Team Relationships

Published on 09/04/2015 by admin

Filed under Hematology, Oncology and Palliative Medicine

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16 Team Relationships

Sarah Friebert, Jody Chrastek, Michelle R. Brown

If they don’t have scars, they haven’t worked on a team. Teams don’t just happen. They slowly and painfully evolve. The process is never complete. The work involved is usually underestimated.

—Balfour Mount

By its very nature, and in fact by legislative decree in the case of hospice, the discipline of palliative care is a team sport. The overall goal of teamwork is to enhance patient care through team performance, member satisfaction, and organizational commitment. Through a cyclic process of “forming, storming, norming, and performing,”¹ teams that are well-formed and well-maintained enhance the delivery of pediatric palliative care by far more than the sum of the individual disciplinary parts. Nevertheless, highly functional teams are not automatic—their creation and ongoing survival and growth require high-level, multimodal skills. This chapter will explore the basic types and dynamics of teams, their critical importance in pediatric palliative care, typical features of functional and dysfunctional teams, and practical strategies to prevent or remedy dysfunction to preserve and protect teams and their members.

Team Structures

Teams come in many flavors. Multidisciplinary teams are groups of individual practitioners who come together to report on what each is doing and work side by side but not necessarily together.² In multidisciplinary teams, professional identities are primary while team membership is a secondary priority. Leadership is generally hierarchical, and practitioners function as wedges in a pie.³ Partly because these teams rarely meet face to face to discuss the needs of mutual clients, the multidisciplinary model is not a good fit for palliative care because the lack of regular communication increases burdens on families who become responsible for keeping their care professionals apprised of changing symptoms and treatments (Fig. 16-1).⁴

Fig. 16-1 Communication burdens in different team types.

Most palliative care teams are self-described as interdisciplinary. In this model, different professionals combine resources and talents to deliver care in an interactive process by which collaboration reveals goals that cannot be delivered by one discipline alone,⁵ and the synergy resulting from collaboration creates an “active, ongoing, productive process.”⁶ Team members engage in joint work from different orientations,⁷ and the objective is to arrive at effective treatment decisions after considering input from all members. Leadership of interdisciplinary palliative care teams is often task-dependent and decisions are usually made by consensus;⁸ this process enables focus on medical concerns as well as wider issues of comfort and total patient-centered care—a founding principle of specialist palliative care practice.⁹

As mentioned above, the interdisciplinary team model of care is the standard of care in hospice, which is one of the only settings in the United States where interdisciplinary teamwork is regulated.^10,¹¹ Functional interdisciplinary care can actually be measured through the Index of Interdisciplinary Collaboration. This instrument assesses teams based on a model of successful collaboration whose components are interdependence, newly created professional activities, flexibility, collective ownership of goals, and reflection on process.¹² Compared to multidisciplinary teams, interdisciplinary teams have been rated by members as higher in coherence, sense of responsibility, work climate, internal organization, and communication.¹³ A true interdisciplinary team illustrates that the function of a hand is far more than the sum of each individual digit.^3,¹⁴ Most interdisciplinary teams are comprised of members who belong primarily to that team, service, program, or division.

Cross-functional teams are a subset of interdisciplinary teams with potential relevance in pediatric palliative care. Arising from the business world out of organizational theory, cross-functional teams are assembled to create sets of skills for a particular purpose. Members cover each other’s weaknesses and maximize strengths as the team together takes responsibility for the well-being of a patient and family. In this way, resources are multiplied by the overlap of roles and a unique forum for problem-solving is developed.¹⁴ A pediatric palliative care program in a large children’s hospital discovered that families receiving care were being balance-billed when their insurance benefits did not cover palliative care services; worse yet, families were also receiving bills after their children had died. The program put together a cross-functional team, which included billing and finance personnel, a social worker, a parent liaison from the hospital’s parent advisory committee, a department administrator, and leadership from the clinical palliative care program, to tackle the issue. Over an 18-month period, the team worked through the logistical confines of the hospital’s accounting methods to create a system that satisfied everyone, especially the families. Some pediatric palliative care teams themselves can be described as cross-functional; in general, these are interdisciplinary teams at the core but also include members from other disciplines, departments, divisions, service lines, or the community, who have other job responsibilities and reporting structures but come together for a defined purpose or patient population.

