Jerry). In other cases, disciplines seemed to be competing with and challenging each other. In the case of Nicholas, for example, team members seemed to attend more closely to consistencies within disciplines than across disciplines. These findings suggest that team members see themselves primarily as representatives of their respective disciplines rather than members of a whole that transcends individual disciplines. Perspectives are splintered rather than united. Team members seem to want to come to a consensus but there are barriers to integrating their findings. In the conflictual situations that were described, the perspective of a more technical and high status discipline (psychology) prevailed. This is consistent with literature suggesting that a hierarchy of disciplines and external factors (required test scores) influence team processes (Mailick & Ashley, 1981; Nason, 1983). According to social conflict theory, conflict is potentially beneficial. In order to assess the value of conflict to the team, the researchers would have to investigate the perceptions of team members after the apparent resolution of the conflict. From the perspective of the researchers, the conflicts in these cases did appear to reduce dissonance sufficiently so that the team could present a coherent message to oarents. Nevertheless. team members did not fully address difkrendes in perspectives across disciplines and in the child's performance across contexts. This resulted in the slippage of doible messages (Steve, regarding readiness for kindergarten) and the devaluing of contradictory data (Steve, Nicholas). The team minimized their own differences in their meetings with the parents, choosing to present a "united front." Social conflict theory does not address the benefits of conflict to outside groups that do not have competing interests, such as clients and client systems. In order to determine whether the conflicts experienced by the team were helpful to the child and the child's family, the researchers would have to interview the parents and follow the cases over time. On the basis of cases described here, an additional case, and interviews with key members of the team, the pre-
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sentation of a "united front" is both advantageous and disadvantageous for families. Many of the families of children who are evaluated in this center have previously received conflicting information and experienced great frustration in their search for "answers" about their children. By prese'nting unified, integrated findings, the center performs the function of clarifying the nature of the child's problem. In communicating a consistent message about the child's functioning, however, the team is not presenting a complete picture. In suppressing or minimizing discrepant results, the team is protecting the parents from hearing all perspectives and from choosing those findings - that are most compatible with the parents' own peiceptions. Regardless of whether the conflict is suppressed or expressed, findings in these cases suggest that conflict is related to differing theoretical perspectives and values. Some of the disciplines represented on the teams that were observed have different views on the value of quantitative data, the validity of certain approaches to testing, and the relationship between performance and context. Further analysis of the data gathered in this study will explore this observation further. The authors see a need for a shared interdisciplinary perspective in which there is a common value base, language, and conceptual framework (Abramson, 1984; Billups, 1987; Green & Harker, 1988) that transcends the bounds of the different disciplines. Such a framework would see diverse findings across disciplines as a stimulus for new questions. Under such circumstances, the team would be able to recognize conflict as an opportunity for growth and integration rather than a win-lose situation. BIBLIOGRAPHY Abramson, M. (1984). Collective responsibility in interdisciplinary collaboration: An ethical perspective for social workers. Social Work in Health Care, 10 (I), 35-43. Billups, J. (1987). Interprofessional team process. Theory into Practice, 2, 146152.
Coser, L.A. (1956). The functions of social conflict. The Free Press of Glencoe. Germain, C.B. (1984). Social work practice in health care: An ecological perspective. New York: The Free Press.
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Green, J.L. & Harker, J.O. (Eds.) (1988). Multipleperspective analyses of classroom discourse. Norwood, NJ: Ablex Publishing Cop. Kane, R. A. (1983). Interprofessioml teamwork. Syracuse, NY: Syracuse University School of Social Work. Lister, L. (1980). Role expectations of social workers and other health professionals. Health and Social Work, 5 , 41-49. Lowe, J.1. & Herranen, M. (1978). Conflict in teamwork: Understanding roles and relationships. Social Work in Health Care, 3 (3), 323-330. . (1981). Understanding teamwork: Another look at the concepts. Social Work in Health Care, 7 (2), 1-11. Mailick, M.D. & Ashley, A.A. (1981). Politics of interprofessional collaboration: Challenge to advocacy. Social Casework, 62 (3). 131-137. Mailick, M.D. & Jordan, P. (1977). A multimodel approach to collaborative practice in health settings. Social Work in Health Care, 2 (4), 445-454. Margolis, H. & Fiorelli, J.S. (1984). An applied approach to facilitating interdisciplinary teamwork. Journal of Rehabilitation, 50, 13-17. Mizrahi, T. & Abramson, J. (1985). Sources of strain between physicians and social workers: Implications for social workers in health care settings. Social Work in Health Care, 10 (3), 33-51. Nason, F. (1981). Team tension as a vital sign. General Hospital Psychiatty, 3, 32-36. . (1983). Diagnosing the hospital team. Social Work in Health Care, 9 (2), 25-45. Sampson, E.E. & Marthas, M. (1981). Group process for the healthprofessions, 2nd ed. New York: John Wiley & Sons. Sands, R.G. (1989). The social worker joins the team: A look at the socialization process. Social Work in Health Care, 14 (2), 1-15. Simmel, G. (1904). The sociology of conflict. American Journal of Sociology, 9. Taylor, S.J. & Bogdan, R. (1984). Introduction to qualitative methoh, 2nd ed. New York: John Wiley & Sons. Wikler, M.E. (1980). Saving face in the status race. Health and Social Work, 5 (2), 27-33.
Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20
"I Beg to Differ" a
b
Roberta G. Sands PhD , Judith Stafford MSW, PhD & Marleen McClelland MS
c
a
Associate Professor, College of Social Work, Ohio State University, Columbus, OH 43210 b
Assistant Professor, Department of Sociology, Social Work, and Corrections, Moorehead State University, Moorehead, KY 40351 c
Staff Physical Therapist, Riverside Hospital, Columbus, OH Published online: 26 Oct 2008.
To cite this article: Roberta G. Sands PhD , Judith Stafford MSW, PhD & Marleen McClelland MS (1990) "I Beg to Differ", Social Work in Health Care, 14:3, 55-72, DOI: 10.1300/J010v14n03_04 To link to this article: http://dx.doi.org/10.1300/J010v14n03_04
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'I Beg to Differ': Conflict in the Interdisciplinary Team
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Roberta G. Sands, MSW, PhD Judith Stafford, MSW, P h D Marleen McClelland, MS
ABSTRACT. Three cases in which interdisciplinary teams experienced conflict were examined in depth. Disagreement within the team was expressed covertly and overtly. In the face of conflicting perceptions, team members attempted to influence others to agree with them, changed their own recommendations, or tried to find an area of compromise. Team members did not fully address differences across disciplines. Interactions during these cases suggest that team members see themselves primarily as representatives of their own discipline rather than as members of a team. Different values and theoretical perspectives seem to influence divergence of opinion. A need for a common value base, language, and conceptual framework was evident. Conflict is a natural and inevitable development of interdiscipli-
nary team life (Kane, 1983; Margolis & Fiorelli, 1984; Sampson & Marthas,
1981). Like anger, conflict m a y be experienced a s dis-
Roberta G. Sands is Associate Professor at The Ohio State University, College of Social Work, 1947 College Road, Columbus, OH 43210. Judith Stafford is Assistant Professor at Moorehead State University, Department of Sociology, Social Work, and Corrections, UP0 947, Moorehead, KY 40351. Marleen McClelland is Staff Physical Therapist, Riverside Hospital, Columbus, OH and is a PhD candidate, The Ohio State University, College of Education, Columbus, OH 43210.
The authors gratefully acknowledge the cooperation of the team members and families observed in this study. Funding provided by The Ohio State University is also appreciated. This article is based on a paper presented at the Interdisciplinary Health Care Conference, Toledo, OH, September 1988. Social Work in Health Care, Vol. 14(3) 1990 The Haworth Press, Inc. All rights reserved.
