The collaborative practice of clinicians across disciplines requires a shared language, appreciation of diagnostic and ther

Integrative health care in a hospital setting: Communication patterns between CAM and biomedical practitioners

SOPHIE SOKLARIDIS 1 , MERRIJOY KELNER

2 , RHONDA L. LOVE

2 , &

J. DAVID CASSIDY 1,3

1 Centre of Research Expertise in Improved Disability Outcomes (CREIDO), University Health

Network, Rehabilitation Solutions, Toronto Western Hospital, 2 University of Toronto, and

3 Department

of Public Health Sciences, University of Toronto, Toronto, Ontario, Canada

Abstract Research in the area of collaboration between complementary and alternative medicine (CAM) and biomedical practitioners often describes their relationships as fraught with power struggles. This paper explores communication among the various stakeholders at an integrative health clinic for artists located in a university hospital. Qualitative research methods were used, in-depth interviews and semi- structured focus groups, to facilitate the gathering of information about patterns of communication among stakeholders involved at the clinic. The findings describe the challenges to communication and integration at the clinic. The lack of communication is described as a scheduling issue, or lack of consistent presence of CAM practitioners, and a lack of formal methods of communication (patient charting). The consequences of these gaps were felt mostly by the CAM practitioners, as their scope of practice was not well understood by other practitioners. CAM practitioners stated that this had a direct effect on their confidence levels. CAM practitioners were relegated to the periphery of the hospital in their role as part-time, contract employees. Their lack of consistent presence at the clinic lead to a lack of understanding of their scope of practice, hence, a lack of referrals from other health-care practitioners, particularly those who were biomedically-oriented.

Keywords: Integrative health care, Collaboration, complementary and alternative medicine, biomedicine, hospital

Introduction

Research suggests that people who consult a complementary and alternative medicine

(CAM) practitioner are more likely than those who do not to have a regular physician, to

have seen a specialist in the past year, to have had 10 or more physician visits in that time,

Correspondence: Dr Sophie Soklaridis, PhD, Centre of Research Expertise in Improved Disability Outcomes (CREIDO),

University Health Network, Rehabilitation Solutions, Toronto Western Hospital, 399 Bathurst Street West, 4-144 Fell Pavillion,

Toronto, Ontario, M5T 2S8, Canada. Tel: þ1 416 603 5800 ext. 5308. E-mail: [email protected]

Journal of Interprofessional Care,

November 2009; 23(6): 655–667

ISSN 1356-1820 print/ISSN 1469-9567 online � 2009 Informa UK Ltd. DOI: 10.3109/13561820902886287

and to have had their blood pressure checked in the preceding two years (Zollman &

Vickers, 1999). These findings imply that people who make heavy use of CAM regarded

their CAM practitioner as an adjunct to their physician.

Integrative health care (IHC) has become a term to describe the combination of CAM

practitioners and biomedical (conventional medicine) practitioners working together to

provide patient care. In this article, we use the term ‘‘integrative’’ as opposed to

‘‘integrated’’ because the former suggests a process that we believe is more representative

of what is happening at the clinic we studied, while the latter suggests an endpoint or that

integration has already occurred.

In response to patient demand for IHC, hospitals are increasingly interested in providing

IHC to patients. For example, a survey to determine the extent of integration of

complementary therapies in critical care units in North and South Thames Regional Health

Authorities in the Greater London area indicated that of the 51.1% of critical care units that

claimed to provide complementary therapies, only 7% provided interventions on a routine,

systematic basis. The general explanation for not providing complementary therapies was

‘‘lack of time and knowledge’’ (Hayes & Cox, 1999).

Although such journals as the British Medical Journal report that CAM is on the rise

worldwide (Thompson & Feder, 2005), the increased acceptance of CAM by the public

does not indicate that communication between health-care practitioners is satisfactory. The

mere coexistence of different modalities does not produce an integrative system of care, and

combining approaches may not work synergistically.

Research in the area of collaboration between CAM and biomedical practitioners in

hospitals often describes their relationships as fraught with power struggles (Shuval et al.,

2002) and entrenched in the medical hierarchy of the health professions (Hollenberg, 2006).

This article explores how CAM and biomedical practitioners at an integrative health clinic

for artists located in a large, urban, academic hospital in Canada perceive the level and type

of communication with one another, the hospital administrators, the Foundation members,

and with the artist clients.