Benefits for pediatric palliative care teams are many:

• This model facilitates new ways of seeing and creating different frameworks, which can be helpful with both clinical and ethical dilemmas inherent in pediatric palliative care.

• Cross-functional team flexibility enables faster and more broad-based responses to patients and families in crisis.

• All members from diverse disciplines are fundamental to complex assessment, providing a much broader perspective than a straightforward medical or medicine or nursing approach.^3,¹⁴

• Palliative care is a dynamic and uncertain environment.

From an organizational standpoint, cross-functional palliative care teams can enhance an organization’s innovative capacities to match the organization to the environment by bundling a large range of discipline-based skills and competencies in different ways, using different team members.¹⁵

The last team type is transdisciplinary. This model is gaining in popularity, though not as commonly in healthcare. The fundamental concept is one of role release in which there exist few seams among member functions. Roles and responsibilities are shared and often blurred.^3,¹⁴ Members of transdisciplinary teams have been heard to say, “Everyone on this team is a little bit nurse, a little bit social worker, a little bit physician. Whoever is in the clinical situation does what needs to be done since we all have a good basic knowledge of what our colleagues do.” While this approach has its advantages, problems with role definition can lead to significant impairments in team functioning in palliative care; such potential downsides will be discussed later in this chapter.

The distinction between cross-functional and transdisciplinary is subtle but clinically relevant. A transdisciplinary team is composed of members of multiple disciplines who all function together with overlapping roles in the care of each family enrolled in the program. Team members do what is requested or required when they are present with a patient or family, which may include blending or blurring their roles. In contrast, a cross-disciplinary team would be made up of distinct disciplines that retain areas of practice and expertise but have a defined angle to approach in patient and family care. Though the team functions as a whole, each patient’s plan of care is assessed through the lens of each discipline, so that each contributes specialized expertise to the overall plan of care. This approach enhances goal-directed or symptom-directed efficacy while preserving individual approach and minimizing blurring of boundaries.

Benefits and Challenges of Team-Based Palliative Care

While clear-cut advantages of high-functioning teams have not been demonstrated empirically in pediatric palliative care, the concept is central to the way in which most clinical work is performed, and its relevance cannot be overstated. Multiple potential and actual advantages of team-based care have been demonstrated for adults, particularly in palliative care, including:

• Higher quality of care due to improved goal setting and care delivery resulting from high-quality collaboration and the resultant synergy created by the collaborative relationship,^10,¹²

• System and/or the organization benefits from more comprehensive care, reduction of overall health care costs, reduced medical services, fewer doctor visits, more complete attention to co-morbidities and complexities of care, and increased client satisfaction,¹⁶^–¹⁸

• Team benefits from the development of joint initiatives not thought of individually, achievement of better care plans for holistic care, higher levels of productivity, and increased staff satisfaction ^,19

• Patient and family benefits from improved patient insight into illness,²⁰ self-reports of pain and non-pain symptoms,²¹ quality of life, satisfaction with overall treatment, communication,^22,²³ patient empowerment and education.¹⁶

Despite this lengthy list of benefits, some authors believe that the emphasis on the interdisciplinary team in palliative care is faulty. For example, Cott asserts that the value of team presupposes untested and perhaps unsustainable assumptions: that team members have shared understandings of norms, values, and roles; that the team functions in a cooperative, egalitarian, interdependent manner; and that the combined effects of shared, cooperative decision making are of greater benefit to the patient than the individual effects of the disciplines on their own.²⁴ At the very least, the as-yet untested benefits in pediatric palliative care necessitate that the team model be created, maintained, and sustained in the most productive and best way possible to maximize whatever potential benefits may be validated in actual practice.