O 1990 by
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turbing or threatening, but from the perspective of group decisionmaking, conflict is desirable (Margolis & Fiorelli, 1984). When differences of opinion surface, team members are able to examine issues from a variety of perspectives, distinguish substantive from interpersonal issues, and identify and address underlying tensions within the team. In the process of negotiation that ensues, the conflict becomes a catalyst for growth. Conflict in teams reflects more than a clash of perspectives among team members. Sometimes the conflict mirrors the emotions experienced by clients and their families or contradictions at the systems level (Nason, 1981, 1983). By looking at its own emotional reactions, the team can diagnose and clarify client issues, provider issues, institutional practices, and societal impediments that underlie the conflict (Nason, 1983). "Disagreements that are internal can be negotiated within the team: disagreements that are a reflection of institYutiona~priorities requirk efforts at system changes, not interprofessional blaming and name calling" (p. 38). The emotions that surface in the team may be related to its own dcvelopmental process. Lowe and Herranen (1981) describe stages in which the team moves from a posture of emotional repression and turf guarding to conflict avoidance to a stage in which overt conflict emerges, to a point in which the group becomes committed to working together as a unit. Germain (1984) describes similar stages of interdisciplinary collaboration in which team members progress from "fragmented thinking about the patient-and context, based on disciplinary specialization, to a holistic or systemic view of patient-environment relationships bearing on health and illness" (p. 203). Teams that achieve higher levels of development have fluid boundaries and flexible roles (Lowe & Herranen, 1981). Decisions are driven by client needs rather than professional rivalries. Conflict in interdisciplinary teams is associated with a number of sources. Disciplines that have overlapping functions may perceive each other as competitors (Lister, 1980; Lowe & Herranen, 1978, 1981). Differences in professional values, professional socialization, philosophy, or theoretical perspective are other sources of conflict (Mizrahi & Abramson, 1985; Mailick & Ashley, 1981). In this respect, some disciplines see themselves as advocates for the client whereas others are concerned with producing factual evi-
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dence of the existence of clinical syndromes. Another source of conflict lies in the status differences between disciplines (Wikler, 1980). Teams that are run by a discipline that views others as ancillary may arouse resentment and run counter to the democratic ideal of team functioning (Kane, 1983). More democratically run teams are in keeping with a collaborative or consensus model of team functioning (Mailick & Ashley, 1981; Mailick & Jordan, 1977). Such teams emphasize egalitarianism, cohesion, group problem-solving, and shared responsibility. Nevertheless, "the pressure for consensus does not fall equally on all of the participants" (Mailick & Ashley, 1981, p. 132). Authority within the interdisciplinary team is related to the status of the profession, legally sanctioned powers, demographic characteristics, and personality traits (Mailick & Ashley, 1981). Accordingly professions with a lower status may feel more compelled to conform to group norms than more autonomous, higher status groups. Furthermore, the split between caring and technical professions and an externally supported technical bias have complicated interdisciplinary collaboration (Nason, 1983).
RESEARCH STUDY This paper derives from a larger ethnographic sociolinguistic research study of interdisciplinary communication in a center in which children are evaluated for possible mental retardationtdevelopmental disabilities. The two teams that were studied operated according to a consensus model. The disciplines that were represented on the teams were pediatrics, audiology, psychology, nursing, dentistry, social work, special education, physical therapy, occupational therapy, nutrition, communications, and adapted physical education. The conceptual framework ("constructivist") and research method are described in a previous paper (Sands, 1989). The organizational setting and disciplines that were observed were regarded as cultures that are characterized by a shared language, norms, values, and ways of perceiving. In keeping with the qualitative research paradigm that was employed, the researchers did not begin with a particular theory about teams that they wished to test empirically.
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Instead, hypotheses and theory emerged inductively from the data (Taylor & Bogdan, 1984). The research process entailed a year-long period of systematic observation of biweekly meetings of two clinical preliminary assessment teams. Data were in the form of audiotape recordings, field notes, and written documents on cases that were presented. In addition, complete interdisciplinary evaluations on five cases (approximately 14 hours per case) were videotaped and studied in depth. The teams followed a standard procedure in the cases that they evaluated. First the cases were formally presented by a case coordinator to the preliminary assessment team. The case coordinator could be a member of any discipline and frequently was a student. A student case coordinator worked under the supervision of a preceptor, who was a professional of another discipline. The initial case presentation took place after the case coordinator had gathered reports from professionals in the community and after contacts with the family and school were made. The presentation consisted of a description of what was known about the case, as well as the client's strengths and weaknesses. Team members interacted with each other in asking questions and raising concerns about the case and together developed an interdisciplinary assessment plan. In the next few weeks, the child was evaluated by team members or supervised students of the relevant disciplines in keeping with the plan. After these evaluations were completed, the team reconvened at a post-clinical meeting to discuss the results of the evaluations and to come to a conclusion about what to tell the family. Next the team met with the parents often together with a professional from their home community. One of the questions that emerged during the process of conducting this research was, "How are differences of opinion expressed on the teams? How, if at all, are they reconciled?" Over time the researchers became aware of recurring instances in which differences in perspective became part of team deliberations in the case studies. In the course of evaluating the data, the researchers found that social conflict theory was particularly relevant to this study.
