Key Messages

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Multidisciplinary working Final 02/05/14

Topic 10: Multidisciplinary Working

• Working together as part of a multidisciplinary team is key to securing the best outcomes for each child and their family. This includes social workers, independent reviewing officers, foster carers and others (e.g. those working in health, education, mental health, substance abuse or domestic violence services) providing services to children and their families.
• Effective multidisciplinary working is associated with improvements in practitioners’ relationships with families, as well as improvements in trust and communication between professionals.
• There are a number of challenges to multidisciplinary working. These include a lack of clarity about roles, inter-professional conflict, a lack of information sharing and poor communication.
• Effective multidisciplinary working relationships are underpinned by:
• common goals and shared understanding
• interpersonal and ‘emotionally intelligent’ skills to build and maintain relationships and to understand the perspectives of others
• paying careful attention to methods of communication
• sharing information
• understanding how the impact of the work may sometimes affect the ability of individuals to respond effectively.

Working together

Joint working between professionals is critical to the experience of all looked after children (HM Government, 2013). The task of helping children achieve ‘the sense of security, continuity, commitment and identity’ (DCSF, 2010) that they need is a shared one. Professionals must work with each other and with children and their families to ensure the best possible outcomes (Boddy, 2013). This means working as part of a team to jointly plan and deliver services (Oliver et al, 2010).

Most children who become looked after are already known to children’s social care and may have been receiving services for some time (Oliver et al, 2010). Each child and their family will probably have been assessed using the Common Assessment Framework. Multidisciplinary working starts at this point and involves consulting the child and birth parents to ascertain their wishes, as well as working with practitioners in other agencies. Multidisciplinary working continues throughout the time that a child is looked after.

Each practitioner with a responsibility for the well-being of looked after children has a distinct role, but all must share a common sense of purpose and an understanding of:

• the needs of the child, the desired outcomes and the route to achieving those outcomes (Firth-Cozens, 2001)
• how to work in a child-centred way (Boddy, 2013)
• the respective roles of individuals and agencies, and the boundaries and shared areas within those roles (Stone and Rixon 2008), as well as an understanding of the different perspectives and challenges of each role
• the relevance for the child of the relationship with their birth family (Boddy, 2013; Neil, 2010; Schofield and Ward, 2011), whether or not reunification is an option for permanence
• how and when to challenge each other (Laming, 2003)
• the commitment needed to build high-quality relationships with children, families, and colleagues (Munro, 2011).

The benefits and challenges of multidisciplinary working

The most commonly cited benefits of multidisciplinary working are improvements in services, joint problem-solving, the ability to take a holistic approach and better understanding and trust between agencies (Atkinson et al, 2005). Practitioners report improved relationships with other professionals as well as improved relationships with families and better communication between professionals (Atkinson et al, 2005).

Factors that facilitate multidisciplinary working include:

• role demarcation – clarity over the roles of agencies, understanding of each other’s responsibilities, and clear role boundaries
• commitment, including a willingness to work together
• trust and mutual respect
• understanding other agencies – an awareness and appreciation of what other agencies can contribute, understanding the range of perspectives
• communication
• information exchange – clear protocols for sharing information. (Atkinson et al, 2005)

Factors that may cause tension and conflict in the team include:

• lack of clarity about roles and expectations – a feeling that others aren’t doing their job or are working independently from the team (focus group discussion RiP/AfC and TACT for DfE Fostering and Adoption project November 2013)
• power differentials (Adair, 1987), including professional hierarchies, power struggles and blurring of professional boundaries (Atkinson et al, 2005)
• assumptions about shared language and meaning (Frost et al, 2005)
• inter-professional conflicts or disagreements about what is in the child’s best interests (Atkinson et al, 2005)
• different professional values or theories about childhood (Rixon and Stone, 2008)
• difficult feelings and personal responses to working with traumatised children and families in the child protection system (Cairns, 2002; NSPCC, 2013)
• poor communication of information, and feelings of not being listened to (Schofield and Ward, 2011; focus group discussion RiP/AfC and TACT for DfE Fostering and Adoption project November 2013)
• a perceived or real lack of support (Jelicic et al, 2013; Schofield and Beek, 2005).

