Interdisciplinary learning in higher education
This chapter builds on Chapter 8, which explored interdisciplinary learning and interdisciplinary practice opportunities for law, health and allied-health students, educators and their service partners. Currently, many professionals work together in a multidisciplinary practice (MDP), such as doctors, nurses, podiatrists, occupational therapists and social workers. Often, as noted in Chapters 6 and 8, it is the justice component that is not common. Also, often absent is the earlier integration of interdisciplinary learning and practice opportunities in the higher educational settings to better prepare future practitioners.
This chapter’s focus is on the higher educational setting. This setting will have to navigate ethical issues that arise in interdisciplinary practice (this can also include the mandatory reporting of child abuse, which bind many non-legal disciplines, but where lawyers are exempt). The chapter provides some practical workarounds for the implementation of interdisciplinary student clinic (IDSC) and some ideas for legal clinical supervisors and law teachers.
The chapter also provides practical guidance for students of different disciplines, their supervisors and cross-departmental work to further break down barriers between professionals. Although ethical hurdles (such as ‘client confidentiality’ and ‘conflict of interest’) exist, they are possible to overcome through facilitating dialogue, training and ‘collaboration’ across different disciplines. One sure way these ethical hurdles can be overcome is through the shared commitment in practice to help and assist clients/ patients with problems (as discussed in Chapter 10) and improve the reach to people who may not be seeking legal help but who have significant and compounding legal problems. The shared objective of making a concerted effort, through this interdisciplinary setting, to jointly learn about and address the SDH both in education and practice has been a useful motivator for successful navigation to get to this destination.1
Although this chapter’s focus is on interdisciplinary educational practice, it correlates with the issues that would be experienced in the operation of a MDP, so this chapter is also relevant to readers from MDP. It also builds on my existing work on ethics and practical navigations in MDPs" by examining it in the interdisciplinary educational practice context.
The practical side of interdisciplinary practice in educational settings
Some ‘clinical legal education clinics’ are run by the university with onsite academic supervisors/practitioners. Other clinics are run by the university but are situated with a partner agency and may have a blend of either agency clinical supervisors and academic supervisors or both. This will depend on the higher education arrangements. Another model is a local agency hosts clinical students and has its own on-staff clinical supervisors who might liaise with the university academic staff (sometimes in exchange for a fee paid to the host by the university).
Student and supervisor preparation
In developing interdisciplinary practice and learning within higher education, it is critical that students, academic supervisors or clinical supervisors involved, understand the paradigms of how each different discipline works, what resources will be needed to work together and who is responsible for creating/delivering/supplying these resources. This is critical so that the systems and staffing are adequate to support the interdisciplinary model.
It is also important to identify which different disciplines are a good fit to work together. This can be easier to understand if services are already involved in an established MDP and where a justice component is needed. It is important that the scope of the work and any parameters are identified clearly amongst all parties to avert misunderstandings. The partner agency may also have some critical input into contribution of resources and the discussions. In IDSCs, this includes management systems.'”
Another essential part of any interdisciplinary practice preparation is to be clear on which client group you are targeting for your service. It is a good idea to not cast the net too wide but to focus on particular client cohort so that the interdisciplinary care team does not overreach itself and can deliver on its promises.
These plans may need to be tweaked depending on what the service actually looks like in operation. It is critical that everyone is clear on the services that will be offered by each discipline. For example, physiotherapists and podiatrists will be working within the framework of improving the social determinants of health (SDH). Lawyers may be looking to improve access to justice by reaching vulnerable or disadvantaged groups.
What is the interdisciplinary clinic and why is it important?
Nursing, psychology and medicine often run their student clinics discipline specific. Law has its own clinics. What the IDSC does is bring all of them together to deliver joint legal, health and allied-health services for clients/patients as appropriate so that pathways for patients and clients are made easier and reach the most vulnerable clients. Educationally, as discussed in Chapter 9, the aim is to increase each discipline’s knowledge of what the other disciplines offer.
The different aims/objectives of each disciplinary team can be addressed/ included by identifying how each service can cross-promote other services to their clients. This might ensure earlier intervention and prevention of legal, health and social matters and the opportunity for clients to access legal services (at the same time as they are accessing other services). It is really critical that preparation work be done around ensuring that all of the disciplines in the interdisciplinary practice or clinic that is being established have the same objectives. This means that they all have a similar vision, commitment and aim even though their professional obligations may differ.
It is suggested that the elements described in Chapters 4 and 5 around legal empowerment and client-centred practice may be a starting point in these discussions. This will bring to the surface differences of view or perspectives the disciplines might hold. It is critical that these discussions occur amongst the academic staff, host partner/agency and the clinical supervisors prior to the enlistment of students. If the clinical supervisors and supervising academic staff are not clear on the different aims and objectives of the interdisciplinary practices, then this makes it more confusing for students coming on board to provide service in an interdisciplinary way.