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Social Conflict Theory The sociologist Georg Simmel was one of the earliest theorists to discuss conflict. To Simmel (1904) conflict is pervasive, built into the social structure, and productive of social unity. During a conflictual situation, disputing parties achieve consciousness, solidarity, and unity and become connected to the social order (Abramson, 1981). Expanding on Simmel's ideas and integrating them with functionalism, Lewis Coser (1956) outlined the ways in which conflict contributes to the maintenance of the social order. So long as the social system is flexibly organized (i.e., open) and the issues under consideration are not central to the existence of the group, conflict can contribute to the maintenance of relationships, revitalization of social norms, development of new norms, release of tension, and an adjustment of the balance of power within the social system. A flexible system allows for "realistic" conflict, that is, conflict that arises from specific issues. In addressing these issues, the organization achieves unity. When a social system is rigid, however, expression of conflict is inhibited and conflicts that challenge basic values and goals arise. Although these conflicts provide a mechanism for tension release, they threaten the basis for consensus in a social system (Coser, 1956). Conflict was evident in three of the five cases that were videotaped. Two of the cases involved pre-school age boys about whom school placement for the following year was at issue. The other case was a child with a speech impediment for whom the recommendation for an alternative communication system aroused conflict. These cases will be described and analyzed separately with special attention to the expression of differences of opinion among proiessionals in the post-clinic team meetings. After the three cases are discussed, theoretical implications will be identified. CASE STUDIES
Case 1: Nicholas Nicholas is a six-year-old boy who was referred to the center by his teacher, who was concerned about his school performance. This
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child was repeating kindergarten and doing poorly at letterlnumber recognition, visual-motor skills, following directions, and completing tasks. In addition to these general cognitive concerns, Nicholas' parents had identified communication as a problem. His communication was largely nonverbal, and his verbal attempts were unclear. Lastly, Nicholas exhibited motor problems, which were initially described as "clumsiness." During the preliminary assessment meeting, the team identified four problems-communication, unknown cognitive status, motor concerns, health issues (wax build up in his ears), and family issues (dual career family). The psychologist observed that according to the information they already had, Nicholas had strength in the cognitive area. When his sensori-motor skills were discussed, someone described Nicholas as "clumsy" whereupon the adapted physical educator remarked, "We don't like the word 'clumsy'-it's a label." The team agreed that the child should be evaluated by audiology, communications, psychology, occupational therapy, adapted education, .pediatrics, nutrition, and social work. .physical During the post-clinic meeting, when the professionals who had performed evaluations gave their reports, there were several issues of conflict. The main point of contention was over the degree of delay exhibited by the child and the resulting recommendation for placement in a developmentally handicapped (DH) classroom. The recommendation was introduced by a psychology intern and was based on IQ test scores of below 50. Two other disciplines, adapted physical education and occupational therapy, found inconsistent responses in their evaluations, and communication said that Nicholas' non-verbal behavior indicated that he had higher capabilities than that which was demonstrated in the psychology examination. The team's disagreement was, at times, vocal and overt. The most salient issue of conflict centered on terminology and the effect of its use to accomplish the team's purpose. In the course of the discussion, terms for the child's assessment included mental retardation (MR), developmentally handicapped (DH), learning disabled (LD), and cerebral palsy (CP). Concern over "labeling" was reflected in the statement, "Once we stick him in that DH class. . . ." A debate over terms is reflected in a discussion among three disciplines:
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Communication: To see that kid in an MR class . . . Psychology: Nobody said MR. Adapted physical education: That's what DH is. The team was aware that its evaluation would be utilized for school placement, but there was concern that the decision would rely solely on the "numbers" reported on psychological tests. As one participant said, "You can't argue with numbers, but I want to, and obviously you're going to say, well, this is the number. . ." In fact, the team coordinator reminded the team of the external demands when she said, "Unfortunately the way, in the state of XXX, that they categorize these kids is by the number." The team spent considerable time and asked repeated questions about the tests themselves. Team members asked which tests were or were not done and challenged the reliability of the tests, the boundaries for scoring, and the capacity of the tests to consider nonverbal as well as verbal responses. In the course of this discussion, another psychologist was called into the room to assist the psychology intern in interpreting scoring techniques. Another topic of intense debate was the evaluation results found to be inconsistent within a discipline or in conflict with the results of another discipline. Testing by occupational therapy yielded different results on the two separate days in which the child was evaluated. Adapted physical education saw "splintered skills." One member stated, "I wonder if there's some inconsistent things going on, something we didn't see that particular day that happens on another day." Despite the disagreements and even upon questioning the reliability of the tests given, the psychology member asserted, "I'm pretty confident in these results." The outcome of the team discussion remained to recommend a developmentally handicapped (DH) placement. There was, however, concurrence to also recommend that Nicholas be reevaluated in one year, even though by law he does not have to be retested for three years. There was some expression of optimism that Nicholas' strengths could be developed within a smaller DH classroom setting and that a year of such programming would yield significant changes in his performance.
