Heading an interdisciplinary rehabilitation ward — team selection, job responsibilities, conflict management and care planning

Geriatric care implies team care. No single discipline can address the impairment–activity– participation chain in a frail older person. Team care means trusting other disciplines with the tasks for which they are trained, while ensuring they never work in isolation.

Terminology: Multidisciplinary = each discipline assesses and treats in parallel. Interdisciplinary = disciplines assess separately but plan and set goals jointly at a common team conference, with shared responsibility for a single care plan.

The ward runs on the 8-step process: Assessment → Goal setting → Therapy → Aids and adaptations → Education → Psychological support → Evaluation → Follow-up. The head of the ward must ensure every step has a named owner and a target date.

Minimum core team: physician (geriatrician), nurses, physiotherapist, occupational therapist and social worker. Optimal team adds speech and language therapist, clinical psychologist, dietician, pharmacist, prosthetist/orthotist, podiatrist and home-care coordinator. Dedicated administrative support is essential and often forgotten.

Special geriatric expertise among team members is crucial — a therapist trained in general adult practice is not automatically competent in frailty, delirium and multimorbidity. Select on interest, aptitude and training in ageing.

Optimum working team size is 4–7 members, united by a common sense of direction and purpose. Every member must be able to state their specific and their general contribution. A flexible working style crossing conventional professional boundaries gives the greatest job satisfaction and the most effective patient care.

Staffing must be structurally supported: dedicated units require additional therapist establishment and environmental adaptations (handrails, non-slip flooring, orientation clocks and calendars, safe walking circuits).

Effective teams do not arise spontaneously. They evolve through forming → storming → norming → performing, and reaching the performing stage needs commitment, skill and time. The storming phase is normal and expected, not a sign of failure.

The interdisciplinary team conference is the single most critical structure. Held after each member has completed their individual assessment, it brings all perspectives together, generates new ideas, sets priorities, disseminates the full assessment, and avoids duplication or incongruity. Most successful trials of geriatric assessment included such a conference.

The team leader must strike a balance between over-structuring ward activity and allowing individuals to function totally independently in a non-hierarchical vacuum. Both extremes damage care.

Efficient team care does not mean endless meetings. Co-location allows frequent informal exchange, supplemented by regular formal meetings. What the team needs is a common language and a common playbook.

Five elements for every problem in the care plan: (i) the problem, (ii) the goal, (iii) the approach/intervention, (iv) the target date, (v) the discipline responsible.

Timing: initial assessment within days of admission; formal care-planning meeting within 1–2 weeks; therapy review daily to weekly; full care plan review at least every 3 months or on significant change. Reassessment at least weekly during active rehabilitation.

Goal-setting rules: realistic, based on premorbid function, agreed by the patient and every team member, split into short-term and long-term goals with flexible, regularly reviewed time frames. Set goals that are ambitious but achievable.

Not every patient can improve. For those who cannot, the plan must shift explicitly to maintenance of function and prevention of further decline. Small functional gains still improve the chance of discharge home and quality of life.

WHO ICOPE 5-step pathway: screen → detailed person-centred assessment → set goals and build a personalised care plan with the older person, caregiver and team → implement and monitor with specialist referral → enlist community and support the caregiver.

Documentation: SOAP format for progress notes; a face sheet carrying the essential database (diagnoses, drugs, contacts, treatment-intensity preferences) that travels with the patient; and flow sheets with serial functional scores (Barthel Index, FIM).

The commonest source of conflict is goal divergence — “a programme can be seriously compromised if key people differ on what each is trying to achieve.” The primary preventive strategy is explicit, documented, jointly agreed goals with the patient present. Other recurring sources: role blurring, discharge-timing pressure, family-versus-patient wishes, and resource competition for therapy slots. Textbook-derived conflict prevention on the ward

Ensure every member knows what the other professions can do and when to call on their skills — ignorance of others’ scope drives most territorial disputes.

Use the team conference to eliminate duplication and incongruity before it becomes friction.

Accept role flexibility across boundaries as a strength, but keep core accountability clearly assigned.

Involve the patient and carer at some stage of every plan, preserving the principle of choice — this pre-empts family conflict.

In ethical disagreements, the older person’s own wishes are paramount. Avoid paternalism and the temptation to infantilise the frail patient.

Build trust deliberately — like a sports team, healthcare teams must practise together.

Rehabilitation is resource-intensive and must prove its effectiveness. At minimum, collect standardised entry and discharge data on every patient.

