11 Team Relationships

Michelle R. Brown, Jody Chrastek, and Kris Catrine

By its very nature, and in fact by legislative decree in the case of hospice,² palliative care is a team endeavor. Through teamwork, palliative care is able to uniquely tailor care plans to the needs of children impacted by complex illnesses and their families. Through a cyclic process of “forming, storming, norming, and performing,”³ teams are ever-evolving, with a flexibility that allows them to accommodate the changing needs of children and families as well as those of the care providers within the larger institution. The creation, ongoing growth, and sustainability of highly functional teams is not automatic; it requires sophisticated, multimodal skills. This chapter explores the basic types of teams, team processes, and relational states that support team performance; practical strategies to preserve and protect optimal team functioning; and common challenges of interdisciplinary teams.

Team Structure

Team relationships are influenced by the inherent structure of the team itself, which varies in degree of communication, collaboration, and integration. Multidisciplinary teams, the most traditional model, are comprised of individual practitioners who work side by side toward shared goals.⁴ Professional identities are primary, while team membership is a secondary priority. Leadership is generally hierarchical, and practitioners function as “wedges in a pie,”⁵ wherein roles and responsibilities remain fixed and circumscribed. Information is most often communicated via the patient’s chart or in staff meetings or rounds where providers report their clinical findings. Their recommendations are added to, rather than integrated into, the plan of care for the child. The lack of integrated care increases burdens on families who become responsible for keeping their care providers apprised of changing symptoms and treatments,⁶ thus making the multidisciplinary model a poor fit for palliative care.

Most palliative care teams, as is evident throughout this book, are self-described as interdisciplinary, a model that builds on and adds complexity to the multidisciplinary approach. In an interdisciplinary team, professionals from different disciplines come together through an interactive, collaborative process, creating a combined wisdom to deliver care that is far more than the sum of the individual discipline.^5,7 The identity of the overall team is set above individual professional identities. Yet it is the unique and varied perspectives from each team member that enables a comprehensive understanding of each patient and family and their specific needs. Treatment plans are developed together after considering input from all team members. Decisions are often made by consensus,⁸ contributing to a sense of shared responsibility and accountability. This flexible working relationship enables interdisciplinary teams to approach patient care holistically, with the relevant providers attending to concerns as they arise and adapting the care plan as needs change over time.

The composition of each specialty pediatric palliative care (PPC) team will vary depending on site, goals, and scope of services as well as available resources. Ideally, every team will include professionals representing the following fields: medicine, nursing, psychosocial (which may include social work, psychology/psychiatry, child life), and spiritual and bereavement care.^9,10 Even if not formal members, most palliative care teams have access to such providers within their institution, along with high-quality adjunct services including pharmacy, nutrition, case management, expressive therapies, rehabilitation, and education. When fully actualized, a PPC team is like a tapestry in which different colored 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 well-woven around the child and family’s goals of care.

Within the hospital setting, there are a variety of specialty pediatric palliative team configurations. Some hospitals have a team whose members are exclusively dedicated to palliative care. In other hospitals, teams may be composed of designated providers from varied departments with a portion of their professional time formally allocated to the team. Alternatively, teams may assemble ad hoc professionals who have particular interest in palliative care. Specialty PPC teams will also collaborate with a range of other professionals as part of the child’s broader care, including other medical subspecialists. When children are out of the hospital, their team expands to include providers in outpatient medical clinics and those who provide care at home and in the community (e.g., formal hospice and palliative care programs or partnerships with pediatric professionals who provide home-based care). The community-based team extends to services provided through the county (e.g., social workers, physiotherapists, child development workers, counselors), the school (e.g., teachers, aides, nurses, counselors), and the religious community.

Although each individual specialty offers a unique contribution to the complex needs of children and their families, the role that each team assumes may vary. Exactly who delivers which aspects of care will change over the course of the child’s illness. For example, for a child with high-risk leukemia, an oncology team may be most prominent during early stages of treatment, while a stem cell transplant team and a palliative care team may become increasingly involved in the event of disease recurrence. Later, a home hospice team may play a primary role or work conjointly with hospital-based teams.

The involvement of multiple teams and the transitions among them can, at times, cause confusion or concern for families, particularly when collaboration is impaired by “competition” or possessiveness as to who best knows the patient. Yet, in optimal circumstances, families feel enormous support when their care is enhanced by rich, collaborative teamwork.

The composition of an interdisciplinary team differs for each patient and may change over time. Figure 11.1 illustrates the kaleidoscope of an interdisciplinary team, with roles at times overlapping and shifting to the meet the needs of the child and family. The specialty palliative care team serves as a bridge across the three settings, providing continuity of care for the patient and family. While some families prefer to minimize the overall number of providers involved in their care and reduce duplication of services, other families prefer the services that each team offers to continue simultaneously. Hence, it is essential that all teams involved in the care of these children and families commit to an agreed-upon philosophy that incorporates the families’ choices and goals of care.