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Analysis Conflict was aroused in this team over the inconsistency of evaluation results within a discipline and between disciplines. The internal consistency (between scores on the psychological tests) seemed to afford assurances to psychology that were not evidenced in other disciplines. Team members could not accept a single perspective that was not confirmed in their respective disciplines. They expressed this overtly by debating about terminology and the reliability of the psychological tests. However the team might feel about "numbers," they were constrained by the fact that scores on psychological tests are the basis for categorizing children. The team recognized this reality in accepting the recommendation of the psychology representative that the child be placed in a DH class. Nevertheless, the team compromised in agreeing to recommend retesting a year later; and in reiterating statements about the child's strengths. Case 2: Steve
Steve was four and a half years old at the time that he was evaluated by the team. The major presenting problems were (1) expressive language development difficulty; (2) short attention span; (3) lack of interest in learning; and (4) difficulty with sequencing. He was referred to the center by his family who requested advice on programming that would prepare Steve for kindergarten the following fall. This case was presented to the preliminary assessment team by a male psychology intern functioning as case coordinator with a female occupational therapist in the role of preceptor. The team discussion centered around whether or not Steve's behavior was due to hyperactivity or attention deficit problems or was age appropriate behavior about which the parents had unrealistic expectations. When the team was developing an outline of the problems, the preceptor said that there was a lack of information about Steve's health. One sub-topic was added-questionable visual activity and visual motor status-after which the pediatrician said that on the basis of the medical record, Steve does not have medical problems; that there was no need for a medical examination. The team, how-
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ever, prevailed upon the doctor to perform such an examination, as this would help assure the family that a complete evaluation had been conducted. The other problems identified were unknown cognitive status, communication difficulties, family issues, and behavioral concerns. The evaluations recommended by the team were to be performed by audiology, psychology, communication, occupational therapy, optometry, pediatrics, and social work. When the team reconvened at the post-clinic session, the pediatrician reported that Steve had no medical problems. On the basis of his evaluation, the psychology internlcase coordinator concluded that Steve's problems were due to emotional stress and that with appropriate structure, Steve would outgrow his difficulties. The other disciplines appeared to agree, except for the occupational therapist (the preceptor). She indicated that her screening tests showed that Steve was behind and was not ready for kindergarten. Because the occupational therapy and psychology test results were in conflict. the occu~ationalthera~istrecommended retestine. The psycholo& intern did not supPoit this suggestion, so afteysome discussion, the team coordinator (an administrator) asked further questions about the tests and reinterpreted the difficulty. Her conclusion was that although both professionals tested behaviors in the same area (sequencing skills), they actually were testing different levels of skills. This explanation seemed acceptable to the team, but it did not reduce the conflict about the recommendations the team would make to the parents. The occupational therapist felt that Steve needed practice and work in the areas in which he was weak. The psychologist offered the compromise of adding the word structured to his recommendation for a pre-school program, and that appeared to satisfy the occupational therapist. The team coordinator then asked how the team wanted to present its findings to the parents. The case coordinator said that he would emphasize the child's strengths and weaknesses. The focus would be on Steve's positive attributes and normal development. The team did spend some time discussing how they could present their findings in ways that would not imply that the parents were at fault, but it was not clear how they would accomplish this. When the team met with the parents, the case coordinator presented the following recommendations: (1) counseling for the par-
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ents; (2) a structured pre-school program; (3) more consistent discipline; (4) monitoring of Steve's progress; and (5) a book on normal development. When the occupational therapist presented her concerns, they were described as "minor, not real extreme difficulties." Just before the meeting ended, the team coordinator mentioned that Steve was not ready for kindergarten. The psychology intern, however, said that he was not comfortable "saying he was or was not; there was lots of time." Downloaded by [North Carolina State University] at 22:04 28 February 2015
Analysis
Although there were discrepancies in the findings of two disciplines who performed evaluations, in this case the team appeared to be avoiding conflict. Whereas in the previous case there was disagreement on the degree of delay, in this case one discipline viewed the child as normal and another said he was delayed. The team responded to the divergent opinions by asking themselves, "How do we reconcile this?" rather than "What does this mean? Have we missed something? Is the client performing differently in different environments?" In this case the team coordinator offered an interpretation that allowed each discipline's results to be correct; and the psychologist offered an acceptable compromise that the child go to a "structured pre-school" (combining his focus on structure with the occupational therapist's report that the child was behind). The compromise, however, was illusory. At the meeting with the parents, the occupational therapist minimized the problems she had identified at the team meeting. Moreover, it was not clear whether a "structured pre-school" would give Steve the kind of remedial help that the occupational therapist said he needed. In the end, when the psychologist indicated that the child may be ready for kindergarten, he seemed to be more aligned with his own recommendation than with the compromise arrived at by the team. The conflict here was not only between two disciplines (psychology and occupational therapy) but between findings of a female preceptor and a male student. The psychology student was older and more experienced than many of the student interns in this setting. Apparently he and the preceptor had not worked out their differences prior to the meeting. Even though the occupational thera-
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pistlpreceptor had a higher status than the student and functioned as his mentor for the case, the psychology student did not take the occupational therapist's recommendations seriously.
