Developing leadership in rural interprofessional palliative care teams

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<ul><li><p>Developing leadership in rural interprofessional palliativecare teams</p><p>PIPPA HALL1,2, LYNDA WEAVER1, RICHARD HANDFIELD-JONES2, &amp;</p><p>MARYSE BOUVETTE1</p><p>1SCO Health Service, Ottawa, and 2Department of Family Medicine, University of Ottawa, Ottawa,</p><p>Ontario, Canada</p><p>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.</p><p>Keywords: Leadership, interprofessional practice, palliative care, education</p><p>Introduction</p><p>In 1994, Ontario implemented an educational initiative to improve palliative care services</p><p>across the province. The Sisters of Charity of Ottawa (SCO) Health Services Palliative Care</p><p>Program (which is affiliated with the University of Ottawa as a teaching site), was given the</p><p>mandate for these educational initiatives for an area of Eastern Ontario from Deep River to</p><p>the Quebec border. This region is commonly referred to as the Champlain District. The</p><p>Province of Ontario recently regionalized health care management; this district is now</p><p>served by the Champlain Local Health Integrated Network (LHIN). The mandate</p><p>included the development of a consultation resource for health care professionals and</p><p>informal caregivers (called the Pain and Symptom Management Team) and a mandate for</p><p>physician palliative care education. Palliative care requires interprofessional collaborative</p><p>teamwork in order to deliver the best quality of care to terminally ill patients and their</p><p>families (Canadian Hospice Palliative Care Association [CHPCA], 2002). In rural areas,</p><p>Correspondence: Pippa Hall, MD, CCFP, MEd, FCFP, Program Director, Palliative Medicine Residency Program, SCO Health</p><p>Service, Ottawa, Associate Professor, Department of Family Medicine, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1N</p><p>8H5, Canada. Tel: 1 613 562 4262 ext 4014. Fax: 1 613 562 6371. E-mail: phall@scohs.on.ca</p><p>Journal of Interprofessional Care,</p><p>June 2008; 22(S1): 73 79</p><p>ISSN 1356-1820 print/ISSN 1469-9567 online 2008 Informa Healthcare USA, Inc.DOI: 10.1080/13561820802028337</p><p>J In</p><p>terp</p><p>rof </p><p>Car</p><p>e D</p><p>ownl</p><p>oade</p><p>d fr</p><p>om in</p><p>form</p><p>ahea</p><p>lthca</p><p>re.c</p><p>om b</p><p>y Q</p><p>UT</p><p> Que</p><p>ensl</p><p>and </p><p>Uni</p><p>vers</p><p>ity o</p><p>f T</p><p>ech </p><p>on 1</p><p>1/20</p><p>/14</p><p>For </p><p>pers</p><p>onal</p><p> use</p><p> onl</p><p>y.</p></li><li><p>few resources exist to develop teams providing only palliative care, and the primary health</p><p>care providers must learn the knowledge, skills and attitudes necessary to provide high</p><p>quality palliative care. This includes learning to collaborate and integrate these approaches</p><p>into their busy primary care practices. Through a series of innovative community-based</p><p>initiatives, strong relationships were formed between the rural communities and the SCO</p><p>Health Service Palliative Care Program, which resulted in outcomes to improve the care of</p><p>the terminally ill in those communities (Hall et al., 1999; Hall 2001).</p><p>An important outcome of this ongoing work together was the development of</p><p>identifiable health care provider teams in eight rural communities. In 2000, the SCO</p><p>Health Service Palliative Care Educational Team shifted their strategy from educators to</p><p>facilitators; they began to facilitate these rural teams to enable them to be the drivers for</p><p>their local educational initiatives, called Community Educational Projects (CEPs). Each</p><p>team identified the needs of its community, established goals and objectives, developed an</p><p>education intervention that suited their local community, and then implemented and</p><p>evaluated it. These projects resulted in innovative and successful community-based</p><p>projects, which have continued to evolve since 2000. In addition, the team members were</p><p>recognized as local experts and leaders for palliative care in their communities, becoming</p><p>advocates for the care of the terminally ill through involvement with committees and social</p><p>action groups.</p><p>The CEP teams formed naturally from among the complementary health care providers in</p><p>their various roles working in their communities. However, leadership of the teams had</p><p>never been formally examined. Though there had not been any significant problems with</p><p>leadership, it occurred to the SCO Health Service Palliative Care Educational Team that</p><p>defining possible leadership models and enhancing leadership abilities would be helpful for</p><p>the teams to work effectively and to continue influencing their communities.</p><p>This project was conducted as part of a national multi-centred project called Issues of</p><p>Quality and Continuing Professional Development: Maintenance of Competence (or</p><p>CPDiQ), as described elsewhere in this supplement. Funded by Health Canada, this project</p><p>fostered a network of faculty members interested in interprofessional health education</p><p>across the 16 Canadian medical schools. This paper describes project at the University of</p><p>Ottawa, designed to explore leadership in the CEP teams, including finding ways to enhance</p><p>the skills of those in leadership roles.