The Team

Published on 09/04/2015 by admin

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6 The Team

Danai Papadatou, Myra Bluebond-Langner, Ann Goldman

It takes a village to raise a child.

—Igbo Proverb ¹

This well-known Igbo proverb highlights the key role played by the community in the healthy development of its members. Such a community takes an active role in the transmission of its beliefs, values, priorities, and practices. It provides the conditions that help infants, toddlers, children, and adolescents develop into responsible, emotionally healthy adults who form respectful and collaborative relationships with others, cope with adversities, and are mindful of the well-being of their community. The quality of life of an individual within such a society is directly related to the quality of life of the entire community.

In the case of children with life-threatening illness and their families one could paraphrase, “It takes a team to care for a child with a life-threatening illness.” Such a team relies on the close collaboration of its members to address the needs of the ill child as well as those who are part of the child’s larger network, including parents, grandparents, siblings, peers, and teachers. For many of these significant people in the ill child’s life, this is the first time they are confronted with the possibility, and in some cases the eventuality, of a child’s death.

The team’s role is to accompany the child and family during the course of the illness and through bereavement. In so doing the team pursues an active and comprehensive approach to care, with the goal of helping the child and family cope with the challenges of the disease and treatment. The team acts to alleviate the patient’s physical discomfort and endeavors to temper the suffering caused by the uncertainties of the prognosis and outcomes of treatment. The team works with the child and family in their quest for a life worth living, that is, a life characterized by quality and meaning regardless of whether or not the child lives. When a child dies, the team offers or recommends services to those who had been involved with the child’s life that are aimed at facilitating their adjustment to the death.

In this chapter we focus on the development and structure of teams, a major feature of the care that is provided to children with life-threatening illnesses and their families. We do so with the caveat that the literature on teamwork in pediatric palliative care is rather limited.^2,³ Conspicuously absent are systematic empirical studies of how teams develop and operate and their effects on team members, patients, families, institutions, and communities.^4,⁵ The literature that does exist is descriptive and of varying depth and breadth.⁴ Articles that deal with teams focus on the educational background of professionals who make up the team, their roles, and responsibilities.⁶ With few exceptions little attention is given to team development, team functioning, and team support in the face of serious illness and death.⁷^–¹⁰ The purpose of this chapter is to draw attention to these issues in order to enhance our understanding of the team’s role in the care of children with life-threatening illnesses and determine what is needed to ensure the highest quality of care. Also, we hope to point the way toward further research and training.

Our discussion and recommendations are rooted in a relationship-centered approach that focuses on relationships among children, adolescents, and families who receive care services, and professionals who offer them. Such an approach recognizes the reciprocal influence between children and families on the one hand, and professionals, teams, and organizations on the other. These professionals, affected by their interactions, seek creative ways to contain, reduce, or transform suffering, and in so doing enhance the quality of care for a child who may never grow into adulthood.^9,^11,¹² In other words, the relationship-centered approach is concerned with the establishment of relations that are potentially enriching, and are rewarding for all involved. Achievement of this goal requires understanding not only the patient’s and family’s subjective views and experiences so as to provide them with appropriate care, but also the professionals’ and team’s subjectivity, which shapes interactions with children and parents, and affects the quality of services.

This view perceives care-giving as a social affair that is determined by the relations among care seekers and care providers. All of them are inevitably affected by the serious illness and death of the child, and as a result, their relationships are impacted by feelings that must be recognized and addressed as they affect the process and quality of care.

