|Year : 2010 | Volume
| Issue : 3 | Page : 393
A Systematic Review of Collaborative Models for Health and Education Professionals Working in School Settings and Implications for Training
SL Hillier, L Civetta, L Pridham
Centre for Allied Health Evidence, University of South Australia, Adelaide, South Australia, Australia
|Date of Submission||02-Sep-2009|
|Date of Acceptance||27-Oct-2010|
|Date of Web Publication||30-Nov-2010|
S L Hillier
University of South Australia, City East, North Tce, Adelaide, SA 5000
Source of Support: None, Conflict of Interest: None
Context: Collaborative engagement between education and health agencies has become requisite since the establishment of school inclusion policies in many developed countries. For the child with healthcare needs in an educational setting, such collaboration is assumed to be necessary to ensure a coordinated and holistic approach. However, it is less clear how this is best achieved.
Objectives: This secondary research aimed to answer the questions: what are the reported models of best practice to support the collaboration between education and health staff and what are the implications for training strategies at an undergraduate and postgraduate level to affect these models?
Methods: Systematic review of current literature, with narrative summary.
Findings: Models of interaction and teamwork are well-described, but not necessarily well-evaluated, in the intersection between schools and health agencies. They include a spectrum from consultative to collaborative and interactive teaming. It is suggested that professionals may not be adequately skilled in, or knowledgeable about, teamwork processes or the unique roles each group can play in collaborations around the health needs of school children.
Discussion and Conclusion: There is a need for robust primary research into the questions identified in this paper, as well as a need for educators and health professionals to receive training in inter-professional teamwork and collaboration beyond their traditional domains. It is suggested such training needs to occur at both the undergraduate and postgraduate levels.
Keywords: Healthcare and education, teamwork, collaboration, child and youth health
|How to cite this article:|
Hillier S L, Civetta L, Pridham L. A Systematic Review of Collaborative Models for Health and Education Professionals Working in School Settings and Implications for Training. Educ Health 2010;23:393
|How to cite this URL:|
Hillier S L, Civetta L, Pridham L. A Systematic Review of Collaborative Models for Health and Education Professionals Working in School Settings and Implications for Training. Educ Health [serial online] 2010 [cited 2022 Jan 19];23:393. Available from: https://www.educationforhealth.net/text.asp?2010/23/3/393/101475
School children with healthcare needs and their families require services and support from a range of agencies from the health, education and social services sector, as well as service providers from various disciplines1. Over the past 40 years, the model of service delivery has gradually shifted from “professionally centred” where decisions are made to “fix the problem” to a greater focus on joint decision-making and sharing of responsibility between parents and service providers2(p. 20). Collaborative engagement between education and health agencies has been highlighted within the international literature. Such multidisciplinary collaborations are required at differing levels, from service planning for individual children to policy and research. This requires health professionals to adopt a change of practice to work effectively in different settings and to collaborate with non-health trained professionals.
Multi-agency collaboration as a means to improve coordination and integration for children with disabilities is a key policy priority in the United Kingdom3,4. In the United States of America there has been a legislative shift from segregated services for children with disability in 1975 (Education for All Handicapped Act (P.L. 94-142) to inclusive settings (Individuals with Disabilities Education Act P.L. 101.76) that require increased communication and collaboration between service providers5. Coben et al.6(p. 428) state that the “success of educational inclusion rests on the ability of special and general educators to communicate effectively when attempting to coordinate educational services for students with disabilities”. Elliott and Sheridan7(p. 315) also state that effective “services for handicapped children in … schools are contingent on communications, decisions, and actions of adults – typically general educators, special educators, parents and specialists such as psychologists, speech pathologists or physical therapists.” Even though the need for multi-agency collaboration has been identified, there is little evidence on the effectiveness of multi-agency working itself or of different models of such working in producing improved outcomes for children and families1,3.
While the concept of collaboration between education and health to provide services for children with healthcare needs has been supported by policy, it continues to remain rare in practice8. Factors influencing this may include limited training for teachers in working in a team and with atypical children, as well as health professionals having strongly-held perspectives of their own discipline which has been fostered by separate and non-collaborative training programs5,9. Difficulties in scheduling time for collaborative planning may also be a key factor in determining the success of integrated practice3,5. Additionally, the amount of collaboration between service providers may be influenced by the structure of the team. Larsson10 found that teams that formed from a range of agencies around the needs of the child were rated by parents as being more collaborative than single agency multidisciplinary teams. Team members have stated that they learn more about other disciplines through the provision of multi-agency or “joined-up services”. However, their willingness to expand their role may be contingent on how secure they feel in their own role and how confident in their abilities3. This may, in turn, be a reflection of their relatively isolated professional training. When a child with healthcare needs attends school, teachers may be getting conflicting messages that while they are capable professionals they are also being surrounded by specialists with information and courses to help them “manage”11. Additionally they may feel uncomfortable because they will need to attend more meetings and have support staff in their classrooms.