</p><p>Methods and activities</p><p>The principal goal of the Ottawa CPDiQ project was to develop and deliver interventions</p><p>designed to enhance the leadership abilities of the designated leaders in the CEP teams. This</p><p>was to be achieved by conducting a needs assessment on leadership issues to determine their</p><p>experience with interprofessional team work, to explore their perceptions of their roles as</p><p>leaders, and to assess what kinds of leadership skills they believed needed to be developed.</p><p>The subsequent objective would be to develop appropriate educational interventions. The</p><p>project had three phases:</p><p>(1) Needs assessment</p><p>The eight CEP teams were invited to participate in the Needs Assessment. Focus groups</p><p>were held in 20042005 with each of the seven CEP teams who agreed. Notes were taken at</p><p>the focus group sessions, and reviewed with group before the session ended. The data was</p><p>then merged and content-analyzed for common themes and issues.</p><p>74 P. Hall et al.</p><p>J In</p><p>terp</p><p>rof </p><p>Car</p><p>e D</p><p>ownl</p><p>oade</p><p>d fr</p><p>om in</p><p>form</p><p>ahea</p><p>lthca</p><p>re.c</p><p>om b</p><p>y Q</p><p>UT</p><p> Que</p><p>ensl</p><p>and </p><p>Uni</p><p>vers</p><p>ity o</p><p>f T</p><p>ech </p><p>on 1</p><p>1/20</p><p>/14</p><p>For </p><p>pers</p><p>onal</p><p> use</p><p> onl</p><p>y.</p></li><li><p>(2) Goals and objective development</p><p>Based on the results of the focus group, suggested educational goals and objectives were</p><p>developed by the project team, in 2005.</p><p>(3) Intervention delivery</p><p>A menu of educational options to achieve the goals and objectives was developed by the</p><p>project team. The results of the needs assessment, the goals and objectives and the</p><p>educational options were then presented to all the CEP teams via videoconference in the fall</p><p>of 2005.</p><p>Outcomes and results</p><p>Seven of the eight CEP teams participated in all three phases. The number of participants in</p><p>each focus group varied, based on the membership of the team, ranging from a minimum of</p><p>two (nurse-doctor dyad) to six (two physicians, nurse, pharmacist, long-term care</p><p>representative, spiritual care professional). Other teams also included representation from</p><p>recreational therapists, occupational therapists, physiotherapists, health care administrators,</p><p>home care case managers and representatives from nursing agencies. The non-participating</p><p>team had completed their earlier project by 2005, presented their results, and several team</p><p>members had moved away before this new project had started.</p><p>The content analyses of the focus group data led to a clear identification of the successes</p><p>and challenges experienced by the teams, and some needs for educational interventions by</p><p>team members.</p><p>The specific factors contributing to the success of their CEP teams included:</p><p>(1) There was no specific Team Leader, but different leaders for different tasks,</p><p>according to the demands of the task. Generally, leadership was shared.</p><p>(2) Though there was no single leader, an administrative coordinator with paid protected</p><p>time was considered essential. This person was responsible for coordinating the</p><p>teams activities, including organizing team meetings (e.g., scheduling, agendas,</p><p>minutes), insuring important tasks were assigned and completed, and generally</p><p>helping to keep the team on track and visible in the community.</p><p>(3) Successful teams had representation of key stakeholders involved in palliative care</p><p>across the community, that is, from acute care, long-term care, and home care</p><p>(Community Care Access Centres and nursing agencies). These members provided</p><p>leadership when needed within the CEP team and for taking the information back to</p><p>their respective agencies and/or professions.</p><p>(4) Teams required a committed physician, but the physician did not have to be the team</p><p>coordinator or the leader.</p><p>(5) Teams required good communication, which was already greatly facilitated by being</p><p>in a small community. Team members showed respect and openness to the ideas of</p><p>all team members.</p><p>(6) Team members shared responsibilities and helped empower others on their team.</p><p>(7) Team leadership required commitment, effective communication, the ability to coach</p><p>other team members, flexibility, and respect for others capabilities.</p><p>(8) Specific challenges of team leadership were: visioning (the ability to see what the</p><p>future could bring); organizational skills; knowing the health care system on practical</p><p>Leadership in rural interprofessional teams 75</p><p>J In</p><p>terp</p><p>rof </p><p>Car</p><p>e D</p><p>ownl</p><p>oade</p><p>d fr</p><p>om in</p><p>form</p><p>ahea</p><p>lthca</p><p>re.c</p><p>om b</p><p>y Q</p><p>UT</p><p> Que</p><p>ensl</p><p>and </p><p>Uni</p><p>vers</p><p>ity o</p><p>f T</p><p>ech </p><p>on 1</p><p>1/20</p><p>/14</p><p>For </p><p>pers</p><p>onal</p><p> use</p><p> onl</p><p>y.