4 Teamwork, managing conflict and self-care

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When you have completed this chapter you should be able to:

  1. Understand how a team functions.
  2. Work as an effective member of a healthcare team.
  3. Recognise the importance of open, honest and empathetic communication between team members.
  4. Recognise and manage conflict between the team and the patient or parents.
  5. Know when and how to refer a patient and mobilise community support.
  6. Recognise and manage the symptoms of burnout and compassion fatigue.
  7. Take care of yourself physically, emotionally, spiritually and socially.

Understanding the basics of the team and teamwork

4-1 What is a team?

A team is a group of individuals who work together to achieve a common goal. In healthcare, this is a group of people working together to achieve the best possible outcome for the patient.

A team is a group of people who work towards a common goal.

Healthcare teams are not always doctor led. In chronic care, the leader of the team may change several times to ensure that the team is effective, allowing different opinions and ideas to be shared and to ensure that patients get the best care possible at all stages of their illness.

4-2 Are there different types of teams?

Yes, there are several different types of teams in healthcare. The types of teams that will provide palliative care for children are usually a multidisciplinary or interdisciplinary team:

Although in practice the words multidisciplinary and interdisciplinary are often used to mean the same thing, i.e. people from different disciplines working together, the interdisciplinary team is considered the better option for providing children’s palliative care.

4-3 What is the advantage of having team members from different disciplines?

To care for and support the child and family holistically, no one healthcare provider or caregiver can provide all the care and meet the needs of both the child and family. The care team will be made up of those members who can provide the care and support for the specific need at the time. Therefore the members of the care team may change as the needs change along the course of the illness. The type of team may also vary according to the availability of different disciplines or professionals, and the setting in which the patient is being cared for.

The type of team that is most effective in providing holistic care is the one that can provide and meet all the needs that the patient and family require at that particular time.

For the purposes of this book we refer to the healthcare team as the ‘care team’.

4-4 What is teamwork?

Teamwork is the ongoing process of interaction between team members as they work together to provide care to patients. This interaction consists of the individual input of each of its members. Effective teams, working collaboratively, can achieve more than individuals can on their own.

4-5 Why is teamwork important in children’s palliative care?

A teamwork environment promotes an atmosphere that encourages collaboration and loyalty. It makes for a pleasant work environment where individuals cooperate with and support each other. Teamwork ensures effective communication which will benefit the team members but, most importantly, the patient. Effective teamwork is especially important in an emotionally charged situation such as an intensive care unit (ICU).

4-6 What are some of the key characteristics of an effective team?

Important characteristics include:

Key characteristics for effective teamwork include mutual respect, trust and good communication.

Honesty, together with kindness, is what is needed to ensure good teamwork.

4-7 What are some of the obstacles to effective teamwork?

Some of the obstacles to effective teamwork include the following:

These obstacles are also common causes of conflict in a healthcare team.

4-8 Why is mutual respect important when working in a healthcare team?

Healthcare teams are made up of individuals who have different skills, different qualifications and different personalities. Because of this, team members and colleagues must respect one another to preserve the optimal functioning of the team and the best interests of their patient.

Mutual respect is important in a care team.

4-9 Who makes up the care team?

The care team are the key people involved in the care of each patient. In children’s palliative care the team members include, but are not limited to:

A care team in palliative care is made up of the patient, close and extended family, healthcare providers and anyone else involved with the care of the patient.

4-10 Why should the child and family be part of the care team?

The child and family are an integral part of the care team. The continuous care of the child rests in the hands of the family, while the healthcare providers are there to provide care and support along the way. Identifying who the main caregivers are and making sure that they are well informed team members, will ensure that the child has good continuity of care when they go home and that their treatment is adhered to. Caregivers that are part of decision making feel included and valued.

It is essential that the child and caregivers are included as integral members of the healthcare team.

4-11 What can the care team do to assist parents and family members to feel part of the team?

There are many things that the care team can do:

4-12 How can we include the child in the care team?

To make the child feel that they are part of the care team:

Allowing the child to be part of the discussions and decision making can assist in helping them feel part of the care team.

4-13 How do you mobilise community support effectively?