There are few examples of co-existing biomedical and CAM approaches of health care,

especially in a hospital setting. The clinic we studied is an occupational health-care clinic

for professional working artists: a unique centre, it offers both biomedical and CAM

approaches of health care to clients in a hospital setting. Disciplines at the clinic include

chiropractic, massage therapy, osteopathy, naturopathy, physiotherapy, psychotherapy,

medicine, and nursing. Two of the publicly funded biomedical practitioners are full-time,

salaried employees of the hospital. All of the CAM practitioners and two of the non-

publicly funded biomedical practitioners have private practices outside the clinic. They

provide their services to the clinic on a fee-for-services basis. The clinic relies

on aggressive fundraising to subsidize these activities. Thus, the number of fundraising

dollars is linked to the number of hours each practitioner is provided by the Artists’

Foundation.

The purpose in conducting this research was twofold. First, we wanted to see how IHC

was working in practice. We examined the mechanisms of communication and the levels of

collaboration among the practitioners, artists, hospital administrators and Foundation

members. Second, to discover how integrative health care might work within a hospital

setting, we explored how the organizational structures of the hospital and the Foundation

influenced the development of IHC at the clinic. This research was deemed important and

thus supported by both the hospital administration (responsible for the daily operations of

the clinic), and the Foundation (responsible for fundraising to pay for the CAM services and

subsidy program for artists).

656 S. Soklaridis et al.

Methodology

We used both in-depth individual interviews and semi-structured focus groups to

understand the social and physical setting of the clinic, including internalized notions of

norms, traditions, roles, and values that were held by the respondents at the clinic. First,

individual in-depth interviews were conducted with each of the ten health-care practitioners

at the clinic. The purpose of conducting individual interviews was to obtain information that

might not initially have been shared in a focus group format among the various practitioners.

It was particularly important to conduct individual interviews with practitioners to obtain

information, including minority or ‘‘silent majority’’ viewpoints, regarding communication

and integration among the practitioners at the clinic. There was representation from the

following health professions: chiropractic, massage therapy, medicine, naturopathy, nursing,

osteopathy, physiotherapy, and psychotherapy.

Second, four semi-structured, qualitative focus groups were convened with a total of 26

key informants with clients of the clinic (n¼8), hospital administrators (n¼5), board members (n¼8), and practitioners working at the clinic (n¼5). The purpose of conducting focus groups was to move beyond the level of the individual and examine knowledge that

was shared among group members. Of the ten health-care practitioners (BIO and CAM)

interviewed initially, five were available to attend the focus group. We were interested in

observing how these practitioners interacted with one another within the focus group setting.

In addition, we wanted to further explore respondents’ opinions and experiences through

group discussion that moved beyond our preliminary analysis of statements during the

individual interviews. With the exception of the practitioners, we assumed that the other

groups shared a common identity, which would not have prevented them from publicly

sharing their opinions, stories and beliefs. Thus, the use of focus groups was deemed to be a

more appropriate data collection tool than individual interviews. The artist group (A)

included representation from dance, visual arts, actors, and writers. The hospital

administrators group (HA) included those who were previously or currently involved with

operational aspects of the clinic. The Foundation board members (BM) group is a volunteer

group comprised of artists and business people who provide a link to the artistic community

and work with the hospital on artists’ health issues. One of the mandates of the Foundation

is to assist professional Canadian artists with financial support to be applied towards the cost

of CAM treatments at the clinic, which are not otherwise covered by the provincial health

plan. There was representation from artists, practitioners, educators, legal and business

professionals in the focus groups.

The study involved purposeful sampling (Patton, 2002), the rationale of which is to select

information-rich cases whose study will illuminate the research questions under study

(Morse & Field, 1995).

Separate guides were constructed for the individual interviews with practitioners and for

each of the four focus group sessions. Although each guide was different, the following

questions were posed to elicit views on IHC, collaboration and communication:

(1) How do practitioners, hospital administrators, artists, and Foundation members

understand and define integrative health care?

(2) How are epistemological differences between practitioners resolved when biomedical

and CAM approaches to health care co-exist?

(3) What are the informal and formal mechanisms for communication between and

among the practitioners, artists, hospital administrators and Foundation members

involved with the clinic?

Integrative health care in a hospital setting 657

(4) How do practitioners, artists, hospital administrators, and Foundation members

describe their everyday interactions with one another?