Team Development

A dynamic, non-linear process

For a group of people to become a team they must share a common purpose, be strongly committed to the achievement of specific tasks, and value teamwork through which they expect to accomplish more by cooperating. Setting a clear task that is owned by each member and sharing outcomes are central to the transition from a group to a team.¹³

Another characteristic that distinguishes groups from teams is their size and leadership.¹³ While groups vary in size, teams contain no more than a few members who share leadership in clinical practice, although at an administrative level they are led by a senior member. Depending on a child’s condition and family’s situation, for example, different professionals may take the lead at any time and make a special contribution in order to achieve the team’s goal and tasks. Regardless of whether the team uses a manager to facilitate the coordination of actions or it chooses to be self-managed, the importance is that responsibility for outcomes be shared. By contrast, in a group, leadership is assigned to one person who imposes his or her leadership style that usually remains unchanged despite the changing focus or work activity.¹⁴

We view teams as dynamic systems that have the potential to evolve, grow, and function with increasing degrees of openness, communication, and collaboration among care providers. A team’s development is not linear. It is characterized by cycles of forward vs. regressive movement, as well as by periods of stability, disorganization, being stuck, and growth. What determines a team’s level of development is related to the ability of its members to establish and maintain collaborations that ensure quality care and are enriching to both families and team members.

Among the available models for understanding team development, and especially applicable to palliative care, are those proposed by Papadatou and Morasz.^9,¹⁵ They take the position that over the course of development, team members experience periods of co-existence, mutual acknowledgment and parallel collaboration, and of collaborative alliance with concomitant changes in disciplinary boundaries^7,^9,^15,¹⁶ (Fig. 6-1).

Fig. 6-1 Dynamics of Team Development.

Redrawn from Papadatou, D. In the Face of Death: Professionals Who Care for the Dying and the Bereaved, New York, Springer Publishing; 2009.)

When functioning in the mode of co-existence, professionals work more as a group than as a team. Goals are generally shared, specific roles are identified, and tasks are divided among care providers who provide services that are fragmented and compartmentalized. Not infrequently a predetermined package of medical, nursing, psychological, social, and spiritual services is offered to families of seriously ill children, who are then introduced or referred to different experts. Transactions among professionals tend to be rigid and communication limited. They rarely report to their colleagues about the nature and outcomes of their intervention or observations—information that could be useful to others in their interactions with the families. Each care provider is focused on his or her field of expertise and communicates achievements through brief reports that are usually included in the patient’s file.

In the mode of parallel collaboration, care providers begin to work as a team. They acknowledge each other’s knowledge and skills, and work in parallel yet independent ways toward shared goals and tasks. Transactions are richer and communication is more open, but it remains superficial. The team members accomplish their job, but lack the ability to integrate the richness of existing services into an explanatory and comprehensive framework.

In parallel collaboration, teamwork is often multidisciplinary and team members do not necessarily adapt their roles and responsibilities to those of other professionals. Information is usually communicated via the patient’s file or in staff meetings where each provider reports his or her work that is added rather than integrated into the plan of care that is offered to a child and family.

In the mode of collaborative alliance, emphasis is placed on effective and open communication among professionals who plan, offer, and evaluate their collective services. Information circulates and team members learn from each other, broaden their horizons of understanding, and critically review their work by acknowledging their strengths and limitations. A reflective process is central to their collaboration and evaluation is periodic both with regard to the outcomes as well as to the process by which services are provided and goals are achieved.

Teamwork now becomes interdisciplinary in nature and is based upon the close collaboration among professionals who set clear goals, decide upon a course of action, and assume the responsibility of care as a team—not as individuals. Team members are characterized by a high degree of interconnectedness and a sense of belonging. The identity of the team is set above their personal identities. Mutual support becomes essential in the pursuit of collective goals and in coping with challenges and difficulties that are inherent in care. Leadership, responsibility, and accountability in interdisciplinary teams are usually shared.

In well-balanced and experienced teams, teamwork often takes the form of a transdisciplinary alliance. Care providers train one another in some domains of their expertise to broaden the horizon of knowledge and skills and become competent in assessing and responding to a wide range of needs without necessarily duplicating their services. This is particularly important when caring for children who are terminally ill and whose families choose to limit the number of relationships with professionals, and focus on the dying child and themselves.

