Embed Size (px)
Citation preview
Developing leadership in rural interprofessional palliativecare teams
PIPPA HALL1,2, LYNDA WEAVER1, RICHARD HANDFIELD-JONES2, &
MARYSE BOUVETTE1
1SCO Health Service, Ottawa, and 2Department of Family Medicine, University of Ottawa, Ottawa,
Ontario, Canada
AbstractThis project brought together community-based practitioners and academics to develop and deliverinterventions designed to enhance the leadership abilities of the designated leaders of seven rural/smalltown-based palliative care teams. Members of these community-based teams have already gainedrecognition for their teams’ leadership and service delivery in their communities. All of the teams hadworked closely with most members of the academic team prior to this project. The team membersparticipated in a needs assessment exercise developed by the Sisters of Charity of Ottawa HealthService and University of Ottawa academic team. Results of the needs assessment identified leadershipqualities that had contributed to their success, as well as their needs to further enhance their individualleadership qualities. The team effort, however, was the most important factor contributing to thesuccess of their work. The interventions developed to address the identified needs had to be adaptedcreatively through the collaborative efforts of both the community and academic teams. Theeducational interventions facilitated the integration of learning at the individual and community levelinto the busy work schedules of primary health care providers.
Keywords: Leadership, interprofessional practice, palliative care, education
Introduction
In 1994, Ontario implemented an educational initiative to improve palliative care services
across the province. The Sisters of Charity of Ottawa (SCO) Health Service’s Palliative Care
Program (which is affiliated with the University of Ottawa as a teaching site), was given the
mandate for these educational initiatives for an area of Eastern Ontario from Deep River to
the Quebec border. This region is commonly referred to as the ‘‘Champlain District’’. The
Province of Ontario recently regionalized health care management; this district is now
served by the Champlain ‘‘Local Health Integrated Network’’ (LHIN). The mandate
included the development of a consultation resource for health care professionals and
informal caregivers (called the Pain and Symptom Management Team) and a mandate for
physician palliative care education. Palliative care requires interprofessional collaborative
teamwork in order to deliver the best quality of care to terminally ill patients and their
families (Canadian Hospice Palliative Care Association [CHPCA], 2002). In rural areas,
Correspondence: Pippa Hall, MD, CCFP, MEd, FCFP, Program Director, Palliative Medicine Residency Program, SCO Health
Service, Ottawa, Associate Professor, Department of Family Medicine, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1N
8H5, Canada. Tel: þ1 613 562 4262 ext 4014. Fax: þ1 613 562 6371. E-mail: [email protected]
Journal of Interprofessional Care,
June 2008; 22(S1): 73 – 79
ISSN 1356-1820 print/ISSN 1469-9567 online � 2008 Informa Healthcare USA, Inc.
DOI: 10.1080/13561820802028337
J In
terp
rof
Car
e D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y Q
UT
Que
ensl
and
Uni
vers
ity o
f T
ech
on 1
1/20
/14
For
pers
onal
use
onl
y.
few resources exist to develop teams providing only palliative care, and the primary health
care providers must learn the knowledge, skills and attitudes necessary to provide high
quality palliative care. This includes learning to collaborate and integrate these approaches
into their busy primary care practices. Through a series of innovative community-based
initiatives, strong relationships were formed between the rural communities and the SCO
Health Service Palliative Care Program, which resulted in outcomes to improve the care of
the terminally ill in those communities (Hall et al., 1999; Hall 2001).
An important outcome of this ongoing work together was the development of
identifiable health care provider teams in eight rural communities. In 2000, the SCO
Health Service Palliative Care Educational Team shifted their strategy from educators to
facilitators; they began to facilitate these rural teams to enable them to be the drivers for
their local educational initiatives, called Community Educational Projects (CEPs). Each
team identified the needs of its community, established goals and objectives, developed an
education intervention that suited their local community, and then implemented and
evaluated it. These projects resulted in innovative and successful community-based
projects, which have continued to evolve since 2000. In addition, the team members were
recognized as local experts and leaders for palliative care in their communities, becoming
advocates for the care of the terminally ill through involvement with committees and social
action groups.
The CEP teams formed naturally from among the complementary health care providers in
their various roles working in their communities. However, leadership of the teams had
never been formally examined. Though there had not been any significant problems with
leadership, it occurred to the SCO Health Service Palliative Care Educational Team that
defining possible leadership models and enhancing leadership abilities would be helpful for
the teams to work effectively and to continue influencing their communities.