(5) What social, economic, and hospital policies/politics influence the level of integrative

health care at the clinic?

(6) How do issues of sustainability, funding, and the subsidy program affect the

integration of health care services and delivery at the clinic?

The transcripts from the individual interviews and focus groups were analyzed using a

constant comparative approach (Brown, Weston, & Steward, 1995). A coding scheme was

developed (SS, MJK, RL) using an iterative approach. SS performed the initial open-coding

of the interviews and focus groups. Codes were compared and contrasted (SS, MJK and

RL) to develop a finalized coding scheme. Once a satisfactory level of agreement over the

coding scheme was reached, it was then applied to each interview and focus group

transcript. According to Glaser and Strauss (1967), ‘‘no one kind of data on a category or

technique for data collection is necessarily appropriate. Different kinds of data give the

analyst different views of vantage points from which to understand a category and develop its

properties’’ (p. 5). The consistency we found in overall patterns of data from the two

different methods, and our explanations for any differences in data, contributed significantly

to the overall credibility of the findings. A qualitative computer software package,

NVIVO TM

(Nvivo, 2002), was used to store and organize the various codes derived from

the data. The software allows each code or theme to be stored and then organized into larger

categories as the research proceeds.

Ethics approval from the university and the hospital ethics review board was obtained for

the study.

Results

This article explores communication among the various stakeholders at the clinic. It is

divided into four sections. The first section examines communication patterns. The second

section describes the mechanisms for communication among the stakeholders of the clinic,

both formal and informal. The third section illustrates some of the consequences of a lack of

communication between these groups. The fourth section offers some of the potential

solutions, as described by the respondents of this study.

In this paper, we focus on the data collected for communication among the practitioners.

As a result, some of the data from the other focus groups is only given consideration insofar

as it relates to communication between practitioners. The voices of the hospital

administrators and board members are given priority in another publication that examines

how the organizational structure of the clinic affects integration (Soklaridis, Kelner, Love, &

Cassidy, 2009).

Communication patterns

The practitioners described three challenges to communication and hence integration at the

clinic. First and foremost, the overall consensus was that there is little everyday interaction,

posing a major challenge to communication and integration. In fact, a few respondents

stated that they had never met one another. Most biomedical practitioners at the clinic

stated that they had met each other. For example, the physician, nurse practitioner, and the

physiotherapists had met and on varying occasions worked together. However, meetings

with CAM practitioners were not nearly as frequent. This, according to both the CAM and

658 S. Soklaridis et al.

biomedical practitioners, made integration difficult – if not impossible – to achieve. One

biomedical practitioner observed that, in general, her interactions with some practitioners

were few and far between:

BIO 4: Even though we are all on board I still haven’t met everybody, so it is hard to feel

like we are integrated in some way when we don’t even know one another. We have not

even had a conversation with some of the individuals.

Second, scheduling served as both an enabler and a barrier to communication and

integration. For example, the few interactions that had occurred did so when the

practitioners occupied the ‘‘same space at the same time’’. At the time of the study,

the biomedical practitioners worked in or had access to the clinic more often than any of the

CAM practitioners. Two of them were permanent, full-time employees of the hospital and

one was contracted to work for three days a week at the clinic. The CAM practitioners were

all contract, fee for service, employees and worked at the clinic from four hours (or less) a

week to one day a week. Five of the six CAM practitioners who worked four hours a week or

less said it was very difficult, if not impossible, to interact with other practitioners during

their shift. A CAM practitioner said:

CAM 4: It is hard to parachute in and parachute out. . . . It is hard to feel the community

when I am there [half a day, once a week], and I think I am the only one there . . .

sometimes I see someone else float in and out, but it’s not as if we chat.

Secondly, there was little consensus among the respondents on the current state of teamwork

and the direction of communication. Issues regarding how information was passed along, by

whom, and when, was identified by most of the respondents as problematic. Most of the

practitioners at the clinic deemed that a certain level of teamwork was necessary for patient

care. A few practitioners said that teamwork was an important part of integrative health care

because it meant familiarity among practitioners, which ultimately had benefits for the patient/

client. As a CAM practitioner said to a biomedical practitioner in the focus group:

CAM 4: But also to me the team aspect does benefit the patient in the sense that there is

the potentiality there so that if they needed to see a physician, if the physician they are

seeing is someone who knows me, who knows my work, who knows the preparation they

are getting the benefit of that even if they only see you once.