There are a number of steps to mobilise the community and thereby include them in the care team:

The social worker or a key family member can help identify community members and extended family that will support the family and child when they return home or while they are in hospital for extended periods.

See chapter 6 for more detail on mobilising community support.

Managing conflict

4-14 What is conflict?

Conflict is a serious disagreement that arises when two or more people cannot agree with each other on a particular matter. Conflict can be positive when it leads to increased creativity and the generation of good ideas in a group, but it can also be negative when it leads to a breakdown in relationships.

Conflict can cause:

4-15 What may result from conflict between healthcare providers and the parents or caregivers?

Families need to feel safe and supported. However, conflicts can arise when parents and the healthcare providers have different ideas on what is best for the child or when communication has not been clear and compassionate. Poor communication between the care team and the parents is likely to lead to a great deal of anger and frustration and ultimately, a breakdown in trust. This is a frightening time for parents and their child. If they do not trust their team or do not feel included, the journey is made even harder for everyone and conflict is likely to occur.

Healthcare providers should be open to differing opinions and allow parents to seek a second opinion if they so wish or get a referral to another team that the parents may feel can provide more appropriate care for their child. The current team should then help facilitate this transfer to alleviate any further stress on the family.

Poor communication and a lack of trust are common causes of conflict.

4-16 How can conflict be managed?

Conflict between patients, families and healthcare providers must be managed empathetically, compassionately and honestly. Team members should be prepared to offer a sincere apology if and when mistakes have been made. Sometimes it may help to bring in an outside professional to counsel and help resolve conflict. Simply overcoming a misunderstanding or enabling the different parties to calmly discuss the problem may be all that is needed.

Conflict needs to be managed empathetically, compassionately and honestly.

Referral pathways

4-17 What is the referral pathway?

A referral pathway is the way that patients are directed to a more appropriate facility or healthcare provider who will take over the care of the patient or management of a particular problem the patient may have. The referral pathway involves a referral process within the healthcare system.

4-18 What role do referral pathways play in good teamwork?

The people referring and receiving the referral are important members of an extended care team. The referral system could include referrals to different facilities or institutions e.g. from a general hospital to a community-based organisation.

4-19 Why do we need an effective referral pathway?

An effective referral pathway ensures a close relationship between all levels of healthcare and helps to ensure patients receive the best possible care closest to home. Referring patients along this pathway allows for the continuity of care of the patient.

Referrals are about good communication to ensure continuity of care.

4-20 When would you consider referring the patient?

There are many reasons to refer a patient. Recognising when to do so, is important:

There are many good reasons for the referral of patients to other healthcare providers or teams.

Many families when faced with a life-threatening diagnosis and complex treatments would value a second opinion. This should be welcomed and encouraged to ensure patient satisfaction and continued good relationship. This does not always mean that the patient or the parents of the patient wish to go elsewhere for care. Families often just want to ensure that they are making the right decisions. Together you can decide what is the best way forward.

4-21 What are the steps to be taken in the referral process?

The steps include:

  1. Identify whether the current place of care has an established referral policy and protocol in place. If in place, follow this. If no formal structures for referral are in place, there should be an initial telephonic conversation requesting the referral.
  2. Discuss the process with the parents and the patient.
  3. A written referral letter giving a detailed explanation of the patient’s history, care plan and reasons for referral, should accompany the responsible person taking the child to an alternative place of care or home.
  4. A copy of the referral should to be placed in the child’s clinical record.
  5. Follow-up on the patient by requesting that there be feedback either telephonically or by written communication. The following feedback information is essential:
    • What was assessed and the conclusions made
    • A clear outline of the care plan going forward
    • How you can manage the pain and other symptoms as the disease progresses
    • What has been explained to the mother and child
    • What other concerns may arise
    • When to refer back to the hospital.

Clear, comprehensive documentation and referral letters are essential when a patient is referred.

Remember: if it is not written down, it is considered “not done”.

Self-awareness, debriefing and self-care

4-22 What is self-awareness?

