Review. Interprofessional collaboration in palliative nursing: what is the patient-family role? Christine McDonald, Antoinette McCallin

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1 Interprofessional collaboration in palliative nursing: what is the patient-family role? Christine McDonald, Antoinette McCallin Abstract Interprofessional collaboration occurs when health professionals from different disciplines work together to identify needs, solve problems, make joint decisions on how best to proceed, and evaluate outcomes collectively. Interprofessional collaboration supports patient-centred care and takes place through teamwork. Team interactions, wider organizational issues, and environmental structures, such as safety, quality, efficiency and effectiveness issues influence this model of care. These broader contextual influences affect practice where there are tensions between the ideals of interprofessional collaboration and the realities of practice. This is evident when the patient and family position in interprofessional collaboration is considered. This article will discuss factors that affect interprofessional collaboration in relation to patients and families in palliative care. First, a definition of interprofessional collaboration is given, followed by an outline of the need for interprofessional collaboration. A brief discussion of key issues that influence collaboration follows, and a review of the implications for practice is presented. Key words: Interprofessional collaboration Patient-centred care Collaborative practice Palliative care Christine McDonald is Palliative Nurse Specialist, Hospice Waikato, Hamilton 3240, New Zealand, and Antoinette McCallin is Co-Director Research and Interprofessional Advisor, National Centre for Interprofessional Education and Collaborative Practice, Faculty of Health and Environmental Sciences AUT University, Auckland, New Zealand Correspondence to: Christine McDonald cmcdonald@xtra.co.nz Palliative care requires health professionals from different disciplines to work together for the patient and family using a collaborative model of care, which has become very popular in all areas of service delivery. Herbert (2005) provides a helpful definition of interprofessional collaboration that assists palliative care nurses, as the patient and family are at the centre of care (Box 1). Interprofessional collaboration involves paying attention to sharing, partnership, joint working, and power issues (D Amour et al, 2005). The World Health Organization (WHO) (20010: 13) believes that collaboration occurs when multiple health workers from different professional backgrounds work together with patients, families, carers and communities to deliver the highest quality of care. Interprofessional collaboration is about working together and usually occurs in teams (Baldwin, 2007; Kemp, 2007). While working together for patients and families drives nursing practice in palliative care, appreciating that interprofessional collaboration seldom occurs in isolation is important. Factors that are more complex in the wider health-care context drive interprofessional collaboration. Why is interprofessional collaboration necessary? Mounting health-care costs, the increasing shortage of health-care workers (Baldwin, 2007), and the rising demand for care have influenced health services delivery. As the population ages, people are living longer with chronic conditions. Consumer health literacy has improved so that patients and families expect services that are more comprehensive. This means that health-care organizations need a model of care that will improve efficiency and effectiveness and reduce service delivery costs (Cashman et al, 2004). In this context, interprofessional collaboration has become an innovative strategy to develop policy and programmes and to bolster the health workforce (WHO, 2009: 7). Supporting patient-centred care and quality service delivery is also important. While patients are central to collaborative care, health professionals can benefit too, as interprofessional collaboration looks promising to improving continuity of care (Robins et al, 2008: 325), potentially increasing job satisfaction, possibly reducing staff turnover. This model of care seems to be ideal at the end of life, where a team approach is assumed essential for the provision of good palliative care (Hermsen and Have, 2005). As such, palliative care practitioners may be considered leaders in interprofessional collaboration and able to show how this model works in practice. However, collaborating with colleagues from different professional groups is not quite as straightforward as it seems. What are the key issues? The key issues of interprofessional collaboration are presented in Table International Journal of Palliative Nursing 2010, Vol 16, No 6

