Working across boundaries: Creating effective transdisciplinary pathways for compassionate care

1. Working across boundaries: Creating effective transdisciplinary pathways for compassionate care Holly Nelson-Becker, Brunel University London holly.nelson-becker@brunel.ac.uk Te Arai Seminar 6th August 2019

2. Acknowledgements • Coleman Palliative Medicine Training grant, material developed in conjunction with Stacie Levine, MD, University of Chicago

3. The Image

4. The message • Interdisciplinary work is like being at an aquarium with many windows: • There is a lot happening at once, • Some things are in the shadows; • There are usually different levels offering different perspectives; • and • The viewer herself/himself is able to “see” or perceive some things better than others. . . . • because of individual characteristics, predisposition/history, and in this case, profession • So, even people standing along one line will have a different experience • It is sometimes challenging to align those perspectives and see them as gift

5. Coleman Fellows represented 27 health systems in Chicago region • Led by physicians • Stacie Levine (Univ of Chicago) & Sean O’Mahoney (Rush University) • Phase 1 (2013-2015) • 35 Fellows: • APNs (23) • MDs (12) • Phase 2 (2015 – 2017) • 29 Fellows: • APNs (12) • Social Workers (7) • Chaplains (6) • MDs (3) • PA (1)

6. Coleman Program Components • 1) Attend workshops • 2-day interdisciplinary workshops, held twice a year. • 3 evening seminars each year, discipline specific • 2) Complete pre and post tests, surveys • 3) Complete 20 hours of self-directed, e-learning curriculum • 4) Submit Intent to Change contract describing a practice improvement project (PIP) • 5) Initiate and schedule monthly meetings with a program mentor • 6) Complete 20 hours of direct observation of designated mentor’s palliative care practice • 7) Collect baseline data for practice improvement projects and implement

7. Palliative and End-of-life Care Today • People are living longer, (increased longevity) • At older ages, people are more frail with unclear living/dying trajectories • Patients are referred late to palliative care and to hospice-Or not at all • Palliative care service knowledge is increasing • More funds are needed to meet higher end-of-life expenses, particularly if aggressive care is sought

8. Professional Knowledge, Skills, and Values • There are all kinds of reasons to do this better • We need to re-utilise available resources to resolve new problems • We need to know and value what our professions bring to the table • The most significant resource is the people who work with others at the end of life • That would be you!

9. Question • What are the three most important tasks you do as a professional? Nurse, chaplain, social worker, pall care doc, or other professional? • 1. Take a moment to think about this • 2. Identify these three tasks • 3. Turn to the person next to you • and discuss in groups of 2s or 3s • Need to be prepared for “elevator” moments—to explain what you do to others and promote your professional views • This is a problem for some professions in the UK • If people don’t know what you do and what you can do, the profession narrows.

10. Did you? • Identify how you spend most of your time? • Identify what you value most? • Identify the most difficult cases you have worked with (and learned from)? • Identify a colleague who helped you understand something differently? • These are strengths of interdisciplinary work.

11. Strengths and Challenges of Transdisciplinary Palliative Care Teams

12. Interprofessonal, multidisciplinary, or transdisciplinary?? • What’s in the descriptor? Some definitions • A. Interprofessional • Provision of comprehensive health services to patients by multiple caregivers who work collaboratively to deliver quality care within and across settings (HealthForceOntario. Interprofessional Care: A Blueprint for Action in Ontario. July 2007; WHO, Collaborative Practice 2010) • Collaborative, integrated teams to achieve the goal of delivering patient-centered, safe and effective care that meets the growing and complex needs of an aging population (IOM, 2014) • Vision for collaborative practice fueled by interprofessional education • Commitment to a new operational framework and developing an integrated healthcare workforce (IOM, 2014)

13. Interprofessonal, multidisciplinary, or transdisciplinary?? • B. Multidisciplinary • People from different professions work or learn together, but there is generally little scope for intercollaborative work. This is a more layered approach—sometimes means 3 or more professions, but less interaction, lots of referrals • In the UK just established in Nov 2017 • The National Framework for Multi-Professional Advanced Clinical Practice (ACP) includes, for the first time, a national definition and standards for the multi-professional advanced level of practice. • ACPs enhance capacity and capability within multi-professional teams by supporting existing and more established roles

