Communication and decision-making in a study of a multidisciplinary team conference with the registered nurse as conference chairman

Inl. J. Nurs. S&d,. Vol. 23, No. 4, pp. 299-314, Printed in Great Britain

002&7489/86 $3.OO+O.Gll Pergamon Journals Ltd.

1986

Communication and decision-making in a study of a multidisciplinary team conference with the registered nurse as conference chairman BIRGITTA

ENGSTRijM,

R.N.

Department of Neurology, University of Urned, s-901 85 umerp, Sweden

Abstract-It was decided that the medical and nursing staff had to communicate verbally concerning the patient’s need for information and to make decisions concerning steps to be taken when satisfying the patient’s need for information. The aim of this study was, accordingly, to investigate if a training programme for registered nurses as chairperson of the multidisciplinary team conference (MTC) changed the communication and decision pattern during the neurological ward conference. The training material provided instructions and a scheme for the chairperson of the MTC. The training was carried through with the help of patient case reports and role play. Data were collected through tape recordings of the communication at ten MTCs before the training and ten MTCs after the training. The strictly medical communication was less illuminated, while the patient’s psychological needs, especially concerning the patient’s need for information, were better illuminated than before the training. After the training 42 information problems were reported and two before. For half of them, decisions were made on the steps to be taken in order to fulfil the patient’s need. For the other half, the discussion concerning the patient’s need for information was communicated between the staff. Only the decision-making was missed.

Introduction In Sweden, it is the registered nurse’s responsibility to see to it that the patient’s need for information is satisfied. That does not mean, however, that she has to give all required information herself. The registered nurse still has to know the patient’s need for information and his satisfaction with given information. This task is impossible without systematic 299

300

BIRGITT.4

ENGSTRo;M

collaboration between medical and nursing staff concerning the patient’s need for information. It was, accordingly, considered that the medical and nursing staff had to communicate verbally concerning the patient’s need for information and to make decisions concerning the steps to be taken when satisfying the patient’s need for information (Faulkner, 1984; Engstrom, 1986). At the neurological ward of the University Hospital in Ume5, the daily multidisciplinary team conference (MTC) was the forum for this communication. The entire team participated. The patient’s “mentor” was instructed to report the patient’s information problems. The informant could then renew the contact with the patient and give him the information needed. From interviews with the mentors it appeared, however, that they very seldom or never reported information problems at the MTC (Engstrom, 1983). It was, accordingly, important to investigate the communication at the MTC in order to find out why the mentors did not report their patients’ information problems. It was then necessary to develop a method for changing this situation. The present study was aimed at: (i) Collecting data on the communication pattern and on how the patient’s psychological care needs in the form of information requirements were handled during the MTC; (ii) Devising a training scheme for changing the communication at the MTC; (iii) Collecting data and making a comparison between the MTC before and after the training was put into effect. Questions which the study attempts to answer are: (i) Does the training influence the personal categories’ verbal activity at the MTC; (ii) Does the training influence the communication content at the MTC; (iii) Does the training influence the communication on the patient’s need of information? Theoretical background The health care system has a hierarchical structure with different medical competence levels and fields of knowledge (Garde11 et al., 1979). The hierarchical system is built upon control and routine duties which demand specialization and little variation in their execution. It can have the consequence that those individuals who work in the lower ranks within the system feel themselves of lesser importance because they are controlled and have to function strictly in accordance with written or unwritten rules and principles (Korman, 1977). Since the physician has the highest medical competence and because socio-psychological goals are not seen as being of primary interest for health care (Berglund, 1975), it is probable that the physician overloads the communication at the MTC with medical aspects of the patient’s care. Medical decisions concerning the investigation are, as a rule, taken at other forums and need only be communicated to the members of the MTC. From this it follows that the main function for the MTC is to plan steps to be taken concerning complicated nursing problems, e.g. concerning the patient’s need for information. A change of the communication content so that it is more socio-psychologically orientated is therefore needed. This demands, however, a structure and a scheme for the communication. From the scheme it must be evident how an integrated view of the patient’s need for care is communicated during the MTC. A chairperson is needed for a meeting when the group is large (8-9 persons) and decisionmaking is involved. The chairperson’s main function is to control the meeting (Rackham and Morgan, 1977), so that all members of the MTC are communicating, the patient’s