Teams in palliative care have a number of specific challenges that are not faced as consistently by other healthcare teams. From the start members must form solid relationships with new colleagues to build an effective working group, acclimate to a field of work with a high emotional burden, and tolerate the significant uncertainty of practicing without defined standards compared to other medical fields.^4,¹³ The ever-increasing complexity of palliative medicine calls, in turn, for recognition of the increasing complexity and multiplicity of teams.²⁵ Teams must navigate more complex patient needs and work with more informed patients and families playing more significant roles in their own care—both a blessing and a challenge—in an environment in which ambiguity and uncertainty are the norms.

The context in which care is given is also increasing in complexity, requiring flexibility related to the diversity of location, culture, family structure, communities, privacy, and interconnectedness.²⁵ Practical conflicts exist as well. Team members must handle ever-changing communication patterns involving the use of alien technology and differences in terminology among disciplines.²⁶ Health-related priorities, targets, resources, and budgets are generally not set by palliative care teams, often resulting in scarcity of resources.²⁶ Increased access and equity, particularly as offered by community-based services, result in a larger service area with limited resources.⁴ In fact, despite the continual change occurring for patients and families, the availability of resources for care is generally either constant or shrinking.¹⁵

In addition to the challenges inherent in clinical work, team functioning itself may be in conflict with the core values of palliative care. For instance, the philosophy of palliative care may be at odds with the clarification of team roles and procedures,⁴ and the focus on team function may end up protecting team members rather than supporting patient and/or family needs.²⁶ Conflict may also occur between the democracy of palliative care teams and the traditional medical model.

Finally, the meteoric, successful rise of palliative care has created the potential that teams will fail to live up to unrealistic expectations. Often, palliative care teams are held up as the hallmark for interdisciplinary team functioning, creating more pressure under increased scrutiny.

Forming and Sustaining Teams: Recipes for Success and Failure

Despite these and other challenges, many pediatric palliative care teams are up and running, sustaining themselves and growing successfully. So how do functional, successful teams form? Many developmental models of team formation exist. One model includes five basic stages described by Lowe and Herranen, and it unites common themes:

1. Becoming acquainted, which represents a period of low group productivity but also minimal conflict,

2. Trial and error, during which team members test boundaries, seek allies, and engage in parallel play,

3. Collective indecision; without strong leadership and assumption of shared responsibility, the result is pseudoconsensus and unilateral action that leads to scapegoating,

4. If scapegoating occurs, generally an internal or external crisis happens, which forces teams to face their issues,

5. With strong leadership and committed team members, the final stage of resolution occurs, resulting in high individual and group productivity.²⁷

The effectiveness of any team collaboration can be affected by structural characteristics, which are influenced by organizational processes contributing to the team’s development and maintenance. Clearly, strong and visionary leadership is necessary for any team to succeed, and its importance cannot be emphasized enough. Box 16-1 describes some of the qualities of true team-centered leaders, which enhance the probability of developing and sustaining high-functioning teams. Further positive influences on team effectiveness comes from manageable caseloads, supportive and collaborative organizational culture, administrative support, professional autonomy, and time and/or space for collaboration.^6,⁷ The larger the team, and the more disciplines involved, the more time that team needs to achieve functionality and growth.⁷

In a survey of four nonprofit health care institutions, two of them pediatric, Proenca established that team empowerment is the mechanism through which team context and team atmosphere affect job satisfaction and organizational commitment.²⁸ This is helpful news for teams because it suggests that modifications of context and atmosphere that facilitate empowerment will lead to positive outcomes of improved satisfaction and organizational commitment. Said another way, direct strategies to empower team members can overcome a large number of variables that likely can’t be modified or eliminated in daily life on a palliative care team.

Oliver et al used a modified Index of Interdisciplinary Col-laboration and found that perceptions of interdisciplinary team collaboration can be measured, and that educational training in a specific discipline and clinical training do not create variance in perceptions of that collaboration. Instead, varied perceptions come from the interdisciplinary nature of the particular team.¹⁰ In other words, it might be thought that collaboration is affected by the varied disciplines or training backgrounds or cultures of the individual team members. But it appears as though the team structure, leadership, empowerment, and functionality influence how members perceive how well the team collaborates. This again is heartening news for interdisciplinary and/or cross-functional teams because it suggests that effort directed at team functioning will overcome differences in individual background and training, which might seem to affect collaboration negatively.