There may also be external and organisational tensions that impact on the work of the team – for example:

• competing policies and procedures
• different rules and protocols around information sharing and confidentiality
• limited time for people to carry out their roles properly
• a lack of resources to meet needs of child or family. (Atkinson et al, 2005)

Sharing information

Not getting the right information is an ongoing problem for children (OCRD, 2013), their families (Schofield and Ward, 2011), professionals, IROs (Jelicic et al, 2013), foster carers and adopters (Selwyn et al, 2003). Poor practice around information sharing has safeguarding implications (the Caldicott Review (2013) of information governance found professional anxiety and mistrust about sharing information). The impact on multidisciplinary effectiveness is critical: in one study, 58 per cent of foster carers and 68 per cent of adoptive parents felt they had not been given adequate information about the child placed with them (Selwyn et al, 2003); in another study, only 8 per cent of IROs said they were always informed about changes in a child’s circumstances that would require a review of the care plan (Jelicic et al, 2013). Not being listened to is equally frustrating. These communication gaps can lead to alienation and impact on the work of the team.

Including foster carers

Foster carers also report not feeling included as part of the team working with the child; they complain that they are not invited to meetings, not shown documents such as court orders, and not consulted over decisions regarding the child. Becoming a formal member of the care planning team and having more contact with the team provides foster carers with the opportunity for involvement and of feeling valued (Geiger et al, 2013).

The importance of involvement was also reflected in the findings of The Care Inquiry (2013) and the ‘consistent messages’ from witnesses ‘about the importance of involving people in planning and decision making’. The Inquiry calls for ‘a broad understanding of the term “workforce”, so that everyone involved with children – foster carers, kinship carers, adoptive parents and residential staff – has attention paid to their training and support needs’. Its report highlights the importance of local leadership in establishing a strong culture to drive the changes needed (The Care Inquiry, 2013).

Facilitating effective multidisciplinary working

The establishment of effective working relationships in a multidisciplinary team depends on four key factors:

• clarifying roles and responsibilities
• securing commitment at all levels
• engendering trust and mutual respect – for example, through sharing skills and expertise
• fostering understanding between agencies – for example, through joint training. (Atkinson et al, 2005)

Shared training is one way of helping professionals to understand their respective roles and responsibilities, build relationships and gain insight into each other’s points of view and decision-making processes (Davies and Ward, 2012; Carpenter et al, 2010). The experience of learning from each other and learning together in both formal and informal ways can be a good basis to build trust and respect; empathy is one of the key interpersonal skills that support successful relationships and collaboration (Goleman, 1996; Covey, 2004).

Good communication and information sharing between agencies is also crucial for effective multidisciplinary working. This includes practitioners in mental health, substance abuse and domestic violence services, as well as children’s social care (Davies and Ward, 2012). If the plan is for the child to return home, maintaining links with these practitioners is especially important in order to monitor whether the problems that caused the child be taken into care have been addressed.

Conflict between professionals from different agencies may arise. If and when they do, they need to be debated openly and worked through to help sustain relationships (Frost et al, 2005). Effective communication depends on information being given to the right person, at the right time and in the right way. It may not be enough to assume the recipient of information has interpreted it correctly or given it the right level of importance. Practitioners need to find a common language to make knowledge accessible to professionals from other agencies, as they may have a different understanding of the vocabulary used (Frost et al, 2005).

The ability to self-reflect is also important. It requires the ability to notice and understand the effect people have on you as well as the effect you have on them. Without this, managing relationships and communicating successfully becomes much harder (Goleman, 1996). In essence understanding other people also involves understanding yourself and may involve retraining yourself to respond differently or pay more attention – for example, by using active listening techniques or motivational interviewing responses (Miller and Rose, 2009) rather than becoming defensive or confrontational.

Relationships are key to holding the structure of the team and the child’s world together and are central to the success of any intervention. Any difficulties will impact on the outcome for the child. For example, foster carers who feel supported are more likely to ‘stick’ with the task of caring for children (Cairns, 2002); and birth parents who get the information, involvement and understanding they want from social workers are more likely to support the child’s placement (Schofield and Ward, 2011). Positive contact, among other factors, is also a good indicator of successful reunification (Sinclair, 2005).

As highlighted above, foster carers also need to feel part of the team supporting the child and to have good communication with social workers (Rodger et al, 2006; Geiger et al, 2013). Geiger et al (2013) highlight the need for professionals to provide recognition, respect and encouragement to foster carers for their dedication and efforts. They also emphasise the importance of foster carers being heard and having their thoughts and feelings taken into account when decisions are being made about the child.