Self-awareness is having a clear idea of your personality, your emotions, beliefs, motivation, strengths and weaknesses. Understanding yourself helps you to recognise why you may be responding in a particular way at a particular time. For example, you might find yourself responding angrily to a patient or a colleague. Self-awareness will help you work out why you are responding in this way. Perhaps it is nothing to do with them but rather that they have evoked that emotion in you.

Self-awareness is having a clear idea of your personality, your emotions, beliefs, motivation, strengths and weaknesses.

4-23 What is debriefing?

Debriefing is when the healthcare team comes together to talk about a difficult event or situation that has happened. The goals of debriefing are to discuss the actions and thought processes involved in a particular patient care situation, to encourage reflection on those actions and thought processes, and to incorporate improvement into future performance.

Debriefing allows members of a healthcare team to meet and discuss a difficult event or situation that has happened or time to reflect after the patient has died.

4-24 Why is debriefing important?

In healthcare we face many difficult situations. Debriefing is an opportunity to deal with the emotions and issues that have arisen during patient care. The function of debriefing is to look at what went well and what did not, and then focus on how improvements in patient care can be made in future. Through debriefing, healthcare providers are able to deal with complex emotions, improve performance and prevent burnout. This is a confidential, safe group session in which to share with mutual respect and honesty. These are all important for a successful debriefing session which will help the team function effectively.

See Appendix C: Debriefing model

4-25 What is burnout?

Burnout is mostly associated with workplace stress and is where an individual is exhausted physically, emotionally and mentally due to prolonged and excessive stress. Burnout is common in overloaded working conditions.

Burnout is where the individual is physically, mentally and emotionally exhausted.

4-26 What are some common symptoms of burnout?

Common symptoms of burnout include:

The above list is just a guide which includes some of the most common warning symptoms. Burnout can lead to depression, if not correctly managed.

Common symptoms of burnout include feeling chronically tired and demotivated, anxious and irritable with poor concentration and sleeping difficulties.

4-27 What can you do if you recognise yourself experiencing any of these symptoms of burnout?

When you become self-aware and begin to understand that you are not coping as well as you could be, it is time to take action. Recognising that you need help is an important first step. It is not because you are weak that you need help – rather that you are human. You need to find someone that you trust who you can talk to.

4-28 What is compassion fatigue?

Compassionate fatigue is most easily understood as the cost of caring. Health professionals, especially nurses, are required, due to the nature of their job, to be kind, caring and empathetic. With repeated exposure to trauma and loss they can become victims of compassion fatigue.

The emotional cost of caring is known as compassion fatigue.

Research has shown that healthcare providers trained in palliative care, and who are familiar with the principles of caring for a patient holistically, are often at less risk of suffering from compassion fatigue.

4-29 What is the difference between burnout and compassion fatigue?

The key difference between burnout and compassion fatigue is that by changing jobs you may well be able to resolve many of the conditions or stressors that lead to your burnout; however, with compassion fatigue, this is unlikely since it is the nature of the work that is the underlying cause.

4-30 What are some common warning symptoms of compassion fatigue?

Common warning symptoms of compassion fatigue include:

A common symptom of compassion fatigue is loss of meaning and purpose in the work that you do.

4-31 What can you do if you recognise yourself experiencing any of the symptoms of compassion fatigue?

If you feel that you are suffering from compassion fatigue or that one of your colleagues is, immediately seek professional help. Usually a counsellor, psychologist, social worker or religious leader will be qualified to help. Compassion fatigue can prove extremely damaging to yourself and your job performance, and can endanger your patients and your own long-term health. Parents and caregivers can also suffer from compassion fatigue.

Healthcare providers are at risk for both burnout and compassion fatigue and should seek professional help.

The above two check lists are by no means a definitive diagnosis that you are suffering from burnout or compassion fatigue or both. They are a useful general check list which can act as a warning. For a more in-depth assessment, ensure that you speak to a professional.


4-32 What is self-care?

Self-care is about you. It is about looking after yourself physically, emotionally, spiritually and socially (mind, body and soul) so that you can be the best person possible both at work and at home. Self-care is different for everyone as it is whatever nourishes and re-energises you. Through self-care you can develop resilience (the ability to bounce back) and the ability to walk forward positively every day. Self-care also ensures that you will be a fully functioning and effective member of a healthcare team. We cannot care for others if we do not also care for ourselves.