Team composition

The ideal makeup of a pediatric palliative care team will necessarily vary depending on site, goals, and scope of services, as well as on resources. Ideally, every team will be made up of medical; nursing; psychosocial, including social work, child life, and psychology; and spiritual and bereavement care; and will be able to access high-quality adjunct services such as pharmacology, nutrition, expressive therapy, rehabilitation, and education. When fully actualized, a pediatric palliative care team is like a tapestry in which different colors of threads are interwoven to produce a complete picture. At times one color—or one discipline—may be more prominent while others take a more background role. But the presence of each makes the tapestry complete when the weaving exists and comes together around a child and family’s goals of care (Fig. 16-2).

Fig. 16-2 A child’s team.

Many programs, however, do not have a complete interdisciplinary team, especially when starting. Provision of high-quality pediatric palliative care can be challenging in this scenario, particularly for the solo provider with limited time and resources. Yet it is still possible for children and families to receive excellent interdisciplinary care through collaboration.

In the hospital setting, professionals who have a particular interest in palliative care can work together as an ad hoc team in the care of an individual child and family. More formally, a variety of departments may work together to provide parts of positions that together make up the needed team. For example, neurology may provide 10 hours of a social worker, NICU may provide 10 hours of nursing, hematology/oncology may provide 20 hours of both nursing and social work, and chaplaincy may provide hours from their department. Perhaps a specific physician in each specialty is willing to be the lead palliative care person for their patient population. Hospital-based volunteer services may have individuals who want to be part of a palliative care team as well. This kind of team is made up of individuals who together can provide excellent interdisciplinary care. Though true with any team, it is especially essential to have regular meetings to ensure good communication and foster the development of the team when members come from multiple departments.

One example of this was seen in a children’s hospital in a small city with a new pediatric palliative care program. The program consisted of a part-time pediatric palliative care nurse, but no other disciplines were specifically designated to the team. The nurse knew that a few people in the hospital were very interested in palliative care and invited them to be on the pediatric palliative care advisory group. She looked for representation from chaplaincy, child life, social work, psychology, and physician groups. As she collaborated and built relationships, the group strategically planned the best way to fill the interdisciplinary needs of a palliative care team. They were able to negotiate parts of positions from a variety of departments. With program growth and demonstrated outcomes, more permanent positions were approved. Such a piecemeal approach can challenge cohesiveness, but with care, it can be done very successfully.

Creativity is essential when looking for palliative care team resources outside the hospital when a community-based team is not available. Certainly, area hospice and palliative care programs can be engaged in partnership with pediatric professionals to provide home-based care when available. Beyond existing community programs, providers can look for other professionals who are involved with the care of the child. These services may come from the county, school, religious community, or other private sources. Many children access county programs that provide social workers, physiotherapists, child development workers, counselors, and others involved in providing care for the child and family. Children on waiver or other support programs may have involved professionals who can be educated and trained in basic palliative care principles and practices. School-age children may be in close contact with the school nurse, counselor, social worker, and the teacher. With the permission of the parents, the palliative care provider or team can contact other caregivers, identified by the parents, and collaborate to enhance expert care within a palliative framework. County workers can help provide specific information from their disciplines, while teachers and counselors can assist adult hospice and palliative care providers to better understand the psychological needs of a child. School nurses can work with the team to ensure the child can attend school whenever possible. That may include working with the school to allow the school nurse to store the child’s morphine in the office or facilitating discussion on how to handle Do Not Resuscitate orders. If the family belongs to a religious community, their spiritual care needs may be met; beyond this, it is essential to find out if the religious leaders should be part of the team. In some groups they may be instrumental in the healthcare decision-making process and should be included as part of the extended palliative care team. Throughout the process, care providers must be attuned to each aspect of the child’s and family’s life so that this complex collaboration can be successful. It cannot be stressed enough that communication is essential to ensure everyone understands and supports the goals of care.

