The challenge of transdisciplinary practice within an interprofessional care model
For anyone who has sought healthcare for a complex medical problem, it often involves specialised input from a range of professionals. This can be associated with frustration, delay and extra costs for people receiving multidisciplinary care (different disciplines working in parallel with the same person, usually under the direction of a leader). There are also challenges for healthcare professionals in understanding the roles and functions that other healthcare professionals have in the care of the patient. Contributing to this are health hierarchies that lack flexibility and promote siloing of information, and contrasting or incompatible professional values. Interprofessional or interdisciplinary care is a model that aims to improve how healthcare professionals in multidisciplinary care work more effectively through better communication, integration of knowledge and methods, and more flexible management and leadership.
The aim of the interprofessional care approach is to improve interprofessional practice through better communication and more flexible leadership structures, while maintaining distinct professional areas of practice (Foronda, MacWilliams, & McArthur, 2016). However, research has identified professional role inflexibility as both a strength and a weakness in interprofessional practice (Mitchell, Parker & Giles, 2011). In contrast healthcare has been traditionally delivered as multidisciplinary care.
Transdisciplinary care
Many healthcare contacts are with a single healthcare professional who may provide care that is within their usual area or scope of practice, but who occasionally provides care in areas typically offered by a different discipline professional. The application of out-of-scope skill-use reflects the model of transdisciplinary care. In this model knowledge and skill from two or more disciplines is shared in a way that transcends professional boundaries, and focuses on pragmatic solutions to real-life problems (Van Bewer, 2017). For example, a practice nurse in a rural setting providing assessments and basic mental health support. Another more challenging example might be a physiotherapist who provides cognitive-behavioural pain-coping strategies in conjunction with physical treatments for arthritis.
This approach of transdisciplinary skill-use and care is often in response to a need for timely patient care, and to reduce the healthcare burden on the patient, but it also has the potential to enhance the particular professional’s within-discipline practice. An example of this may be the use of relaxation methods to reduce distress during painful medical procedures. This transdisciplinary model of developing overlapping skill sets has also been applied in interprofessional care teams, within a care structure that coordinates individual professions as required in the overall care (King et al., 2009).
This more transdisciplinary model raises concerns for a professional operating outside of professional scope and competence, with the potential for ineffective and possible adverse outcomes. Solutions to these issues are important not just for a better health experience but also for better health outcomes. While there have been a number of attempts to address these issues, these approaches continue to challenge existing healthcare models and also raise questions of quality of care, timely and affordable access to care, as well as disagreements about professional identities and roles.
The case for psychological practice
Psychological practice is often at the nexus of multidisciplinary and transdisciplinary care because many of the components of psychological care, including mental health assessment, behaviour change and emotional support, are important requirements to support clinical goals of other professions. There is a strong argument for the value of interprofessional communication, whilst maintaining professional boundaries, to promote better patient outcomes. There is also a strong argument concerning access, health workforce limitations, and economics against maintaining discipline skill separation in care for delivery of less specialised healthcare (sometimes called low-intensity care; Bennett-Levy et al., 2010).
There is also growing evidence of the value of these transdisciplinary approaches in improving patient outcome. While interprofessional care has the potential to promote a synergistic integration of care and improved efficiencies, there are also unique opportunities offered by transdisciplinary training, such as delivery of care in times and place that would not otherwise be available. There are also, arguably, common basic areas of skills that still allow professionals to operate broadly within their scope of practice (e.g., facilitation of adherence and compliance, basic emotional support) which may not require consideration as arising from a transdisciplinary care model.
The transdisciplinary care approach does bring some significant challenges. Within care that blends two disciplinary areas there is a point at which the professional moves beyond their scope of practice, into the other disciplinary scope of practice. The professional working in this different area, should, in theory, only act in that new area, as long as it facilitates their goals and scope of their disciplinary practice. However, once operating within this out-of-scope area, it is possible for the healthcare professional to move beyond areas of skill and competence.
In these instances there is an ethical obligation to have in place a process of understanding for when the boundaries of scope of practice have been breached or when the skill-set learned has reached its limits. For this case, it should lead to the care moving into the scope of practice of another professional group. For example, the physiotherapist providing pain-coping skills to the patient with arthritis, may incidentally become aware of significant marital discord that is potentially undermining the patient’s progress. The temptation might be to investigate this as it is impacting on adherence to prescribed exercise. The more appropriate course, however, is to refer the patient to a psychologist. Implicit in this process is understanding of both the clear limits of transdisciplinary care and the role and skills of the psychologist.
Another issue is the capacity or compatibility of individuals within a profession to deliver the practice of other disciplines. The question could be asked whether every professional whose scope of practice is within physical care can successfully adopt and apply psychological care and, if so, would they want to?
Evidence would suggest that while successful training in transdisciplinary care is indeed possible, it is not for everyone (see Bryant et al., 2014). Finally, there are unique and complex ethical issues that both facilitate and threaten transdisciplinary care, such as the role that physical contact plays in psychological support. Physical contact is a powerful tool for enhancing interpersonal connection, but its potential for harm in this context is also present.
Making transdisciplinary practice work
Interprofessional care is a common mantra in contemporary healthcare training and practice. It holds great promise for improved healthcare experiences for patients and staff. In addition, I would suggest that transdisciplinary care can be complementary with the interprofessional care model but with limits. Effective transdisciplinary care should involve collaborative engagement of at least two disciplines to ensure that not only is there quality assurance in the care, but that there is integrity in the care process.
Furthermore I would suggest that a consultation and/or co-supervisory process between members of the relevant discipline is necessary (e.g., Bryant et al., 2014). Finally, there must be an emphasis on the boundaries of transdisciplinary care and the avenues and mechanisms for escalated care. Thus, the result is a blend of both approaches in which interprofessional communication and transdisciplinary practice work together.
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