14. Interprofessonal, multidisciplinary, or transdisciplinary?? • C.Transdisciplinary teams • Transdisciplinary teams are willing to transcend standard professional orientations to get the work done through novel methods or new kinds of solutions (Hermsen & TenHave, 2005) • In research. . • Working jointly to create new conceptual, theoretical, methodological, and translational innovations that integrate and move beyond discipline-specific approaches to address a common problem. • In healthcare • Transdisciplinary refers to greater fluidity, synergy, and growth in team working • -Understand the grand narratives of their professions • -Have collective ownership of goals • -Build good communication pathways • -Manifest fluidity • -Engage in self and team reflection • -Benefit from structural supports • (Nelson-Becker & Ferrell, 2013)

15. National Consensus Project Guidelines for Quality Palliative Care (US) • Focus is on all setting and many professionals • Palliative care is a person and family-centered approach to care for people with serious illness. • Palliative care includes comprehensive physical, emotional, spiritual, and social assessment; skilled management of pain and other distressing symptoms; and expert communication about what is most important to patients and families and implementing care plans to achieve those goals. • Palliative care can be delivered in all care settings, is frequently provided over a longer period of time to patients based on their need and not their prognosis, and can be offered by various types of organizations. • Palliative care should be provided in any setting by any clinician with appropriate preparation and training.

16. Competency domains • “Inter-professional”competency domains Include the following: • Inter-professional communication • Patient/client/consumer/family/carer centred care • Role clarification • Team functioning • Collaborative leadership • Inter-professional conflict resolution • (ACT Health, Australian Capital Territory, 2018) • Elements of collaborative practice include • responsibility, • accountability, • coordination, • communication, • cooperation, • assertiveness, • autonomy, and • mutual trust and respect • (NIH, 2011)

17. Transdisciplinary Teamwork : Strengths & Challenges Strategies for Maximizing the Health/Function of Palliative Care Teams, Center for Advanced Palliative Care (CAPC), 2013

18. Strong transdisciplinary teams. . . • Have a well-defined program or are building one • Have a vision and goals • Have clearly delineated roles for each discipline-AND • Appreciate expertise while acknowledging shared tasks • Appreciate each discipline’s unique ethical code and relational responsibilities • Work at creating shared values that each can articulate • Establish lines of reporting, accountability, and supervision both within the profession and across professional lines • (Atwell & Caldwell, 2006; Kearney, 2008; Parker-Oliver, Wittenberg-Lyles, & Day, 2006; Reese & Sontag, 2001; Netting & Williams, 1998)

19. Characteristics of strong transdisciplinary teams. . . • Open communication to • Develop trust • Resolve unnecessary conflict • Work towards common goals • Enhance leadership skills • Demonstrate respect (team regard) for • Individual team members and • Team as a whole (from Strategies for Maximizing the Health/Function of Palliative Care Teams, CAPC, 2013

20. Challenges • Failures in communication accounted for more than 60 percent of the root causes of “sentinel events” that occurred between 1995 and 2004 (The Joint Commission, 2005) • Social Determinants of Health may be hard to impact—e.g if a patient needs a medication kept cool and has no refrigeration • Research also has demonstrated that • 70 percent of all medical errors can be attributed to poor healthcare team interactions (IOM, 2014) • When surgical teams less frequently shared information during intraoperative and handoff phases, results included increased odds of major complications or death (IOM 2014)

21. Transdisciplinary Challenges • Shared skill sets – creates the potential for duplication or competition • Role confusion and blurred boundaries • Identifying psychosocial issues does not equal knowing how to intervene (like pain assessments) • Sense of isolation in the role

22. Communication Challenge in the IDT • IDT communication study-81 patient care meetings video-recorded, 1917 messages (Wittenberg-Lyles, Oliver, Demiris, Regehr, 2009) • Format of message: • Assertion, open question, successful talk-over, unsuccessful talk-over, incomplete sentence, closed question, and interruptions assessed. • Three control types • One-up: interaction aimed at gaining control of the exchange. • One-down: interaction that allows, seeks, or accepts control of the exchange. • One-across: interaction that neutralizes control of the exchange. • Response mode of the message: • Ranged from support, nonsupport, extension of topic, reply to open question, instruction, an order, disconfirmation, a change in topic, and an answer to a closed question

23. Communication Challenge in the IDT • Expected to find majority of one-across messages, neutralizing control of the exchange • Communication was dominated by one-up messages • Almost half of the communicative efforts of nurses, social workers, and chaplains were aimed at gaining control of the exchange. • Nonmedical information such as patient’s psychological or spiritual well-being was diminished as a result of the focus on primary reporting by the nurse • Interpersonal communication does not always lead to interpersonal collaboration.