For a collaborative alliance to develop, care providers must spend time working together, sharing experiences, exploring different points of views, and developing a common language that does not exclude any member. Interdisciplinary and transdisciplinary teamwork require interdependent collaboration and are possible only if the team functions as an open system that makes use of relevant information. Relevant information is any information that helps members to understand how they operate as a system, how they manage suffering and adversities, and how they make use of their resources.^9,¹⁷ Such information helps team members learn from experience, consider alternative ideas and coping patterns, embrace new initiatives, take risks, implement changes, and grow as a team. Unless there is opportunity to share information about what is happening in the day-to-day work, how things are accomplished, and how professionals think, feel and behave, team members cannot be in control of the quality of services they provide, and the system cannot be self-correcting.¹⁸ Such openness is not simply limited to the disclosure and airing of feelings and thoughts, but demands a reflective openness that enables team members to challenge their own and others’ thinking, suspend a sense of certainty, and share experiences with a receptiveness to having them challenged or changed.^16,¹⁹

In such a team, care providers derive satisfaction from both the provision of services that are helpful and meaningful to patients and families, as well as from their collaborations with one another in the pursuit of a common purpose.

Organizational culture and context

A team’s development is not solely determined by its members.^9,²⁰ The social and organizational context in which it provides services has a major impact on how it develops and functions. For example, in some places pediatric palliative care services are delivered by teams in the community through home, respite, or hospice programs.²¹^–²⁴ In others, they are introduced in the hospital and offer consultation services to professionals, families, and other teams.^4,²⁵ In many countries that lack resources or are reluctant to acknowledge the needs of dying children and grieving families, palliative care teams are either non-existent or encounter major social, institutional, and legal obstacles in the provision of interdisciplinary services. Even in resource-rich countries that acknowledge the needs of dying children and grieving families, provision of interdisciplinary and palliative care services may be hampered by the country’s healthcare system.

The value system of a given social context affects the culture of the organization or service to which a team belongs, which, in turn, influences the services it provides. The organization’s culture plays a major role in how seriously ill children are perceived, how they are cared for, and how they are integrated into the organization or service. Organizational culture also has an impact on how suffering is regulated, hope is instilled, and time is managed when a child’s life is threatened.

Some organizations that assume a cure-oriented approach tend to dismiss or downplay the role of palliative care services, and instead adopt a protective approach by concealing the possibility of death from the child and occasionally from parents. Other organizations strive to integrate curative, life-prolonging and palliative care services and create a space for mutual collaborations among several teams and family members who are actively involved in the decision-making process.

Hence, the culture of an organization or service may promote or hinder different forms of teamwork, depending on its philosophy of care, its values, goals, and priorities. This does not mean that teams do not shape their own course of development, rather, some are helped and supported through this process, while others have to work harder to fully develop and pioneer their approach through the healthcare system.

Teams at Work

Indicators of team development, functionality, and effectiveness

We take the position that teams are active and dynamic systems with potential to change, develop, and grow. Teams, like the individuals who compose them, are not passive agents. Teams, like their members, are active agents who both shape and are shaped by their individual and collective responses to life-threatening illnesses, loss, suffering, and those whom they encounter in their work. Teams, like their members, are both subject to and react to internal and external stressors associated with the care of seriously ill patients and their families. Affected by the wider social and organizational context of work, team members, consciously or unconsciously, decide how to operate and collaborate with each other in order to meet the challenges of life-and-death situations. The team’s development, functionality and effectiveness are reflected in the patterns by which its members manage team boundaries and team operations as well as suffering and time.⁹

Experience and Management of Time

When a child’s life is threatened by a serious condition, time is perceived and experienced in unique ways by families and by care providers.²⁶ A team that paces its work encourages children and their families not only to reflect on and work through their grief, but also to live a life that is meaningful to them. Such a team also takes the time to process work-related experiences that evoke anxiety in team members. The team learns from the past, integrates knowledge into the present practice, and strives toward future goals that aim at increasing the quality of the services it provides. In contrast, teams that avoid difficult subjects and experiences stagnate. Those teams become unable to take action, make decisions, and effect interventions. They delve into apathy and inertia. They become frozen in time. Some teams act as if time could be eliminated. They do too much; perhaps to avoid difficult issues such as case overload, loss, or death. Time is experienced as event-full. Work is driven by events or crises. An ongoing over-agitation prevents the team from slowing down in order to process its experiences and use relevant information for learning, changing, and growing.^9,¹⁷

