Team Relationships

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. 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. 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 ).

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, and the synergy resulting from collaboration creates an “active, ongoing, productive process.” Team members engage in joint work from different orientations, 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; 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.

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. 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. Compared to multidisciplinary teams, interdisciplinary teams have been rated by members as higher in coherence, sense of responsibility, work climate, internal organization, and communication. A true interdisciplinary team illustrates that the function of a hand is far more than the sum of each individual digit. 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. 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.

• 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.

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. 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,

• 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,

• 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

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

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. 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. The ever-increasing complexity of palliative medicine calls, in turn, for recognition of the increasing complexity and multiplicity of teams. 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. 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. Health-related priorities, targets, resources, and budgets are generally not set by palliative care teams, often resulting in scarcity of resources. Increased access and equity, particularly as offered by community-based services, result in a larger service area with limited resources. In fact, despite the continual change occurring for patients and families, the availability of resources for care is generally either constant or shrinking.

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, and the focus on team function may end up protecting team members rather than supporting patient and/or family needs. 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.

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. The larger the team, and the more disciplines involved, the more time that team needs to achieve functionality and growth.

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. 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. In other words, it might be thought that collaboration is affected by the varied disciplines or training backgrounds or cultures of the individual team members. But it appears as though the team structure, leadership, empowerment, and functionality influence how members perceive how well the team collaborates. This again is heartening news for interdisciplinary and/or cross-functional teams because it suggests that effort directed at team functioning will overcome differences in individual background and training, which might seem to affect collaboration negatively.

Team composition

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

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

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

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

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

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

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

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

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