In summary, for the school child with healthcare needs in an educational setting, collaborative engagement between teachers and health professionals is assumed to be necessary to ensure a coordinated and holistic approach. However, the pragmatics of such collaboration can be piecemeal and variable across different health and geographic sectors. More information is required to facilitate best practices in the intersection between the education and health sectors and to ensure professionals in these domains enter the workforce with the requisite skills and knowledge. To begin a process of inquiry into the published literature in this area, a secondary research or systematic review approach was utilised to address the following questions:
- What models have been reported and/or evaluated for successful interactions between educators and health professionals, within a multiple agency setting for school children with healthcare needs?
- What are the implications for training at an undergraduate and postgraduate level to put these models into effect?
To answer these questions, using a systematic review approach to the literature, the following protocol was adopted. Types of studies: All levels of evidence or types of research or report were considered, with preference for the highest level of research (for example, if a process was evaluated, preference would be given to a randomised controlled trial rather than a case study). In order to answer all of the questions it was anticipated that papers using quantitative and qualitative designs would be included. Types of participants: We included any paper which reported on a multiple agency or disciplinary team setting, where the interface involved both education and health professionals for children of school-age. Papers which described the interface between education and other sectors (for example, judicial) or within the health sector only were not included. Types of phenomena/intervention: For the first question, the phenomenon of interest was the intersection between health and education professionals. The intervention of interest was the use of interdisciplinary or multidisciplinary teams – all models were included where at least one member of the team was from education and at least one from health. All studies which reported and/or evaluated these models were included. Also of interest were any conclusions drawn about the knowledge or skills required by the professionals to promote these models. Types of outcome measures: For effectiveness studies that evaluated different models empirically, all outcomes were considered, with preference given to those with a child-focus. Search strategy: Databases, sources of grey literature (unpublished documents or policy statements) and search terms were identified and selected in a consultative process with staff in the area of Interagency Health at the Department of Education and Children’s Services and staff from the International Centre for Allied Health Evidence, University of South Australia.
The initial search was conducted on the following databases: A+ Education; Academic Search Elite; AED Online; Australian Education Index; Australian Education Research Theses; Cambridge; Current Contents; Ed Research Online; Education; Education-Line; ERIC; Ingenta Connect; JSTOR; MasterFILE Elite; Medline; PCI; PsycINFO; Science Direct; Swetswise Interscience; Social Sciences Citation Index; Wiley. The following search terms were used: Educators; Teachers; Schools; Interprofessional; Multidisciplinary; Interdisciplinary; Interagency; Cross Agency; Cross Institutional; Multi-agency; Children; Child; Adolescent; Health and Learning. Identified papers were searched for additional titles in their reference lists. The search was limited to papers published after 1975 and to those written in English. Two assessors worked independently at each stage of decision-making. Where there was a lack of agreement, a third party was available to facilitate consensus.
Where papers were experimental in design, an appropriate critical appraisal (risk of bias) tool was used. Papers that were descriptive were not appraised but were analysed for content relative to the research questions. Information relevant to the questions was extracted from each paper and collated via a spreadsheet formatted to reflect each question. Data were then synthesised narratively, as there were no quantitative data to meta-analyse.
A total of 220 titles were identified and from these, two assessors identified 72 for further investigation using the acceptance criteria arising from the review questions (see criteria for considering studies). From the retrieved papers, 34 were included in the review and data subsequently extracted. Table 1 summarises the included papers. The list of excluded studies, with reasons for exclusion, is available from the authors. Of the included papers, five were of primary research (using a qualitative paradigm) and one was a systematic review of multidisciplinary teamwork. The remaining 28 were descriptive of practice only. No appropriate studies of effectiveness were identified - papers were either without evaluation or any evaluation performed was not described. Because of the low (research) quality of papers, a formal critical appraisal tool was not applied. Rather, the papers were accepted at face value (i.e. descriptive) and scrutinised for information or reporting that offered answers to the review questions. These data were extracted using a spreadsheet format and a narrative synthesis approach adopted to report results.
Table 1: Systematic Review – Table of Included Studies (in alphabetical order)
The majority of papers were from health-related journals rather than educational journals, and the majority of authors were not generalist educators – often either an allied health professional or special educator (see Table 1). The findings are reported in the following as a meta-synthesis under each review question, with sources identified.