Run a team-based QAPI cycle: each discipline reports its data → team reviews quality indicators → sets targets → develops a plan and a measurement method → assigns an individual or subcommittee → progress report at the next meeting. Use run charts, fishbone diagrams and root-cause analysis. Ward indicators: falls with injury, pressure ulcers, restraint use, Barthel/FIM gain, discharge-to-home rate, length of stay, 30-day readmission.

Geriatricians are ideally placed to lead because interdisciplinary management and teamwork are at the core of geriatric training, and geriatricians are comfortable entrusting responsibility to team members and sharing the problem-solving process.

Chairing the team meeting is an evidence-based skill A 2025 observational study of interprofessional collaboration during multidisciplinary team meetings in geriatric rehabilitation (BMC Geriatrics) found collaboration improves when the meeting is led by a designated person with leadership skills — the ability to organise and to build strong team relationships. The chair is accountable for coordination and adherence, and involving complementary participants — professionals, patients and informal caregivers — shifts the discussion from monodisciplinary or multidisciplinary objectives to common interprofessional goals.

Psychological safety is the current framework for team climate A 2025 Frontiers in Medicine paper applies Clark’s four stages — inclusion safety, learner safety, contributor safety and challenger safety — and identifies well-defined roles and responsibilities as a direct driver of psychological safety. AHRQ’s TeamSTEPPS was developed to overcome the difficulty of speaking up in a hierarchical system, empowering every team member to voice observations and concerns.

Named conflict-management tools for clinical teams AHRQ TeamSTEPPS (reviewed 2023) provides: formative feedback, CUS (when conflict places the patient at risk), the Two-Challenge Rule (differing information), and the DESC script. DESC = Describe the specific situation → Express your concern → Suggest alternatives → state Consequences in terms of patient/team goals. CUS = “I am Concerned… I am Uncomfortable… this is a Safety issue.”

Conflict-management styles in practice A 2024 systematic review in Nursing Reports (22 studies, 2014–2024) found accommodation and collaboration/integration are the most common styles among nurses, with compromising also frequent, and recognises five styles: dominating, integrating, compromising, avoiding and obliging. Avoidance was most common among experienced and managerial nurses, while collaboration was favoured by more highly educated nurses; younger nurses tended toward compromising and accommodating, older nurses toward collaboration. Competing was the least prevalent. Proactive strategies are more effective at preventing conflict than reactive ones, and tailored conflict-management training is recommended.

Interdisciplinary care written into guidelines, and the case for the ward The 2024 VA/DoD Clinical Practice Guideline for Stroke Rehabilitation is written with explicit emphasis on an interdisciplinary care approach. The 2024 BMC Medicine meta-analysis showed geriatric rehabilitation reduced mortality, care-home admission and functional impairment; the BGS 2024 report argues rehabilitation should be a component of every service for older people and that denying access on the basis of “no rehabilitation potential” should end. A 2023 BMC Geriatrics focus-group study identified involvement of the person with dementia in goal setting and the mediating role of team members as the key challenges, but found the refined model achieved well-functioning, competence-enhancing and time-saving teamwork.

Indian context NPHCE delivers rehabilitative geriatric services through 19 Regional Geriatric Centres and 2 National Centres for Ageing. AB-PMJAY extended to all citizens aged ≥70 years (₹5 lakh per family per year) creates a funding pathway for post-acute rehabilitation. Practical constraints in Indian units: absent or shared therapist posts, no dedicated clinical psychologist or prosthetist, and heavy dependence on family attendants — so task-sharing and structured family training must be built into the care plan from day one.

Multidisciplinary = parallel working; interdisciplinary = shared goals and one common care plan.

Doctors treat impairment, therapists treat activity restriction, social workers treat participation restriction, nurses do all three.

Optimum team size = 4–7, with a shared sense of direction.

Team stages: forming → storming → norming → performing; storming is normal.

The interdisciplinary team conference sets priorities, shares assessments and prevents duplication and incongruity.

Every care-plan entry needs: problem, goal, approach, target date, responsible discipline.

Care plan timing: meeting within 1–2 weeks, review 3-monthly or on change; therapy review weekly.

Commonest cause of team conflict = divergent goals.

DESC = Describe, Express, Suggest, Consequences; CUS = Concerned, Uncomfortable, Safety issue.

Five conflict styles: dominating, integrating, compromising, avoiding, obliging. Collaboration is best; avoidance is commonest.

QAPI cycle: report data → set targets → plan → assign owner → re-measure at next meeting.

Effective team care needs a common language and a common playbook — it never happens spontaneously.