pants are assumed to be providing patient care at higher and higher levels of quality.

The collaborative process itself will be described in the following sections, with
further distinctions made between such forms as conferring, cooperating, consulting, and
teaming.
Collaborative Practice:
Conferring, Cooperating, and Consulting
Conferring is one of the most common collaborative processes in health care. The social
worker and nurse in an extended care facility confer about the meaning of a residents sudden
regression in behavior, and they exchange views about the probable cause and ideas of how
to help him return to his prior level of functioning. Conferring assumes a reciprocity between
colleagues. It requires reciprocal respect and trust so that observations are exchanged, views
are freely expressed and compared, and each is free to agree or disagree. Ideally, greater
clarity about a need or problem is achieved, and feasible solutions are developed, to be
carried out mutually or singly as appropriate. In a rehabilitation service, for example, the
social worker and the spouse of a stroke patient soon to be discharged may confer with the
speech, physical, and occupational therapists in order to assess the homes physical
environment, plans for ongoing care at home, arrangements for needed services, and
availability of respite for family members.
Conferring can be a group effort as well when more than two professionals are
involved, together with patient and family, as in the example just mentioned, or when persons
from other agencies such as the school, a child welfare agency, or a rape counseling center
meet with the health organizations staff members. Such a group is not a team. They are
comping together only to confer on a case for planning purposes. Each participant remains
autonomous. Someone-often the health care social worker-has called the meeting with an
explicit agenda that includes an exchange of views about objectives for the patients care and
division of responsibilities and tasks to be carried out by each participant, including, perhaps,
the patient and family members.
Still another type of conferring takes place when the social worker confers with the
chief of service in an arthritis clinic, and then with medical and nursing staffs, about her
interest in offering a group for patients and their spouses or partners. She shares her ideas
about the needs that could be served and the impact of such a group on the clinic and elicits
the ideas of the others. If she hears no objections or meets objections satisfactorily, she
moves foward with the plan and keeps the conferees informed of the programs development
and its outcomes. Such information may be communicated by written reports or informally in
face-to-face contacts, depending on the norms of the setting.
Even within a structured team informal conferring may have a place, as indicated in
the previous section. Out of these various avenues to conferring may also come a process of
cooperating. The large group brought together for an exchange of ideas through a case
conference may agree to cooperate on a particular issue with a patient or family. They are
still not a team but will work in symmetrical ways to resolve a particular issue or to help the
patient work on a particular task. One member may be designated as coordinator to monitor
the process and to reassemble the conferees should it falter or should the original agreement
have to be changed.
 Consulting, more formal and more structured, involves less reciprocal exchange than
conferring. In this process the consultee usually seeks out the consultant as someone believed
to have the knowledge and skill to provide needed advice or guidance in a matter related to
health, illness, or disability. Whereas in conferring the participants put their heads to gether
and compare notes and exchange views, in consulting one participants is the seeker of
information or advice and the other is the provider. But like conferring, the consultee is free
to act on the advice or information or to ignore it. Unlike team process, in which decisions
are made by the leader (multidisciplinary) or consensus (interdisciplinary) and all members
are expected to work on the agreed-upon tasks and goals, consultation is an advisory process.
In home health care, for example, the social worker may not be able to see every
patient with psychosocial needs, but he serves as consultant to the nurse in helping her to help
the patient with some of the social and psychological consequences of the illness or
disability. One nurse in an urban home health agency consulted with the social worker about
how to handle the stressful interaction between a seriously limited MS patient and her
sixteen-year-old son who was drinking heavily. In an adolescent health center the social
worker consulted with the centers law student about what might be done to counter the
refusal of the backup hospital to admit a teenage patient. In a geriatric facility the
administrator consulted with the social worker about how best to plan with the patients for a
move to the institutions new location.
