Instructor Resource ManualModule 7 – TeamTable of Contents

Lecture content outline 2Post-lecture knowledge assessment items 6Answer key and rationale for knowledge assessment items 8Observation assessment form and scoring rubric 9Sample Case 11Sample case group debrief questions and instructor guide 12Sample case role-play activity 13Reflective writing assignment and instructor guide 15

1

Content Outline for Lecture

I. Introduction to COMFORTa. COMFORT is an acronym that stands for 7 basic principles designed to be taught in

early palliative care communication, care provided for individuals with a life-threatening or serious illness

b. The curriculum is based on empirical research in hospice and palliative care, including observations of interprofessional teams, team meetings, team member collaboration, and interviews with team members across a range of healthcare professions.

c. This lecture will provide an overview of module 7 – Team, and more specifically team meetings. This module is an introduction to entry-level communication skills.

II. Objectives overviewa. The objectives of this session are to provide a summary of interdisciplinary team

collaboration and talk about communication in team meetings.

III. Interdisciplinary Collaborationa. Interdisciplinary collaboration is so much more then just putting interprofessional

health care workers team members in one room.b. It requires you to share resources, engage in shared power by identifying common

goals and establishing a unified message for the patient and family.c. It also requires that you respect your colleagues by practicing active listening

IV. Interdependence & Flexibilitya. To begin our discussion about team communication, I’d like to review the elements of

interdisciplinary collaboration. First, interdependence and flexibility among colleagues is necessary.

b. Flexibility means that your job or task changes for every new case. If you approach each case with the same task list, then you may not be engaging in the collaborative process.

c. For every member of the healthcare team, the goal is to provide holistic psycho-spiritual care (Grey, 1996). For example, sometimes you will need to answer questions about medication (even if you are a social worker) and sometimes you will be asked about religious beliefs (even if you aren’t a chaplain).

V. Newly created tasks & responsibilitiesa. The second element of collaboration is that when you work with your colleagues, new

tasks and responsibilities emerge. Again, do you have flexibility in what you provide for patients and families? Could working with team members change how you care for patients/families?

b. When team members collaborate, they share information with each other. This is much more then a shift change or a sharing a patient’s medical history. This is about sharing your expertise, your knowledge about best practices, successes, failures – and most of all, being available to colleagues.

2

VI. Collective ownership of goalsa. The third element of collaboration is collective ownership of goals. Collaboration

establishes shared responsibility and a common purpose for this team.b. Yes, a healthcare team’s goal is to provide patient-centered care. But how does each

team member define that for the patient? If it varies, then there will be problems with team collaboration.

c. Team members must work together to clearly identify and define the plan of care and same goals for the patient/family.

VII. Reflection on processa. Finally, the fourth element of collaboration is reflection on process. And honestly,

this where teams have the most problems.b. Most teams do not do this as a routine team function. Teams typically don't do this

unless there is a problem with team communication!c. Reflection on process involves reviewing the team process. Evaluating your own

process – taking a checks and balances of team communication. Stopping to establish a team goal, a motto, or a mission statement – or using your company’s mission statement – as a way of checking to see if your working process lines up with the goals of patient care.

VIII. Team Meetingsa. The goal of the team meeting is to collaborate.b. As a team member, your responsibility is to make sure that your expertise contributes

to the patient/family care plan.c. Team meetings are where conflict between team members happen, team members

talk about their problems with patients/family, and coordinate care.

OPTIONAL: Ask the Audience to come and share their team meeting experiences or to describe the environment of team meetings that they have observed. If the audience has experience with teams, here are some questions to ask to promote further discussion:- Are your team meetings boring?- Do they have an environment where back-channel politics and personal attacks

thrive?- Are controversial topics ignored?- Does the team fail to tap into all the opinions and perspectives of team members?- Does the team waste time and energy with interpersonal risk management?

IX Communication Impaired Individuals (Rao, 2011; Mathisen, Yates & Crofts, 2011)a. 22-42 million people with hearing impairment in care settingsb. 46 million people with disordered communication in care settingsc. To improve patient outcomes, diagnoses and treaments, patient/family

understanding, and satisfaction, teams must attend to impaired individualsd. Work collaboratively with interpreter service, nursing, medicine, allied health,

dietary, EM, pharmacy, and pastoral caree. Value team roles to achieve effective communication, appreciate diverse

responses, understand different assessments, and reflect on practice and impact

3

IX. Groupthinka. Definition of groupthink.

X. Groupthinka. Unfortunately, many health care teams fall into groupthink patterns. b. Groupthink can occur when “deeply involved” cohesive group members engage in a

mode of thinking that centers on unanimity over the motivation to rationally assess various courses of action (Janis, 1982).

c. Group “work” becomes fixed on cohesion, rather than decision-making. Essentially, team members agree to agree.

d. One reason why groupthink occurs is because many healthcare teams are not evaluated for their team processes.