Where the IDSC is in start-up phase, time will need to be taken to identify not just the client cohort, but the disciplines available and willing within the university are a good fit to the client cohort. In some examples of IDSC, the health and allied-health students are already providing services into an agency and the justice dimension was added at a later stage. It is important to be mindful of such pre-existing relationships. This was the case in UniSA’s IDSC.iv
Examples of only selecting services that provide the right fit for the clients included the Bendigo health-justice partnership (HJP) at Kangaroo Flat (see Chapter 6), which was a specific demographic area with a high rate of public housing and the service targeted parents with children who have a disability. IMCL HJP (see Chapter 6) focused its initial program within the wellbeing team (social workers) at the Women in the Sexual Assault Unit with a specific focus on assisting women experiencing family violence (EV). The Justice Connect has a HJP (see Appendix 3), with a focus on elder abuse, so its cohort was the elderly. The interdisciplinary student health-justice student clinic (IDSHJC) that I have been advising at UniSA (see Chapter 8) has as its focus homeless clients who present at the ODHC program at the Salvation Army. This IDSHJC engages law students alongside podiatry and physiotherapy students who were already offering a clinic at Open Door Health Clinic (ODHC) previous to the law school clinic joining them.
What all of these clinics have in common is that they try to provide generalist legal services as they know that their clients are from vulnerable cohorts and will often have multiple legal problems. This averts having to refer clients to other services, if they have more than one legal problem, thus avoiding a referral roundabout, enabling a more holistic service. For this reason, it can also be useful, for IDSCs helping the poor and disadvantaged, to have a relationship with pro bono services with specialised expertise so that when matters arise that need specialist knowledge, the clinic can gain access to this specialist advice and if necessary the clinical students can support the client along the way to help the client engage with the pro bono lawyer or other discipline experts, such as mental health services.
In my experience as a clinical supervisor, it is also important to spend considerable time (given many of our students have led privileged lives and had the opportunity of going to university) familiarising students with the context within which their clients live. This might include ramifications of exclusion, low literacy and/or numeracy, the impacts of poverty, the complications of different cultural backgrounds and norms, the impact of ‘trauma’, implications of poor health and so on. Engaging students in challenging environments, without orientation, is neither fair on students nor the clients/patients attending the interdisciplinary practice.
Tools and training
The development of practice tools, prompts and training modules will be needed. One suggestion is to utilise students’ work in the initial run, by asking them to develop training models after doing the research themselves. This can then be built into assessment tasks.
Another suggestion is to get past clinical students involved. The newer students can video and interview past clinical students (on their mobile phones) about their experiences in an interdisciplinary practice or clinic, sharing their stories and perspectives on some of the challenges. This is a good way of inducting new students into any given interdisciplinary practice program and it can be re-used for later semester IDSC programs with the consent of participating students.
Additionally, enlisting clinical students in the clinic to research the law to find simple legal solutions and checklists suitable for training is helpful. I would ask them to prepare the power points and a training plan with activities. I would then give them feedback on their training plan. Depending on the topic, I would either deliver the training alongside my clinical students and other disciplines or have students deliver the training on their own while I observed.
Note: de-identification of clients is essential in any of these materials and in any offsite teaching.
Developing the interdisciplinary care team
Developing students, clinicians and collaborative personnel as a care team, rather than in isolation, is one of the key challenges for any IDSC. Practical matters will need to be taught, such as understanding the referral requirements of each discipline; how to complete official paperwork, meeting with intake and reception staff and building good relationships with them, as they will be the referral point for many clients/patients. This practical training for the clinical students familiarises them in doing this intake and referral process (information gathering), which is a reality in future MDP practice. Such practical training in differing processes of each discipline applies as equally to the clinical supervisors as it does to students.
By students knowing the boundaries of their expertise and understanding the roles of each other within those boundaries is also important. The clinical students need to be encouraged within their interdisciplinary setting to be visible and sociable with students of different disciplines and their supervising staff. Icebreaker activities may help students meet and converse with their new colleagues. This gives all of the clinical students and supervision academic staff or clinical supervisors an opportunity to interact in an informal social setting and to know each other. This will later make referrals between disciplines easier and more likely. Barriers and stereotypes that different disciplines may have of each other can also exist among students. Humility, respect and active listening skills ought to be reinforced before launching into any interdisciplinary practice or clinic so that collegiality and collaboration can develop and thrive (see Chapter 10).
Promotion of the interdisciplinary clinic
Promotion of the clinic and its services to the community and frontline staff, such as the receptionists in the clinic, cannot be underestimated and should be done routinely. This might include a leaflet handed to clients/ patients at the reception desk, or to clients and community members as they enter the building; it might be the provision of such leaflets on public housing estates or at the local social security office. I routinely dropped off leaflets at social service agencies in my area and would always have a discussion with the receptionists about what the leaflet contained and what services were offered. After these drop-offs, there would often be a peak in new clients turning to the service for help.
