Shared care: the barriers encountered by community-based palliative care teams in Ontario, Canada

To meet the complex needs of patients requiring palliative care and to deliver holistic end-of-life care to patients and their families, an interprofessional team approach is recommended. Expert palliative care teams work to improve the quality of life of patients and families through pain and symptom management, and psychosocial spiritual and bereavement support. By establishing shared care models in the community setting, teams support primary healthcare providers such as family physicians and community nurses who often have little exposure to palliative care in their training. As a result, palliative care teams strive to improve not only the end-of-life experience of patients and families, but also the palliative care capacity of primary healthcare providers. The aim of this qualitative study was to explore the views and experiences of community-based palliative care team members and key-informants about the barriers involved using a shared care model to provide care in the community. A thematic analysis approach was used to analyse interviews with five community-based palliative care teams and six key-informants, which took place between December 2010 and March 2011. Using the 3-I framework, this study explores the impacts of Institution-related barriers (i.e. the healthcare system), Interest-related barriers (i.e. motivations of stakeholders) and Idea-related barriers (i.e. values of stakeholders and information/research), on community-based palliative care teams in Ontario, Canada. On the basis of the perspective of team members and key-informants, it is suggested that palliative care teams experience sociopolitical barriers in an effort to establish shared care in the community setting. It is important to examine the barriers encountered by palliative care teams to address how to better develop and sustain them in the community.     

Evaluation of a Chaplain Residency Program and Its Partnership with an In-Patient Palliative Care Team

In 2009 a Consensus Conference of experts in the field of spiritual care and palliative care recommended the inclusion of Board-certified professional chaplains with at least 1,600 hours of clinical pastoral education as members of palliative care teams. This study evaluates a clinical pastoral education residency program’s effectiveness in preparing persons to provide spiritual care for those with serious illness and in increasing the palliative care team members’ understanding of the chaplain as part of the palliative care team. Results showed chaplain residents felt the program prepared them to provide care for those with serious illness. It also showed that chaplain residents and palliative care team members view spirituality as an integral part of palliative care and see the chaplain as the team member to lead that effort. Suggested program improvements include longer palliative care orientation period, more shadowing with palliative care team members, and improved communication between palliative care and the chaplain residents.     

Healthcare organizations, linguistic communities, and the emblematic model of palliative care

The linguistic-communicative paradigm offers some interesting perspectives in a context where the perception of patient needs is considered a critical step in high-quality care. This study describes healthcare organizations as linguistic communities based on the conceptual framework of Habermas' communicative action theory. Four communicative models are present in healthcare settings: objectifying-instrumental (hegemonic model), where elements of interaction are objectified for clinical purposes; dialogic model with strategic perspectives, in which conversations are used unilaterally as tools to access subjective states; non-dialogic-transmissional model, in which linguistic exchanges are replaced with artifacts to transmit information; and full communicative model (present in palliative care based in homecare and informal caregivers, emphasizing health team/family interactions). Based on these premises, we considered palliative care an emblematic communicative model based on multidisciplinary teams devoted to transdisciplinary collaboration. In these settings, linguistic interaction with patients and their families could provide a solid basis for organization of healthcare networks.     

‘The unknown becomes the known’: collective learning and change in primary care teams

Context The growing emphasis on teamwork within the National Health Service (NHS) has made it a priority to understand how health care teams learn together and cope with change. Objectives This study aimed to explore how collective learning and change happen in primary care teams and how the process varies across the disciplines of general medical practice, pharmacy and dentistry. Methods This study reports on qualitative data gathered from 10 primary care teams over 1 year, by means of observational visits and 38 semi‐structured interviews. Results Informal collective learning is a powerful team coping mechanism that develops through experiential, evolving and implicit learning processes. These processes are predominantly relational in that they rely on the extent to which team members know and understand one another as people. This makes shared learning an effective but ‘messy’ dynamic, the motivation for which is internally generated by the team itself. Teams report that if they cannot learn together, they cannot meet patient needs. Conclusions These findings demonstrate that teams share their knowledge because they believe it has value, not because they are driven by external incentives or are monitored. This challenges the prevailing assumption that, to be effective, interprofessional learning should be externally managed. As health care develops, it will become increasingly important to consider how to support the internal learning processes of care teams as they navigate complex organisational changes and the shared learning experiences that characterise those changes. Those who support learning and development within the NHS should therefore focus on how relational processes, as well as educational content, contribute to a team’s collective learning capability and the quality of care its members provide.     

