Integrated Care: Navigating Roles and Responsibilities in Multidisciplinary Healthcare Teams

While it comes to providing complex care to critical patients, an integrated approach is necessary for conducting multidisciplinary working in health and social care that improves the quality of care delivery (Anderson et al. 2019). The multidisciplinary working and teamwork not only improve patient’s care journey but also improve the way service providers maintain their professional integrity and accountability towards their profession. This study will discuss the roles and responsibilities of multidisciplinary working in terms of improving patients' care journey thereby promoting the holistic wellbeing of the patients. Then this study will demonstrate the different types of teamwork in healthcare about the chosen case study. Additionally, this study will discuss how integrated and multidisciplinary working enable care providers to meet the care needs of a patient.

An integrated approach is fundamental to providing complex care to patients who suffer from a complex health conditions. Mr C is a 70 years old gentleman who suffers from severe lung infection and dementia. The patient is cared for by his wife who is 65 years old. Mr C suffers from severe chest infection frequently and takes antibiotics for this infection. Due to his poor lung function, most of the time he needs oxygen support. Three days ago he has been admitted to the acute elderly ward of the local hospital due to severe breathing issues and chest pain.


While providing integrated care to vulnerable patients, nurses must adhere to the policies and provision of health and social care. As mentioned by Rosengarten (2020) the ability of health care providers in providing a high standard of integrated care to vulnerable patients is highly dependent on how they will follow and implement the health and social care provision into their practice. In Mr C’s case, his carers and nurses must adhere to the policies under the Care Act 2014. During the home care setting a community care nurse and health, the worker needs to be appointed for Mr C to provide him with high standard care. Under Care Act 2014, the carer and nurses will determine and support the health needs of Mr C thereby developing and implementing an effective care plan for promoting Mr C’s holistic wellbeing.

Under the Protection of Vulnerable Adults (POVA) provision, the home carer and nurse will provide Mr C with a highly safeguarding environment inside and outside the home (Anderson et al. 2019). Care providers must ensure that Mr C will be protected from any kind of harm, harassment and abuse thereby ensuring the good health and safety of Mr C. Under the home care setting Mr C will be treated with proper respect, dignity and care. Carer and community care nurses must ensure that they listen to the needs, decisions and choices of Mr C and involve Mr C in his own treatment and care process. On the contrary O’Neill et al (2018), in the case of vulnerable adults, healthcare providers often face ethical dilemmas in terms of choosing the right decision regarding promoting safe care to patients. In Mr C’s case, nurse’s and carers who take care of him at his home must conduct a clear interaction and communication with Mr C to make a mutual understanding between them which will create a shared decision-making process. In integrated care delivery shared decision making is important for health providers to discuss the health issues, health needs, treatment process and health outcomes of treatment with patients to improve the quality of care.

Under Disability Discrimination Act (2010), in the home care setting the community care nurses must inspect whether Mr C faces any kind of violence or bias or discrimination due to his physical disabilities (Welp et al. 2019). Nurses must inform Mr C regarding the process that Mr C can follow to seek immediate help from the local health and social care agencies. The carer and community care nurse need to work in partnership with Mr C to improve the knowledge and understanding of Mr C regarding his rights to confidentiality and accessing health and social care resources.

Under NMC (2018) Codes of Conducts, while providing integrated care to Mr C in-home setting nursing professionals must treat him as an individual and determine his personalised needs. As mentioned by Suhonen et al. (2018), integrated care is associated with determining the personalised care needs of each service user thereby developing the appropriate care plan to meet these needs to promote the holistic wellbeing of patients. The community care nurse and carer who are assigned to provide the integrated care at a home setting to Mr C must comply with all the four NMC (2018) codes such as prioritising people, promoting professionalism, practices effectively and reserving safety (Marguet and Ogaz 2019). Thorough adhering to the provision under the NMC (2018) code, nursing professionals must ensure that a protective, positive and caring environment is created surrounding Mr C at his home in which he is free from any kind of abuse or harm but also will receive the best possible care and support from his carers and nurse.

By conducting a health assessment, healthcare professionals determine the care needs of patients. Mr C has several care needs such as physical, psychological, emotional and nutritional needs, which need to be considered while developing the care plan for him (Suhonen et al. 2018). Under NMC (2018), while designing any care plan to improve the care journey for patients, nurses must consider the care needs of a particular patient. The different patient has different care needs based on their physical and psychological health condition. In the case of Mr C, he needs a good medicated regimen, a proper diet chart, a good exercise chart and proper nutritional advice. He also needs psychological and social care in which he can receive fair and bias-less treatment in society and hospital.