You can utilise clinical students to create their own tailored cartoons, posters, simple video clips or social-media messaging, but know that digital resources are out of reach of many clients, although their professional supports can use them for marketing to clients, patients and within their own team. Clinical students or law students from other courses in the higher education facility can also be deployed to develop such resources as part of their learning. Explaining what you do, who you have helped and how you have helped them can all assist in building the profile of your practice. This has the benefit of involving students in not only creative endeavour but also in applying their legal knowledge using plain English to communicate legal and non-legal information. Note: if the students are borrowing materials from other sources, they will need to get permission from the copyright owner before they can repurpose the content.
What is important is that you can simply explain what your service can do to help them and the sorts of situations in which you can help. For example: ‘Are you being chased by debt collectors?’, ‘Are you being harassed for a debt you don’t owe?’ and ‘This may be unlawful, have a look at this webpage, which will tell you what your rights are’.
It is important to never take the support of the higher educational facility for granted. Clinicians and academic supervisors will need to regularly demonstrate the impact and importance of their work to the higher education facility to demonstrate that it is an important investment and that it leads to student outcomes.
A lot of universities worldwide are now being required by government (as part of their accountabilities) to demonstrate the employability of their students and graduates. This is critical leverage for innovative clinical programs such as an IDSC as the practical skills they develop in their IDSC training prepare them for future jobs. In my experience, these conversations about the benefits of clinics for the students need to be occurring routinely within faculties, central university management and at dean and chancellor level. I make it a habit at the end of each semester to report on the value of the clinic to either my dean or head of school. This can be done by using de-identified case studies around the breakthroughs in a clinic, its work with clients and the challenging learning outcomes that students were able to reflect on in their evaluations and feedback on the course.
Similarly, it is important to get into a routine reporting phase of the work of your IDSC with your partner agency and not take their support of your work for granted. Case studies about breakthroughs in the clinic can be used to report to their board and/or to the leaders of critical care teams within the organisation. It is important to demonstrate the ongoing value of their support to the service. This is especially the case when not-for-profit organisations go through austerity phases with losses to their funding, losses to parts of their programs or feel that their resources are being stripped.
Being able to report and demonstrate that by having students working together in an interdisciplinary way not only benefits the clients/patients of the partner agency but also enhances and energises the capacity of the staff to deliver services in a broader way. In some of the clinical/legal training programs, I have taught or supervised students in, it has often been the case that the partner agency has recruited students from the clinic because they have been impressed with their performance during clinical placement. This ability to act as a feeder for the recruitment of future professional staff for the partner agency is attractive to them. This is because they know that students are already grounded in good practical skills and they understand the values and aims of the partner agency. This advantage to the partner agency, as a reservoir of future staff, can also be something to report back to the higher education facility.
Protocols, policies, procedures and regulatory frameworks
Being mindful of each discipline’s funding arrangements, privacy laws, policies, procedures and accountabilities may also be something to explore early on. This can include issues around public liability insurance and conditions of accreditation.
One of the complications can be that arrangements for funding do not necessarily reflect intentions to work in an interdisciplinary way. Government departments that arrange funding often work in silos despite the rhetoric around joined-up services. None of these things need be fatal to an interdisciplinary practice, it is more about a consciousness and appreciation of the context in which other professions need to operate that will lead to workarounds that can facilitate and accommodate. Again, the main point is to have ongoing conversations so that each discipline is aware of the constraints and leniencies of the other.
Gyorki’s' report around breaking down silos is pertinent. She notes that Pro Bono Law Ontario (PBLO) at the SickKids Hospital in Canada has clinical medical and law students onsite with the clinical law students supporting patients to complete paperwork for social welfare and social support payments. At Duke University in North Carolina, supervisors observe students interacting with patients through the use of (consensual) videos from interview rooms.
Taking time to develop protocols for referrals, intake, assessment, processing, sharing information, privacy, security, confidentiality and triggers to pre-empt likely problems and problem-solve in advance is important to work out how these will be managed?' Every type of practice will differ from the personnel involved to the particular exigencies that need to be covered for different client groups, for example, children with intellectual disabilities, victims of FV, the homeless, elderly or people with multiple/ complex needs that can exist within one client cohort.
When engaging in interdisciplinary work, partners should be aware of the different reporting requirements that different disciplines might have. For example, in Australia, legislation requires most professions to mandatorily report any indication of a child’s risk to sexual or physical abuse to the relevant authorities. Note that one profession exempt from this is the legal profession. As indicated in Chapter 6 on MDPs, this may mean that a social worker or teacher may feel obliged to report child abuse if they hear reference to it in a legal interview. This is tricky territory for an interdisciplinary practice to navigate. The lawyers need to be clear about how they handle such situations. This may include having separate interviews with the client and only including other professional staff to discuss specific matters pertaining to their help. Or, suspending a client interview when it looks like confidential information might be about to be shared. The lawyer can then see the client independently and provide advice in relation to their matter. Separately, the
Interdisciplinary learning 227 social worker or teacher can interact with the child or parent and, if issues arise that trigger mandatory reporting, honour their legal obligations.