General practice and specialist palliative care teams: an exploration of their working relationship from the perspective of clinical staff working in New Zealand

With the future focus on palliative and end‐of‐life care provision in the community, the role of the general practice team and their relationship with specialist palliative care providers is key to responding effectively to the projected increase in palliative care need. Studies have highlighted the potential to improve co‐ordination and minimise fragmentation of care for people living with palliative care need through a partnership between generalist services and specialist palliative care. However, to date, the exact nature of this partnership approach has not been well defined and debate exists about how to make such partnerships work successfully. The aim of this study was to explore how general practice and specialist palliative care team (SPCT) members view their relationship in terms of partnership working. Five focus group discussions with general practices and SPCT members (n = 35) were conducted in 2012 in two different regions of New Zealand and analysed using a general inductive approach. The findings indicate that participants’ understanding of partnership working was informed by their identity as a generalist or specialist, their existing rules of engagement and the approach they took towards sustaining the partnership. Considerable commitment to partnership working was shown by all participating teams. However, their working relationship was based primarily on trust and personal liaison, with limited formal systems in place to enable partnership working. Tensions between the cultures of ‘generalism’ and ‘specialism’ also provided challenges for those endeavouring to meet palliative care need collaboratively in the community. Further research is required to better understand the factors associated with successful partnership working between general practices and specialist palliative care in order to develop robust strategies to support a more sustainable model of community palliative care.     

“A More Rounded Full Care Model”: Interprofessional Team Members’ Perceptions of Home-Based Primary Care in Ontario,Canada

This study explores interprofessional team members’ perspectives and experiences providing home-based primary care (HBPC) in Ontario, Canada. Employing an inductive qualitative methodology using procedures informed by grounded theory, themes emerged in the data in relation to the benefits of the HBPC model, and the barriers associated with its provision, as well as the key components that enable or hinder interprofessional collaboration in the HBPC environment. This research deepens our understanding of the key features and processes of interprofessional teams providing high-quality care in the home.     

Exploring the use of social network methods in designing healthcare quality improvement teams

Teams are an integral component of quality improvement efforts in healthcare organizations. Quality improvement teams may involve persons either from the same or different disciplines. In either case, the selection of team members may be critical to the team’s success. However, there is little research to guide selection of team members for quality improvement teams. In this paper, we use tools from social network analysis (SNA) to derive principles for the design of effective clinical quality improvement teams and explore the implementation of these principles using social network data collected from the inpatient general medicine services at a large academic medical center in Chicago, USA. While the concept of multidisciplinary teams focuses on the importance of the professional background of team members, SNA emphasizes the importance of the individual and collective connections of team members, both to persons outside the team and to each other. SNA also focuses on the location of individuals and groups between other actors in the flow of information and other resources within larger organizational networks. We hypothesize that external connections may be most important when the collection or dissemination of information or influence are the greatest concerns, while the relationship of team members to each other may matter most when internal coordination, knowledge sharing, and within-group communication are most important. Our data suggest that the social networks of the attending physicians can be characterized sociometrically and that new sociometric measures such as “net degree” may be useful in identifying teams with the greatest potential for external influence.     

Why are newly qualified doctors unprepared to care for patients at the end of life?