XI. When Groupthink Occursa. Groupthink occurs when there is pressure on group members to agree not to disagree

(Napier & Gershenfeld, 1999).b. Group members embrace a decision even though they recognize it may not be the best

decision.c. Sometimes difficult patients and/or family members can be perceived as a threat to

the healthcare team. d. Team members have to be careful not to stereotype patients/family members and

focus on the unique dynamics of the patient/family case.

XII. Aspects that influence Groupthinka. An awareness of relational factors can influence the way a team collaborates, or does

not collaborate. For instance, power is a major element in groupthink and this is established via age, education, experience, and position on the team.

b. But also, individuals have their own inherent way of dealing with conflict---some are more comfortable with it, others see it as a threat.

c. A primary cause of Groupthink is self censorship. When multiple perspectives are suppressed, a lack of ideas and sharing occurs. If a dominant medicalese is used during team meetings and not all team members are familiar with terminology, self-censorship is likely to occur.

d. Structural and organizational constraints include high caseloads, administrative support, time and place of team meetings.

XIII. Ways to combat Groupthink (Whyman, 2005)a. Here are some ways to help a team stay focused on collaborative decision-making.b. Commonly, teams have a designated organizational leader. Leadership style can have

an impact on team decision-making. Rotating leaders among the various interprofessional team members can enhance collaborative communication.

XIV. Assessing team experiencesa. Additionally, here are some things to think about the next time you are in a team

meeting or observing a team meeting.

4

OPTIONAL: Ask the audience to share their team experiences or team observations. Offer the following options among those audiences who have current clinical team experiences:

i. My team is assessed, but I don’t know how.ii. My team is assessed, but there is no clear protocol.

iii. My team is assessed regularly using clear protocols.iv. My team is not assessed.

References

Grey, R. (1996). The psychospiritual care matrix: a new paradigm for hospice care giving. Am J Hosp Palliat Care, 13(4), 19-25.

Janis, I. L. (1982). Groupthink. Boston, MA: Houghton Mifflin.Mathisen, B., Yates, P., & Crofts, P. (2011). Palliative care curriculum for speech-language

pathology students. International Journal of Language and Communication Disorders,46, 273-285.

Napier, R. W., & Gershenfeld, M. K. (1999). Groups: Theory and Experience (6th ed). Boston, MA: Houghton Mifflin Company.

Rao, P. (2011, November). Our role in effective patient-provider communication. The ASHA Leader, 17.

Whyman, W. (2005). A question of leadership: What can leaders do to avoid groupthink. Leadership in Action, 25(2), 12.

Wittenberg-Lyles, E., Goldsmith, J., Ferrell, B., & Ragan, S. (2012) Communication and palliative nursing. New York: Oxford.

5

Post-Lecture Knowledge Assessment Items

1. What members of the team should practice psychospiritual care?a) only medical professionalsb) only chaplainsc) only chaplains and social workersd) all members of the care team

2. The Model of Interdisciplinary Collaboration includes the following principle(s):a) New professional activities are created for each team member.b) Team members work dependently. c) Team members regularly reflect and evaluate their collaborative process.d) Both A and C.

3. What is the purpose of meeting as a team?a) To discuss organizational policyb) To establish team hierarchyc) To facilitate team collaborationd) To vote

4. Which of the following is most likely a result of groupthink? a) Team members rationally assess various courses of action.b) Team members work collaboratively to develop a plan of care unique to the

patient/family.c) Team members effectively discuss and resolve conflicts as they arise.d) Group members begin to think in terms of unanimity

5. Self-censorship, and structural characteristics are all potential contributing factors to a communication phenomenon called ____________________.

a) Collaborationb) Groupthinkc) Shared powerd) Conflict

6. Which of the following is not involved in the principle of interdisciplinary collaboration—collective goal ownership?

a) Team members perceive the patient and family as an integral part of the interdisciplinary team.

b) Team members come to share a common purpose.c) Team members working on the same plan of care do not need to meet. d) Team members share the responsibility of producing holistic end-of-life care for

patients and family members.

7. Identify one way to combat Groupthink during team meetings:a) Your team should designate a team member to play devil’s advocateb) Limit your meeting time to increase efficiency

6

c) Place your most senior staff member as the team leaderd) Avoid sharing team member feelings about patient care

7

ANSWER KEY - Post-Lecture Knowledge Assessment Items

1. Answer: DRationale: Interdisciplinary team members are united by psychospiritual care, the underlying care required to meet the needs of patients’/families’ personal labor with terminal illness that often brings psychological suffering and spiritual realities. Psychospiritual care is complex, ambiguous, and cannot be attended to best by any one core team member.