Teams and Families

A partnership in care

Most parents want to assume a central and active role in the care of their ill child. They acquire in-depth knowledge of the child’s condition and treatments, and develop appropriate skills in order to meet their complex needs.^27,²⁸ Parents of seriously ill children are faced with challenges and crises that are different from anything they have ever encountered in their lives.²⁷ In their desire to be effective in this new parenting role, they have to interact with the professionals who can help them develop strategies and skills in order to manage present situations and anticipate future needs in both their sick and healthy children.^27,²⁸ This close involvement often leads to the erroneous assumption that parents are members of the team. Contrary to some clinicians who have written about teams and palliative care, we take the position that parents and patients are not members of the team.^8,²⁹

To speak of a patient or parent as a member of the team works best at a metaphorical level, and even then it is misleading. No parent or child can ever be a member of a multidisciplinary or interdisciplinary team in any real sense. They do not share the team’s history, its achievements and failures, its traumas and successes, or its trajectory through time. Nor do they necessarily have the same goals, values, and priorities that a team holds for itself and the families it serves. And not insignificantly, to view parents and patients as members of the team is to demean the unique relationship not only between ill children and their parents, but also between teams and those they serve.

A more appropriate way of conceptualizing the patient and parents’ place with and around the team is to consider that all share a symbolic space in which care is offered and received. This space belongs neither to the family nor to the team, but to their unique relationship.

It is hoped the relationship develops into a partnership. As partners, professionals and families define goals of care, which may change over the course of the illness, and rely upon each other in order to achieve them. While team members assume the responsibility of providing information, guidance, advice, and specialized care, family members are responsible for participating in decisions and communicating their needs, concerns, values, and preferences. The family’s responsibility should be taken into consideration when developing a care plan.

In this partnership, children’s views, concerns, and desires must be considered and approached with sensitivity and skill. This requires awareness of the differences in the ways children express both directly and symbolically, their physical, psychosocial and spiritual needs, preferences, and concerns; children and parents’ positions in the family; the rights, duties, and obligations each has to the other; and the impact of team’s actions on the patient’s and parents’ futures.³⁰

Teams that are well-balanced and well-developed function as open systems. They have flexible yet stable boundaries that enable families of seriously ill children to move in and out, according to need. Team members are not threatened by becoming overwhelmed by the family’s grief, confusion, disorganization, despair, or suffering. They are able to contain these experiences. They assist parents and children in acknowledging, expressing, and accepting their feelings as well as in assimilating their experiences, and adjusting to a reality that is often filled with challenges, uncertainty, and surprises. They accompany families in their trajectory through the child’s illness, cure, or death and in some instances maintain enduring bonds throughout the long period of bereavement.

Teams that experience difficulties with various aspects of boundary maintenance, goal setting, or time management are more likely to establish enmeshed or avoidant relationships with the patient and family.⁹ An enmeshed relationship develops when both the team and the family are unable to contain suffering, as well as the threat or reality of death. They become one, and remain undifferentiated, sometimes even after the child’s cure or death. For example, a team may need families that adore and glorify it, while at the same time some families need the team to maintain the memory of their deceased child to avoid moving on with life. An avoidant relationship between a team and a family, on the other hand, transforms their partnership into a strictly bureaucratic affair, a consumer-provider business that aims to manage practical issues without addressing the emotional and spiritual aspects of living with a life-threatening illness. Avoidant or enmeshed relationships are often reflective of the team’s and family’s inability to effectively manage the challenges of living with or dying from a life-threatening illness.