Medical Education 2011: 45 : 389–399 Context Death and dying occur in almost all areas of medicine; it is essential to equip doctors with the knowledge, skills and attitudes they need to care for patients at the end of life. Little is known about what doctors learn about end‐of‐life care while at medical school and how they learn to care for dying patients in their first year as doctors. Methods We carried out a qualitative study using face‐to‐face interviews with a purposive sample of 21 newly qualified doctors who trained in different medical schools. Results Data were analysed using a constant comparative approach. Two main groups of themes emerged. The first pertained to medical school experiences of end‐of‐life care, including: lack of exposure; a culture of ‘clerking and signs’; being kept and keeping away from dying patients; lack of examinations; variable experiences, and theoretical awareness. The second group of themes pertained to the experiences of recently qualified doctors and included: realising that patients really do die; learning by doing; the role of seniors; death and dying within the hospital culture; the role of nursing staff, and the role of the palliative care team. Conclusions Undergraduate medical education is currently failing to prepare junior doctors for their role in caring for dying patients by omitting to provide meaningful contact with these patients during medical school. This lack of exposure prevents trainee doctors from realising their own learning needs, which only become evident when they step onto the wards as doctors and are expected to care for these patients. Newly qualified doctors perceive that they receive little formal teaching about palliative or end‐of‐life care in their new role and the culture within the hospital setting does not encourage learning about this subject. They also report that they learn from ‘trial and error’ while ‘doing the job’, but that their skills and knowledge are limited and they therefore seek advice from those outside their usual medical team, mainly from nursing staff and members of palliative care teams.     

A day in the life: a case series of acute care palliative medicine--the Cleveland model

Palliative care in advanced disease is complex. Knowledge and experience of symptom control and management of multiple complications are essential. An interdisciplinary team is also required to meet the medical and psychosocial needs in life-limiting illness. Acute care palliative medicine is a new concept in the spectrum of palliative care services. Acute care palliative medicine, integrated into a tertiary academic medical center, provides expert medical management and specialized care as part of the spectrum of acute medical care services to this challenging patient population. The authors describe a case series to provide a snapshot of a typical day in an acute care inpatient palliative medicine unit. The cases illustrate the sophisticated medical care involved for each individual and the important skill sets of the palliative medicine specialist required to provide high-quality acute medical care for the very ill.     

Clinical indicators of treatment futility and imminent terminal decline as discussed by multidisciplinary teams in long-term care

Focus group methodology was used to describe how members of multidisciplinary teams in long-term care facilities recognize when residents are approaching end-stage disease, document evidence that associated treatment futility has occurred, and convey this information to the residents, each other, and family members. In addition to the typical clinical indicators of treatment futility found in the literature (e.g., recurrent infections, weight loss, falls, functional decline), team members described a set of physical and affective changes that were apparent to them as their residents approached trajectories of imminent terminal decline. While more difficult to quantify and measure, these other indicators have a significant impact on the ways that team members assess and interpret a person's survival potential. Using these indicators of both treatment failure and imminent decline requires knowledge of a resident's history, clinical condition, course of care, and individual idiosyncrasies. Together, the indicators offer important cues that are needed for the identification of persons who might benefit from earlier transitions to palliative care.     

Advanced practice nursing, health care teams, and perceptions of team effectiveness

This article summarizes the results of an extensive review of the organizational and health care literature of advanced practice nursing (APN) roles, health care teams, and perceptions of team effectiveness. Teams have a long history in health care. Managers play an important role in mobilizing resources, guiding expectations of APN roles in teams and within organizations, and facilitating team process. Researchers have identified a number of advantages to the addition of APN roles in health care teams. The process within health care teams are dynamic and responsive to their surrounding environment. It appears that teams and perceptions of team effectiveness need to be understood in the broader context in which the teams are situated. Key team process are identified for team members to perceive their team as effective. The concepts of teamwork, perceptions of team effectiveness, and the introduction of APN roles in teams have been studied disparately. An exploration of the links between these concepts may further our understanding the health care team's perceptions of team effectiveness when APN roles are introduced. Such knowledge could contribute to the effective deployment of APN roles in health care teams and improve the delivery of health care services to patients and families.     

Conflict and Stress in Hospital Nursing: Improving Communicative Responses to Enduring Professional Challenges

Nurses function as central figures of health teams, coordinating direct care and communication between team members, patients, and their families. The importance of nurses to health care cannot be understated, but neither can the environmental struggles nurses routinely encounter in their jobs. Organizational communication and nursing scholarship show conflict and stress as two visible and ongoing challenges. This case study aims to (a) explore the ways conflict communication and communicative stress are experienced and endure in nursing and (b) understand how nurses discursively (mis)manage conflict and stress. Open-ended survey comments from nurses (N = 135) employed at a large teaching and research hospital were qualitatively analyzed. Weick’s model of organizing, specifically his notion of communication cycles, emerged as a conceptual lens helpful for understanding cyclical conflict and stress. Results show that exclusionary communication, specifically nonparticipatory and unsupportive messages, contribute to nurse conflict and stress. Nurses tend to (mis)manage conflict and stress using respectful and disrespectful discourse. These communication patterns can facilitate or prohibit positive change. Metaphorically, nurse communicative conflict and stress can be depicted as fire. Relationships can go up in flames due to out-of-control fires in the form of destructive conflict. However, conflict and stress, like fire, can be harnessed for positive ends such as organizational decision making and innovation. Findings suggest conveying respect may help nurses manage and even avoid flames of conflict and stress. Solutions are offered to mitigate the effects of conflict and stress while developing respectful organizational cultures.     

