Introduction

The purpose of this article is to provide a narrative review of a qualitative study on interprofessional collaboration in multidisciplinary settings by doctors of chiropractic, conducted by the author and colleagues. While most DCs practice in solo practitioner offices or small single clinics, growing numbers of chiropractors are choosing to deliver healthcare in public and private-sector medical centers, primary care practices, integrative medicine settings, and specialty hospitals such as cancer or rehabilitation hospitals.1-5

Chiropractors who work in integrated settings express interest in offering musculoskeletal-based diagnostic, therapeutic, referral, and case management services to patients; providing educational opportunities to chiropractic students and medical professionals; serving in administrative and professional leadership roles; and making contributions to clinical research.4

Benefits of integrated practice for chiropractors may include improved patient outcomes, access to broader referral networks and clinical services, reduced overhead costs, shared health records, and easier communication pathways among colleagues.2-4,6 Chiropractors also experience challenges when establishing practice in conventional medical settings, such as organizational resistance to the new service, inadequate infrastructure including clinic space and equipment, and uncertainty among professional staff and patients as to their role and responsibilities.2,3,6-8 Our team explored this last point in a qualitative study of stakeholder perspectives on adding a chiropractor to a multidisciplinary rehabilitation team.9 This article reviews key study findings, highlighting the preferred qualities, expectations, and anticipated challenges for DCs who join an established healthcare team in a medical setting. Quotations from the study interviews are included to offer the reader the thoughts of study participants in their own words.

Study Design

Our research team designed an organizational case study to evaluate the planned integration of a DC into a multidisciplinary team at a 62-bed rehabilitation specialty hospital, located in the northeastern United States.9,10 Our team tried to understand what stakeholders (the people who will be affected by a change in the organization) thought about adding a chiropractic program to the services currently provided to patients. Facility stakeholders included patients, family members, healthcare workers, administrators and community members. Most patients had experienced profound neurological deficits from traumatic brain injuries, spinal cord injuries, or strokes.11 All needed extended periods of inpatient therapy, nursing and medical care to recover from those injuries. Many suffered from musculoskeletal complaints associated with their original injury, other chronic conditions, or the physical rigors of the rehabilitation process.

The qualitative research design gathered stakeholders’ thoughts, opinions and feelings about chiropractors and chiropractic in general, with data collection methods focusing on words rather than numbers.9 This non-numerical data included in-person observation, public information about the facility available online, interviews and focus groups. Audio-recorded interviews were conducted with patients, families, and healthcare workers including medical physicians, nursing staff and members of the therapy team (including physical and occupational therapists and assistants, speech pathologists, psychologists, adaptive technology engineers, and therapeutic recreation specialists). Sixty participants considered what the chiropractor needed to know about the patients in this setting, as well as how to best work with the current staff. Content analysis of the written transcripts from these conversations identified 13 qualities that these patients and professionals preferred in the chiropractor who would join the staff.12

Patient-Centeredness is Central

Figure 1 depicts a model of the preferred qualities of chiropractors working in a multidisciplinary rehabilitation setting.9 The central quality, described by all participants and linked to the four other categories of the model, was patient-centeredness. In this setting, health professionals were described as “patient-centered” when they provided care that was respectful and responsive to the values, preferences and needs of the patient. While knowledge of the patient’s injury and medical history was important, participants encouraged the DC to understand the person beyond their present health challenges, as these challenges were only one part of the recovery journey. As one patient in this study said, “Every person here has their own story, so what is good for one person may not be good for another person.” Beyond patient-centeredness, preferred qualities in the collaborating chiropractor fell into four domains: professional, interpersonal, interprofessional and organizational.9

Professional Qualities of Chiropractic Competence

Professional qualities focused on clinical knowledge, competence, and proficiency in the field of chiropractic and were described by themes such as clinical acumen, efficacious treatment and safe practitioner. Participants agreed that the DC should have a sound knowledge of the principles of chiropractic, but also a deep understanding of neuro-anatomy and how brain injuries could impact how patients move, talk and think. As one medical doctor noted, “A lot of patients with head injuries have a difficult time controlling their behaviors and moods,” which “would be a challenge potentially…with the hands-on care that chiropractic care involves.” Treatments backed by clinical evidence that would provide a measurable impact on patient outcomes were important, as was demonstrating a focus on patient safety. Keeping patients from harm and recognizing adverse events was vitally important for rehabilitation patients who might have spinal cord injuries or difficulty with verbal communication after a stroke.