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Key questions for multidisciplinary teams

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Methods
Suitable for self–directed learning or reflection with a colleague or supervisor.

Learning Outcome
Review your understanding of multidisciplinary working and identify actions that can improve its effectiveness.

Time Required
Two sessions of 45 minutes

Process
Thinking of current multidisciplinary team working, answer the following questions:

• Who are the other key professionals who contribute to the health and well-being of the child?
• What roles do they have?
• How can their skills and input be put to best use in the multidisciplinary team?
  • What tensions exist between these roles?
  • What impact do these tensions have on the child, the team and the outcomes that can be achieved?
    • Reflect on a situation where there was confusion over someone’s role or responsibility: why did this happen and what could have been done to prevent it from happening?
    • How can you ensure that others are clear about what you can and can’t do?
    • Foster carers and adopters are rightly considered to be core members of the team (DCSF, 2010).
    • How might perceived differences in professional status impact on team decisions and information sharing?
    • Is some knowledge more valid than others? (Finlay, 2000 in Stone and Rixon 2008). If so, what is that based on?
      • Issues around contact (Neil, 2010) and delegated authority are often areas of conflict between carers, social workers and birth parents.
      • How can you ensure that every perspective is considered with the best interests of the child guiding the decision making?
        • Who brings or represents the child’s voice?
        • What conflicts might occur depending on who represents the child or interprets their views?

Key questions for the child’s and family’s social worker

Methods
Suitable for self–directed learning or reflection with a colleague or supervisor.

Learning Outcome
Review communication between the multidisciplinary team and identify actions to improve it.

Time Required
30 minutes

Process
Thinking of a child you work with, answer the following questions:

• How can you ensure that the child’s IRO and foster carer get all the information they need to do their job?
• Foster carers often say they do not get the feedback they need from social workers to support the child after a contact visit (focus group discussion RiP/AfC and TACT for DfE Fostering and Adoption project November 2013).
• Why might this happen and what steps could be taken to improve this?

Key questions for IROs

Methods
Suitable for self–directed learning or reflection with a colleague or supervisor.

Learning Outcome
Review how the IRO can maintain independence and manage tensions across the multidisciplinary team.

Time Required
30 minutes

Process
IROs are part of the team of professionals working around every child in care, seeking with other team members to promote the welfare of that child. However, IROs are in certain important respects, independent of that team and have particular duties and powers arising from that independence (NAIRO, 2013).

• How can IROs maintain their independence?
• What are the tensions between the different roles/perspectives?
• How can these be managed?

Key questions for foster carers and adopters

Methods
Suitable for self–directed learning or small group discussion.

Learning Outcome
Review your understanding of how multidisciplinary groups work and communicate.

Time Required
30 minutes

Process
Thinking of the members of the multidisciplinary team you meet, answer the following questions:

• Who are the other key professionals who contribute to the health and well-being of the child?
• What roles do they have?
• Who brings or represents the child’s voice?

Active Listening to promote communication and multidisciplinary working

Methods
Suitable for work in groups of three, within a team or as a facilitated exercise in a workshop.

Learning Outcome
To support the development of skills in active listening.

Time Required
60 minutes (15 minutes to read the summary and 45 minutes practice and feedback).

Process

• Split into groups of three and read the summary on active listening.
• Each group practices active listening by:
• One person talks about a piece of work they are doing for 10 minutes.
• One person actively listens and uses verbal and non-verbal techniques in response.
• The third person focuses on the listener and makes notes about what they observe and hear.
  • 5 minutes feedback to be provided by the observer and then swap roles so each person has a go.

Active listening summary

Active Listening uses:

Non Verbal techniques

• Silence
• Nods
• Facial expression
• Appropriate eye contact
• Body language

Encouraging and Eliciting Techniques

• Tone of voice
• Minimal encouragements “uh-huh” “go on “ “I see”
• Door Openers “I’d like to her more “ “Tell me about that”
• Closed questions “Do you like your teacher?”
• Open Questions “How did you respond?” “What happened next?”

Reflective responses for example

• “You are angry about the visit being cancelled; I would be upset too”
• “You feel uncomfortable when we talk about your family”

Summarisation

• “Here’s what I think you said….”
• “So because this happened you thought …..”

Active listening isn’t – agreeing, giving permission, giving advice or jumping in. Don’t be afraid of silence.

Working as a team to support a child

Methods
Suitable for self-directed learning or a facilitated group discussion between key members of a group with responsibility for a child.