Client confidentiality, conflict checks and duty of loyalty
‘Conflict of interest’ (as described in Chapter 9) is an ongoing process that should be ascertained at intake, post-interview and throughout the advisory process; as over time, different parties may be involved. This becomes especially relevant when in assisting one client, you may have clinical students of different disciplines working together holistically for other clients and their families. This increases the chance of conflict of interest, and so all parties need to be vigilant so that clients are not precluded from receiving help.
The development of intake tools that pre-empt the risk of conflict is invaluable. One way is to only provide general advice at case management meetings with other disciplines. Then the lawyer or law clinical student can leave the meeting prior to any specifics being discussed. Both lawyers and non-legal professionals need to be trained to develop a method of signalling when a conversation may need to take a different direction. This ensures that clients can gain access to justice without disclosure being inadvertently made that would preclude the lawyer from helping, as the lawyers’ ‘duty of loyalty’ to clients means they cannot act for either client once they are privy to certain information. So, great care is needed.
‘Vigilance’, careful consideration of the use of information and its appropriateness are constants in interdisciplinary work; however, this does not make working collaboratively impossible. Different disciplines can work alongside each other to achieve the best outcomes for their clients, mindful of ‘client confidentiality’ and the ‘duty of loyalty’ the lawyer has to their client.
There are other murky areas, such as not advising on medical negligence in relation to the partner agency, or a complaint about the poor conduct of someone who is part of the interdisciplinary care team. Clearly this would represent a conflict of interest. For instance, a conflict between the interest of the client in pursuing a remedy against the non-legal partner agency, and the personal interest of the lawyer in preserving multidisciplinary (MD) working relationships in that partner agency.
It would be incumbent on any lawyer in such a situation to refer the client to another agency or a private law firm with expertise in medical negligence. Again, in such a situation, if it arose in a client confidential situation in a client interview with a lawyer, the lawyer would have a duty of confidentiality not to tip off the relevant non-legal health professional or the interdisciplinary partner agency. This would be a breach of client-patient confidentiality by the lawyer.
These examples serve to illustrate the importance in any interdisciplinary clinic or practice of good training around ethical hurdles and how these operate and intersect between the organisations that are working in collaboration for the client’s best interests.
Document privacy and security
In my experience working on MDPs, different models exist to protect document privacy and security. When I worked at a community health centre, their files were kept in a completely different location from the legal service files. Although the staff work together, the holding of documents was maintained according to the discipline and according to the rules guarding privacy and security that operated within that discipline. The legal service had its own separate offices in the building with a locked room and a locked compactum in which all files were kept. It had not yet gone onto a virtual file system and so this was not relevant.
In another MDP I worked ar more recently, all of the hard copy documents and virtual files for each discipline were stored separately and also on separate IT systems, which other disciplines could not access. Again, although software being used is the same, it was kept under a different and secure arrangement to protect privacy and the different disciplines could not access information from each other. Firewalls were also in place.
In Australia, the rulings around the establishment of ‘Chinese walls’ are very strict. This is important in order to protect client confidentiality. This, however, does not preclude effective MDP as long as care and thoughtful processes that enable separation and preclude access are in place.
Protecting client-legal privilege
Medical files can be subpoenaed in a court process as can other health and allied-health material. Therefore, great care is needed in giving legal advice (alongside other disciplines or with other disciplines in attendance) so that it does not compromise the clients’ right to confidentiality in such cases. This could prejudice a client’s situation were a matter to later go to court. Also the lawyer would be in breach of their client-legal privilege obligations. This is the fundamental underpinning of ‘the rule of law’ that a client should be able to seek frank legal advice about their legal position and options without risk of disclosure of the information they share with a lawyer. If clients were not able to do this, they may be reticent to seek legal advice. If the lawyer does not take care to circumscribe what is discussed, and at what times, then a court may hold that the client has waived their client-legal privilege.
When you work in a MDP with disciplines on a regular basis who have been trained and understand the implications of breach of client-legal privilege, then not only do they trust you, but you will also trust them. They will have participated in ethics training about both their own profession’s ethics and your legal ethics, and so you can have confidence that their focus is on your joint client and doing the right thing by them.
As noted in Chapter 8, if it is appropriate for a third party to attend a legal interview, it is wisest to gain their consent, which includes them signing a
Interdisciplinary learning 229 non-disclosure agreement. It might be that such a document can contain areas where the other discipline sits in with the law discipline and conducts a joint health-justice assessment. This might be to share, for example, client health contexts, complications and information around treatment and so on.
In my experience, this can be navigated through careful thought, discussion and dialogue between the disciplines about the specific roles in relation to a client and a frank and honest discussion with the client themselves. It need not be difficult if the disciplines involved are cognisant.
A cautionary tale
This cautionary tale, although not in an interdisciplinary context, alerts readers to the vagaries of third-party consent. This was a big lesson for both myself and my clinical student. The client, a young mother, was very distressed about the removal of her child by the department. The main basis for the removal was around the mother having spent time as an adolescent in care; therefore, she would be more likely to be of risk to her child. Having explained to both the client and the social worker (who was from a separate agency) separately regarding the risk of having a social worker present in the legal interview (including the implications for client-legal privilege), the client was adamant that she needed the social worker as support.