A basic understanding of palliative care concepts is essential for all team members. If this is not the case, then the plan of care can easily go wrong. Professionals who have always worked to cure or who are accustomed to practicing within a narrow discipline-based definition may need encouragement to focus on palliative care goals and the child’s and parents’ priorities. Consider the physiotherapist, whose goal for the child is to be in a stander for 1 hour three times a day; if the child is uncomfortable and progress is not the family’s goal, then the therapist will need to adjust treatment goals to align with the family’s goals for comfort. The child and family will benefit when every discipline understands the goals of care and works to align their plans to the overall palliative plan of care.

Palliative care staff can be instrumental in helping the extended team keep the focus on the family’s stated goals of care. In one rural community where a child had very rapid disease progression and did not have any community services, the school played a major role in his care. The palliative home care nurse coordinated with the school nurse, teacher, and social worker who were eager to do what they could to help. The church community also stepped in to provide support. They worked with the rest of the child’s expanded team to provide spiritual as well as practical support. The family practitioner provided medical oversight for symptom management, using the home-based expertise of the palliative care nurse in concert with phone support from the tertiary oncology center. The congregation provided help with yard work and extra attention for the siblings. This model of using community resources can work especially well for minority families who may not speak English or understand the dominant culture. Their cultural needs may be better served by collaborating with community members with whom the family most identifies.

Volunteers are an especially important part of the team for hospital- or community-based palliative care. They are an important link to the community and can extend the support that the team can provide. In addition to helping with office-based tasks, volunteers provide a number of services that others on the team cannot. This may include being the special friend for the sibling or reading a book to the child to provide a parent with time to take a nap. Careful screening, training, and follow-up are each key to ensure volunteers are prepared and supported in their work. There should be a professional contact person on the team as a point person for the volunteer to discuss questions and concerns. Clear guidelines of what their roles are in the home are essential for volunteers to maintain good boundaries.

Parents, as partners with the palliative care team, can play an important role. The child and family are the center of the unit of care, but are not truly members of the palliative care team (see Chapter 6). Nevertheless, parents and even patients themselves can and should play important roles. Mature patients, bereaved parents, or parents of chronically ill children, with appropriate training, can make excellent advisers to palliative care teams in terms of advocacy, clinical programming, and research initiatives. Parent and patient volunteers can take on team-based tasks such as assisting with bereavement outreach, memorial service planning, newsletter production and distribution, holiday or birthday and/or death day card writing. In addition, many hospitals and community agencies have mentor programs through which parents can be paired with others in similar circumstances to offer support and guidance. Resources such as the Institute for Family-Centered Care (www.familycenteredcare.org) provide excellent materials on training parent advocates to be effective members of the healthcare team.

Frameworks of Team Function and Dysfunction

The ways in which a palliative care team functions are influenced by a multitude of factors.

Based on purpose or mission, a team must have established goals or tasks and clearly defined objectives, and the strategies to achieve these, all of which need consensus and clarity.^5,²⁵

Interdisciplinary teams in particular need clearly defined internal and external role expectations. In practice, there is actually little congruence between the way a group of professionals defines its own roles and the way others define them.²⁷ Thus, because of the nature of the work, palliative care teams must delineate clear internal lines of responsibility and norms the unwritten rules governing the behavior of people in groups–before navigating the vague and changing environments in which they integrate.

Communication is perhaps the single most important factor in team success. Palliative care teams must establish defined communication patterns. At a minimum, this process should involve a clear definition of tasks and of responsibility and accountability for task completion.²⁵ Team members need accurate, common language for transmitting information and an agreed-upon philosophy of care, both of which incorporate mechanisms and capacity for team members to ascertain what others need to know to practice effectively.⁴

Other core concepts for functional teams include recognizing the specific personal contribution of every team member in their discipline, while respecting the same in others.²⁵ It is important to have a lack of hierarchy but a clear decision-making process. This allows for collaborative decision making while minimizing confusion about how things get decided. A culture that prioritizes autonomy, has realistic work expectations, and encourages high levels of personal feedback from colleagues as well as from patients and families²⁹ will strengthen the team. The successful team needs strong collaborative leadership that nurtures an atmosphere to cope with the specific challenges of palliative care. Factors particular to palliative care team success are procedures for evaluating effectiveness and quality of care, recognition of the contribution of patients in furthering professional understanding, and bereavement care of staff²⁵ (Box 16-2). Particularly in the challenging world of palliative care, team function and dysfunction come in many flavors and have been investigated by several authors. Some general observations about teams and categories of dysfunction in team based-care:

• Styles of decision making usually follow one of five patterns, in ascending order of functionality: default, unilateral, majority vote, consensus, or unanimity,²⁷

• Types of intra-team conflict can generally be separated into conflicts around task or relationship,

• Role stress is a frequent issue. New teams in particular face, three major role stressors: role ambiguity, role conflict, and role strain,^27,³⁰

• Poorly defined accountability is especially exemplified by poor performance feedback ^,33

• Lack of clear leadership designation

• Poor or maladaptive communication, including underground communication or team secrets, which destroy trust and openness;^3,³¹ the gatekeeper phenomenon wherein a member who is not the team leader becomes the unofficial spokesperson for a subgroup of the team, withholding information or sharing information that may not reflect all opinions within the group,³²

• Boundary violations may be rigid and/or blurred

• Issues for long-standing or well-established teams in which there is resistance to change or new ideas ^,3

• A quasi-matrix system of authority, versus a traditional line model, where lines of authority are not clearly drawn and employees have more than one manager with specific areas of authority that are divided along professional or service lines,³³

• Territoriality, usually stemming from lack of a common philosophy, language, and style among professions and services or from restricted contact among various busy professionals,⁴

• The formation of subgroups and alliances or other agendas distracting from the main mission, which may result in less connection to participation in what a service delivers or difficulty taking personal responsibility for the team’s overall quality of care ^.3

BOX 16-2 Characteristics of Effective Palliative Care Teams

• The whole is greater than the sum of the individual component parts

• Interdependent—all members succeed or fail together

• Stimulating, and spurs individual members to greater achievement

• Fun–members enjoy a sense of belonging and camaraderie

• Civilized and structured: members blend individual aspirations into group objectives as they learn to share and interact. Roles are clearly defined.

• Demand a certain conformity, but not uniformity

• Members share their vulnerabilities as well as their strengths

• Difficult conversations are conducted face-to-face

• Deal with disagreement and anger in a constructive manner

• Work with existing healthcare teams without overstepping the advisory role

• Allow flexible professional roles

• Share difficult decisions

• Recognize that personal exchange can lead to professional growth

• Provide mechanisms for formal review to improve future performance

Examining team health in pediatric palliative care

As is clear from the previous section, there are a multitude of frameworks in which to dissect the structure and function of interdisciplinary teams. In The Five Dysfunctions of a Team, Lencioni posits a helpful construct to discuss pediatric palliative care teams more specifically. Lencioni’s five dysfunctions build on each other in pyramid fashion. An absence of trust, created from an unwillingness to be vulnerable, creates fear of conflict, which results in veiled discussions and guarded comments. This environment generates lack of commitment, which progresses to avoidance of accountability resulting from lack of buy-in; and then to inattention to results, putting individual or divisional needs above those of the team. In contrast, truly cohesive teams trust one another, engage in unfiltered conflict, commit to decisions and action plans, hold each other accountable for delivering, and focus on the achievement of collective results.³⁴

The costs of dysfunction in interdisciplinary teams can be extremely high. In addition to ineffectiveness and team member dissatisfaction, poorly functioning teams impact the patients and families we serve. Patient reactions to team dysfunction can lead to splitting or increased dependency on team members. For example, during the collective indecision phase of team development, patients and/or their families may ask multiple staff members the same questions and get different answers, leading to more anxiety. Even more significantly, patient or family lack of confidence in their care team may increase patient symptomatology.²⁷ Ultimately, of course, unnoticed or uncorrected dysfunction can lead to an implosion that results in the total dissolution of even the most well-intentioned group of like-minded people. Similar to what can be seen with individual patients and families, this so-called demoralization syndrome of teams stems initially from poor leadership and unreasonable burdens, and results in absenteeism, apathy, resistance to change, and deep sadness. Untreated, it progresses to a fatal loss of vision or loss of belief that objectives are worth striving for or even achievable.²⁵

Viewed through the lens of Lencioni’s model, the following sections of this chapter review five common pitfalls of team function in more detail that can deleteriously affect interdisciplinary pediatric palliative care teams.