Figure 1. Preferred qualities of chiropractors working in multi-disciplinary rehabilitation settings

Interpersonal Qualities to Promote Healing

All participants thought DCs could create a healing environment for the person undergoing neurorehabilitation. The preferred interpersonal qualities of the chiropractor included a comforting patience, familiar connections and emotional intelligence. Patients and their families often thought the therapy areas of the facility were uncomfortable places, since this was where the patient engaged in difficult and unpleasant exercises to achieve therapeutic goals. In contrast, the chiropractic visit was considered a potential time and space within the rehabilitation setting where patients might slow down and experience rest, relaxation and self-care. As one family member said, “One thing that would definitely be beneficial is a very calm, quiet area where the patients could have their session with the chiropractor.”

Beyond offering a comforting patience, the DC was encouraged to make familiar connections based not only the doctor-patient interaction, but person-to-person relationships. In long-term settings where people lived for weeks to months, staff strived to know patients’ favorite TV shows, sports teams and hobbies. Emotional intelligence, or the capacity to understand the emotions of others, be aware of one’s own emotions, and manage emotional states, was the third quality described by participants. One nurse described how the emotional changes brought on by a traumatic injury might impact the DC’s interactions with patients: “Have a thick skin, don’t take anything personally…the patient will have this anger, it’s being directed at you, but it’s not about you…you have to remember that when you work with this population.”

Interprofessional Qualities for Delivering Team-Based Care

Healthcare workers stressed the preferred interprofessional qualities of their future team member, encouraging the chiropractor to demonstrate three characteristics important to working in an interdisciplinary setting: teamwork, resourcefulness, and openness to feedback. Teamwork involves the cooperative, collaborative efforts of the clinical team toward their shared purpose and agreed-upon patient care goals.

Resourcefulness was another key attribute. As the rehabilitation setting had no “typical” patient, clinicians often had to change an approach and develop creative solutions to care for challenges or technical problems. Stakeholders encouraged both openness in thinking as well as openness to feedback, and the ability to incorporate new ideas or information into one’s practice. As one therapist said, “You’ve got to be open because you may have never done anything [similar] in the past.” Team meetings were important for receiving and offering such feedback. As a medical staff suggested, a chiropractor should “come to the same meetings we all go to so that they can ask questions, learn [about] our patients” and “know who does what… as opposed to working out there by themselves.”

Organizational Qualities for Joining a Healthcare Facility

Three themes comprised the organizational qualities for working in the hospital evaluated, but which may be transferrable to others: personality fit, institutional compliance and mission alignment. Personality fit focused on listening, humor, enthusiasm, persistence, positivity, caring, professionalism and gratitude. As one therapist offered, “finding joy in the smaller pieces, smaller rewards, is not something that everybody can do.” Rules must be followed (institutional compliance), including adherence to credentialing procedures, insurance and use of electronic health records. Finally, stakeholders advocated for hiring a chiropractor whose personal mission is in alignment with that of the organization. As a community member noted of this facility, “From the president to someone sweeping a floor, they are just wonderful people… it’s just doing such good work for so many people.”

Conclusion

This qualitative study explored stakeholder perspectives on the preferred qualities sought in chiropractors working in multidisciplinary rehabilitation settings.9 Patient-centeredness served as the central theme, with additional qualities identified in the professional, interpersonal, interprofessional and organizational domains. The results of this study are limited to some extent by the context-specific nature of the data gathered in one specialty hospital, although some transferability to other settings is suggested by previous research and recent commentaries on professional excellence in chiropractic.13-15 Chiropractors interested in pursuing collaboration or practice in interdisciplinary settings may cultivate these and other attributes to enhance patient outcomes, contribute to clinical decision-making and interprofessional teamwork, and impact the missions of healthcare organizations.

Acknowledgements

The research study described in this article was funded by The Kiernan Chiropractic Care in Rehabilitation Program at Crotched Mountain, sponsored by Dr. William J. and Mary A. Kiernan and The Kiernan Family Trust. Ethics approval was granted by the Institutional Review Boards of the Palmer College of Chiropractic and the Crotched Mountain Foundation. This article was originally published in a longer format in Chiropractic & Manual Therapies and distributed under the terms of the Creative Commons Attribution 4.0 International License.

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