We secured a signed third-party consent in writing not to disclose from the social worker. During a break in the interview (as the client was overwhelmed and distressed), the social worker, who had taken a cigarette break at the rear of the building, was on the phone to the department discussing the legal interview. She felt that her obligation was to her agency’s funder, the government department in the care and protection case and that this trumped her obligation to the client. My clinical student overheard the social worker outlining the measures that the client was going to take to assert her rights as a parent. She conveyed the advice that had been provided to the client in the legal interview, about her rights and the flaws in the department’s arguments and their lack of evidence.
The clinical student reported overhearing this conversation immediately to me (sensing it was wrong) and while the social worker was still on the phone to the department. She was then asked by me to go to the social worker and tell her to end the call and to wait in reception room, as we would need to talk to her. The client was called into a separate interview. We explained the events that had transpired in the break. The client was furious with the social worker and instructed us to remove her from the rest of the interview and to take action to protect her interests.
The clinical student quickly researched the ethical obligations of the social worker and then contacted the legal ethics support line of the law society about what to do. I dealt with the social worker in a separate room.
Our first step after the separate interviews was to contact the children’s court and alert them to the fact that a social worker had breached client-legal privilege. We argued that the department’s case was fully compromised, asa result of the conversation that had occurred between the department and the social worker. We then contacted the chief executive of the agency from which this social worker was employed. We also noted that she had signed a third-party consent. The chief executive agreed that it should be the subject of disciplinary action and professional development.
We then contacted the department and spoke to the legal office advising them there had been a clear breach of our client’s legal privilege. We made it clear that the department could not rely on any material that had been disclosed. We advised that we had notified the court of the breach in order to protect the client’s interests. Without any further detail on what occurred, suffice it to say that the department was forced to withdraw its case against the client.
After this case, I became vigilant about what I would discuss with the client if a support person was present. I would streamline the conversation or ask the support person to leave the room when necessary. If there was detailed advice, I wished to give my client, I would do so at a later point over the phone or wait until a social worker had left the room.
Home visits are often undertaken by health professionals or allied-health professionals that the interdisciplinary clinic will have working alongside. Lawyers could learn from this practice. Many people are frail, elderly, suffer from chronic conditions, have a disability or for other reasons are unable to leave their home. Being isolated from the help of a legal professional because they need to attend the lawyer’s offices is problematic. One of the complications in a clinical context is university requirement about students being offsite from where the legal service or clinic is operating. However, universities usually have a flexible public liability framework, which if certain protections are in place, may be operational. For example, this may include the provision for a student to be accompanied by another clinical law student or clinical supervisor during home visits. The other possibility in an interdisciplinary clinic context is for the legal student and the health or an allied-health student to conduct the assessment jointly. This can be very helpful where someone is unwell and wants to make a will or apply for a social security benefit. I have attended a home visit with an occupational therapist and a law student to assess whether or not the elderly client was being unduly influenced by their adult child in the making of a will.
Given that in an IDSC home visits will be likely; so, to reach the most disadvantaged of clients; thought should be given in discussion with your partner agency and the university about their policies and procedures for offsite visits.
My golden rule in practice was, ‘if in doubt, don’t’. It will of course depend on the type of case, for example, a family law, child abuse issue or a personal injuries claim. Another issue is whether a lawyer can enter into a legally binding contract of retainer with a child under 18. Also, the
Interdisciplinary learning 231 appropriateness of taking instructions from a child in the absence of an adult would also depend on the age and maturity of the child. The Gillick test'" is often used in medical assessments of children. This assesses whether the child has sufficient maturity and intelligence to understand the nature and implications of that treatment. The use of this test is a matter of lively debate both in medical and legal circles. McLean,viii for example, raises concern about the test’s application and has noted that children may be silent about their wishes as they are intimidated by their parents’ presence, or unaware they could give or refuse consent themselves. It may be appropriate to ask parents to leave and to speak to the child alone. Alternatively, Gillick competence may be discussed with children and parents together. Burton'* also outlines some ethical and human rights reservations around applying the Gillick test where a young person or child’s confidentiality may need protection, for example, matters of sexual identity, where the child understands and can deal with advice and implications.
It is unwise to invite a caseworker who may not understand the nature of ‘client-legal privilege’ present to a client interview. As noted in Chapter 9,1 would make sure, prior to any legal interview (were a caseworker might be present from a different discipline) that the client is fully aware of the implications of having that person sitting on the interview. This includes checking that the client has fully understand the implications by asking them to repeat their understanding in their own words. I also secure a signed consent from the caseworker to not disclose on the basis that the interview is for the primary purpose of legal advice. If I am still not confident about the case worker, I interview the client separately and explain why I feel uncomfortable. One never fully knows the power dynamic between a client and their support worker, and so great care is needed.