Self-care is important so that you can be your best both at home and at work.

4-33 Why should self-care become a daily practice?

Daily self-care practices will help you build up resilience to deal with the emotional and sometimes traumatic health events that you face daily with your patients. Resilience is the ability to bounce back after a stressful time. Each of us is like a pot of liquid with a lid over a fire. The logs in the fire under the pot represent the stress in our lives. As more logs are piled onto the fire it gets hotter and the liquid in the pot begins to boil. If we do not find a way to lift the lid and relieve some of the pressure, the contents will bubble over. Once that has happened we are unable to get all that liquid back into the pot. Self-care is like lifting the lid a little every day to stop it boiling over.

4-34 How can we take care of ourselves at work?

Self-care is about caring for your body, mind and spirit. It takes discipline to eat a balanced diet, sleep enough, exercise and ensure we keep our minds healthy. In healthcare teams you should take time each day to check in with one another. Each of us is a human being and this should never be forgotten. There are a number of things you can do at work to help take care of yourself:

4-35 How can we take care of ourselves in our private life?

There are a number of things that will help:

The key lesson of self-care is that you cannot care for your patients or work well with others if you are not also taking care of yourself.

True self-care is not an occasional luxury treat or holiday. It is the discipline to care for your mind, body and spirit; building the life you want to live.

4-36 What is mindfulness?

Being mindful is simply being fully aware of what is happening in the present. The aim is to stay calm, quiet and reconnect with yourself and nature. Mindfulness is the basic human ability to be fully present, aware of where we are and what we are doing. The idea is to not be overly reactive or overwhelmed by what is going on around us. Mindfulness is an awareness of our thoughts, feelings, bodily sensations, and surrounding environment. There are a number of ways you can practice being mindful:

Mindfulness is an effective way of decreasing anxiety and stress and increasing self-compassion.

Mindfulness is an effective way of decreasing anxiety and stress.

You can read more about mindfulness and its benefits at https://www.mindful.org/what-is-mindfulness

4-37 What barriers are there to self-care?

There are many barriers to self-care:

4-38 What must self-care include?

Good self-care includes making sure that boundaries are in place and that you are protecting your mental health. So, make time and make space for yourself. If you do not, the consequences can be severe for all involved in the healthcare relationship. This includes not just your work environment and patients but also your family and loved ones.

Good self-care includes setting boundaries and taking care of your mental health.

4-39 What are boundaries?

It is important to set both personal and professional boundaries as they are a key part of self-care:

Boundaries are a key part of self-care. ‘In work or in our personal relationships, poor boundaries lead to resentment, anger, and burnout’ (Nelson, 2016). Setting boundaries helps to avoid burnout and stay in the profession longer (Bernstein-Yamashiro and Noam, 2013). Read more about boundaries at https://www.ncsbn.org/ProfessionalBoundaries_Complete.pdf.

4-40 How can we be aware of our boundaries and crossing them with our patients and their families?

There are a number of ways to be aware of our boundaries:

Patients and their family members are dependent on you for the care of their loved ones and therefore they are vulnerable in your care. Respect this vulnerability and do not violate it in any way. Trust on both sides of the relationship is key.

Case study 1

A 15-month-old baby, Sipho, has been in intensive care since birth. The little boy has a rare muscle disease and is being ventilated via an endotracheal tube. The family and healthcare team are finding it difficult to work together due to a breakdown in relationship between the doctor, who leads the care team, and the family. Sipho’s parents feel excluded from their son’s care. They feel unheard and desperate. There is also a breakdown of relationship between the nursing staff and doctors in the intensive care unit, particularly those looking after Sipho. This strained teamwork has made the family very uncomfortable.

1. What negative impact has this lack of teamwork had on the family?

The family feels unheard, alone and desperate. This has led to a breakdown of relationship between the family and the healthcare team.

2. When caring for children how can you include the family in the journey?

Healthcare staff can ask the family their opinion and ensure that before any medical action is taken, the family is properly consulted. Staff should also take time to carefully discuss the advantages and disadvantages of any treatment or procedure and regularly check in with the family to ensure that they feel heard, understood, included, informed and supported.