24. Distress in Colleagues Alleviate emotional and moral distress Offer perspective Refocus on patient needs Provide emotional support for critical incident, e.g. when team member is triggered or feels overly responsible for a death or situation Provide emotional support for personal crisis of a team member, e.g., seriously ill family member. Active Listening Assess for meaning of distress Assess for counter-transference and projection Cognitive restructuring (re-framing) Goals Theory Informed Interventions

25. What do nursing, social work, chaplaincy bring to the table? • Knowledge of building and maintaining relationships • Comfort with difficult dialogues • Background in family systems and a holistic approach to care • Listens for: • “Non-compliance”—what causes it, how does it manifest? • “Holding out for the miracle”and other beliefs about illness and healing • Physical, social and structural barriers to continuity of care • Mistrust of healthcare systems • Misperceptions about palliative care and hospice

26. Strategies for Improving Team Functionality

27. Strategies for Improving Team Function: Feedback • If done well-- feedback can be the most important tool for learning, enhancing skills, and developing as a professional • If done poorly-- feedback risks alienation and leaves clinicians stuck or confused • Feedback is a relational process as much as it is about content • How feedback is given and heard facilitates or impairs the learning process and future relationships

28. Feedback Definition • Formal and informal • Nonverbal/verbal • One of the best ways to improve our ability to give feedback well is by improving our understanding of what it takes to receive feedback well

29. Exercise • Think of a piece of feedback in the recent past that you found tough to receive • What immediate thoughts went through your mind as you received this feedback? • What were your physiologic reactions? • What thoughts went through your mind later and what did you feel?

30. Three Feedback Triggers(Adapted from Stone & Heen, 2015) • Truth Triggers- we characterize the content of feedback as wrong, unfair, or unhelpful. Allows us to dismiss it or react defensively. • Relationship Triggers- we question the person giving the feedback or the relationship. We may lack trust in this person. • Identity Triggers- we question ourselves and our self-worth. We go to that place of vulnerability, rather than seeing the feedback as what it is.

31. Components of Receiving Feedback Well • Being curious • Sorting and filtering • Learning how the other person sees things • Trying on ideas, even if they seem like a poor fit • Shelving or discarding the parts of feedback that seem off or not what you want right now

32. Three Kinds of Feedback (Stone & Heen, 2015) • Appreciation • Coaching • Evaluation • -What kind of feedback is given most often on your team? Least often? • -How is appreciation expressed-privately, publicly, words, actions? • -Whose coaching is most helpful? • -When is evaluative feedback helpful? When is it not? When you give feedback, how do you do it?

33. What Helps? • Be mindful of your blind spots • What do you often not see? • Don’t Wrong Spot • Occurs when we name everything wrong with the feedback • Get aligned • Avoid Switch Tracking-separate the feedback from the person giving it

34. Navigating the Feedback Conversation: Three Parts • Open • Body • Close

35. Open • What is the purpose of this conversation? • What kind of feedback would I like? (Appreciation, coaching, evaluation) • What kind of feedback is the giver trying to give? • Is the feedback negotiable or final? A friendly gesture or a command?

36. Body • Listen • -Ask clarifying questions • -Paraphrase what the giver is trying to say • -Acknowledge their feelings • -Be curious, ask for examples • Assert – a mix of sharing, advocating, and expressing • Manage the conversation process • Problem-solve

37. Close • Clarify commitments • Create action steps • Identify benchmarks • Follow-up, find new strategies

38. Coach Your Coach • Find ways to collaborate • Put your ideas out there • Discuss your feedback temperament • Explain growth areas you are working on • State in terms of effectiveness rather than ambition • Don’t be a feedback fanatic

39. A clinician who learns from feedback is: • Mindful • Intuitive, self-aware, thoughtful • Able to take care of self • Open, creative • And has: • Concern for others; agenda is welfare of patients • Ability to hold his/her personality flexibly • Sense of self-relatedness