This discourse highlights that planning to keep a child safe from abuse or FV is a vexed area and that careful thought and referral to ethical experts/ and your ‘community of practice’ (noting client confidentiality) for guidance is necessary.
In the vexed area of mandatory reporting of child abuse, discussed above in ‘Confidentiality’, I would avoid including a non-legal professional in a client meeting if a controversial topic might be exposed, as it would require them to report the situation. Instead, I would separately interview the client to ensure we had a safety plan in place, or counsel them around their options and the apparent risks. The other discipline, in the capacity of their discipline, would in a separate interview, work/advise as they normally do with the client/patient in line with their obligations. It is merely a matter of explaining to the non-legal personnel, if they alert you to the possibility of a mandatory reporting issue, that it is unwise for them to attend the legal consultation.
In these situations, if it is a maternal and child health nurse, they will often be the only person that the client is engaging with. If they were to stop working with the client, then the client may be in danger of being isolated from legal help, and exposed to further abuse (that is, if FV is involved). The lawyer can have a role in developing a safety plan separately to the work of the maternal and child health nurse. The client and nurse can then proceed to continue with the appointment secure in the knowledge that any concerns around FV are being dealt with by the lawyer.
By way of example, if a maternal and child health nurse working with a cohort of young parents and disadvantaged young people (a group often more likely to be exposed to FV or some form of child abuse) can refer them on to a legal professional early, and as a matter-of-course, then the legal component of the service can advise about their rights and choices. Then the maternal and child health nurse can work with the group in the knowledge that a safety plan has been put in place, and that the correct advice has been given in relation to FV or child abuse.
It is important to have opportunities for debrief in the early stages of setting up an interdisciplinary clinical practice so that issues can be identified early, and workarounds found. It is important to note that this is a new way of working and learning, and not easy as it is seen as time consuming, which is challenging for students and supervisors alike. In a debrief, patient/client rights and the acknowledgement of different disciplines’ ethical duties can all be canvassed. Improvements to practice can be ongoing and needs for further support identified through the debrief process.
Legal health checks and assessment tools
It is my suggestion that any one discipline wants to engage in an interdisciplinary clinic or practice look to the partner and other members of the practice to see what intake tools are already in place, so to see if your questions can be incorporated into an existing framework.
In Australia, HJPs use legal health checks to assist health professionals to identify the range of problems for which legal help can be possible. This overcomes some of the misunderstandings about the narrowness of the perceptions on the scope of what law can help with (see Chapter 1) that can limit people from getting legal help when it is available. In the developmental days of HJPs, health agencies told me that when asked to use these legal checks they were resistant. When they asked me to scrutinise some of the tools, many were convoluted, complex and impractical. A range of disciplines have already developed effective legal checks for example family violence services, which can be adapted for the HJP purpose. What is critical is that this extra layer of checks not adds unnecessary burden to the work
Interdisciplinary learning 233 of other disciplines who may also conduct checks for discipline-specific purposes or a history of FV.
In the United States, the HJP network has developed an IHELP tool.x Health Justice Australia* has also developed a start-up toolkit and Queensland Public Interest Law Clearing House (QPILCH)xii has also developed an effective assessment tool. In Canada, the Halton Community Legal Services'"' has developed its own evaluated legal health check tools and Community Advocacy Sc Legal Centre (CALC) has a legal health checklist.xiv PBLO at SickKids Hospital, paediatricians, has developed a poverty screening tool.1“'
Reaching into communities, not previously assisted by legal services, through working with non-legal agencies will take time. If referrals to the legal component of the interdisciplinary clinic are slow, it is not realistic to reduce hours or close shop but to offer non-legal professionals from other disciplines, legal secondary consultations (LSCs). You can then reach clients who may be apprehensive about seeing a lawyer or too overwhelmed. Being visible, socialising in the lunchroom (see Chapter 6), chatting to people who are likely to refer clients/patients is key to making your service visible. Being prepared to sit in the waiting room with clients and engage in informal conversation with staff from other disciplines will help build these referrals and confidence in people making the first steps towards an appointment. In time, this will lead to referrals and client caseloads. Also, a lot of people have great trepidation in seeking help from lawyers or may not be aware that their problems are capable of a legal solution.
Another way of streamlining a referral process is to allow for ‘warm referrals’. This is where the client is supported into the referral by either a trusted intermediary or support person, or a conversation occurring, after consent has been received. The person making the referral talks directly to the referring agency to facilitate an appointment, and in turn the client feels supported.
It is my practice as a lawyer, to spend time informally chatting to clients in the waiting room (and encourage my students to do so). I do not disclose that I am a lawyer, but ask a few questions, and inevitably I find that people disclose problems with a justice dimension, not knowing that lawyers can help.
An example of this was in 2019, when I was chatting to an elderly woman in a HJP as she waited for her physiotherapy appointment. I discovered that she was about to be evicted from her rental premises. I suggested she chat to the legal clinic, ‘oh no I don’t like lawyers’, she said. She was able to share with me the documentation that she carried around with her everywhere. I was able to quickly make an assessment; it was evident that the proper procedures had not been followed by the relevant authorities. Then, with the support of the partners’ administration staff, I suggested she have chat to the student lawyers in the IDSC, which she then did quite enthusiastically.
