Once the adults were done with their questions, small adjustments, and general fussing, 8-year-old Sam (not his real name) raced over to his Thomas the Tank Engine set, smiling with the combined relief of being free from the meeting and the joy of playing with his favorite characters. This session was to fit Sam for his first wheelchair. He had cerebral palsy and could walk a bit with a gait trainer, but this was an effort that demanded all of his concentration and both of his hands. It made his muscles stiff with tone and sometimes left him sweating, even after a short distance. He had a devoted family who had hoped walking would become easier for him with an intensive childhood physiotherapy program, but it had become clear this wasn't going to be a practical way for their child to get around on his own.
The fitting went well. Sam was whizzing around fully independently with apparent ease and had textbook photo-quality posture. The only small remaining issue was controlling his head a little better now that his tone was more relaxed in the newly supportive seating. This improved during the two-hour visit, so we agreed the system could be altered for more head support if he continued to struggle. Despite this, Mom's interactions were noticeably cooler than during the wheelchair assessment six weeks before. She was concerned about specific issues not previously raised and did not seem pleased at this milestone in her son's independence. It can be a shock to see your child in a wheelchair, so I figured her demeanor was part of that adjustment. Then, she called a week later.
She reported the boy's school physiotherapist was raising concerns with the wheelchair and Mom was clearly unsure who to trust. When I called the physiotherapist to discuss, she said she "wasn't happy with that backrest," although I couldn't elicit any specific reasons. I suspected another therapist leading the case, or a worry that efforts in the development of walking skills were being undermined didn't help the interaction. Now all of use were feeling irritated and I wasn't quite sure how to sort it all out.
The conclusion was largely a muddling through. Nothing changed on the wheelchair and seating system, as it met his needs. He was even fine with holding his head up indefinitely after a few weeks. But I have felt uneasy about it since. We had failed to provide the best service, somehow turning a positive outcome into a negative one.
Consensus in a multi-disciplinary team
In the many years since this incident, I have improved in negotiating these sorts of issues, but it remains a challenge. Therefore, it was encouraging to see an entire session devoted to the skill of consensus building at this year's International Seating Symposium conference in Pittsburgh. Michelle Lange, along with co-presenter Filipe Correia, identified key barriers to building consensus and proposed ideas to support better collaboration.1 Taking the approach of the lead clinician as being responsible for molding consensus, she highlighted the following as obstacles to navigate through in the wheelchair and related assistive technology provision process:
- Hierarchy of roles - does everyone feel welcome to contribute, regardless of title?
- Differences in experience/knowledge - the most vocal team member may or may not be the most competent or experienced.
- Expectations and goals, founded on different and potentially competing philosophies - is the point of the wheelchair to support therapy goals, enable daily activities, or achieve anatomical alignment?
- Funding - a key constraint underpinning the entire goal setting process.
Once factors impeding consensus building are identified, the team must work through them to arrive at one central aim "so basic everyone can agree on it." Michelle proposed the most important way to build consensus is to take several steps back, widening the focus to find common ground. It is only by really starting on the most essential and core part of the problem, rather than the solution, can the team move forward collaboratively. Simple concepts of accessibility, enabling independent mobility, better forward vision, and other similarly broad targets can help a team start with a shared purpose. From this, interactions should be built on empathy and respect for the expert knowledge each member brings. Where education is required, approach respectfully and clearly.
Although this sounds straightforward, establishing an environment of respect takes attention and reflection. With stubbornly expanding waiting lists, persistently inadequate time, and goodwill resources often exhausted by workplace pressures, it is difficult at times to allocate even more emotional energy to foster an inclusive approach. Other team members and clients have their own opinions and expectations, and we only have a short time in our interactions to gain their trust. But this early investment saves difficulties later on.
Asking "Why?" more than once
Another helpful approach in consensus building comes from the industry-based concept of the "5 Whys." Originally proposed by Sakichi Toyoda in the 1930s2, it seems to identify the root cause of something by asking "Why?" five times. For example, a client may want a wide wheelchair - one the therapist is concerned may be hard to propel and may lead to low back pain:
- Why? To have space.
- Why? For my handbag.
- Why? There are things I want to keep with me.
- Why? I am worried I will lose them.
- Why? I need my keys to not get locked out, and my phone for almost everything.
Maybe in this case, the real goal is not to get a wider wheelchair, but a place to store a few items securely that the client could still access. A cushion with an integrated pouch or a wheelchair bag that rests behind the calves may accomplish this and allow a seat size that offers better support. This may not be the only "why" - standard assessment guidelines of considering transfers and other daily tasks still apply.
The prescribing occupational therapist, physiotherapist, or other lead healthcare professional in a provision may have the ultimate responsibility of arriving at a wheelchair and seating system, but is not the sole decision maker. Building a consensus early can prevent problems later, and as prescribing clinicians, leadership is an integral part of the role that we must seek to develop throughout our careers.
References
- Lange, M., Carreira, F. (11-15 April 2023). Building Consensus in Seating and Wheeled Mobility Evaluations. [Conference presentation]. International Seating Symposium, Pittsburgh, PA, United States. https://www.iss.pitt.edu/
- Ono, Taiichi (1988). Toyota production system: beyond large-scale production. Portland, OR: Productivity Press. ISBN 0-915299-14-3.
Faith Brown is an HCPC-registered occupational therapist with over 20 years of international experience in the field of seating and mobility including the British National Health Service, as well as the private and NGO sectors. She has worked with all ages and levels of complexity, including leading an NHS special seating division. She is a research champion for the Royal College of Occupational Therapists and has a history of lifelong professional development. Her post-qualification education includes a postgraduate certificate in Postural Management for People with Complex Disabilities from Oxford Brookes University, an MSc in Health Research Methods from the University of Birmingham (UK) and completion of an engineering module in wheelchair design at the University of San Francisco.