Teams Working Together

Principles, practices and particular challenges

It is common for pediatric palliative care teams to collaborate with a range of other professionals and teams. These include teams who specialize in specific disease-directed intervention (such as cystic fibrosis team, oncology team, neuro-muscular team), those that perform organ transplantations, or critical care interventions, and also those involved in day-to-day care such as home care teams, community care teams, hospice and educational teams. Palliative care teams also work closely with mental health and bereavement specialists who provide counseling services to family members. These parallel collaborations with other professionals, teams, organizations and services are vital to pediatric palliative care, however they require good communication, planning, mutual respect, and an approach that has been described by Payne as “open teamwork,” discussed below.³¹

Although all of these teams may recognize that other teams are also necessary for meeting the complex needs of children with life-threatening illnesses and their families, the particular problems that each addresses and the roles that each assumes may overlap. Exactly who delivers which aspects of care may also vary over the course of the child’s illness. For example, the oncology team may include in their domain issues of pain and symptom control as well as the child’s and family’s social and emotional needs during treatment with curative intent. However, as the disease progresses and the possibility of death emerges, the oncology team may see the responsibility for pain and symptom control as well as meeting the social and emotional needs of the child and family as falling more within the purview of the palliative care team. The child and parents may not perceive or desire this dichotomy at all, and want the services that each team offers to continue simultaneously.^28,³² Hence, it is essential that all teams involved in the care of these children and families be committed to an agreed-philosophy, which also acknowledges the families’ choices. Often families’ preferences are for an approach that integrates disease-directed care along with treatment of symptom-directed and supportive care.^28,^33,³⁴

For children with life-threatening illnesses and their parents the possibility of recurrence, further deterioration, and death are never far from their thoughts. These thoughts often emerge at those times when critical decisions need to be made about further disease-directed care and treatment. The challenge is intensified not only by the nature of the decisions to be made, but also by the variety of people who are involved and affected by such decisions. Teams have a shared responsibility in guiding patients and families through the decision-making process.

Like families, all teams caring for children with life-threatening illnesses are confronted with the possibility of the children dying. While disease-directed teams may spend more of their energy against death, it would be wrong for these teams to proceed as if the possibility were not an eventuality for many of the patients they treat. Similarly, while palliative care teams accept childhood mortality as inevitable in some cases, and acknowledge their limitations in reversing a terminal disease, they cannot proceed as if battling the disease is not present in the minds of some team members, other teams they work with, or the patients and families. All must resist declarations such as “Things may get better tomorrow,” or “There is nothing we can do.” Instead, teams need to work with families to contain a suffering that is inevitable when life is seriously threatened and death becomes imminent, to address their needs and concerns during the most stressful period of their lives and to accept the reality before them.⁹

While the alleviation of suffering remains a priority, it can never be eradicated. At diagnosis, at each relapse of the disease, with each sign of physical deterioration, and particularly during the terminal phase, the family experiences a grieving process that is intense and often chronic.³⁵ All teams who work with these families must acknowledge that suffering cannot be fixed with quick solutions and pre-determined interventions. Patients and families must be assisted in coping with their losses and grief, and in building resources and resilience that will enable them to live through the disease as well as after the child’s death.

The Team’s Ability to Function with Competence

All teams confront a number of challenges in the uncertainty and grief that mark the experiences of the children and families. Teams mobilize various patterns to cope with the anxiety and suffering these realities evoke. Functional patterns are most likely to occur when three basic conditions are present. These are a commitment to clearly define goals and tasks and to a team member’s co-workers, a holding environment for children, adolescents, families, and care providers, and open teamwork through interdisciplinary collaborations.⁹

Commitment

Working in a field that causes increased distress requires a high degree of commitment from care providers who perceive their services to seriously ill children and families as meaningful and valuable. These professionals must recognize both the possibilities as well as the limitations of science in the treatment of life-threatening diseases, and facilitate conditions that promote quality of life. Their commitment in this field of work has two components: a commitment to a philosophy of care with clear, realistic, and well-defined goals and tasks, and a commitment to co-workers and to the team.