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301

total need for health care is taken into consideration, a more or less equivalent length of time is devoted to each patient, the conflict situations which can arise are resolved, and decisions are made concerning steps to be taken satisfying the patient’s need for information. In addition, the chairperson has an important role in mastering the difficulties which lie in all the possibilities for erroneous interpretation and misunderstanding which can occur in a communication process in which several individuals are involved (Campbell, 1958). From this it follows that a competent and skilled chairperson for the MTC is needed if, for example, the practical nurse is to be able to report what she knows about the patient’s need for information and the MTC members are to plan for the measures to be taken. Since the registered nurse has both a medical and a nursing competence and nursing is a collaborative function, it seemed logical that she was the chairperson of the MTC in this study. She had, however, no formal training for this position. General prerequisites

The neurology ward had 30 beds and was the only specialist neurology department for a population of 650,000. The majority of the patients (80%) who attended for neurological examination were accepted on the basis of planned admittance. The mean length of ward stay was 10 days. On the neurological ward, the organization of the delivery of medical and nursing care was by team care. There were two teams, each retaining the same group of patients during the patients’ hospital stay (Engstrom, 1986). Information

problems

If the patient has drawn wrong conclusions from information received, lacks important knowledge or is dissatisfied with received information, then there is an information problem. According to Engstrom (1984, 1986), it was shown that patients after discharge considered that they had the greatest need of information on prognosis and examination results. Their need of this information was, however, the least well satisfied. This situation is negative for the patients, who are therefore not instructed and prepared in the best way to accomplish their own care after discharge. It is possible that neither the health care personnel nor the patient appeared to be cognisant of the time after hospital discharge and of what awaited the patient concerning his own care. The patient may be thinking that he will receive information concerning socio-psychological consequences of the disease when examinations are undergone. The physicians and other staff, on their part, may be thinking that they do not have enough factual knowledge regarding the socio-psychological consequences for the patient before the total investigation and diagnostic procedure is complete. When the day for discharge is reached, too little~attention is given to the patient’s subjective need for information in this regard. The patient is not given enough time to ask questions and think over the information received before he leaves the hospital (Engstrom, 1984). The information to the patient should instead be given continuously and the patient given the opportunity to think over the information and ask questions and receive answers. This means that the patient’s information problems must be treated throughout the hospital stay. The usual situation for information giving is a communication from an informant, e.g. a physician or a nurse to a receiver, e.g. a patient. A series of messages exchanged between persons is called interaction (Watzlawick et al., 1967) and is illustrated within the frame in Fig. 1. This method has proved to be inadequate (Engstrom, 1984), which resulted in a method aimed at decreasing the problems in the information and communication process. Systematic routines were established for general and medical information to the patient,

BIRGITTA

302

ENGSTR&4

_

MTC

Fig. 1. A schematic

model of the communication

in the neurological

ward when information

is given to a patient.

follow-up of information with the help of a mentor system, and written communication between the informants and the mentors about the patient’s need for information (Engstom, 1986). The verbal communication between the informants, mentors and the other staff on the patients need for information should take place at the MTC. A schematic model of the communication in the neurological ward when information is given to a patient is shown in Fig. 1. The MTC was a daily forum for collaborative communication established in order to increase the foundation for decisions made on and about the individual patient’s health care. The instruction was that the patient’s need of psychological, social, cultural, physical and medical care would be taken into consideration. This should be possible because the entire team participated. The team consisted of physicians, registered nurses, enrolled nurses, nurse’s aides, physiotherapist, occupational therapist, counsellor and students. Enrolled nurses have undergone a two years basic training and nurse’s aides one year. In the following presentation both will be termed practical nurse. All members of the MTC team are required to report their observations on the patients at the MTC. The MTC partly replaced the function of the medical round in gathering and analysing information about the patients but functioned also as an occasion for the physician’s directives to the registered nurse. The registered nurse was the team leader and chairperson of the MTC. No formal rules were formulated as to how the chairperson role and the problem-solving process should function. The MTC was scheduled each morning at 9.30-10.15 a.m. After the MTC the physician and the registered nurse had a medical round to the patients who were allocated to their team.