Learning Outcome
To support effective multidisciplinary working.

Time Required
45 minutes.

Process
Consider a child you are working with and reflect on the effectiveness or otherwise of how the multidisciplinary group around the child is carrying out its roles and responsibilities. Use the questions below to guide your reflection.

Or

Bring together key members of the group and collectively discuss the effectiveness of co-working. Use the questions below to guide the discussion. Use a facilitator if an outside perspective to support the group process is indicated.

John Adair (1987) describes groups as having three types of needs:

• The task – the thing to be accomplished.
• The maintenance of the group – the need to maintain working relationships.
• The individual needs of each member.

Task

• Who are the key members of your group? (e.g. foster carer, social worker, supervising social worker etc.)
• Describe the overall task of your group and the sub-tasks?
• Is everyone clear about their roles and responsibilities?

Maintenance

• How does your group maintain relationships with each other?
• What interpersonal skills are needed?
• What is in place to assist day to day communication?
• Can members challenge each other?
• Who gets the final say?
• What would make working relationships better?

Individual needs

• Are individual needs getting met?
• What do individuals find supportive or difficult?
• Do individual needs get met at the expense of the group?
• Is someone feeling they aren’t being heard or that they don’t have a say?

Promoting Positive Partnership Working

Methods
Suitable for self-directed learning or reflection with a colleague or supervisor.

Learning Outcome
To explore and overcome barriers to effective partnership working.

Time Required
30 minutes.

Process
Reflect on a child in placement where you have a role.

• Identify existing or potential areas of tension, role confusion or conflict in your partnership working on the table below (not all will be relevant)
• Write down what is already in place or is needed to promote positive partnership working?
• What actions can you take?

You can record your ideas in the table.

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Working together to facilitate positive reunion contact

Download these notes as a PDF:
Multidisciplinary working Final 02/05/14

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10 Multidisciplinary exercises and questions as a Word DOCX file 22/04/14
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DfE Topic 10 Multidisciplinary exercises_22/04/14

Methods
Suitable for a facilitated workshop. Case study with small group exercise, work in pairs and large group feedback

Preparation
Hand-out with Dillon’s case study. Hand-out with questions to consider in pairs

Time Required
60 minutes

Learning Outcome
To explore contact from the perspective of others.

Process

1. Divide the group into two for the first task. Provide Dillon’s case study as a hand-out.
   Group1 – consider the case study from the point of view of Dillon’s new social worker
   Group 2 – consider the case study from the point of view of the supervising social worker. Each group spends 20 minutes discussing the case and considering the key issues they want to raise with the professional from the other group.
2. Pair up a member from one group with one from the other; resulting in pairs taking on the roles of social worker and supervising social worker in the next task.The pairs should spend 20 minutes discussing key issues from their role’s perspective and draw up an action plan for positive reunion contact, taking account of the following questions:-
   • Have you considered all the factors to ensure the contact arrangements will meet Dillon’s needs?
   • What other information /advice do you need to make a decision /plan and how will you get that?
   • What research can you draw on to help?
   • Who will support his birth mother, Dillon and the foster carers?
   • What support will they need?
   • Discuss your respective anxieties about the contact.
   • Do you agree on the purpose of the contact?
   • Are there any information sharing issues and how can these be managed?
   • What tasks will you take away with you in your role?
   • In what ways have you kept Dillon’s needs central to your thinking?
3. When they have been working together for 20 minutes give them this piece of new information and allow for a further 5 minute discussion to consider how it impacts on planning and decision-making.
   “The school has said that Dillon has been quite distressed recently and has been using the Makaton sign for mum quite a lot. The classroom assistant who knows Dillon well, is not enthusiastic about the contact and agrees with the foster carers that this will be an unsettling experience for Dillon”
4. Allow for 15 minutes feedback to the wider group

Below are some prompts for you to use during the feedback session:

• What were the key differences between reviewing Dillon’s needs from one perspective (part 1) and reviewing them from the social worker’s and supervising social worker’s point of view (part 2)?
• Any areas of disagreement, how did you resolve them?
• How did you allocate tasks?
• What makes working relationships easier?

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Presentation slide deck

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Download the presentation handout in the topic PDF file.