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Case 3: Jerry
Jerry, a 13-year-old, was referred to the clinic by a private psychologist who had been working with the boy and his family. Jerry had cerebral palsy and was in developmentally handicapped classes. Recently he had engaged in a number of aggressive behaviors at school and home. Other concerns were his drooling, unclear speech, and coordination. In view of Jerry's forthcoming change in schools (from a fourth grade developmentally handicapped class in an elementary school to a seventh grade DH class in a junior high), recommendations for programming, resources, and behavior management were requested. It was noted that Jerry was 5 ' 1 0 and weighed close to 130 pounds. The case was presented to a preliminary assessment team by a psychology intern working with a dentistlpreceptor. During this meeting a staff psychologist asked if an alternative communication system had ever been considered and continued to say that based on this child's intelligence scores, he would be a good candidate. He added there may be some physical problems that interfere with Jerry's ability to speak. This suggestion was followed by questions about the nature of these devices and how they are carried. Someone joked, "Maybe next year they'll be the size of a pack of cigarettes." Later the team decided to adopt an objective to determine the need for adaptive equipment. At this point the social worker argued that many people with cerebral palsy function socially without alternative communication devices. The psychologist insisted that the device was very important for a child in school. The social worker said that that was a good point, thus ending the discussion. A month later, after evaluations by various disciplines were made, the team reconvened to discuss the case. The communication specialist reported that Jerry did not drool during her evaluation and that he was almost 100% intelligible in structured tasks, 75% intelligible if the topic was understood, and 50% if the topic was unknown. The nutritionist and physical therapist reported some
.
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drooling in their sessions. On the basis of her evaluation the communication specialist remarked, "There's no way that I would recommend an alternative communicatipn system." The dentistJpreceptor, who had observed a number of the evaluations, concurred with the communication specialist but added that Jerry's speech was clearer during the communication evaluation than it was with other disciplines' assessments. The psychologists, nonetheless, pecommended an alternative communication device. They argue4 that Jerry had the ability to use one, it is frustrating for him to make himself understood by others, and that his teacher will not be willing to take the time to understand him. The communication specialist wondered whether using such a device would result in his having fewer opportunities to practice his language. The team coordinator wondered if the machine was a good model. The dentist said he is surrounded by good models and that computerized speech is not a better model. Someone wondered about the vocabulary the machine has and was told it had an unlimited one. The team discussed his using this to place an order at a fast food restaurant. There was a great deal of simultaneous talk during this discussion. Finally the team coordinator said, "The only thing to say at this point is that it is an option that is possible." She said that inasmuch as the team is having a hard time deciding, let the family and the child decide. The dentistlpreceptor concurred. After further discussion about Jerry's possibly becoming too dependent on the machine, the physical therapist said, "1 think that it could be a nice additive to the speech and language skills. . . ." The conclusion, stated by the preceptor, toward the end of the meeting was, "We're going to suggest that it's available if they want to pursue it." The child's private psychologist, who attended this meeting, however, remarked, "If you say that as a mild suggestion, it won't be followed up" (by the family). The team was not able to agree to anything beyond exploring this option with the family and offering to show the family one of the devices and demonstrate how it is used. The psychologist was asked to find a model device for the family. Ordinarily the team meets with the family immediately following
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the post-clinic team meeting, but on the day both sessions were scheduled, the family had an emergency and had to reschedule the meeting. Two weeks later, the team reconvened for a short meeting prior to session with the family. Before the formal beginning of this session, the preceptor told those who had arrived that he wished to. clarify the issue of the communication device. He asked the psychologist if she still wished to bring up this issue. The psychologist said that she did and that she had identified a place in the community in which a device could be seen. The communications person said that she was willing to go along with the recommendation but was concerned about Jerry's feelings. She then asked the psychologist to present her thinking on the subject. The psychologist said that it would help Jerry interact in certain situations (such as ordering food at a fast food restaurant) but it was not to be a substitute for speaking. She added that there was concern about Jerry's becoming dependent on the device; that Jerry needed to interact with other people; and therefore her recommendation would be that if the family wants this option, he should use the device as a supplement to ordinary speech. The communication person said that Jerry's feelings should be clarified, and the psychologist concurred. The physical therapist said that they had an obligation to present options to families and not to assess their value. The preceptor commented that the group had mixed feelings. The psychologist said that they were in agreement to leave it up to the family. The preceptor wondered how they could present ii as an option when the team did not have a sample to show the family. The team coordinator said that they could point the family in the right direction if they are interested; that clearly this was not a strong recommendation. During the session with the the psychologist recommended the communication device as an option. She said that it might give him mobility in social interactions so iong as he did not use it as a crutch. The communications specialist asked the family how they felt about it. The mother said that it would be like using a calculator instead of learning how to do math. The preceptorldentist admitted that the team had mixed feelings about it. The psychologist said that they can facilitate the family's getting one; that he can
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use it only in certain situations. The family did not pick up on this recommendation. The team went on to discuss other topics.