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Methods

Subjects, procedure and evaluation A schematic plan of the study is shown in Fig. 2. The project started with data collection by tape recordings of ten MTCs in May 1982. The tape recordings were made of five consecutive MTCs for both groups. The number was chosen to correspond to all weekdays with MTC (Monday-Friday) and so that all team leaders were included. After that, the training material was developed. It consisted of (1) an instruction to the chairperson regarding his/her behaviour during the MTC, (2) a scheme for the order in which the care areas should pass through the phase of planning, (3) patient case reports for role playing at the training MTC (Fig. 2). Other studies have shown that the introduction of new working methods are successful if personnel get a structured education which is as true to the real working conditions as possible (Davis and Nyhlin, 1982; Bowman et al., 1983). The educational programme was followed on 23 February and 1 March 1984. The two multidisciplinary team groups attended one day each. Seven registered nurses practised as chairperson while physicians, practical nurses, occupational therapists, counsellors, etc., functioned as the medical and nursing staff at the MTC. The instruction, the chairperson role and the case histories were devised by the project researcher. She was also the head nurse of the neurology department but on leave during the project. The educational programme was carried out with the help of the nursing instructor. Throughout March the researcher took part in one of the two MTCs every day (MondayFriday). After each MTC, a short time was allotted for private conference between the chairperson and the researcher. The object was to give the registered nurses feedback and support in their training for the role of chairperson. The evaluation of the influence of the training was studied in June 1984 with the help of tape recordings of ten MTCs. The time between the educational sessions and the data collection was chosen so that the team leaders should have time to practise and become as skilled as possible as chairperson. The tape recordings were played back several times and for each one the form and content of the staff’s communication was registered. The content of the communication at the MTC was classified as investigation, treatment, prognosis, and aspects of social, psychological, cultural and physical care. The classification of most of the categories are obvious and demand no further explanation. The staff’s statements, questions and viewpoints concerning the patient’s experiences, thoughts, ponderings, etc., were coded as psychological aspects. An adaption of the technique developed by Bales for analysing the content of verbal interactions was employed (Bales, 1950). Six of Bales’ 12 categories were selected along with “sum up” and “prescribe” (Table 2). To “sum up” was considered as an important task for the chairperson and “prescribed” was registered when someone made a decision during the MTC. Reported information problems were analysed concerning content, degree and quality of problem solving. The patient’s questions, ponderings, reflections and incorrect conclusions reported by a member of the staff at the MTC were classified as information problems. For example, the registered nurse had assessed that the patient had drawn incorrect conclusions about what caused his illness and why he was committed to the neurological ward. Her report was classified as an information problem concerning the investigation. Another example is a mentor’s report that a patient speculated about a

TAPE RECMlOINGS OF THE CMUNICATION AT TEN MTCs

QEVELOPlNG

NURSING

INSTRUCTOR

CASE REPORTS

INSTRUCTiONS

STAFF.8

ROLE

Fig. 2. A schematic

PLAY

19R4 1F THE UCL SO,.

I

GATION

I

YEhiT

INYESTI-WE*,-

GIVES/ASKS FOR ORIENTATION SUGGESTION OPINION

I

PHYSICAL

I

PROGNONOSIS

I

NURSING CARE

I

MEDlCiL CARE

SUPPORT AN0 FEEDBACK TO THE CHATWLRSON THROUGHOUT THE lth MONTH AFTER THE TRAINING

~._._.-*-._.-.-._._.---.-_--_.-_-.-._.__

plan of the study.

i

i

i

i i

i

i

i i i i

-b

\ \

I

1984

\

\

:

TAPE RECORDINGS OF THE C@QlUNICATiON AT TEN MTCs

DATA COLLECTION

JUNE,

N -

0

s

I

R

4

P

u

-

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305

withdrawal of his driving licence. This problem was classified as an information problem concerning social aspects. From the discussion between the members of the MTC, which followed the report, the researcher then classified the content of the discussion, if decisions were made or not on the steps to be taken in order to answer the patient’s questions, etc., and if the personnel categories made at least one utterance each concerning each information problem. Ference’s model for problem solving in organization was used to study the quality of the problem-solving process concerning the reported information problems (Ference, 1977). Ference differentiates between five main stages in the problem-solving process. That is, problem recognition, which continues with identification procedures and then later information acquistion and integration, defining the constraint set. The fifth stage includes comparison and adaption. From the tapes were recorded the communication regarding the planning of the steps to be taken when satisfying the patient’s subjective need of information. The occurrence of Ference’s five stages were recorded on a rating sheet. All ratings were made by the researcher after several practice sessions, thus avoiding problems of rater differences. Statistics The Chi-squared groups.

test for independence

was used in order to test differences between

Results

The communication was analysed and compared between the MTCs before and after the registered nurses were trained as chairpersons. Forty-one different patients were hospitalized during the period of pre-measurement. Since the same patients were discussed during more than one MTC, the total number of ten MTCs was 142 patients. During the period of post-measurement 35 patients were hospitalized and 102 patients were discussed during ten MTCs after the practice sessions. The personnel categories’ verbal activity The registered nurse, the practical nurse and the occupational therapist had increased their verbal activity during the MTC at post-measurement (Table 1). A percentage comparison shows that the physician reduced his share of the total communication during the MTC in comparison to the other personnel categories.

Table 1. The personnel categories’ utterances per group of 15 patients at ten MTCs before and ten MTCs after training. Number of utterances: N= 118 before, N= 191 after Personnel categories

Utterances per group of 15 patients After Before % (N) 8 %

Physician Reg. nurse Prac. nurse Physiotherapist Occup. theraoist Counsellor _

61 29 2 5 1 2

(72) (33) ( 3) (6) ( 1) (3j

33 41 14 5 5 2

(63) (79) (26) (10) ( 9) ( 4)

BIRGITTA

306

ENGSTROM

From Table 2 it can be seen that the largest reduction for the physician was for “Gives opinion”, “Gives orientation” and “Asks for orientation”. The registered nurse increased her share of the verbal activity except for “Gives orientation”. The share in the number of questions put by the registered nurse rose. The practical nurse expressed no opinions At the postand made only 2% of “Gives orientation” at the pre-measurement. measurement she gave 3% of the opinions that were expressed and made 10% of “Gives orientation” (Table 2). The group of specialists, that is, physiotherapist, occupational therapist and counsellor, altered their share of the communication the least of all. The specialists were not engaged with every patient and did not participate in every MTC, which partially explains why their share of the total communication was relatively low. “Asks for suggestion” and “Asks for opinion” and “Sum ups” occurred so seldon, and only among physicians and registered nurses, that the calculation of percentrage was zero. “Prescribes” consisted of physicians’ orders for investigations and prescriptions of drugs and occurred very seldom (Table 2). Table 2. The personnel categories’ verbal activity at ten MTCs before and ten MTCs after training. Number of utterances: N= 1132 before and N= 1316 after Verbal activity

Gives opinion

Physician aft. bef. (%)

R.N.iChairman bef. aft. 10701

Prac. nurse bef. aft. (070)

Specialist* bef. aft. (%)

5

3

6

0

3

2

3

3

0

0

4

0

0

0

0

29

20

18

19

2

IO

4

5

14

6

6

I1

0

I

3

5

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Prescribes

5

2

0

0

0

0

0

0

*Physiotherapist,

occupational

Give5 suggestion Gives orientation Asks for orientation Asks for suggestion Asks for opinion Sum ups

II

therapist,

counsellor

The content of the personnel categories’ communication The physician’s communication per 15 patients declined in regard to investigation and treatment of the patient (Table 3). The registered nurse’s communication per 15 patients increased concerning psychological aspects of care from 1% at pre-measurement to 13% at post-measurement. The practical nurse’s communication also increased as regards psychological aspects of care. The specialist’s communication was comparable at both measurements (Table 3). From Table 4 it can be seen that 78% of the personnels’ utterances per 15 patients at pre-measurement concerned investigation and treatment. The rest were aspects of social, psychological and physical care. At post-measurement, 56% of the utterances per 15 patients were aspects of investigation and treatment and 44% aspects of social, psychological and physical care of the patient. Communication concerning prognosis arose twice and was classified as psychological aspects since it was a mentor’s reports on patient’s questions, etc. No communication about cultural aspects of patient care arose (Table 4).