3. How can the breakdown in relationship between the care team and the parents affect the care that Sipho receives?

Breakdown of relationships leads to loss of trust, anger, frustration and an ongoing cycle of poor communication. An intensive care unit can be an emotionally charged environment and it is likely that some clinical issues can be missed and mistakes made. For example, the question of whether to continue ventilation may need to be discussed. This could negatively impact on the overall care of Sipho.

4. How can this family be helped to feel part of an effective care team?

The team should include various healthcare professionals with diverse skills, who listen and use an interdisciplinary team approach to care and to provide the holistic care Sipho needs. The team should check in regularly to see if there is anything the parents need and if they are feeling heard and included in decisions.

Case study 2

A 5-year-old girl known to have advanced bone cancer comes to the clinic in severe pain. Her mother is distressed because the child is crying and has not slept all night. Your clinic only stocks paracetamol for pain. The mother is also very worried because her 13-year-old daughter is alone at home.

1. What can you do?

This child needs an urgent referral to a higher level of care as your clinic does not stock the suitable medication that will alleviate her pain. You will need to phone ahead and write a detailed letter explaining both the physical and emotional concerns. Perhaps a neighbour could be contacted to stay with the older sister.

2. What else can you do?

When making the referral, urgent advice can be sought as to how to manage the pain with the available clinic resources. This is good teamwork.

3. At your clinic, who else can be involved in the care of this family?

As this child has a very serious terminal illness, she will need assistance from the many members in the care team. A social worker can help for emotional support and advice regarding the patient, while physiotherapy could help for positioning. Nurses could provide physical care and emotional support to soothe the mother and the child.

4. Is there anyone else that could be involved in the care of the child?

Beyond the clinic team there may be a local hospice or community-based organisation that can assist with palliative care at home. The family may belong to a supportive religious community who can assist with prayer and spiritual care. Both children’s teachers can be informed to offer additional support.

5. What should be included in the referral back to you?

It would be useful to understand what was assessed and the conclusions that were drawn with respect to the child’s condition. A clear outline of the care plan going forward, especially how you can manage the pain and other symptoms as the disease progresses, what has been explained to the mother and child, what other concerns may arise and when to refer back to the hospital.

6. How can you care for the clinic healthcare team?

Dealing with a terminally ill child in pain and a distressed parent is enormously stressful for most healthcare providers. The clinic supervisor should arrange an urgent debriefing of the staff to look at what went well, what could have gone better and how things can be improved in future. The team can then go home feeling supported and having had their emotions dealt with safely.

Case study 3

An incident happens at work during tea time. You chose a coffee cup from the cupboard. Your colleague came in very angry and upset. She shouted at you in front of the whole team saying you purposefully picked her favourite cup knowing it would upset her. You have noticed a few of these outbursts over the last few months. She has also taken many sick days which is unusual for her.

1. Could she be suffering from burnout?

Yes. She is showing the following signs of burnout: quick to anger over a small issue, paranoia (she accused you of purposefully trying to upset her) and absenteeism.

2. What other signs would you look out for?

The things to look out for are her emotional state, frequent complaining, poor concentration and being tired all the time.

3. How should you approach your colleague?

Approach her very gently. There is a good chance that she is not aware that she is burning out. In a calm moment you could empathetically tell her that you are worried about her. Ask if she has noticed how she is feeling. Allow her to do most of the talking.

4. What can you do if she is not willing to talk to you?

Burnout can lead to a prolonged depression with a very slow recovery. It can also result in poor patient care, mistakes and complaints. If you are concerned you must discuss this with your senior manager to take it further.

5. How can you prevent yourself from burning out?

The key to preventing burnout is proper self-care, looking after your mind, body and spirit. This involves sleeping enough, exercising, eating well and investing in activities that nourish you as an individual. You can also ensure you have boundaries in place.

6. How can you set personal boundaries?

Setting boundaries is about deciding what you will and what you will not be responsible for. It can be very difficult to say no to others and therefore take too much on yourself. Ensuring that you know your own priorities so that you can find a healthy balance between work and home is very important.

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