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Analysis The interdisciplinary team that evaluated Jerry was ambivalent about recommending an alternative communication device from the time the suggestion was raised by psychology at the preliminary assessment meeting. Differences of opinion were diffused among the members throughout the process. At the first post-clinic team meeting, the communication specialist expressed the opinion that, on the basis of her evaluation, there was no need for such a device. The psychologist, however, argued for the device, getting some support and some objections from others. Individuals on the team who had leadership roles recognized that the team had mixed feelings (the preceptor) and moved the team toward consensus (team coordinator). This resulted in the compromise that the team present the family with the option of the child's utilizing this device. When this mild recommendation was presented to the family, the family expressed a lack of interest. Interestingly, the preceptor told the family that the team was having difficulty coming to an agreement on this issue. It is significant that psychology and communications disagreed on this issue. The use of a communications device seems to be an issue relevant to the professional domains of both fields. Psychology views communication as a component of cognition. Communication sees verbal, non-verbal, and auxiliary communication as part of its domain. This case touched on the borderland between disciplines.
DISCUSSION The conflicts that occurred in all three cases were problematic for the team. The expectation was that the team come to a consensus so that when they would meet with the parents as a group, they could present a "united front." In all cases a compromise was reached, but in the case of Steve, this involved one discipline's minimizing
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areas of conflict, and in the case of Nicholas, the team introduced a recommendation to mitigate the recommendation (retest a year later). Team members did not seem to look at conflict as an opportunity for growth. Instead, they appeared to recognize three alternatives: (1).influence others to agree with them; (2) change their own recommendations; (3) find a middle ground or some area in which they can agree. In one case (Steve) an illusory compromise was reached. In another (Nicholas), one discipline's recommendation prevailed. In the third case (Jerry), the team agreed that it could not agree and passed the decision on to the parents. It mav be that the structure of the teamine orocess contributed to some o i the difficulties. Representatives orihe various disciplines presented their conclusions and recommendations at the post-clinic ieam meetings. By this time, they had already come to'decisions, which they defended. With the pressure of coming to a consensus within an hour (after which time the family arrived), the need for expedience influenced outcomes. Accordingly compromises that preserved a united front but did not explain or integrate differences occurred. Only in the case of Jerry, in which two post-clinic team meetings were held, did the team have time to air their concerns and at least agree that they disagreed. This case was unique, too, in that the family was told that the team was not of one opinion on the issue. Team members expressed their differences of opinion in a variety of ways. Disagreement seemed to be masked in pre-assessment planning meetings through questioning, joking, and commenting on the use of terminology. At the post-clinic team meetings differences were expressed through asking pointed questions, expressing diver.gent opinions, making affirmative statements, challenging, and arguing. At a number of these junctures, loud and simultaneous talk occurred. During the meetings with parents, differences of opinion were rarely expressed. In all three cases, the team grappled with inconsistencies. Some children performed well in one evaluation and poorly in another. The consistencies of test results and behaviors within a discipline's evaluation and across disciplines were discussed. The team's ap-
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proach to dealing with differences across disciplines and evaluation contexts varied. Sometimes they used the inconsistencies as a point of discussion to better understand the case and why differences occurred across contexts (e.g., Jerry). In other cases, disciplines seemed to be competing with and challenging each other. In the case of Nicholas, for example, team members seemed to attend more closely to consistencies within disciplines than across disciplines. These findings suggest that team members see themselves primarily as representatives of their respective disciplines rather than members of a whole that transcends individual disciplines. Perspectives are splintered rather than united. Team members seem to want to come to a consensus but there are barriers to integrating their findings. In the conflictual situations that were described, the perspective of a more technical and high status discipline (psychology) prevailed. This is consistent with literature suggesting that a hierarchy of disciplines and external factors (required test scores) influence team processes (Mailick & Ashley, 1981; Nason, 1983). According to social conflict theory, conflict is potentially beneficial. In