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307

Table 3. The content of four personnel categories’ utterances per group of 15 patients at ten MTCs before and ten MTCs after training. Number of utterances: N= 118 before, N= 191 after Content of utterances

Physician bef. aft. Vo)

R.N./Chairman bef. aft. (%)

Prac. nurse bef. aft. (910)

Specialist* bef. aft. (Q)

Investigation

40

21

19

18

0

3

4

4

Treatment

11

6

4

4

0

0

0

0

Prognosis

0

0

0

0

0

0

0

0

Social aspects

5

3

2

4

0

1

3

5

Cultural aspects

0

0

0

0

0

0

0

0

Psychol. aspects

3

3

1

13

0

5

0

0

Physical aspects

3

2

4

3

1

4

0

1

*Physiotherapist,

occupational therapist, counsellor.

Table 4. The content of the personnel’s utterances per group of 15 patients at ten MTCs before and ten MTC’s after training. Number of utterances: N= 118, N= 191 after Content

Utterances per group of 15 patients After Before % (M % (N)

Investigation

63

(74)

45

(86)

Treatment

15

(18)

11

(20)

Prognosis Social aspects

0 10

(0) (12)

0 14

(0) (26) (41)

Psychological aspects Cultural aspects

4

(5)

21

0

(0)

0

(0)

Physical aspects

8

(9)

9

(18)

Information problems The patient’s questions, ponderings, speculations and erroneous conclusions were included in the information problems. The demand was that they should be assessed and reported by one of the staff at the MTC. On this basis two information problems were reported for 142 patients at pre-measurement and 42 for 102 patients at post-measurement. No statistical comparison between before and after the training could be done because so few information problems were reported at pre-measurement. Thirty-one per cent of the communication at the MTCs after training was communication concerning reported information problems. From Table 5 it can be seen to what extent the content of the discussion concerning the reported information problem corresponded to the total communication content. Fifty-six per cent of the utterances regarding psychological aspects of the patient’s care concerned the information problems.

308

BIRGITTA

ENGSTROM

Table 5. The content of the communication concerning the reported information problems in percentage of the content of the utterances at ten MTCs after training Content Utterances I%

Communication Utterances concerning information problems N %

Medical aspects

72K

184

25

Social aspects

180

40

22

Psycholog. aspects

282

159

56

Physical aspects

126

22

17

Forty-seven per cent (N= 20) of the information problems at post-measurement dealt with the medical investigation (Table 6). That is, for example, questions about examinations and their results, ponderings about diagnosis, anxiety about the presence of a tumour, etc. One fourth (26%) contained questions and reflections on treatment. For example, for how long shall I take this drug; which dosage shall I have; what effect will this new drug have; shall I be given any physiotherapy. Reflections and speculations which, for example, dealt with the possible granting of sickness pension, anxiety over withdrawal of a driving licence, continuation of care in an institution or in the home, etc., were classified as social aspects. This type of information problem arose seven times. The information problems regarding prognosis and other aspects of the patient’s care were so few that they are not included in the following presentation. Table 6. The content and frequency of information problems reported at ten MTCs after training Content

Information %

problems (N)

Investigation

47

(20)

Treatment

26

(11)

5

(2)

17

(7) (2)

Prognosis Social aspects Others

5

The content of the discussion between the staff concerning the reported information problems can be seen in Table 7. Fourteen per cent of the discussion was the mentor’s communication on psychological aspects of the patient’s information problem. Twentythree per cent was the physicians communication on the medical aspects of the patient’s information problem. The registered nurse communicated both medical aspects (18%) and psychological aspects (14%) on the information problems. There were no statistical differences (x2 = 1.24, Ps 0.05)between the practical nurses, registered nurses physicians and the specialists regarding expression of at least one utterance each in the discussions about every information problem. The specialists were not involved with all patients and did not take part in the MTC every day. Further, they had not made the acquaintance of all the patients’ and consequently could not have opinions about their needs. From Table 8 it can be seen that the specialists had not expressed any utterances at all concerning 10 information problems about the patients’ treatment.