Clear, simple and transparent referral pathways are critical. Unless the process is clear, understandable and not cumbersome, it is unlikely to be used if non-legal professionals are busy. Some agencies have existing online processes that can facilitate quick turnaround and information gathering. These can be utilised to develop common referral pathways simplifying the bureaucratic process. The use of online forms that can be easily completed and shared is also useful. Of course, client/patient consent will be a critical component of this. For lawyers, they will not be familiar with some of the detailed assessment and intake procedures other non-legal professionals are required to undertake. It is important to respect the referral and intake protocols of other agencies you need to refer your clients to, as it is likely that these are required by the agency’s funding bodies.
The use of secondary consultants (SCs) (see Chapter 6) can assist in encouraging referral pathways if the non-legal professionals have had a positive experience of the clinical supervisor/lawyer and their clinical students during the SC. This is also the case if they are accustomed to seeking SCs from the non-legal service or IDSC in general.
It was common when I was a clinical supervisor in a HJP, for me to get a call from a doctor or a nurse asking if they could come to my office and bring a patient with them. Obviously, this is not always going to be possible if you have a lot of appointments. However, building into the practice the flexibility and preparedness to allow this to occur and making time for such unexpected consultations has huge benefits, particularly if the client being referred is homeless or has a history to not follow through. It also demonstrates to the non-legal professional, such as the doctor, that you will make time for their patients. Such facilitative practices are important in an interdisciplinary context so to build trust and confidence in referral.
Another suggestion is to demonstrate how the legal assistance might simplify the non-legal professional’s job. I found there was often scepticism from doctors particularly about involving lawyers in their patients’ affairs. Doctors tend to have short consultations and quick turnarounds. The 10-minute sessions under government guidelines and health funding arrangements can be limiting. For the lawyers to be able to facilitate their ability to sort out a patient’s issues can be resolved through a quick SC before or after their patient appointment might help.
Another useful service a clinical legal education student can provide is the provision of a template form for the doctor to fill out. This can be provided by the law student and may be a much more effective use of the doctor’s time and may lead to positive outcomes. An example of this was, in the HJP where I was a clinical supervisor, doctors were repeatedly required to provide letters to the government for patients every three months stating that patients with permanent ongoing disabilities still had them, in order for social supports to
Interdisciplinary learning 235 continue. Students researched the requirement and drafted a template letter for the doctors, where all they needed to do was incorporate the client’s specific medical condition, and the criterion was already outlined. This made the doctor’s job much quicker and easier and they realised that both students and lawyers could value add. These are simple ways that students can build trust.
Another example of support of a non-legal professional through SC is having a quick chat through SC to a psychologist who has to give evidence or write a report for a court on behalf of a client/patient. I was able to take the psychologist through the criterion that the judicial officer needed to consider before they could make a finding in favour of the client/patient. The psychologist then, knowing very specifically what the judge needed to take into account, would have clarity about what she needed to include in the report about the patient’s condition by having the relevant criteria to hand. The psychologists would say that this gave them peace of mind and that they felt much better able to write an appropriate report or give evidence with less trepidation and anxiety.
In over two decades of providing SCs, the last six years of studying them have shown a sophistication with which non-legal professionals now know their limitations, and know to check in if the situation or circumstances slightly different or complex before acting on legal information or legal advice that have been if they have been previously given. Most non-legal professionals are very attuned to the limits of their own legal expertise and will defer to the lawyer through the SC process rather than give advice that they are uncertain about. This is verified in a number of empirical studies undertaken exploring how SCs are used at a later time to assist other clients or members of their leadership team.xvi
‘Reciprocal training’ is where lawyers train non-legal professionals in legal issues, and other professionals reciprocate by training lawyers in regard to relevant aspects of their discipline.
One practice I developed, after conducting ‘professional development’ alongside non-legal professionals, was to offer blocked legal appointments for clients after any training offered. This prevented non-legal professional raising their specific case during training, where they might be at risk of compromising their own confidentiality or increase the chance of a later conflict of interest, which might preclude them or other parties from gaining help. Participants in the training could then avail themselves of these appointments by making them for later in the week if they felt that they had identified a patient that might need assistance. Many of the non-legal professional participants were not aware that a client problem could have a legal solution or the possibility of a legal solution prior to the training. I could say to the person in the training, ‘this is sounding very specific, I’m happy to see you after the training to advise in person’.
Having lawyers onsite who can do on-spot training at staff meetings, team meetings, joint professional development days, during rounds, in the induction of new staff, etc., leads to an increase in referrals and the relationships are enhanced breaking down the poor stereotypes discussed in Chapter 5. But similarly, having students from different disciplines and their clinical or academic supervisors, the exchanges and learning is equally valuable. An example of this collaboration was attending staff meeting with my students, where the impacts of people on psychotropic medication were discussed. This cross-learning reshaped how we worked with this client group and clarified any misconceptions we previously held about the subject matter.