order to assess the value of conflict to the team, the researchers would have to investigate the perceptions of team members after the apparent resolution of the conflict. From the perspective of the researchers, the conflicts in these cases did appear to reduce dissonance sufficiently so that the team could present a coherent message to oarents. Nevertheless. team members did not fully address difkrendes in perspectives across disciplines and in the child's performance across contexts. This resulted in the slippage of doible messages (Steve, regarding readiness for kindergarten) and the devaluing of contradictory data (Steve, Nicholas). The team minimized their own differences in their meetings with the parents, choosing to present a "united front." Social conflict theory does not address the benefits of conflict to outside groups that do not have competing interests, such as clients and client systems. In order to determine whether the conflicts experienced by the team were helpful to the child and the child's family, the researchers would have to interview the parents and follow the cases over time. On the basis of cases described here, an additional case, and interviews with key members of the team, the pre-
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sentation of a "united front" is both advantageous and disadvantageous for families. Many of the families of children who are evaluated in this center have previously received conflicting information and experienced great frustration in their search for "answers" about their children. By prese'nting unified, integrated findings, the center performs the function of clarifying the nature of the child's problem. In communicating a consistent message about the child's functioning, however, the team is not presenting a complete picture. In suppressing or minimizing discrepant results, the team is protecting the parents from hearing all perspectives and from choosing those findings - that are most compatible with the parents' own peiceptions. Regardless of whether the conflict is suppressed or expressed, findings in these cases suggest that conflict is related to differing theoretical perspectives and values. Some of the disciplines represented on the teams that were observed have different views on the value of quantitative data, the validity of certain approaches to testing, and the relationship between performance and context. Further analysis of the data gathered in this study will explore this observation further. The authors see a need for a shared interdisciplinary perspective in which there is a common value base, language, and conceptual framework (Abramson, 1984; Billups, 1987; Green & Harker, 1988) that transcends the bounds of the different disciplines. Such a framework would see diverse findings across disciplines as a stimulus for new questions. Under such circumstances, the team would be able to recognize conflict as an opportunity for growth and integration rather than a win-lose situation. BIBLIOGRAPHY Abramson, M. (1984). Collective responsibility in interdisciplinary collaboration: An ethical perspective for social workers. Social Work in Health Care, 10 (I), 35-43. Billups, J. (1987). Interprofessional team process. Theory into Practice, 2, 146152.
Coser, L.A. (1956). The functions of social conflict. The Free Press of Glencoe. Germain, C.B. (1984). Social work practice in health care: An ecological perspective. New York: The Free Press.
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Green, J.L. & Harker, J.O. (Eds.) (1988). Multipleperspective analyses of classroom discourse. Norwood, NJ: Ablex Publishing Cop. Kane, R. A. (1983). Interprofessioml teamwork. Syracuse, NY: Syracuse University School of Social Work. Lister, L. (1980). Role expectations of social workers and other health professionals. Health and Social Work, 5 , 41-49. Lowe, J.1. & Herranen, M. (1978). Conflict in teamwork: Understanding roles and relationships. Social Work in Health Care, 3 (3), 323-330. . (1981). Understanding teamwork: Another look at the concepts. Social Work in Health Care, 7 (2), 1-11. Mailick, M.D. & Ashley, A.A. (1981). Politics of interprofessional collaboration: Challenge to advocacy. Social Casework, 62 (3). 131-137. Mailick, M.D. & Jordan, P. (1977). A multimodel approach to collaborative practice in health settings. Social Work in Health Care, 2 (4), 445-454. Margolis, H. & Fiorelli, J.S. (1984). An applied approach to facilitating interdisciplinary teamwork. Journal of Rehabilitation, 50, 13-17. Mizrahi, T. & Abramson, J. (1985). Sources of strain between physicians and social workers: Implications for social workers in health care settings. Social Work in Health Care, 10 (3), 33-51. Nason, F. (1981). Team tension as a vital sign. General Hospital Psychiatty, 3, 32-36. . (1983). Diagnosing the hospital team. Social Work in Health Care, 9 (2), 25-45. Sampson, E.E. & Marthas, M. (1981). Group process for the healthprofessions, 2nd ed. New York: John Wiley & Sons. Sands, R.G. (1989). The social worker joins the team: A look at the socialization process. Social Work in Health Care, 14 (2), 1-15. Simmel, G. (1904). The sociology of conflict. American Journal of Sociology, 9. Taylor, S.J. & Bogdan, R. (1984). Introduction to qualitative methoh, 2nd ed. New York: John Wiley & Sons. Wikler, M.E. (1980). Saving face in the status race. Health and Social Work, 5 (2), 27-33.