</p></li><li><p>and political levels; understanding educational planning; and balancing between</p><p>educational and clinical team demands.</p><p>(9) For success, the team needed practical support. This included: time to meet, discuss,</p><p>plan, implement and assess their educational initiatives; funding and administrative</p><p>support for the team coordinator; and on-going support from SCO team of palliative</p><p>care experts for educational updates and information relevant to their projects</p><p>The focus group participants identified the following specific skills for a leader and other</p><p>team members, which they believed would best help their abilities to facilitate the above</p><p>factors.</p><p>. Interpersonal skills (conflict resolution, facilitating meetings, communication)</p><p>. Academic skills (public speaking, presentation skills, coaching skills, writing proposals/abstracts)</p><p>. Organizational skills (keeping statistics, writing reports, budgets, keeping minutes,computer skills)</p><p>. Other skills (time management, change theory).</p><p>To enhance these skills, a number of education interventions were initially planned with and</p><p>for the CEP teams. The major one would be a day-long face-to-face workshop on managing</p><p>change and conflict resolution given by two experts in this field from the University of</p><p>Ottawa. There would also be a series of one-hour teaching sessions given through</p><p>videoconferencing on other specific skills (e.g., presentation skills, time management,</p><p>writing, etc.).</p><p>At the time these education interventions were being developed, the Ontario government</p><p>was establishing the new local health authorities, called LHINs, across the province. Among</p><p>their other roles, LHINs support palliative and end-of-life care through End-of-life Care</p><p>Networks and committees. At the same time, Cancer Care Ontario was also implementing</p><p>a palliative and end-of-life care strategy, and was asking the CEP teams to lead an</p><p>educational needs assessment for oncology and palliative care for the entire eastern Ontario</p><p>region. The members of the CEP teams, recognized as advocates and champions for their</p><p>small rural communities, therefore assumed leadership roles on these additional networks/</p><p>committees.</p><p>Thus, the professionals involved in this leadership project became extremely busy with</p><p>these burgeoning new demands. The educational interventions first planned had to shift to</p><p>meet the new and evolving needs of the teams; there was now less time available for the team</p><p>members to participate in the proposed interventions.</p><p>In collaboration with the CEP teams, the original needs were re-examined and a set of</p><p>new education interventions were developed to better match the reality of the leaders and</p><p>teams in a busy and changing environment. The newly modified plans would still allow the</p><p>teams to reach the goal of enhancing leadership qualities through the following activities:</p><p>(1) The creation of a Champlain-wide hospice palliative care resource manual, based on</p><p>the two manuals that had been developed by, and currently existed in, two CEP</p><p>communities. The manual would contain symptom management chapters, contact</p><p>information for local and Champlain-wide resources, and forms for screening</p><p>symptoms and referring to specific palliative care programs. The manual was to be</p><p>available to all primary health care providers who could use it as a reference as well as</p><p>to contact their identified local and regional palliative care experts. The collaborative</p><p>76 P. Hall et al.</p><p>J In</p><p>terp</p><p>rof </p><p>Car</p><p>e D</p><p>ownl</p><p>oade</p><p>d fr</p><p>om in</p><p>form</p><p>ahea</p><p>lthca</p><p>re.c</p><p>om b</p><p>y Q</p><p>UT</p><p> Que</p><p>ensl</p><p>and </p><p>Uni</p><p>vers</p><p>ity o</p><p>f T</p><p>ech </p><p>on 1</p><p>1/20</p><p>/14</p><p>For </p><p>pers</p><p>onal</p><p> use</p><p> onl</p><p>y.</p></li><li><p>work on the manual insured that: all the teams had common, up-to-date information</p><p>that reflected the realities of rural and small town practice; resources available in each</p><p>community were identified; the teams had on-going dialogue with each other.</p><p>(2) The creation of a bereavement services inventory for the Renfrew County. The</p><p>inventory would highlight all the agencies and the bereavement services they</p><p>provided, as well as a profile of each of the services. Although each palliative care team</p><p>was aware of their local resources, other health care providers often were not. The</p><p>inventory was to facilitate dialogue across the region, to build on each others</p><p>strengths and could identify gaps that the region needed to address.</p><p>(3) The provision of monthly pain and symptom management education in 6090 minute</p><p>sessions, via videoconferencing, for the CEP teams. The series would cover 68</p><p>symptoms, and link to other educational sessions when possible. In this way, the</p><p>teams would be able to up-date their knowledge an...</p></li></ul>