The third facet of communication was the direction of that communication. For instance,

communication was often facilitated through the patient/client, who was described as the

vehicle for information-sharing among their colleagues. Such a method of communication

was not seen as an optimal way to obtain information regarding patient care, since patients

were thought to interpret therapies and the outcome of their therapies differently than

intended. On the other hand, several CAM and biomedical practitioners, for financial

reasons, chose to communicate with one other instead of making referrals, which seemed to

run contrary to the premise of the clinic as an integrated. At the clinic, patients were

provided with a subsidy for therapies not covered by the provincial health plan. However,

having to work within the subsidy allowance, one biomedical practitioner stated:

BIO 3: I can go and talk to [CAM 2] and say, ‘‘what can you recommend?’’ And in that

way they [the patients] don’t necessarily have to see him, because . . . the integration is

Integrative health care in a hospital setting 659

there, the only thing that is harder is the price. It is still expensive [for the patient] to get

these other modalities, so even if we have subsidies it is still an expense. . .

Mechanisms for interaction

Two types of communication at the clinic were described, informal and formal.

Informal types of communication included hallway consultations, quick telephone calls,

e-mails, and even sticky-notes posted by health-care practitioners to the patient charts.

Formal types of communication included documenting patient visits, diagnosis, and

recommendations in a patient chart, and staff meetings. The practitioners described both

types of communication as dependent on a shared language.

Most of the practitioners agreed that they did not often talk about patients and when they

did, communication between them was very informal. This kind of communication is

illustrated here:

BIO 2: Occasionally we talk about patients but that is only about 10 percent of the time.

So I know, I guess I know, I have spoken to people but I think it is mostly talking to people

in the hallway.

For formal communications, clinic practitioners generally use standard tools such as

charting. Common in most health-care settings, patient charting involves the process of

entering diagnostic, prescriptive, progress or other notes regarding the patient, which are

then kept in a main patient file. However, charting took on different meanings when CAM

and biomedical practitioners used the same patient file.

The chart, in essence, was deemed by the majority of practitioners at the clinic as an

ineffective communication tool. Issues emerged that were common to most practices, such

as unruly handwriting, and when CAM and biomedical practitioners used one chart, issues

of language and style also created some difficulty.

During the focus group a CAM practitioner described her inability to read a patient chart

due to messy handwriting:

CAM 4: And also something that I was experiencing was not being able to read peoples

handwriting very well on our charts. And I use the charts a lot . . .

A biomedical practitioner said he was frustrated with the lack of systematic charting, and

therefore he did not read the patient charts:

BIO 2: We could do a whole other focus group just on the charts you know what I am

saying . . . I don’t even read, I barely read charts that’s terrible to say but there is no

systematic charting, because we have never come to conclusion or consensus how

we are really going to chart, is it going to be done by professions, or are we just going to

doodle along . . . and then the reality is that there is also a whole vocabulary and

nomenclature and a way of charting that physiotherapists use, that I need to be educated

about.

The issue of biomedical language in particular was discussed during the focus group with

the practitioners at the clinic. One CAM practitioner explained how difficult it was to

understand some of the acronyms that the other biomedical practitioners seemed to take for

granted:

660 S. Soklaridis et al.

CAM 4: I am going to get her [biomedical practitioner] to tell me . . . what she is doing

and to learn what she means by ‘‘SOT’’?

BIO 4: Yeah, but that is standardized charting formula.

CAM 4: Yeah . . . well that is sort of a medical convention, yes it is but if you are not part of a

medical model, and this is the issue here for us is that we have to figure out a way to include

every one and to make sure that we don’t get caught up in the medical model because we are

trying to do something innovative here . . .

Consequences of minimal interactions

A formalized structure of communication had not been established, creating a lack of

communication and integration. As a consequence, the majority of respondents felt there

were disadvantages to practitioners’ work environments and personal growth. Firstly, they

believed this situation perpetuated a lack of understanding regarding the scope of practice of

each practitioner. In turn this led to a lack of referrals for those who were least understood

(in this case, the CAM practitioners at the clinic). Secondly, the limited communication and

integration inhibited the establishment and nourishment of practitioner confidence. Thirdly,

the lack of communication and integration among the various stakeholders continued to

limit and keep practitioners at the clinic disconnected from the larger hospital and

community resources. We will now elaborate each of these points in turn:

Not knowing other practitioners’ scope of practice had a direct effect on referral patterns.