Lack of Commitment

Although most, if not all, providers of palliative care likely maintain shared values and a common commitment to the cause, perceptions around appropriate goals and strategies for accomplishing such goals may vary widely. When team goals are undefined, care providers may be uncertain of their professional role or lack direction regarding their personal contribution to the team. Such ambiguity may thereby impair their sense of overall commitment to their team. Poorly defined goals are equally problematic. For example, a newly formed team in a pediatric hospital may identify the expansion of clinical services as a primary goal. Yet expansion can occur through various pathways. Should the team focus their limited resources on collaborating with a specific medical service such as neurology, which treats a large percentage of children with life-threatening conditions, or would resources be better spent working with the families of children admitted to the pediatric intensive care unit? Should financial resources be spent on a part-time nurse practitioner or a full-time clinical social worker? Without well-defined goals, individual members of the team may become frustrated with what they perceive as substandard care or limited progress of the program as a whole.

In contrast, clearly defined goals assist in orienting team members to the collective purpose. Similarly, the individual responsibilities of each care provider should be delineated in order to clarify personal role and obligation to the larger team. Sense of commitment is fostered when team members believe that duties have been appropriately distributed and that all members are working hard for the greater good. When roles are not adequately delineated, diffusion of responsibility becomes more likely. Team members may blame others for lack of progress, leading to hostility and ill will. Chronic unresolved conflict or dissatisfaction may lead to personal detachment or fractioning within the team.

In addition to clear, realistic, well-defined goals, commitment to supportive and collaborative relationships is equally important to healthy team functioning. As noted by Papadatou, “While team goals orient our actions, supportive and collaborative relationships help us to achieve them.”³⁵ In fact, the two may be considered interdependent as the more supported we are by team members, the more likely we are to commit ourselves to work tasks and to the development of compassionate relationships. Thus committed care providers are dedicated to meaningful goals, rely upon each other in order to achieve them, and are mutually supported through the process. Four specific aspects of support that we seek and expect to receive from colleagues are informational support, instrumental support, emotional support, and support in meaning construction (Table 16-1). Each team values and encourages different aspects of support at different times. For mutual support to be effective, it must be timely and responsive to the specific needs and preferences of care providers, which vary from one team to another and at different times under different circumstances. Team functioning may be compromised when such support is unavailable or unresponsive to the needs of team members.

TABLE 16-1 Types of Support

Informational support	Involves the exchange of information about the people served and the team’s mode of operation; it comprises mutual feedback about and evaluation of individual or team performance with opportunities to expand one’s knowledge and skills.
Instrumental support	Involves helping each other with practical issues such as sharing the workload, and the coordination of efforts toward the achievement of specific tasks. Shared goals, role clarity, and trust in each other’s knowledge and skills enhance this form of support.
Emotional support	Involves opportunities for sharing personal feelings and thoughts in a safe environment in which one feels heard, understood, valued, and appreciated. Sometimes the presence of another colleague during stressful moments is all that is needed.
Support in meaning construction	Involves opportunities to reflect on and work through work-related experiences and invest individual and collective efforts with meaning. Care providers help each other understand their responses, correct distortions, and reframe situations in ways that make sense to them.

Adapted from Papadatou D. In the face of death: professionals who care for the dying and bereaved. New York, 2009, Springer Publishing.

For example, care providers who are committed only to their own work tasks in their effort to demonstrate their own competency may fail to value or develop genuine interest in other team members. Relationships may even be experienced as competitive or conflicted. Although such care providers may offer sufficient informational support, they may be unable to accept or supply emotional support to other team members when in need. If a mismatch exists between individual members and the team as a whole around areas of support that are highly regarded or considered essential, then team functioning may be negatively affected.

Other teams may be disrupted by limited instrumental support, such as when scarce financial resources require disparate allocation of job funding across individual team members. In such situations, team members may have similar task expectations yet are not equally compensated for the time provided to complete such tasks. Those individuals who receive less compensation for their time may be perceived as less committed to the team if they are less available to participate in activities or provide service to the team. Other times, disproportionate financial support may lead less-compensated team members to feel underappreciated or undervalued and, therefore, to feel less committed to the team as a whole.