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References

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Multidisciplinary working Final 02/05/14

References

• Adair J (1987) Effective Teambuilding. London: Pan Books
• Atkinson M, Jones M and Lamont E (2005) Multi-agency Working and its Implications for Practice: A review of the literature. Reading: CfBT
• Boddy J (2013) Understanding Permanence for Looked After Children: A review of research for the Care Inquiry. London: The Care Inquiry
• Cairns K (2002) Attachment, Trauma and Resilience: Therapeutic caring for children. London: BAAF
• Caldicott F (2013) Information: To share or not to share? The Information Governance Review. London: Department of Health
• Carpenter J, Hackett S, Patsios D and Szilassy E (2010) Outcomes of Interagency Training to Safeguard Children: Final report to the Department for Children, Schools and Families. (Research Report DCSF-RR209) London: DCSF
• Covey S (2004)The 8th Habit: From effectiveness to greatness. New York: Free Press
• Davies C and Ward H (2012) Safeguarding Children Across Services: Messages from research. London: Jessica Kingsley Publishers
• DCSF (2010) The Children Act 1989 Guidance and Regulations Volume 2: Care planning, placement and case review. London: Department for Children, Schools and Families
• Finlay L. (2000) The challenge of professionalism in Brechin A, Brown H and Eby M.A. (eds) Critical Practice in Health and Social Care London: Sage
• Firth-Cozens J (2001) ‘Multidisciplinary Teamwork: The good, bad, and everything in between’ Quality & Safety in Health Care 10 (2) 65–66
• Frost N, Robinson M and Anning A (2005) ‘Social Workers in Multidisciplinary Teams: Issues and dilemmas for professional practice’ Child & Family Social Work 10 (3) 187-196
• Geiger J, Hayes M and Lietz C (2013) ‘Should I Stay or Should I Go? A mixed methods study examining the factors influencing foster parents’ decision to continue or discontinue providing foster care’ Children and Youth Services Review 35 (9) 1356-1365
• Goleman D (1996) Emotional Intelligence: Why it can matter more than IQ. London: Bloomsbury
• HM Government (2013) Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. London: Department for Education
• Jelicic H, Hart D, La Valle I, Fauth R, Gill C and Shaw C (2013) The Role of Independent Reviewing Officers (IROs) in England: Findings from a national survey. London: National Children’s Bureau
• Laming H (2003) The Victoria Climbié Inquiry. London: The Stationary Office
• Miller W and Rose G (2009) ‘Toward a Theory of Motivational Interviewing’ American Psychologist 64 (6) 527–537
• Munro E (2011) The Munro Review of Child Protection: Final report. A child-centred system. London: Department for Education
• NAIRO (2013) Nairo Management Protocol (Draft), March 13, Draft Protocol for the Management of IROs within Local Authorities c/o. National Association of Independent Reviewing Officers
• Neil E (2010) ‘The Benefits and Challenges of Direct Post-adoption Contact: Perspectives from adoptive parents and birth relatives’ Aloma: Revista de Psicologia, Ciències de l’Educació i de l’Esport Blanquerna Núm 27 89-115
• NSPCC (2013) Vicarious Trauma: The consequences of working with abuse. (NSPCC research briefing) London: NSPCC
• Oliver C, Mooney A and Statham J (2010) Integrated Working: A review of the evidence. Leeds: Children’s Workforce Development Council
• Research in Practice, Action for Children and The Adolescent and Children’s Trust (2013) focus group discussions for DfE Fostering and Adoption project November 2013
• Rodger S, Cummings A and Leschied A (2006) ‘Who is Caring for Our Most Vulnerable Children? The motivation to foster in child welfare’ Child Abuse & Neglect 30 (10) 1129-42
• Schofield G and Beek M (2005) Risk and Resilience in Long-term Foster Care. British Journal of Social Work 35 (8) 1283–1301
• Schofield G and Ward E (2011) Understanding and Working with Parents of Children in Long- term Foster Care. London: Jessica Kingsley
• Selwyn J, Sturgess W, Quinton D and Baxter C (2003) Costs and Outcomes of Non-infant Adoptions. Report to the Department of Health. Bristol: Hadley Centre for Adoption and Foster Care Studies, University of Bristol
• Sinclair I (2005) Fostering Now: Messages from research. London: Jessica Kingsley Publishers
• Stone B and Rixon A (2008) Towards Integrated Working. In Foley P and Rixon A (eds) Changing children’s services, working and learning together. Bristol: Policy Press
• The Care Inquiry (2013) Making Not Breaking. Building relationships for our most vulnerable children. London: Nuffield Foundation

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