Team Relationships

Published on 09/04/2015 by admin

Filed under Hematology, Oncology and Palliative Medicine

Last modified 09/04/2015

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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.