The majority of practitioners (both CAM and biomedical) said that they would not refer

their patients to a therapy or modality that they did not understand. For example, one

biomedical practitioner stated that unless a patient requested it, she would not refer to a

modality that she was unfamiliar with. We asked the CAM practitioners, who were least

likely to get referrals, about the referral process and their perceptions of why other

practitioners were not referring patients to them. They attributed the lack of referrals to the

(mostly) biomedical practitioners’ lack of understanding of their scope of practice:

CAM 6: I don’t think that most people know what osteopathy is, so how are they going to

refer to an osteopath when they don’t even understand what the difference is between

osteopathy and maybe physio. . . . So that’s part of the barrier too with these alternative

therapies coming in.

Several practitioners said that they wanted to learn and better understand how each

practitioner’s scope of practice related to their own and how they could support each other

in providing better patient care. With regards to supporting each other in their practice, a

CAM practitioner stated:

CAM 4: I need to understand what the other practitioner is doing because a lot of them do

refer to me or the patients themselves self refer for [health service], so I need to be able to

be supportive around their Naturopathy or their psychotherapy or their osteopathy or their

physiotherapy so I need to be able to understand that.

Second, and linked to providing support to one another, was the concept of practitioner

confidence. The idea of practitioner confidence was not a question in the interview guide

and if it did not emerge organically from the interviews or focus groups, the question was not

directly asked. However, most of the CAM practitioners said that communication and

Integrative health care in a hospital setting 661

integration among the different therapies and modalities could increase practitioner

confidence and help them grow as practitioners. Conversely, the biomedical practitioners

did not discuss the link between integration and practitioner confidence.

CAM 3: I think the over all confidence level of the practitioners, all of us medical and

alternative, would increase if we had a format to talk openly about what we are thinking

what we are struggling with what we are not sure about in a forum where there are people

of different mindsets and different lens that they are looking through. I think that would

be exciting and would build the confidence level that I could easily go and ask and not feel

like I was in jeopardy in any way or so but that would take time and some familiarization.

Another CAM practitioner hypothesized that an element of self-consciousness occurs

when one is not familiar with the scope of practice of other practitioner in the clinic:

CAM 2: I think the practitioners suspect that there is something I could do naturally, but

they haven’t conferred with the case so they are reluctant right and they don’t want to be

embarrassed.

Another CAM practitioner said that increased practitioner confidence was linked to not

assuming ownership of patients; explaining this, she stated:

CAM 1: So I think there has got to be a lot of respect and personal confidence that there is

not that ownership of the patient, and it [IHC] really is for the good of the patient. And I

think it really it’s that thing that really needs to be reminded [to practitioners] because,

yeah, there is overlap.

The majority of clinic practitioners said that a lack of communication and integration,

coupled with the clinic’s unique location (in a hospital), meant that they felt isolated. They

did not know if there was a network that could be tapped into, and they described feeling like

the larger hospital community was completely unaware of their presence. According to all of

the CAM practitioners, the sense of not knowing what was available, or even what they could

ask for, had implications in their everyday practice. A few of the CAM practitioners said that

were not aware of what they were entitled to ask for from the hospital administrators or

board. One of them stated:

CAM 6: Maybe, and knowing what we can ask for, is it feasible for me to say, ‘‘I want

these couple of posters up in the room’’, ‘‘I would like a spine a model of a spine’’, ‘‘I

would like this anatomy book that has these pictures because when I talk to people about

what there injury is I refer to these diagrams’’. . . you know things I use often in my

treatment. I don’t know if it is feasible for them to provide me with this stuff or not.

Improving communication and integration

Respondents were asked to reflect on what they believed would assist in improving

communication and integration. One overarching theme emerged from the interview and

focus group data; having face-to-face and/or virtual team meetings. In addition, the

respondents said that e-mail exchanges and electronic technology could help facilitate some

of the current issues in communicating and charting.

662 S. Soklaridis et al.

The majority of practitioners strongly believed in the benefits of staff meetings. Although

most said that they believed meetings, especially ones without pay, were not convenient to

attend. None of the CAM practitioners were permanent employees of the hospital; they were

hired as contract, fee-for-services, part-time employees; all of them described this as a

limiting factor for integrative health care. For example, attending meetings or anything

outside of patient care at the clinic was unpaid. However, they generall

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