Within the circle of care, the child and family reside in the center, as “partners” with the palliative care team in their own child’s care. Yet, in partnering with the care team, the patient and family do not become members of the team. While absolutely critical in their child’s care, parents 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.¹¹

Framework of Team Functioning

The very nature of the work in PPC necessitates a high level of attention to the dynamics and care of its individual members and the team as a whole. Every interdisciplinary PPC team has, at some point, engaged with families or providers who challenge the integrity of the team. Without careful maintenance, the cohesiveness of PPC teams can splinter, fragmenting the care provided to children and families. (See Chapter 16 on resolving intrateam conflict.) What enables an adaptive, well-functioning team? Models within the healthcare system have identified core processes—referred to as the C’s of team performance—that are critical for optimal relationships both within and between teams.^12,13 Those especially relevant to palliative care include cognition, collaboration, coaching, and communication in addition to the relational states of cohesion, mutual trust, and psychological safety.

Team Processes

Cognition

Cognition refers to shared mental models,^12,14 identified as one of the critical mechanisms that undergird effective teamwork in general¹⁵ as well as in healthcare specifically.^16,17,18 Within the palliative care team, shared mental models refer to a common understanding of the goals of patient care, the plan for treatment, and the roles and tasks of the individuals in the team. This is often described as the team being “on the same page.”¹⁹

Most providers of palliative care hold a shared mental model regarding its philosophy, with common values and commitment to the approach. However, perceptions around strategies for accomplishing appropriate goals may vary widely. When team goals are poorly defined—or not defined at all—care providers may be uncertain of their professional role or specific value to the team. Such ambiguity can impair their sense of overall commitment. 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, or would resources be better spent working with children from many different services who are admitted to the pediatric intensive care unit (PICU)? Should resources be allocated for a nurse practitioner or a clinical social worker? Without well-defined goals, discord can develop within the team as to the “right” action, and frustrations can arise from the perceptions of substandard care or limited progress of the program as a whole. In contrast, clearly defined goals orient team members to the collective purpose.

Teams may be further strained when agreed-upon goals lack specific outcome measures. For example, in an effort to “improve palliative care,” a team may implement educational initiatives for nursing and increased clinical availability to various medical services. Outcome measures could be (for example) pre- and post-questionnaires to assess the educational intervention and satisfaction ratings from medical services. Without such measures, the effectiveness is unknown. Team members can be frustrated when, despite significant time and energy—and often the perception of positive impact—there is no evaluation of outcome in place. Without evidence of positive outcomes, these efforts may go unrecognized by the administrators who allocate financial and other resources to programs within the organization.

The delineation of roles and responsibilities is important to clarify each individual’s contribution to the team. When team members believe that duties have been fairly distributed and that everyone is working for the greater good, a sense of commitment and cohesion is fostered. In contrast, when roles are not adequately delineated, diffusion of responsibility becomes more likely. Team members may blame one another for lack of progress, leading to hostility and ill will. Chronic unresolved conflict or dissatisfaction may lead to personal detachment or fractures within the team. A lack of clearly defined roles can precipitate the blurring of professional boundaries, whereby team members’ engagement with patients and families can overextend into areas that are not their primary expertise nor typical for the culture of the broader team. The risk of this occurrence increases when team members distrust others’ ability to provide optimal care in their defined role.

In addition to the risk of causing greater challenges for families, clinicians who overextend their roles can set up other team members to be judged as less engaged in care. They also can cause confusion among consulting services, who may come to expect a higher degree of availability than what the palliative team can realistically offer. The risk of these situations occurring may be reduced by regular and ongoing review of team roles specific to each patient and family.

Collaboration

In addition to well-defined goals and roles, commitment to collaborative relationships is crucially important to healthy team functioning. While team goals orient actions, supportive and collaborative relationships help to achieve them.²⁰ In fact, the two may be considered interdependent because the more supportive the team, the more likely members are to commit to work tasks, meaningful goals, and to the development of compassionate relationships.¹¹

Coordination and cooperation have been identified as two separate but related processes that synchronize team dynamics.¹² As such, collaboration requires team members both to recognize the unique roles and specific contribution of every other member and to integrate their work efforts to achieve team goals. Through this interdependence, the whole becomes greater than the sum of the individual parts. For a collaborative alliance to develop, care providers must spend time working together, sharing experiences, exploring different viewpoints, and developing a common language that does not exclude any member. It requires an open, reflective process that enables team members to challenge their own and others’ thinking and share experiences with a receptiveness to potential change.²¹ Together, teams can consider strategies for coping, implement new initiatives and change, enhance the ability to take risks, and, ultimately, grow as a team.

Collaborative relationships are sustained by mutual support. Studies indicate that one of the primary factors that contributes to professional burnout is not the team’s confrontation with multiple child deaths, however distressing, but rather a team’s inability to support its members.^22,23,24 Four essential types of support include informational support, instrumental support, emotional support, and support in the construction of meaning.²⁰ The specific form of support provided will vary at different times under different circumstances (see Box 11.1).

Related posts:

Quality in Pediatric Palliative Care Program Development Fatigue Practical Aspects of Palliative Care Communication Advanced Heart Disease Children’s Voices: The Experience of Patients and Their Siblings

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