Question 1: What models have been reported and/or evaluated for successful interactions between educators and health professionals, within a multiple agency setting for school children with healthcare needs?
Interprofessional practice is the current health industry terminology used to describe the situation where two or more professions are working together as a team with a common purpose and commitment (WHO, 2010)12. Within this mode of practice, several models of teamwork have been described in relation to their composition and discipline responsibility. For example, the literature describes the continuum of multidisciplinary, interdisciplinary and transdisciplinary teams. The essential difference between these three is the level to which individual member disciplines accept transference of traditional roles and the degree to which they work together. For example, in a multidisciplinary team there is assumed to be a constant role for the individuals, based on their discipline. The individual team members work in relative isolation but all contribute to multidisciplinary meetings and planning. In the interdisciplinary model, there is the expectation that role overlap will enable the blurring of discipline boundaries - for example, the teacher role may blur with the role of the occupational therapist. The assumption in the situation of role-blurring is that it is purposeful and negotiated. In this model, the individual members may work together or alongside each other. In the transdisciplinary model, the role boundaries may dissolve and one discipline may perform the role of another. As an example, the physiotherapist may fully implement a speech therapy program, or the teacher will take responsibility for implementing the entire program (physical, language and emotional) in order to maximise consistency with the child. Again the assumption is that in this model such role-sharing is tacit and supported by all members13-15. A further aspect of these three teams is that consumers (in this context, the school child and family) are integral members of the team.
Another model of teamwork arising in social welfare and health domains is that of case management where there is a central person within the team who takes the lead role in managing the “case” (the child) and its needs. This person may be a specially-trained case manager or may be nominated from within the multi/inter/transdisciplinary team. The ‘spoke’ model is a variation of the case manager model where one agency takes the lead in facilitating interaction, planning and liaison between other constituent agencies. Inherent in these kinds of approaches, where member agencies/individuals may operate at differing sites, is the need to establish the environment of action. This has particular implications for both planning and implementing services. Are the meetings held (or actual intervention strategies conducted) in a neutral site, in the child’s home or school environment or off-site at another agency8?
Further models for education-health interactions have been proposed: consultative; collaborative; and teaming. Particular emphasis has been placed on interactive teaming as a composite of consultation and collaboration. Consultation predates other models and is described as a triadic model: the consultant; the mediator; and the target (client or learner). The consultant (who has the expertise) indirectly brings about changes for the client (learner) through the mediator who is the professional working directly with the client. More recently, consultation models have moved to a more cooperative approach where there is a more equitable interaction between two individuals in the problem-solving/decision-making process. However it seems the “client” does not participate fully in this model – it is more about one worker discussing change or management with another6.
Collaboration has been described by Thomas et al.16 as an end point on a continuum, with cooperation and coexistence in the middle and conflict at the opposite end. Cook and Friend6(p. 25) defined it as “a style for direct interaction between at least two co-equal parties voluntarily engaged in shared decision-making as they work toward a common goal”. The difference between consultation and collaboration may lie in the question of “ownership”. Collaborators have joint responsibility for particular situations whereas consultants retain ownership of situations6. Equity of participation or status is another differentiating feature between the two models.
Teaming has been used as a variant of collaboration. Pfeiffer17 defined a team as “an organized group of personnel, each trained in different professional disciplines and possessing unique skills and perspectives, who share a common purpose of cooperative problem solving”. Coben et al.6 propose interactive teaming is an integration of consultation and collaboration and define it as “mutual or reciprocal effort among and between members of a team to provide the best possible educational program for a student”. The strength of this approach is the potential for effective, comprehensive and cohesive services when all the people involved work together instead of functioning as separate individuals or disciplines16. Authors confirm that the team make-up and size varies “depending on the complexity of the child’s needs and the stage of the process (e.g. assessment, planning, implementation, evaluation), and could include: educational, medical, administrative, vocational and allied health specialists, social services personnel and parents”6(p. 430). The defining characteristics are mutual goals, voluntary participation, equal valuing of all members contributions and shared resources, authority and accountability6. Idol et al.18 confirm this model is student-centred, the least restrictive and shares responsibility.
All of the models identified for the health-education interface were reported descriptively and no formal evaluation results were included in any of the reports. Therefore, the second aspect of the question (evaluation) remains unanswered.
Question 2: What are the implications for training at an undergraduate and postgraduate level to put these models into effect?