Occasionally a potential consultant may reach out to a potential consultee to offer
specialized knowledge or skill. The parents of an eight-year-old boy with diabetes told their
physician in an HMO that he was refusing to go to school. David said he didnt like his
teacher, and his classmates teased him about his needed for snacks during the day. With the
permission of David and his parents, the social worker visited the teacher. He found that she
knew little about diabetes, was fearful about the childs falling into a coma, tended to restrict
his activity unnecessarily, and singled him out for her special attention. When the social
worker, after accepting her fears and feelings as understandable, offered to answer any
questions she might have, the teacher eagerly accepted. The worker answered her questions,
provided some information about causation and treatment regimens, and suggested several
alternate ways she might wish to consider in helping improve the interactions between David
and his classmates. At the teachers request he agreed to make a follow-up visit in two weeks
to review with her how things were going and what else might be needed so that David would
be happier at school.
Consultation is carried on only until the problem or concern of the consultee has
been resolved. Not infrequently, however, a successful consultation may develop into a group
process. In this example, the school might have had a number of chronically ill or disabled
students, and the principal, following the teachers suggestion, might then have asked the
consultant to provide one or two group sessions on childhood disability for all teachers in that
school.
Because consultation is a formal process, certain practice principles have been
specified for effectively carrying out the role of social work consultant (Collins, Pancoast,
and Dunn, 1997). For example, in most consulting the consultants relationship is with the
consultee, not with the persons with whom the consultee is working. Nevertheless, the
consultation is client-focused, as in the case of David, or program-focused, as when a social
worker is asked to work with nurses in her health organization to help them prepare for
leading patient groups. Even in that instance, however, the social workers professional
interest is centered on the potential group members.
Whether the social worker is acting as consultant to an individual or group in her
own health care organization or in another agency, it is important that she learn as much
about the consultee and the particular setting as possible. In the more structured kinds of
consultation, it is also desirable that consultant and consultee discuss their expectations of the
process with each other in order to be clear about their objectives, respective roles, and so on.
In the case of an outside agency, it is also important that the same clarity and contracting be
achieved with the administrator as well, including issues of confidentiality regarding the
consultees statements.
Once the consultant has decided she has needed competence to provide the requested
consultation, has learned all she can about the consultee and setting, and has clarified the
process with the consultee, the consultation formally begins. Occasionally it becomes clear
that the consultee is really seeking supervision, therapy, or even a substitute to take over a
troubling situation; it is important that the consultant not assume these roles. Instead, she
must convey willingness and ability to help the consultee with the clinical tasks through a
mutual process or problem-solving.
The first step is asking the consultee for specific data related to the problem or
predicament, what has previously been done about it, and how is it like or different from the
consultees usual array of problematic situations. Collins and associates (1997) suggest that it
is usually best to avoid rushing in with a solution, especially since the questions asked may
alone help the consultee to understand the situation better, think about it differently, and
come up with his own solution, it may also be wise to suggest a second session to continue
the discussion; the consultant can explain that in the meantime she will consider the data in
the light of her experience with similar situations. In other words, it is important to avoid
establishing an image of herself as a superior expert with instant answers to a situation that
the consultee has found difficult, perhaps over a period of time.
When the consultant is ready to present several alternative ideas-even in the initial
session, if that is to be the only one-it is wise to present them as possibilities only. It is
important to avoid any suggestion that the consultants view is the right one. Presenting the
consultee with several ideas increases his own cognitive and decision-making powers and
hence his competence in his own profession. This is the ultimate goal of social work
consultation.
Consultation should be terminated-at least on a particular problem-as soon as the
consultee has decided on a tentative course of action and feels secure enough to proceed. It is
helpful if the time limit can be set at the outset and referred to before the final session. In the
last session (generally most consultations do not go beyond three sessions), a review of the
consultation and its positive and or negative effects on the client or program can help the
consultee see how he has added to the knowledge and skill that he already had.
These principles of consultation are especially pertinent to a significant area of
social work consultation, nursing homes. Federal regulations and sometimes state licensing
require that social work services be provided to patients in long-term facilities if they are to
be eligible for Medicaid reimbursement.*Depending on size, commitment to quality patient
care, level of care (skilled nursing care, intermediate care), and other factors, some facilities
have qualified social workers on their full-time or part-time staffs. Most nursing homes,
however, designate a staff member, who may be a nurse or clerical person, to provide such
services and retain a fully qualified professional social worker as consultant. Most such
consultants only consult with the social work designee on specific cases. Some consult with
nursing and other staffs in programmatic areas such as work with dying patient, with families,
and the like. But relatively few consult with administrators on organizational and
management issues such as admissions procedures, staff development, or administration-
patient relationships.