Meaning-making support can be especially vital to palliative care teams and the absence of such support may degrade an individual’s commitment to providing care. For example, while offering bereavement services to a parent whose child had recently died, the team nurse practitioner felt especially burdened by the mother’s doubt around her decision to forgo a second stem cell transplant for her child. The mother had declined further curative efforts in order to allow the child more comfort yet, in the end, the child’s last days were spent in an inordinate amount of pain and suffering. Upon reflection, the nurse practitioner worried that she had unwittingly influenced the mother to make the wrong decision. However, a later discussion with a fellow team member served to remind her that the mother’s questioning was a normative feature of the grieving process. Without the opportunity to reframe her experience, the nurse practitioner may have been burdened by cognitive distortions that could negatively affect her commitment to working with other families.

Avoidance of Accountability and Conflict

Every PPC team needs to have a foundation of trust and openness among its members, wherein individuals can express their vulnerability with each other, disagree openly and remain respectful of one another. It is no surprise that team members who trust each other function effectively together to achieve their goals. This does not mean that they always agree with each other, but rather that there exists a basis of respect and openness that allows for expression of different views. Healthy discussion and effective resolution of conflict will enhance the level of trust and communication within the team.³⁴

Although this sounds simple, it demands an ongoing commitment of time and energy by each team member and the team as a whole to ensure this process. Often people may not want to take the time to work on team building, given the intensity and the needs of the children and families we serve. Frustrated team members may think or actually say, “This work is hard enough without having to deal with my team members’ dysfunction!” Unless individual team members deal directly with these issues and are open enough to accept responsibility for part of the dysfunction, they will be doing a disservice to the children and families they most want to help. If the team is not built on a solid foundation of trust and openness, it cannot serve those who need it most.

Few if any palliative care team members choose conflict over collaboration, yet conflict is a given part of the life of any team. However, the way in which the conflict is handled between individuals and within the team can either strengthen or damage the whole group. Not uncommonly, in a misguided effort to be collaborative, the actual heart of the conflict may not be discussed and the source never identified or verbalized. When this occurs, people often become frustrated as they desperately try but fail to communicate without dealing with the conflict.³⁴ This is the proverbial elephant in the room that palliative care clinicians are so skilled at helping families face. Under the guidance of strong leadership, teams must draw upon their individual and collective skills in this area in order to address difficult issues in conflict resolution. Some helpful interventions are focusing on learning more about others’ perspectives and using language that is open and less blaming. These strategies, explored in more detail later in this chapter, will go a long way in improving the functioning of team as a whole.³⁴

As a practical example, one large team that did not have a strong foundation of trust addressed this issue by making a commitment to address every conflict within 24 hours of occurrence in a direct, private and personal way. This was a tough choice as it was a change from the norm, but the team as a whole agreed to it. The decision resulted in many private face-to-face meetings of team members as they worked to address issues head on. For most team members it was an uncomfortable and difficult task. Yet, it resulted in an overall reduction of underground discord and improved team functioning. Importantly, the team also needed to revisit this process periodically, as conflict resolution is not a one-time accomplishment but rather an ongoing process.

Practical applications of conflict resolution, encouragement of open and respectful debate, and using collaborative communication are important aspects in developing and maintaining an effective team.³⁶ A well-functioning team should be able to discuss disagreements openly and accept that there are often different ways to solve a problem. This environment allows individuals to be accountable for their mistakes, to avoid shame or punishment, and to use these situations as learning experiences for the team as a whole. An attitude of open discussion when things do not go well should be encouraged and supported both in word and deed. In one team interaction a clinician was offended by what was meant as an innocent action by another team member. She addressed this directly in the weekly interdisciplinary team meeting, and both clinicians shared their view of what had happened. Because this was not the way the team had operated previously, the process was somewhat uncomfortable for the individuals and the team as a whole. However, it was a growth experience for all. It did resolve the issue, and provided an example of how conflicts can be dealt with in a healthy way.