These goals and tasks promote the welfare and quality of life of children, adolescents, families, and of people who are significant to them. They help delineate the team members’ roles, responsibilities, and methods by which to achieve them. When goals and tasks are vague or conflicting, professionals are less likely to be committed to them and tend to assume responsibilities that are off-task or transgress role boundaries.

One of the challenges in caring for children with life-threatening illnesses is that teams strive to achieve ideal or unrealistic goals of excellence.³⁶ Realistic goals acknowledge the limitations of what care providers and teams can offer. For example, sometimes death cannot be avoided, nor life prolonged. At times, despite the best efforts of all involved, the dying trajectory is painful. There are also times when death occurs under traumatic conditions or the impending reality of death is not being dealt with by the family. Even though it is crucial for a team to work toward ensuring a dignified life for the entire family, and a dignified death for the patient, in reality there is only one thing that care providers can promise: the availability of a relationship. In that relationship, they will remain present, available, and able to introduce continuity in the midst of loss, separation, and suffering.

A commitment to co-workers and to the team is necessary to achieve the desired goals and to form an ethos of collaboration and of mutual support among team members. Professionals often experience grief and suffering while working with children with life-threatening illnesses. Acknowledging the professionals’ pain, and doing something about it, implies the sharing of personal experiences among team members who assume the responsibility to care for themselves as well as for each other. When committed to co-workers, they display care and concern through holding behaviors and mutual support.^9,³⁶^–³⁹

Holding behaviors involve acts of care, kindness, and support. Examples include listening to a colleague’s experiences and pain, offering feedback instead of advice and therapy, or standing by a co-worker during distressing times. Such behaviors are essential in establishing a culture of mutual support. Mutual support is marked by:^9,³⁷

• Informational support: the exchange of information about patients and families, as well as about the team’s operations through feedback that is conducive to quality care, change, or adaptation,

• Practical support: the provision of practical advice, help, or assistance in the process of completing specific tasks,

• Emotional support: the establishment of opportunities for sharing personal feelings and thoughts in a safe environment where team members feel heard, understood, valued, and appreciated,

• Support in the construction of meaning: the provision of opportunities for reflection and processing of work-related experiences so as to attribute meaning and integrate them into the team’s history.

It is important to note that while all types of mutual support are essential, the form that the support takes must be responsive to the needs and preferences of care providers, which vary at different times. Mutual support has been found to be a factor that determines professionals’ degree of job satisfaction.⁴⁰^–⁴² Studies indicate that one of the primary factors that contributes to professional burnout and turnover is not the team’s confrontation with multiple child deaths, however distressing, but rather the team’s inability to support its members.⁴⁰^–⁴² Committed care providers are devoted to meaningful goals and tasks, and rely upon one another to achieve the goals while providing mutual support through the process of care giving.

Holding environment

The concept of holding environment was first proposed by Donald Winnicott, an English pediatrician and psychoanalyst who described the significant role played by parents in providing their infant with effective care, which contributes to the child’s psychosocial development.⁴³ Parents create an environment with safe boundaries that provides the infant with a sense of protection from the external world. In this environment parents cultivate a sense of order, continuity, and predictability that eventually helps the child to move from the safety of the parental relationship to the external world, which is gradually assimilated and to which the child adjusts.