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Table 7. The content of the discussion between the personnel categories following the reported information problems Content of the discussion Social Psychological aspects aspects % (N) % (M

Personnel categories

Medical aspects % (M

Physician

23

(92)

2

(8)

8

(29)

Reg. nurse

18

(71)

3

(12)

15

(60)

Mentor

4

(14)

2

(7)

14

(57)

2

(8)

Prac. nurse

1

(5)

0

(1)

l

(5)

0

(2)

0

(2)

3

(12)

2

(8)

0

(1)

Specialist* *Physiotherapist,

Physical aspects % (M

1 1

(6) (5)

occupational therapist, counsellor.

Table 8. Distribution on whether four personnel categories express one utterance each concerning every reported information problem Information problems N= 38

Physician Yes No

Investigation (N= 20)

20

0

Treatment (N= 11)

11

0

Social aspects (N= 7)

Utterances R.N./Chairperson Prac. nurse Yes No Yes No

Specialist* Yes No

20

0

17

3

4

16

11

0

9

2

1

10

7

0

5

2

3

4

I 6

1

*Physiotherapist, occupational therapist, counsellor. x2=1.24, 6 df, n.s., PsO.05.

Decisions on measures to be taken were made for 52% of the reported information problems. The difference between information problems decided upon or not was not statistically significant (Ps 0.05) (Table 9). The five stages in Ference’s model for problemsolving in organization were not found in entirety in the staff’s communication regarding the planning of steps to be taken when satisfying the patient’s subjective need for information.

Table 9. Distribution on decisions taken or not taken on the reported information problems Information problems (N= 38)

Decisions taken Yes No

Investigation (N= 20)

8

12

Treatment (N= 11)

8

3

Social aspects (N= 7)

4

3

x2=3.2, 2 df, ns., PsO.05.

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BIRGITTA

ENGSTRdM

Discussion

The aim in this project was that an illumination of the patient’s total need for health care should occur throughout the MTC. In particular the patient’s need for information should be illuminated and satisfied with the help of mentors and their reports. This demanded, however, that all personnel categories took part in the conference and contributed with their specific knowledge about the patients. It is important to remember that this study is a sample and has only evaluated the communication at the MTC. The consequences for the patients and their experiences of the care will be presented in another paper. Tape recorders were used when collecting data. This was a disturbing factor in the communication at the MTC. It was, however, possible to assume that the tape recorder influenced the members of the MTC to perform better than usual. The tape recorder influence was accordingly positive for the communication evaluated. The registered nurse as chairperson

The results indicate that the practical nurse’s verbal activity was very limited at the premeasurement, which, most probably, was due to the fact that communication at the MTC was principally medically and diagnostically orientated and largely took place between the physician and the registered nurse. At the post-measurement, the communication between the latter had diminished and the chairperson requested to a greater degree orientation from the other participants and principally from the practical nurses. At the premeasurement, medical students took part in the MTC and a considerable part of the time was therefore devoted to their medical education. This did not occur, however, at the postmeasurement, and could be one reason why more utterances were recorded after the training. Physicians are trained for autonomous decision-making, personal achievement and the the importance of improving their own performance (Weisbord, 1976; Stoelwinder and Clayton, 1978). Accordingly, the physician needs to change his view of the health and illness care field in order to allow significant roles, besides his own, to be featured and valued in it (Mauksch, 1981). Often they seem unaware that other medical workers possess skill and knowledge which they themselves do not have (Kalisch and Kalisch, 1977). Since the practical nurse was a mentor and had special knowledge about her patients, she would have had an opportunity to give reports at the MTC. The fact that the mentors did not communicate at the pre-measurement suggests, according to Rackham and Morgan (1977), that a chairperson who was skilled and could control participation of all members was needed. Otherwise the physicians dominated with that communication that they themselves found important in diagnosing the patients medically, an observation in line with Wessen (1972) who found that physicians tend to look upon the hospital only as an institution for supplying their relevant professional needs. The findings that the utterances about the patient’s psychological needs had increased with 17% of the total communication per patient, and that the utterances about the patient’s investigation and treatment had decreased for the benefit of social and psychological aspects of the patient’s care, suggest that the chairperson had altered her verbal behaviour. That means that the instructions and scheme for the chairperson functioned in this regard. A skilled chairperson was expected to ask for information more often and to give information less often than the rest of the group (Rackham and Morgan, 1977). The results indicate that the registered nurse had understood through the education received the importance of the chairperson requesting information and not to give herself at first hand,