After the health assessment and diagnosis, the care journey of Mr C includes developing and implementing the care plan for him (Marguet and Ogaz 2019). While developing a care plan the multidisciplinary team considers many factors such as the ongoing medicines of Mr C, his current health condition, his current food habits and diet chart, his preferences of food, his nutritional needs and his medical regimen. Under this care plan, the most important things that Mr C needs to follow is the systemic lifestyle and the prescribed medicated regimen (Rosengarten, 2020). Under this care plan, nurses and health professionals will encourage Mr C to take all the antibiotics and other medications regularly. Nurses will refer Mr C to the experienced nutritionist who will make an appropriate diet chart for Mr C by mentioning the food that he must take in a day and the food that needs to be avoided. Pharmacists within the multidisciplinary team will assist nurses to conduct an effective medicine administration for Mr C who will promote the safe and effective use of medicine for Mr C.

Along with following the medicated regimen, patients must be provided with the proper emotional, physical and mental support during the care journey for promoting patient’s empowerment. In the case of Mr C, nurses must use empathetic communication to make effective conversations with him. Nurses and doctors must provide emotional and psychological support to Mr C and empower Mr C by developing effective decision making and self-management skills in him. As mentioned by Marguet and Ogaz (2019), self-management skill is an essential part of the care journey of a patient which empowers the patient in relation to improving the patient's skill in controlling his or her health and wellbeing. In this context, nurses will refer Mr C to a highly experienced psychotherapist for providing Mr C with proper Cognitive Behavioural Therapy (CBT). CBT is proved to be highly effective in case of improving decision making and problem-solving ability in dementia patients. In this context, for Mr C the CBT will be highly effective in empowering his cognitive skill.

Teamwork in healthcare is important for providing integrated care to patients for improving patients' care journey (Marguet and Ogaz, 2019). In the case of Mr C, all the health and social care professionals work celibately with the members of a multidisciplinary team to optimise the health outcomes for Mr C. Teamwork enables service providers to discuss the health issues and care needs of the patents with different team members thereby developing the effective care plan to meet these needs. In the case study of Mr C, nurses work in a multidisciplinary team with doctors, pharmacists and senior nursing associates to discuss the care needs of Mr C which enables the team to design and implement an effective care plan for Mr C.

Under this care journey, another important thing that Mr C receives is health education which improves his knowledge and understanding regarding his health condition (Rosengarten, 2020). Through providing proper health education regarding what is COPD and chest infection, what is dementia, and how these conditions can be managed, nurses can improve the self-management skill of Mr C to have proper control of his own health and wellbeing.

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From the above-mentioned care journey, it can be concluded that an integrated approach of a multidisciplinary healthcare team is necessary for providing complex care to patients. Teamwork is crucial to improve patients' care journey by providing the patients with high-quality care and support. An effective and systematic care journey improves the way patients receives the care and treatment for meeting their care needs.

Reference list:

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Barton, G., Bruce, A. and Schreiber, R., 2018. Teaching nurses teamwork: Integrative review of competency-based team training in nursing education. Nurse education in practice, 32, pp.129-137.

Goh, P.Q.L., Ser, T.F., Cooper, S., Cheng, L.J. and Liaw, S.Y., 2020. Nursing teamwork in general ward settings: A mixed‐methods exploratory study among enrolled and registered nurses. Journal of Clinical Nursing, 29(19-20), pp.3802-3811.

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Salinas, D., Johnson, S.C., Conrardy, J.A., Adams, T.L. and Brown, J.D., 2019. Sustaining nursing grand rounds through interdisciplinary teamwork and interorganizational partnership. AJN The American Journal of Nursing, 119(4), pp.41-48.

Sandelin, A., Kalman, S. and Gustafsson, B.Å., 2019. Prerequisites for safe intraoperative nursing care and teamwork—Operating theatre nurses’ perspectives: A qualitative interview study. Journal of clinical nursing, 28(13-14), pp.2635-2643.

Suhonen, R., Stolt, M., Habermann, M., Hjaltadottir, I., Vryonides, S., Tonnessen, S., Halvorsen, K., Harvey, C., Toffoli, L. and Scott, P.A., 2018. Ethical elements in priority setting in nursing care: A scoping review. International journal of nursing studies, 88, pp.25-42.

Welp, A., Rothen, H.U., Massarotto, P. and Manser, T., 2019. Teamwork and clinician burnout in Swiss intensive care: the predictive role of workload, and demographic and unit characteristics. Swiss medical weekly, 149(1112).

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