In a parallel way, the team cultivates in families a sense of safety, order, predictability, and continuity, all of which are critical in times of crisis, ambiguity, uncertainty, and loss. However, such a team must also provide its members with a similar environment by creating a safe organizational space in which stresses, conflicts, suffering, and hopes associated with the challenges of caring for children with life-threatening illnesses can be worked out. This is important, because professionals can more effectively hold children and families through a serious illness when they are themselves held by their team and organization.⁴⁴

Repeated encounters with death can deplete a team’s resources and leave professionals alone to manage their pain and suffering.^39,⁴² When a holding environment is in place, care providers can feel safely overwhelmed by experiences, acknowledge, and accept their suffering as natural, and lean temporarily upon others who understand, validate their feelings, and have faith in their abilities to manage work challenges. In a paradoxical way, being securely attached and held by others enables team members to be self-reliant.³⁸ Intra-team relationships are characterized by mature dependence, and are marked by a collective healthy respect for autonomy and for relatedness.³⁹

A holding environment does not disempower care providers by overprotecting them, nor does it excuse their shortcomings. Instead, it provides a shelter in which they can retreat when they feel distressed, anxious, angry, sad, or frightened and offers a secure base from which they can work through their experiences and move toward, rather than away from difficulties and anxiety-provoking situations.

A holding environment fulfils five important functions for team members:⁹

A sense of safety creates boundaries that protect team members from destructive interferences from outside sources such as organizational, bureaucratic, and financial restrictions, or from intra-team sources including gossip or misapplied blame. In a safe environment, care providers feel free to express feelings, thoughts, frustrations, and concerns, without the fear of being judged or criticized.

The containment of experiences is an ability to empathically understand and hold within experiences that are painful or threatening without dismissing, repressing, masking, distorting, or dividing them into parts. Rather than moving away from distressing feelings and experiences, the team moves toward them and openly addresses the anxiety, pain, or distress.

The elaboration of experiences involves exploring and assimilating difficult experiences, losses, and frustrations. It prevents immobilization, especially in situations that are traumatic or cause increased anxiety. It requires circulating information among team members who explore the underlying dynamics of a given situation, and use this information to develop as individuals and as a team. Elaboration helps them adopt alternative perspectives in an anxiety-provoking situation, reframe painful events, reconstruct meaningful narratives, and develop a better understanding of self, others, and of the team.

The regulation of distress and transformation of suffering provide team members with opportunities to pace their work, prioritize tasks and minimize chaos, confusion, and distress. The goal is not to eliminate the stressors that are inherent in caring for children with life-threatening illnesses, but rather to manage them, and transform the inevitable suffering caused by loss and dying in meaningful ways. In this way the team builds upon its resources and develops its resilience.

Fostering interconnectedness, interdependence and a sense of belonging prevents care providers from feeling alone, and teach them to hold others while being held by them. Mutual respect and shared responsibility are at the core of effective collaborations, which cultivate interdependence and promote autonomy.

The development of a holding environment always contains a risk for the team: to be directly confronted with the fear, anxiety, despair, powerlessness, and other aspects of personal and collective suffering elicited by uncertainty, loss, and death, which are often perceived as too threatening. Such confrontation, although painful, is necessary because it allows experiences to be processed and integrated into the team’s story, and enhances a forward movement. However, there are teams that are not willing to take this risk and sabotage every conscious effort toward building a holding environment by preventing members from reflecting and elaborating difficult experiences or distressing emotions. They reinforce a culture of invulnerability and omnipotence that compromises the team’s competence. While a holding environment allows the emergence of pain, it also serves as an antidote to the distress and suffering that is associated with the care of seriously ill children.

Interdisciplinary collaboration and open teamwork

Competence is reflected in the team’s capacity to promote interdisciplinary collaboration among professionals with different expertise, who do not simply co-exist or juxtapose their services but integrate them into a comprehensive framework of care. Such integration is at the core of a relationship-centered approach that responds, in appropriate ways, to the needs of a network of significant people who affect, and are affected by, the life of a seriously ill child.

Integration of services into a comprehensive framework requires open teamwork. The team develops relations and collaborations with other professionals, teams, organizations, or services within the larger organization or community. The team maintains permeable yet flexible boundaries, thereby allowing the circulation of information within and beyond its boundaries. Open teamwork is facilitated when the team provides a secure base for its members, who temporarily leave their base to form coalitions with different groups and teams, which are subsequently drawn into the team. This process helps the team respond in a comprehensive way to the multiple and complex physical, psychosocial, and spiritual needs of children and families, which emerge over the course of the illness in various settings. Open teamwork is also vital when the team must facilitate the transition of patient care from pediatric experts to adult experts—a consequence of the number of children diagnosed with life-threatening illnesses in childhood who live well into adulthood.