This project was conducted as part of a national multi-centred project called ‘‘Issues of
Quality and Continuing Professional Development: Maintenance of Competence’’ (or
CPDiQ), as described elsewhere in this supplement. Funded by Health Canada, this project
fostered a network of faculty members interested in interprofessional health education
across the 16 Canadian medical schools. This paper describes project at the University of
Ottawa, designed to explore leadership in the CEP teams, including finding ways to enhance
the skills of those in leadership roles.
Methods and activities
The principal goal of the Ottawa CPDiQ project was to develop and deliver interventions
designed to enhance the leadership abilities of the designated leaders in the CEP teams. This
was to be achieved by conducting a needs assessment on leadership issues to determine their
experience with interprofessional team work, to explore their perceptions of their roles as
leaders, and to assess what kinds of leadership skills they believed needed to be developed.
The subsequent objective would be to develop appropriate educational interventions. The
project had three phases:
(1) Needs assessment
The eight CEP teams were invited to participate in the Needs Assessment. Focus groups
were held in 2004–2005 with each of the seven CEP teams who agreed. Notes were taken at
the focus group sessions, and reviewed with group before the session ended. The data was
then merged and content-analyzed for common themes and issues.
74 P. Hall et al.
J In
terp
rof
Car
e D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y Q
UT
Que
ensl
and
Uni
vers
ity o
f T
ech
on 1
1/20
/14
For
pers
onal
use
onl
y.
(2) Goals and objective development
Based on the results of the focus group, suggested educational goals and objectives were
developed by the project team, in 2005.
(3) Intervention delivery
A menu of educational options to achieve the goals and objectives was developed by the
project team. The results of the needs assessment, the goals and objectives and the
educational options were then presented to all the CEP teams via videoconference in the fall
of 2005.
Outcomes and results
Seven of the eight CEP teams participated in all three phases. The number of participants in
each focus group varied, based on the membership of the team, ranging from a minimum of
two (nurse-doctor dyad) to six (two physicians, nurse, pharmacist, long-term care
representative, spiritual care professional). Other teams also included representation from
recreational therapists, occupational therapists, physiotherapists, health care administrators,
home care case managers and representatives from nursing agencies. The non-participating
team had completed their earlier project by 2005, presented their results, and several team
members had moved away before this new project had started.
The content analyses of the focus group data led to a clear identification of the successes
and challenges experienced by the teams, and some needs for educational interventions by
team members.
The specific factors contributing to the success of their CEP teams included:
(1) There was no specific Team Leader, but different leaders for different tasks,
according to the demands of the task. Generally, leadership was shared.
(2) Though there was no single leader, an administrative coordinator with paid protected
time was considered essential. This person was responsible for coordinating the
team’s activities, including organizing team meetings (e.g., scheduling, agendas,
minutes), insuring important tasks were assigned and completed, and generally
helping to keep the team on track and visible in the community.
(3) Successful teams had representation of key stakeholders involved in palliative care
across the community, that is, from acute care, long-term care, and home care
(Community Care Access Centres and nursing agencies). These members provided
leadership when needed within the CEP team and for taking the information back to
their respective agencies and/or professions.
(4) Teams required a committed physician, but the physician did not have to be the team
coordinator or the leader.
(5) Teams required good communication, which was already greatly facilitated by being
in a small community. Team members showed respect and openness to the ideas of
all team members.
(6) Team members shared responsibilities and helped empower others on their team.
(7) Team leadership required commitment, effective communication, the ability to coach
other team members, flexibility, and respect for others’ capabilities.
(8) Specific challenges of team leadership were: visioning (the ability to see what the
future could bring); organizational skills; knowing the health care system on practical
Leadership in rural interprofessional teams 75
J In
terp
rof
Car
e D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y Q
UT
Que
ensl
and
Uni
vers
ity o
f T
ech
on 1
1/20
/14
For
pers
onal
use
onl
y.
and political levels; understanding educational planning; and balancing between
educational and clinical team demands.
(9) For success, the team needed practical support. This included: time to meet, discuss,
plan, implement and assess their educational initiatives; funding and administrative
support for the team coordinator; and on-going support from SCO team of palliative
care experts for educational updates and information relevant to their projects
The focus group participants identified the following specific skills for a leader and other
team members, which they believed would best help their abilities to facilitate the above
factors.