40. A clinician who learns from feedback • Seeks as much patient engagement as possible within constraints • Doesn’t run away from tough stuff • Pushes the limits of his/her own reliable performance • Overcomes automatic thinking • Plans, strategizes, tracks, reviews evidence, changes outcomes

41. Feedback is a relational process • The first step in giving and receiving feedback is to ASK for it • What can I do to improve? • How can I say this better, do this better? • Inviting feedback sets up a dynamic of reciprocity • I want to know what you think so I can improve

42. Strategies for Improving Team Function:Time for Reflection • Periodically, teams should engage in a reflective process together • This builds cohesion, identity, understanding • Increases trust • Team members better understand positions (role and the person in the role) • Team members enhance capacity to fill gaps in care • Encourages ability to support each other in the work

43. Strategies for Improving Team Function:Build Team Success • Support time for: • Training • Attending conferences and giving presentations, opportunities to share knowledge • Celebrating life transitions and use of humour when things are grim • Building a safe and responsive environment with a growth orientation

44. Conclusion • Creating effective transdisciplinary pathways is the work of everyone on the palliative care team • Collaboration is a learning process, especially when many different disciplines are involved • There is no one right way • The way that allows people to integrate their personal strengths while meeting needs of their patients and team needs is a good one. • It will change, requiring ongoing adaptation • Make sure your voice is heard--and other team voices are respected • Compassion should comprise all our interactions

45. A note Material for this presentation comes out of Nelson-Becker, H. (2018). Spirituality, Religion, and Aging: Illuminations for Therapeutic Practice. Thousand Oaks, CA: SAGE press. Brunel University London

46. References • Agnew, A., & Duffy, J. (2010). Innovative Approaches to Involving Service Users in Palliative Care Social Work Education. Social Work Education,29(7), 744-759. • Atwal, A., & Caldwell, K. (2006). Nurses’ perceptions of multidisciplinary team work in acute health‐care. International Journal of Nursing Practice,12(6), 359-365. • Center to Advance Palliative Care (CAPC). 2017. https://www.capc.org/ • Conference Proceedings. Team Based Competencies: Building a Shared Foundation for Education and Clinical Practice. 2011. Washington, DC. http://www.aacn.nche.edu/leading-initiatives/IPECProceedings.pdf • HealthForceOntario. (2007). Interprofessional Care: A Blueprint for Action in Ontario. Toronto, Ontario. • Hermsen, M. A., & Ten Have, H. A. (2005). Palliative care teams: Effective through moral reflection. Journal of Interprofessional Care, 19(6), 561-568. • Kearney, A. (2008). Facilitating interprofessional education and practice. The Canadian Nurse,104(3), 22-6. • Nelson-Becker, H. (2006). Voices of resilience: Older adults in hospice care. Journal of Social Work in End-of-Life and Palliative Care, 2(3), 87-106. • Nelson-Becker, H. (2018). Spirituality, religion, and aging: Illuminations for therapeutic practice. Thousand Oaks, CA: Sage Press. ISBN: 9781412981361

47. References 2 • Nelson-Becker, H., & Ferrell, B. (2011). Social work and nursing: Creating effective collaborations. In T. Altilio & S. Otis-Green (Eds.), Oxford textbook of palliative social work (pp. 477-481). New York: Oxford University Press. • IOM (Institute of Medicine). 2014. Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC: The National Academies Press. • Oishi, A, Murtagh, FEM. The challenges of uncertainty and interprofessional collaboration in palliative care for non-cancer patients in the community: a systematic review of views from patients, carers and health-care professionals. Palliat Med. 2014;28(9):1081–1098. • Beresford, P. (2007). User involvement, research and health inequalities: Developing new directions. Health & Social Care in the Community,15(4), 306-312. • Reese, D., & Sontag, M. (2001). Successful interprofessional collaboration on the hospice team. Health & Social Work,26(3), 167-75. • Stone, D . & Heen, S. (2015). Thanks for the Feedback: The science and art of receiving feedback well," by Douglas Stone and Sheila Heen, • WHO. (2010). Framework for Action on Interprofessional Education & Collaborative Practice. Health Professions Network: Nursingand Midwifery. • Wittenberg-Lyles, E., Oliver, D., Demiris, G., & Regehr, K. (2009). Exploring interpersonal communication in hospice interdisciplinary team meetings. Journal of Gerontological Nursing,