Enlisting students collectively in their mixed disciplines, or on a specific topic, to do background research and attend these cross-learning sessions and to participate in them is a wonderful experience for students. Some clinical students have never attended a staff meeting in their lives, so including them in this sort of activity gives them some further on-the-job training and if they had come prepared (having done research), I would often defer to them which they also enjoy and find empowering.
Chapter 11 discusses the approaches to such training that need to be considered to make it effective. This can also be a student offering in IDSCs. Initially, this training may be simple seeking to demonstrate the sorts of problems that might be capable of a legal solution. This information can assist other disciplines in being able to identify the sorts of issues that their clients/patients have that a lawyer can assist with. This can form part of the student assessment with a component for reflection and feedback. Over time, the topics might become more sophisticated for members of staff who have already had some initial training. Given high staff turnover in some workplace’s reiteration and repetition of some of these training sessions may be useful for new staff or those who missed the original session.
Topics can be varied but should reflect the interests or imperatives of the partner and other disciplines in attendance and should also reflect the sorts of problems that clients are presenting with. Topics that assist non-legal professionals juggling their ethical responsibilities and knowing the parameters around their responsibilities can also be useful in assisting them to make the right decisions on behalf of their patients/clients.
Client consent and feedback to interdisciplinary teams
One of the areas that Gyorkixvii reports on is that legal professionals have to be very careful that they do not discuss their client’s case openly with others. She notes that other professionals are accustomed to being open about client problems and issues as they work jointly together to meet their duty of care to their client. This can set up a pressure point as lawyers can be seen as being uncooperative or not working as a team by not sharing information about joint clients.
Strategies to avoid confidentiality issues
Some strategies for managing client confidentiality include:
- • Secure confidentiality waivers so that organisations within the IDSC or practice can discuss the needs of the client in a MD context.
- • At the start of the service explaining the nature of the MDP and seek the client’s consent for the different providers to be able to talk to each other about their case or set limits around the nature of any discussions between the disciplines.
- • Consider not involving the lawyer in case planning so to reduce their conflict of interest and not jeopardise duty of loyalty to the client.xviii
- • Gain trust with your interdisciplinary partners by explaining your legal obligations to the client; dos and don’ts, client permission, etc.
- • Clarify the issues for lawyers in working with other disciplines.
Non-legal colleagues will naturally want updates and feedback as to what is happening with the clients/patients that they refer and continuing to assist with their non-legal issues. For this reason, it might seem strange to other disciplines that the legal profession needs to keep client information private, even from collaborators in the client’s care team. A workaround is for the lawyer/law student to gain clear written client consent about which professionals the lawyer can talk to and about what. This may also facilitate a feedback loop.
Working with interdisciplinary teams
Being clear and honest about the limitations to why the legal profession cannot disclose client information and confidence goes part of the way to reducing disappointment in non-legal team members. They need to learn to adjust to the limitations of information sharing when there is a justice component to an interdisciplinary team. It is possible for the legal professional to provide general feedback, for example, the sorts of things the service is assisting with and how the referral process is working in general, and what breakthroughs are occurring without specifically disclosing client confidential information or identifying information.
Allowing time to develop, learn and build relationships with opportunities for interdisciplinary debrief and reflective practice is critical.
Over time, different disciplines in an interdisciplinary clinic or practice will not hesitate in talking to each other across disciplinary lines. It can be done so seamlessly and effortlessly; having worked through all the safeguards mentioned in this chapter, with a holistic and client-focussed brief. Client care, client autonomy and self-determination, and seamless wraparound services are an indication that integration is occurring. It suggests that partnerships have been bedded down. This is not a rime for complacency as the relationships to be sustainable, need to be continually discussed, debriefs need to be regular and reflective practice should be ingrained (see Chapter 14). When an interdisciplinary practice is working well, it can make great inroads to client care (see Chapter 5), however, it needs to be constantly recalibrated, evaluated and nurtured and is always a work in progress with reflective practice shaping and improving on service and individual approaches to service delivery and personal growth.
i A useful health chart from Community Advocacy & Legal Service (2018).
ii Curran (2017e), 25-35.
iii Roberts, Currie (2012).
iv Atkinson, Curran, Ferrar, Kontolian (2020).
v Gyorki (2014), 77-80.
vi Tobin-Tyler (2008b), 17.
vii Gillick v West Norfolk and Wisbech (1986).
viii McLean (2000), 551.
ix Burton (2016), 708.
x Marple (2015).
xi Health Justice Australia (2018 reprint of 2015).
xii QPILCH (n.d.).
xiii Halton Community Legal Services (2014).
xiv A legal health awareness poster from Community Advocacy & Legal Service (2014).
xv Gyorki (2014), 77-80.
xvi Curran (2017a, 2017c, 2020); Curran, Taylor-Barnett (2018).
xvii Gyorki (2014), 77-80.
xviii Ibid., 61-2.