. Interpersonal skills (conflict resolution, facilitating meetings, communication)
. Academic skills (public speaking, presentation skills, coaching skills, writing proposals/
abstracts)
. Organizational skills (keeping statistics, writing reports, budgets, keeping minutes,
computer skills)
. Other skills (time management, change theory).
To enhance these skills, a number of education interventions were initially planned with and
for the CEP teams. The major one would be a day-long face-to-face workshop on managing
change and conflict resolution given by two experts in this field from the University of
Ottawa. There would also be a series of one-hour teaching sessions given through
videoconferencing on other specific skills (e.g., presentation skills, time management,
writing, etc.).
At the time these education interventions were being developed, the Ontario government
was establishing the new local health authorities, called LHINs, across the province. Among
their other roles, LHINs support palliative and end-of-life care through ‘End-of-life Care
Networks’ and committees. At the same time, Cancer Care Ontario was also implementing
a palliative and end-of-life care strategy, and was asking the CEP teams to lead an
educational needs assessment for oncology and palliative care for the entire eastern Ontario
region. The members of the CEP teams, recognized as advocates and champions for their
small rural communities, therefore assumed leadership roles on these additional networks/
committees.
Thus, the professionals involved in this leadership project became extremely busy with
these burgeoning new demands. The educational interventions first planned had to shift to
meet the new and evolving needs of the teams; there was now less time available for the team
members to participate in the proposed interventions.
In collaboration with the CEP teams, the original needs were re-examined and a set of
new education interventions were developed to better match the reality of the leaders and
teams in a busy and changing environment. The newly modified plans would still allow the
teams to reach the goal of enhancing leadership qualities through the following activities:
(1) The creation of a Champlain-wide hospice palliative care resource manual, based on
the two manuals that had been developed by, and currently existed in, two CEP
communities. The manual would contain symptom management chapters, contact
information for local and Champlain-wide resources, and forms for screening
symptoms and referring to specific palliative care programs. The manual was to be
available to all primary health care providers who could use it as a reference as well as
to contact their identified local and regional palliative care experts. The collaborative
76 P. Hall et al.
J In
terp
rof
Car
e D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y Q
UT
Que
ensl
and
Uni
vers
ity o
f T
ech
on 1
1/20
/14
For
pers
onal
use
onl
y.
work on the manual insured that: all the teams had common, up-to-date information
that reflected the realities of rural and small town practice; resources available in each
community were identified; the teams had on-going dialogue with each other.
(2) The creation of a bereavement services inventory for the Renfrew County. The
inventory would highlight all the agencies and the bereavement services they
provided, as well as a profile of each of the services. Although each palliative care team
was aware of their local resources, other health care providers often were not. The
inventory was to facilitate dialogue across the region, to build on each other’s
strengths and could identify gaps that the region needed to address.
(3) The provision of monthly pain and symptom management education in 60–90 minute
sessions, via videoconferencing, for the CEP teams. The series would cover 6–8
symptoms, and link to other educational sessions when possible. In this way, the
teams would be able to up-date their knowledge and provide education to their
colleagues.
The outcomes of these three activities were achieved as planned. The Champlain District
Hospice Palliative Care Resource Manual was developed (the first draft was launched in
March 2007), the Renfrew County Grief and Bereavement Services Inventory was compiled
(completed in February 2007), and a series of noon-hour educational sessions on pain and
symptom management were provided from November 2006 to June 2007.
These new activities addressed many of the identified needs of the teams and leaders,
especially the academic skills such as writing, communication, and interprofessional and
inter-agency collaboration through the work on the manual and inventory. The education
series helped to maintain the clinical skills of the teams and of other interested health care
professionals in the communities. The three activities served a larger number of health care
professionals than just the members of the CEP teams and fit better with demanding work
schedules.
Discussion
Important features of leadership qualities in rural interprofessional palliative care teams were
identified. Key among these were the concepts of shared leadership (different team members
being responsible for different tasks) and shared responsibilities. The specific qualities
identified for a leader include good communication skills, respect and openness to the team
members’ ideas, commitment, flexibility and the ability to coach the other team members. A
leader is expected to possess the abilities to see what the future may hold (visioning),
knowing the health care system, and understand educational planning. Shared leadership is
discussed in most textbooks on leadership (Yukl, 2006; Glaser, 2005). The importance of
this style of leadership in collaborative practice settings is being raised in the interprofes-
sional/interdisciplinary literature (Hall & Weaver, 2001; Sullivan & Decker, 2001).