The capacity to work individually and in teams is a graduate-level component of many universities that offer professional programs across disciplines and sectors. However, it may be haphazard whether any undergraduate teacher or allied health training program formally offers experience in multidisciplinary or interdisciplinary teamwork where the constituent members are across the health and education sector. This is clearly an area for further discussion and investigation. Authors, such as Bucci and Reitzammer19 and Papa et al.20, identify the need for such inclusion in undergraduate field experiences on the basis that this offers the opportunity for teamwork to be modelled to the undergraduate educators and to raise their awareness of factors involved in successful team functioning. It has also been suggested that undergraduates should experience modelling of interdisciplinary working by the university faculties themselves19-22. Other authors also note the need for postgraduate and/or work-site specific training to promote awareness and skills in interprofessional collaboration. This latter professional development type of training can focus on more specific issues related to the agencies and professionals involved, along with targeted learner needs23-25. Therefore, the literature (at the level of expert opinion) supports the need for training at both undergraduate and professional levels to promote successful team function.
Considering the specific key elements required in the training of professionals to facilitate teamwork, much was related to knowledge and consistency with policies, structures, the philosophy of organisation(s) and the guiding principles for team members26,27. Particular authors note that preliminary team-building work and commitment of individuals is the biggest predictor of success25,28. Team-building exercises across the professional training programs have been described as:
- Achieving consensus on each member’s role/s – including commonalities and discipline-specific differences. This may require observation of each other’s work to enhance role clarification28-35.
- Clarification of perspectives - for example, exploring health versus well-being models, and/or where the educator may have a global view of class progress and see group norms with outliers, whereas the health worker may have an individual progress perspective and only ever see outliers27,28.
- Language and communication – awareness and understanding is required to ensure all members understand each other and are not disempowered by each other’s jargon23,33,35-37.
- Confidentiality – different disciplines may have different views on confidentiality23,28,30. Guiding principles specifically for training and skills development required for the Interactive Team have been adapted from Thomas et al.16 and are summarised in Table 2.
Table 2: Guiding Principles for Interactive Teaming
While it is important that undergraduate and postgraduate programs focus on the enablers discussed above, training is also required to increase awareness of the barriers to successful teamwork. For example, workforce or systems-based issues can present structural barriers to successful teamwork. Possible barriers may include:
- Service conditions – different team members may have different employers and funders which affect decisions about who takes responsibility27,28,33,37.
- Differing employment may also involve different pay scales and, therefore, status barriers28,33.
- Staff shortages impact on time and personnel resourcing23,38,39.
- Differing case or workloads23,38,39.
- Differing resourcing - e.g. dedicated time to meet, discuss/contact/liaise; some professions work on an appointment basis which allows for meetings whereas classroom educators are often committed to their class all day23,26,27,40,41.
- Differing access to each other - e.g. some staff on site for informal liaising whilst more external members may miss informal networking opportunities23,26,39,40.
- Need for central coordination/liaison roles – this role does not seem to be discipline-specific and has been described for various professions from special education to nursing31,33,42.
From the literature we reviewed, there are many models of interaction between disciplines within the domains of health and education, arguably developing along continua. However, we found no evaluations in the education-health context to offer any guidance for recommendations. In the context of evidence-based practice, where there is a lack of research evidence, expert opinion (preferably consensus) and values and preferences of consumers become the sources for decision-making43. In this context, the literature represents expert opinion, while the values and preferences of consumers (students and families) remain unclear. The models with a higher degree of collaboration implicitly reinforce the need for both individual and agency expertise – that individual educators, health professionals, etc. bring personal and professional skills and experience to the table as well as the resources and philosophies of their respective employing systems (agencies).
The literature confirms that the skills and attitudes necessary for effective teamwork in the educator and health professionals should be introduced at the undergraduate level. It is suggested this is initially through interprofessional education and practical experience as well as through modelling of interprofessional collaboration at the faculty level. While this need is well acknowledged within the health disciplines12, it is not addressed across different sectors (in this case health and education). Furthermore, the literature stresses that training and support is required at a postgraduate or professional level to foster the methods and strategies utilised to support effective team functioning. There is a paucity of research evidence to guide recommendations but there is consistent expert opinion that considerable goodwill, discussion and planning is required at both a systems and individual member level to ensure teamwork is positive for all stakeholders.
Models of interaction and teamwork are well-described but not well-evaluated in the education-health domain. There appears to be consensus that significant work is required from individuals and lead agencies to ensure successful collaboration that is child-focussed and inclusive of families. The literature identifies that training in interprofessional teamwork is required at several levels and offers content to be considered when implementing the various models. There is a clear need for robust primary research into the questions investigated in this review.
We thank Ms. Debra Kay, Department of Education and Childrens’ Services, Adelaide, South Australia for commissioning this work on behalf of her Department.
Source of Funding
Department of Education and Childrens’ Services
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