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information which the practical nurse could just as well have given. If all members of the MTC are to consider themselves engaged in the conference, then they must have the possibility to participate through reporting what they themselves know, which also agrees well with Korman’s theory on work motivation (Korman, 1977). The findings that the chairperson did not ask for opinions and suggestions suggest that a planned problem solving process was still missing. In the physicians’ training and experience, a focus is, however, built into the identification and treatment of pathology (Cobbs, 1975). Nurses also have a symptom-orientated training (Johansson, 1983). Accordingly, their concentration on medical aspects in the communication during the MTC was not surprising, but worked against an integrated view of the patient. This means that the chairperson has to be well-versed in the problem-solving model so that he/she can concentrate upon the task of controlling that decisions are made on all types of nursing care problems that are reported. This presumes, however, that the registered nurse, preferably already during her basic training, has been trained as chairperson for a group with different professional competences. The findings at post-measurement indicated that the prerequisities for an illumination of the patient’s whole situation and a focusing on his psychological needs had increased. The medical and nursing staff’s discussions concerning half of the reported information problems lacked, however, the decision-making on steps to be taken. The importance of collaboration on the patient’s psychological care need The finding that the medical communication between the physician and the registered nurse was reduced at post-measurement was also a condition for the patient’s psychological needs to be illuminated and taken into consideration. In reality, most of the medical decisions concerning the diagnostic investigation and treatment procedure, were made in other forums, e.g. the X-ray conference, the neurophysiological conference and at the chief physician’s and hospital resident’s joint review of the patients. This means that the medical communication during the MTC should primarily consist of directives to the registered nurse on examinations and investigations which the patients were to undergo and prescriptions of drugs they were to receive. In addition, an orientation over the medical investigation was presented for the members of the MTC. The nursing staff still have no formal qualifications to,take part in these types of medical decisions, other than to report observations which concern the patient’s illness and treatment. These reports of the patient’s physical symptoms, medical registrations, etc. led to, as a rule, the physician deciding on eventual steps to be taken based upon these reports without the other members having the competence to contribute recommendations, etc., in a problemsolving process. The patient’s psychological, social, cultural and physical health care needs should, on the other hand, be the object of a problem-solving and decision-making process at the MTC. Since especially the patient’s psychological needs are unique, there are no routine solutions to chose between. Besides it is very difficult to make decisions on this part of the patient’s health care needs. The demand is, therefore, that so many as possible contribute information about the patient (Berglund, 1975; Wilson-Barnett, 1979). All personnel categories have the competence within their own functional area to contribute with their knowledge of the patient. Collaboration is thus needed, and the MTC is a self-evident forum for this. Strangert (1983) found, however, that health care personnel in long-term care had insufficient knowledge in care psychology of practical value and that the communication