Overall, open teamwork promotes initiatives and developments, and integrates different approaches and services into a plan of care that benefits the entire family as well as the individuals who are significant to them. Another positive outcome of open teamwork is that it enables care providers to see how others perceive their services, and aids in assessing the impact they have upon a community by realizing what society gains from their contribution.

Assessing the Team’s Ability to Function with Competence

Teams are systems that are constantly changing and evolving. Acknowledging that their competence is enhanced by working conditions that promote commitment, a holding environment and open teamwork, can help professionals determine which among these conditions are well-developed and which require the team’s attention and further enhancement. Ideally, the development of all three conditions form an equilateral triangle with a base representing commitment to a philosophy of care, to clearly defined goals and tasks, and to each other. According to Ketchum and Trist, “commitment to work is central to people’s lives.”⁴⁵

The more solid the commitment, the more likely team members are to trust each other in creating a holding environment, which can contain their experiences and emotions, and the more willing they are to take risks and collaborate with other professionals and teams for the benefit of their patients. In a parallel way, the more reliable a holding environment is in providing team members with a sense of safety, order, predictability, and continuity in times of distress, then the more committed they remain to shared goals and co-workers. Similarly, the more open care providers are to interdisciplinary collaborations within and beyond the team, the more likely they are to become enriched, to grow and value their work that further reinforces their commitment to their job and team.

It becomes obvious that the described conditions are closely interrelated, and that the development of one enhances the development of the others (Fig. 6-2, A).

Fig. 6-2 A, Working conditions of a team that functions with competence. (Adapted from Papadatou D. In the Face of Death: Professionals Who Care for the Dying and the Bereaved, New York, NY: Springer Publishing 2009.) B, Working Conditions of a Team That Functions Without Full Competence. C, Second Example of Working Conditions of a Team That Functions Without Full Competence.

The following figures represent difficulties experienced by two teams in developing work conditions that ensure competence. In one pediatric palliative care team (Fig. 6-2, B), the professionals are committed to well-defined goals and tasks, and are supported in a holding environment in which they feel relatively secure to share cases and talk openly about their emotional responses, misgivings, or mistakes. Rather than going through suffering alone, team members draw on the experience and feedback of their colleagues. However, in the team described here, there is a gap between the need for nurturing and mutual support and the existing holding environment which, although in place, is not fully developed. As a result, team members engage in limited risk-taking because they feel uncertain that their team will hold them in times of high distress or crisis. The shorter line of open teamwork reflects the team’s tendency to avoid or restrict collaborations with other professionals in the larger organization and community. This affects families, who are deprived of valuable services, and care providers, who rely solely on their resources, with both becoming secluded into a cocoon-like environment. While this environment provides them with a relative sense of safety and protection, it concurrently marginalizes them from the rest of society.

Fig. 6-2, C, illustrates the working conditions of another pediatric care team, which remains too open and too permeable to collaborations with other professionals and teams without securing the boundaries of a holding environment, as indicated by the dotted line. This hampers the team’s ability to process experiences, frustrations, conflicts, and emotions resulting from its members’ interactions with others. Information that goes out from the team and information that is introduced into it is not used effectively to benefit families and team members. If team goals, tasks, and practices are not reviewed, enhanced, or changed, commitment to them, although strong, remains rigid. Concurrently, commitment to colleagues and co-workers is circumstantial and depends from the nature of collaborations that develop within or outside the team, at a given time.

The internal space of the triangles in Figs. 6-2, B, and 6-2, C, is limited by comparison to the space in Fig. 6-2, A, and graphically represents the limited opportunities of these teams to develop and use their resources in order to develop their competence.