Coordinating efforts in complex clinical cases: added value of palliative care at a university teaching hospital

Palliative care is generally understood on caring for terminal patients in chronic settings but more recently these units are developing also in acute care settings or university hospitals as consultants teams. We report the case of a complex patient with rectal adenocarcinoma and four problems of difficult approach: uncontrolled neuropathic pain despite opioids treatment, systemic infection, depression with intense demoralisation and open surgery wound. We show the measures adopted and how an excellent inter-departmental collaboration under the co-ordination of palliative medicine consultant team helped to resolve the untenable situation.     

Provider insights about palliative care barriers and facilitators: results of a rapid ethnographic assessment

Palliative care remains underutilized in the United States. This may represent failure of translation of research into practice (diffusion of innovation). Qualitative methods can identify barriers to and facilitators of diffusion of innovation. The aim is to identify potential barriers to and facilitators of inpatient palliative care utilization at a large urban hospital, as articulated by health professionals. Rapid ethnographic assessment methods were used among health professionals with subsequent extraction of predominant themes illuminating factors influencing adoption of palliative care services. In all, 3 stakeholder categories and 7 major themes emerged. Analysis revealed consistent need for organized, cross-disciplinary education/training services and a clearly-defined team approach. Denial at all stakeholder levels and in most themes was a barrier to implementation of palliative care. Consistent, defined educational, policymaking, and procedural standards were requirements for best adoption of palliative care. Denial was a striking obstruction to diffusion of innovation.     

The Japan HOspice and Palliative Care Evaluation study (J-HOPE study): study design and characteristics of participating institutions

This article describes the study design and background data of participating institutions in the Japan HOspice and Palliative care Evaluation (J-HOPE) study. The J-HOPE study is a large nationwide survey about the dying experience of cancer patients. The primary aim of this article is to describe the design of the J-HOPE study for the bereaved family members of Japanese inpatient palliative care units and home hospices. Secondly, the aim was to describe characteristics of participating institutions. The authors conducted a cross-sectional questionnaire survey in 2007. One hundred Japanese inpatient palliative care units and 14 home hospices participated. The questionnaires were sent to 7955 bereaved family members of the Japanese inpatient palliative care units and 447 of the home hospices. The authors describe the structure of the Japanese inpatient palliative care units and home hospices, including type of staff, architectural structure, number of patients, and death. In addition, the authors describe available treatments at the Japanese inpatient palliative care units and home hospices.     

Key indicators of nursing care team performance: insights from the front line.

Self-directed nursing care teams (NCTs), comprised of a registered nurse (RN) team leader and two or more non-licensed caregivers, are a key feature of patient-focused care reengineering. In well-functioning teams: (1) role overlap routinely occurs; (2) team members express satisfaction with interpersonal communication; and (3) team members express the belief that their shared purpose--and that of the health care organization--is the patient. Focus groups of team members in two case study hospitals expressed generalized dissatisfaction with performance on all three key imperatives of well-functioning teams, but also generally agreed that team delivery of bedside nursing care can work if properly managed. Based on study findings, recommendations for process improvement are made.     

Cross-functional teams in health care organizations

Cross-functional teams in health care organizations provide a comprehensive view of problems and are highly useful in designing and implementing improvements in work processes. Several potential obstacles may impede team progress, but these can be overcome. Cross-functional teams must develop norms that guide the interactions of team members. Individual team members must display behaviors that serve task accomplishment and team spirit. The promise of cross-functional teams for health care organizations is great. These promises, however, will not be fulfilled without the positive support of health care supervisors.