The make-up of the team has an equal impact on the success of the leaders (and therefore
the teams), including being interprofessional with representatives from a number of
agencies, having one person identified as the organizer for meetings, and other practical
support (e.g. computer skills). The team members also need time, financial support and
ongoing support from palliative care experts to maintain cohesion and to achieve success in
being catalysts for change in their communities (Greenhalgh et al., 2004).
Team members in the Eastern Ontario palliative care Community Education Projects
(CEPs) were committed, but extremely busy with clinical and administrative obligations. By
adapting the original plans for specific education on leadership skills, the CEP teams gained
Leadership in rural interprofessional teams 77
J In
terp
rof
Car
e D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y Q
UT
Que
ensl
and
Uni
vers
ity o
f T
ech
on 1
1/20
/14
For
pers
onal
use
onl
y.
further expertise in leadership and created the tools (the Champlain Resource Manual and
the bereavement inventory) to give them recognition for their extensive knowledge and
collaboration. While working on these projects, they strengthened their teams and created
new relationships. The CEP teams are leaders in their communities, and demonstrate their
effectiveness by sharing leadership roles, responsibilities and tasks. Together, they had the
vision to see what the palliative care community as a whole would most benefit from, and the
commitment to go through with the projects. They showed that leadership is not within one
person, but within a team. It takes the skills and attributes of a group of people, both
interprofessional and inter-agency, to achieve significant change that is rigorous and meets
the needs of the entire community.
Providing high quality palliative care in busy primary care settings can be challenging, but
the members of these interprofessional CEP teams have demonstrated that through
collaborative teamwork that integrates community care settings, hospitals and other care
institutions, this goal can be attained. To be effective, education for those committed to
enhance the care of the terminally ill must adapt to the needs of these champions as well as
provide support during the development of their leadership roles.
Conclusions
Busy community-based professionals are committed to improve their capacity to deliver the
best care to the patients and families they serve. These clinicians were able to develop
creative, practical ways to integrate learning into their busy work schedules and to
strengthen links throughout their communities through the associated networking. The role
of the academic team was to listen carefully and with respect to the needs being voiced, to
facilitate the dialogue, to provide guidance when appropriate, and to provide the necessary
resources in a timely manner. The milieu fostered flexibility and openness between all
partners, allowing for the identification of the changing realities of the community-based
practice and for the necessary adjustments. Through the project, we have learned ‘‘with,
from and about each other’’ (Barr et al., 2005) and have emerged with a better
understanding of the realities of the partnership between practice and academia.
Acknowledgements
The academic team would like to acknowledge the tremendous work the palliative care
community education project teams in Renfrew County and the Five Eastern Counties of
Ontario have done, and continue to do. In particular, we thank them for their contributions
to this project, where we have learned so much from their participation.
Declaration of interest: The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
References
Barr, H., Koppel, I., Reeves, S., Hammick, M., & Freeth, D. (2005). Effective interprofessional education – Argument,
assumption and evidence. London: CAIPE & Blackwell Publishing.
Canadian Hospice Palliative Care Association (CHPCA) (2002). A model to guide hospice palliative care: Based on
national principles and norms of practice. Ottawa: CHPCA.
Glaser, J. E. (2005). Creating we. Massachusetts: Platinum Press.
Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service
organizations: Systematic review and recommendations. Milbank Quarterly, 82, 581–629.
78 P. Hall et al.
J In
terp
rof
Car
e D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y Q
UT
Que
ensl
and
Uni
vers
ity o
f T
ech
on 1
1/20
/14
For
pers
onal
use
onl
y.
Hall, P., Weaver, L., Hupe, D., & Seely, J. (1999). Community based palliative care education: Can it improve care
of the terminally ill? Academic Medicine, 74(10), S105–S107.
Hall, P. (2001). Serendipitous ripples: Unexpected outcomes of a palliative care educational project. Journal of
Palliative Medicine, 4(3), 345–352.
Sullivan, E. J., & Decker P. J. (2001). Effective leadership and management in nursing. New Jersey: Prentice Hall.
Yukl, G. (2006). Leadership in organizations, 6th edn. New Jersey: Pearson Prentice Hall.
Leadership in rural interprofessional teams 79
J In
terp
rof
Car
e D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y Q
UT
Que
ensl
and
Uni
vers
ity o
f T
ech
on 1
1/20
/14
For
pers
onal
use
onl
y.