In a study of 28 consultants and 49 designees in Arkansas (where consultants
number 42 and designees 232) the average consultant is female, thirty-five to forty years of
age, with the MSW degree, ten years paid experience as a social worker, and less than five
years experience as a consultant (Mercer and Garner, 1981). She maintains a full-time job or
is retired, although one-third worked full time as consultants to long-term facilities. The
average consultant has taken one or more courses or workshop on social work consultation.
She has worked for less than two years at the facility where she is currently providing
consultation. Most have worked for one to four facilities, but some consult with more than
ten.
Among the purposes of their consultations with designees, the consultants identified
the following in descending order of frequency:
1. To teach or demonstrate social work techniques
2. To review the designees work
3. To assist with problems relating to residents, the staff, or the community
4. To provide ongoing evaluation and support (Mercer and Garner, 1981, p. 7)
Other purposes included direct work with patients and families and promoting higher-quality
care.
Mercer and Garner concluded that these consultants seemed to function most as case
supervisors perhaps because most (60 percent) perceived the staff person designated for
social work, and not the administrator or the facility itself, as the consultee. Their view of
function was therefore limited to direct services rather than expanding to include
programmatic, administrative, and organizational foci. Not one consultant in this sample
sought to develop professional social work services within the facility. The authors indict this
supervisory model of consultation for falling short of the aims for an integrative and
comprehensive activity. Consultants, they suggest
have special access to the facility and the opportunity to influence not only the provision
of social services but the entire system of long-term care. To assume a role of professional leadership
in this situation, the consultant must be prepared with the knowledge, skill, and attitudes appropriate
to administrative and managerial functions as well as to casework. Clearly, guidelines regarding the
goals and objectives of consultation and the qualifications of consultants must be developed
standardized, and maintained. To do less would be to negate the professional responsibilities to those
institutionalized elderly who call a facility home. [Mercer and Garner, 1981, p. 13]
While it is true that supervision of the designee is an inappropriate model of
consultation, influencing the entire system of long-term care is probably more pertinent to the
advocacy function at legislative levels than to the consultative function. As such, it will be
considered in the Epilogue. Nevertheless, a skillful consultant to designees who recognizes
that the facility is the proper consultee may work, as Mercer and Garner suggest,to engage
the administrators interest in and agreement to mutual work on administrative, managerial,
and programmatic ways to improve services. An example of such organizational influencing
is given in Chapter 9.
The provision f consultation to the administrator is appropriate only if he has asked
for the consultants knowledge and skill in achieving a particular goal or has accepted the
consultants offer of such collaborative work. It is important to remember that the consultant
is in the facility usually only because the law requires her presence. Moreover, most nursing
homes are operated for profit; most administrators have little or no knowledge of social work
and tend to think that any staff person is fully capable of doing whatever needs to be done in
the real, of social services. For these reasons the social work consultant is apt to be viewed by
administration and staff with suspicion if not outright hostility. In their eyes, she is an
unneeded, expensive commodity.
It is therefore important that in entering the nursing home the consultant seek to
establish with all staff a climate of trust, respect, and mutual concern for the patient care.
Acceptance is likely to be attained through affirming the facilitys strengths and relating
improved services where possible to reduced costs and increased contentment of patients and,
hence, of staff.

Collaborative Practice: Teaming

The word team has several dictionary meanings. It denotes two or more draft
animals harnessed to something heavy such as a plow or vehicle, which connotes
cooperation. It is also used to denote a number of associated persons vying against another
such group in a match or game, which connotes competition. But it is used in health care, and
in mental health and industry as well, to denote a group of persons organized to work
together, which connotes the integration of differentiated functions (Pepper, 1976). Teams
my be categorized as multidisciplinary or interdisciplinary, depending on their structure and
functions.
Multidisciplinary teams have a longer history than interdisciplinary teams and are
probably still the more prevalent form. They are hierarchical in nature, with leadership and
control vested in the physician because of her medical expertise and her legal responsibility
for the pa-