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during the MTC was constantly ill-defined when psychological care problems were discussed. Accordingly, that the patient’s psychological care needs were seldom dealt with at premeasurement suggest that deficient knowledge could be a problem limiting the development of collaboration concerning the patient’s psychological care needs. Another problem, according to Kalisch and Kalisch (1977), is that physicians feel that nurses have placed such a great emphasis on the psychological aspects of the patient care that they are guilty of ignoring the physical needs. Nurses, in their turn, believe that physicians have forgotten the patients as persons. The finding that there was no verbal activity regarding the progress of the patient’s disease, either at the pre- or the post-measurement, and the fact that the information problems which were reported at the post-meaurement dealt to a large extent (73%) with hospitalbound care problems regarding the medical investigation and treatment, suggest that neither the health care personnel nor the patient appeared to be cognisant of the time after hospital discharge and of what awaited the patient concerning his own care. Dealing with the patient’s information need Many studies have shown that patients’ need of information were not satisfied during hospital stay (Ley, 1972; Boman et al., 1983; Engstrom, 1984, 1986). That is perhaps not so surprising if we take into account that only two information problems were expressed for 41 patients throughout the MTCs at pre-measurement. The research project had been going on for three years before the data collection, and the mentors were instructed to report the patients’ information problems at the MTC. At post-measurement 42 information problems concerning 20 of the 35 patients were reported. Half of the expressed information problems did not become the object of decisions on measures to be taken. This can, besides the chairperson’s incapability to lead the MTC on to decisions, be a result of information, opinions and questions from patients being treated sometimes as insignificant by the physician (McGilloway, 1976). If this is occurring frequently there is a risk that the registered nurse arrives at a conflict between the patient’s need for information and the physician’s wishes. Since the physicians have high status in the group and their opinions tend to dominate, this is bewildering also to the mentors and the other members of the MTC. They will experience uncertainty and do not know if they can demand that decisions are made on steps to be taken in answering the patient’s questions, etc. The findings suggest that the education of the registered nurses and the scheme for the chairperson of the MTC led to the chairperson, to a greater degree than previously, requesting other than physicians for information. Information problems came from the patient and were most often assessed by some of the patient’s mentors. In this way more information problems came to the attention of the group. The discussion which followed the report of the information problems involved both medical, social, psychological and physical aspects of care and involved all the personnel categories. That the registered nurse communicated both medical and psychological aspects was probably the result of her unique competence. The fact that there was no statistical difference between the practical nurse, the physician and the registered nurse regarding their contribution to communication concerning the reported information problem suggests that all members were active in giving their viewpoints when measures for information to the patient were planned. This is one important way to avoid stereotyped dealing and improve the individualization of the information. The education did not, however, lead to the registered nurse being able to lead the MTC

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through to decisions by utilizing the complete problem-solving process when planning for implementation. In spite of this, decisions were made on 52% of the reported information problems. An adoption of Ference’s model would also lead to an increase in the quality of the problem solving. It is, however, important to remember that competition and controversy are inevitable on the road to collaboration. This role realignment causes an enormous amount of anxiety, uncertainty and frustration for each member (Kalisch and Kalisch, 1977). The process of change, which is needed in planning the steps to be taken as a result of the patient’s information problems, is still in its first phase. The MTC is an important forum for the registered nurse in her task of seeing to it that the patient’s need for information is satisfied during hospital stay.

Conclusion

The MTC was a forum for communication and decision-making on and about the individual patient’s health care. The forum was important for collaboration between the medical and nursing staff regarding complicated nursing problems, e.g. concerning the patient’s need for and satisfaction with information. The physician dominated the communication process with reference to investigation and treatment so long as there were no formal rules for chairmanship. It did not help that the mentors had unique knowledge about the patient’s need for and satisfaction with information. With the help of the registered nurse as a trained chairman the patient’s need of social and psychological care was better illuminated during the MTC. At premeasurement, two information problems were expressed. At post-measurement, the expressed information problems (N= 42) became, in half of the cases, the object of decisions on the steps to be taken. The educational material was, however, insufficient in training the registered nurses adopting Ference’s model for problem-solving. The chairperson must be better prepared if all problem-solving will end in decisions concerning steps to be taken when satisfying the patient’s need for information. Acknowledgements-This study was supported by grants from the Faculty of Medicine, University of Umei, Sweden, the Swedish Nurse’s Association and the Foundation for Multiple Sclerosis, Sweden. I am also grateful to Astrid Nordeson, RNT, for her co-operation in the education programme.

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Birgitta Engstr(im has been a registered nurse since 1963. Since 1970 she has been ward sister in the Department of Neurology, Umei University Hospital, Ume%. She has been undertaking Doctoral studies since 1978.