Cross Cultural Practice at the End of Life

The Dignity of Difference – Cross cultural practice at the end of life

When beliefs conflict: cohesion and conflict in teams

Maggie DraperNHS North Yorkshire and York

07961 834942Maggie.draper@nyypct.nhs.uk

Dignity of differenceCross cultural practice in Teams

What do we bring to our practice ?

Individual belief systems and influences Culture of Professional rolesCulture of teamsCulture of Institutions Beliefs about service users and end of life care

Conflict and Cohesion in Teams 2

Individual Beliefs and values

3

Individual Beliefs and values

4

Individual Beliefs and values

What do I bring with me to the team?• Values about a “good death”• Values about family, responsibility, freedom• Beliefs about vocation/ work • Power in roles, language, education,

professional identity, health hierarchies• Palliative care myths and culture

5

Where individual beliefs might conflict

• Attitudes to preservation of life at all costs• Religious beliefs about choices service users

make • What is unacceptable individual behaviour ?• What is a reasonable expectation of services ?• What if my belief conflicts with yours ?

6

Team culture and differences

Literature on organisation culture, power and performance and changing cultures

In our work settings - issues of: • Gender• Ethnicity• Expert Knowledge Power• Professional Roles and status• Professional beliefs

7

Professional values British Association of Social workers: “ ... Responsibility to encourage and facilitate the self-realisation

of each individual person with due regard to the interests of others.”

General Medical Council :“...duty to make the care of your patient your first concern”

Institute of Health Care Management:

“strive for accessible and effective health care according to need”

8

Problems in teams include:

• Debate and confusion over what is palliative care

• Lack of understanding of contribution of others

• Role tension and role confusion• Lack of continuity of team members +“Team work takes the form of client discussions

…… marginalising clients and contributing to their disempowerment” (Corner 2003)

9

Why do teams get into difficulties ?

• Lack of clarity and understanding re roles• Lack of structure• No clear visions and explicit goals• Inadequate Resources• Poor organisational climate• Perceived inequalities

(King, 2005)

10

The “challenging” patient and family

How did it make the staff feel ?

Nurses - mixed views• could not get it right• patient not trying, manipulative and

ungrateful• In an inappropriate place• She has the right to be non-compliant

11

The “challenging” patient and family

Medical views:Patient – is she dying or stable disease ?Pressure on bedsUnreliability of reporting of symptomsConcern re manipulationUnfettered permission to stay

12

the “challenging” patient and family

Chaplain - rejected by patient and distressed to hear patient describe herself as “being tossed in a little boat in a big sea”

Physiotherapist Conflict re professional safety, skin careNon compliance and patient complaintRight to refuse all care - and then not to complain

about lack of care

13

the “challenging” patient and family

Social WorkerAngry with team for being “punitive” re moving

out of side roomInability to give re-assurance to pt and family re

permission to stay Issues of equity re length of stay Inability to find good quality alternative care

14

How did it make the team feel ?

• Split• Powerful and powerless• Vocal and non vocal• Angry• Ashamed of Hospice reaction

How do we make decisions in teams? Does 2 HCAs + Chaplain = I consultant ?

Who has responsibility ? Does everyone want it ?

15

Cohesion in teams- case review

Case review using “Thinking Hats” (De Bono) tool

• Acknowledge what did go well • What did not go well – without blame• What we could have done differently in ideal • What we can do differently • Action plan

16

• The MDT – Fact or Fiction ? - J Corner (2003)

Successful teams:

– Members share a common language

– Do not feel threatened by other professional groups

– Individuals value the different contributions made by team members

– Professional values and cultures shared

Characteristics of effective teams

18

• Clear team goals and objectives• Clear accountability and authority• Clear individual roles• Regular formal and informal communication• Confronting conflict constructively• Team rewards (King, 2005)

• Acknowledging and valuing patients and staffs diversity

Institutional Abuse and “culture of niceness” in end of life care

19

“Culture of Niceness”

Gunaratnam’s work challenges• the public myth of goodness and compassion

of hospice staff - and the danger of the myth• Challenges vocational calling of palliative care• “founding history, structures, philosophies

and practices in speciality .. with emphasis on individualised care” = lack of challenge of abuse of power

20

Culture of NicenessIs there pressure on staff to do more than is

reasonable? /“donate” extra timeLower rates of pay/Tolerate poor working

conditions / generational expectationsBullying and Harrassment in small work groupsAvoidance of conflict – and emphasis on

“cultural sensitivity rather than race equality” - Because - “Its a charity - they are dying – tomorrow will

be too late”21

What helps us work with difference ?

• Knowing yourself - acknowledging what you bring to the work, to the relationship

• Knowledge about other people’s beliefs and values and organisational agreement about safe challenges

• User involvement - focussing on patient experience and outcomes

22

What helps us work with difference?

• Time - Teams become more collaborative and consensual – a coalition develops over time

• Clinical Case review – way of safe reflection and challenge

• Celebration of difference – and willingness to engage in the challenge

23