2 Uncertainty As interprofessional collaboration is a multi-faceted concept, professionals may be unsure about what exactly is involved. Some authors, for example, describe interprofessional collaboration in terms of organizational and interpersonal relationships (McWilliam et al, 2003; Belanger and Rodriguez, 2008; Pullon, 2008). Others describe interprofessional collaboration in terms of interactional, organizational and systemic determinants (Martin-Rodriguez et al, 2005). Theoretical discussions focus on interprofessional collaboration in relation to social accountability in health care (Ho, 2008), management of the interprofessional environment (Rogers, 2004), and contingency theory (Willumsen, 2008). In reality, these inter-relationships are complicated, especially when service delivery crosses organizational, agency and professional boundaries (Johnson et al, 2003). Multi-provider service delivery The second issue of interprofessional collaboration concerns the challenges associated with multi-provider service delivery. Not surprisingly, interprofessional collaboration is essential if multiple agencies work together (Mitchell, Harvey and Rolls, 1998; Infante, 2006) or when community stakeholders are involved (Ansari and Phillips, 2001). As a single provider rarely provides palliative care (Hermsen and Have, 2005; Dawson, 2007) this issue is very relevant. Interprofessional collaboration facilitates care although the quality of care, standards, and safety issues become even more critical in an inter-agency situation. Indeed, the link between poor communication and patient safety is well recognized in the health-care community (Boaro et al, 2010: 1). Communication and role understanding The third and most common issue in interprofessional collaboration involves communication Table 1. Key issues of interprofessional collaboration 1. Health professionals are unsure about what exactly is involved 2. Challenges when multi-provider service delivery is required 3. Communication and role understanding are problematic 4. The role of the patient and family is unclear and variable Box 1. Definition of interprofessional collaboration [Interprofessional collaboration is] a practice orientation, a way of healthcare professionals working together with their patients. It involves the continuous interaction of two or more professionals organized into a common effort, to solve or explore common issues with the best possible participation of the patient. Collaborative patient-centred practice is designed to promote the active participation of each discipline in patient care. It enhances patient- and family-centred goals and values, provides mechanisms for continuous communication among care givers, optimizes staff participation in clinical decision making within and across disciplines and fosters respect for disciplinary contributions of all professionals. Source: (Herbert, 2005: 2) that overlaps with role understanding. Interprofessional collaboration encourages and facilitates communication (Shaw et al, 2005) through interaction and the sharing of knowledge. However, if role confusion is present, or there is poor understanding of roles, collaboration is compromised (Shaw et al, 2005). Lack of understanding of other professional roles and responsibilities influences team communication in what can be a confusing or negative manner (Conner et al, 2008; Demiris et al, 2008). Therefore, knowledge of roles, responsibilities, and good communication skills are crucial for effective interprofessional collaboration (Robinson and Cottrell, 2005). Communication skills recognized as important include networking, interpersonal skills, conflict resolution, managing change, and negotiation (Norris et al, 2005). Unclear roles The final and most important issue in interprofessional collaboration relates to the role the patient and family have in this model of care. Advocates for greater patient and family involvement argue that including the patient as a team member makes care safer (Howe and Sherman, 2006). There is little mention of how and when this might happen. Whether or not the patient and family want to be included is another matter. Inclusion may improve communication, yet it is not routine (Oliver et al, 2005; Thompson, 2007; Demiris et al, 2008). While inclusive processes are poorly documented, those that are documented are not necessarily good examples of interprofessional collaboration (Hall et al, 2007). Power sharing seems to be an issue that challenges everyone involved. Overall, the patient-family position in interprofessional collaboration is unclear. Although the WHO (2009) certainly sees the patient-family as central to collaborative practice this is not necessarily the norm within practice. One exception is the Canadian Nurses Society position statement International Journal of Palliative Nursing 2010, Vol 16, No 6 286

3 The patient and family cannot be the centre of care if they are not included in the collaborative process at every level on interprofessional collaboration, which states (Canadian Nurses Association, 2005: 2): Health professionals work together to optimize the health and wellness of each individual and involve the individual in decision-making about his or her health. Once again, there are no guidelines to indicate how this working together might happen. So far, there is little research on the patient and family role in receiving interprofessional care in palliative care. Not understanding the roles of the patient and family make it very difficult to practice using a collaborative model of care. These problems do not stand in isolation and have implications for practice. Implications for practice The notion of interprofessional collaboration is interesting when examined more closely. On the face of it, this model of service delivery has much to offer. A closer inspection suggests there are other contextual and cultural issues at stake that have implications for practice (Table 2). For example, palliative care providers assume that the dying patient has multiple complex problems that a single discipline cannot solve. Because problems are considered complex, the patient and family needs access to the knowledge and skills of various experts. Providing this care under the collaborative umbrella should ensure that the patient has a good death. However, if problems are not complex or the only problem is impending death, the risk is the identification of unnecessary problems, simply because a collaborative team is available. This may occur in part because the definition of hospice and palliative care states that care must involve collaboration and teamwork. If the patient and family are included in the collaborative process, risks decrease. The second practical problem requiring some scrutiny is that the patient and family is the centre of care. However, the patient and family cannot be the centre of care if they are not included in the collaborative process at every level. On the one hand, the patient and family may want an active role at the end of life. Alternatively, Table 2. Implications for practice Contextual, cultural and diversity issues Patient and family is the centre of care No comparison to other models of care Further research is required they may find that participation takes time and energy that they would rather spend elsewhere at this sensitive time. Whatever the choice, the various levels of participation must be respected. What is important for palliative care nurses is to find out if the patient and family see themselves as the centre of care. If they do, how might they choose to engage in the sharing of responsibilities, partnership working, and power sharing? If their preference is not to take on this role, whom do they want to make decisions on their behalf? These are beginning questions and the diversity of patients and families is such, many more are likely. Overall, what is known is that in health care generally, interprofessional collaboration as a practice norm is rare (Gardner, 2009). It is most unlikely that palliative care functions differently although those who work in this area may disagree. This means that the collaborative model of care should be viewed cautiously in what is a highly specialized area of practice. In some situations, it will work very well and in others, an alternative model of care might be a more practical option. Context, culture and the diversity of all involved will influence choice. Certainly, few have argued against interprofessional collaboration as the best model of care but there is no research examining or comparing different team models in palliative care (Higginson et al, 2003). In the final analysis, it is important to remember that interprofessional collaboration is not required for all decisions and collaboration is not a panacea, nor is collaboration needed in every situation (Gardner, 2009). Conclusion In this paper, factors affecting interprofessional collaboration in palliative care have been examined. This model of practice is not quite as straightforward as it seems. There are several issues to consider, including understanding exactly what is involved in interprofessional collaboration and how interprofessional collaboration happens when multiple-provider service delivery is required. Of particular note are the issues of communication and role understanding, both of which raise questions about the patient and family and where they sit in this model of care. While there is no doubt that interprofessional collaboration involves patient-centred care, teamwork and partnership working, the role of the patient and family is not at all clear. Caution is required before embracing this way of working wholeheartedly, as one model of care does not suit every family, and alternatives may be required to ensure care focuses on patient needs. Research 287 International Journal of Palliative Nursing 2010, Vol 16, No 6

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