2. Answer: DRationale: Based on the model, interdisciplinary collaboration consists of: (1) interdependence and flexibility; (2) newly created professional activities; (3) collective ownership of goals; and (4) reflection on process.

3. Answer: CRationale: The team meeting facilitates communication that produces an interdisciplinary plan of care for each patient/family. During the meeting teams form a single care plan wherein team members share responsibilities and implement their part of the plan. Ideally, each member provides information about the patient’s plan of care and the patient’s family is addressed with a discussion.

4. Answer: DRationale: Groupthink can occur when “deeply involved” cohesive group members engage in a mode of thinking that centers on unanimity over the motivation to rationally assess various courses of action. In these groups, the focus of groupwork is on group cohesion and group relations rather than decision-making; groupthink results in poor decision-making and/or lack of collaboration.

5. Answer: BRationale: Structural constraints that influence group cohesion and the ability to collaborate include manageable caseloads, an organizational culture that supports and encourages interdisciplinary collaboration, administrative support, professional autonomy, and the time and space for collaboration to occur. Self-censorship occurs when group members elect not to share their opinion to counter a prevailing thought in the group. Structural characteristics and situational contexts also influence group cohesion, resulting in Groupthink. In these groups, the focus of groupwork is on group cohesion and group relations rather than decision-making; groupthink results in poor decision-making and/or lack of collaboration.

6. Answer: CRationale: Collaboration is produced through a collective ownership of goals as team members have a shared responsibility for producing quality holistic care. While each discipline has its own goal of care, team members have a shared common purpose.

7. Answer: ARationale: Appointing a team member to serve as devil’s advocate can help the team consider all options and enhance their ability to engage in creative problem solving.

8

The COMFORT Communication Assessment ScaleModule 7 - Team

Student:_______________________

Element Unacceptable(1)

Poor(2)

Acceptable(3)

Good(4)

Assesses and evaluates the team environment

No assessment of team environment or infrastructure

Acknowledgement of team environment and infrastructure

Collection of information about team environment and infrastructure

Evaluation of professional roles, personal and structural characteristics, and history of collaboration to assess and plan for interdisciplinary collaboration and/or groupthink

Employs team-based hospice and palliative care

One health care professional determines the patient plan of care

Team members with biomedical expertise participate in the planning process

Most team members participate in the planning process

All members of interdisciplinary team participate in the planning process and employ distinctive attention to patient and family quality of life

Engages in constructive conflict

Avoids conflict Enacts a recurring pattern of negative conflict between particular team members resulting in a pattern of withdrawal

Understands the growth and productivity of constructive goal disagreements and avoids Groupthink.

Welcomes and approaches conflict by engaging in active listening, defining the problem, asking open questions, clarifying responses, paraphrasing and reframing the discussion

Demonstrates collaborative communication skills

Fails to demonstrate collaborative communication skills

Inconsistently uses collaborative communication skills

Frequently uses collaborative communication but does not evaluate team goals or satisfaction

Consistently employs active contributions, fosters opposing viewpoints, and collectively evaluates team goals and communication processes

Practices interdependence and flexibility

Reluctance to engage in care tasks beyond expertise

Minimal engagement in care tasks beyond expertise

Substantive engagement of multiple roles and responsibilities

Regular sharing of information, tasks and role responsibilities, with aims to achieve care outcomes through versatility

Creates new tasks and responsibilities

No recognition of individual team member expertise

Members are available to one another at limited times

Members share information and tasks with the goal of providing optimal care for the patient/family

Members demonstrate interdependence through accessibility, information sharing, and task accomplishment, which maximizes member expertise

Performs reflection and evaluation

No reflection about team processes and communication

Awareness of poor team communication

Identifies shortfalls in team processes and communication practices

Recognizes shortfalls of team processes, establishes collaborative team goals, and evaluates team communication practices

Demonstrates interdisciplinary collaboration through task and relational communication

Emphasizes individual professional expertise rather than resources and information sharing

Attends to task communication predominantly

Incorporates task and relational communication across most team members.

Shares in success and failure, provides insights on communicating with patients/families (task), supports team members, shares in workplace stress (relational)

9

10

Comments to be filled out by students following recorded encounter:1. Regarding team communication skills, what did you think went well?

2. Regarding team communication, what, if anything, would you do differently?

3. What are the barriers and pathways you see in communicating with this team?

4. Any other observations or comments about this particular team encounter?

NOTE: Feel free to refer to T-Team of COMFORT when reflecting on which tasks you accomplished, as well as the way in which you accomplished them.

11

Sample Case

At age 47, Sam Sims was experiencing frequent urination and some difficulty maintaining erections. His wife, Vera, decided that he should check with an urologist about his complaints. Sam visited a urologist who found his PSA (prostate specific antigen) was seriously elevated and referred Sam to an oncologist for further testing and treatment—suspecting cancer.

Sam’s oncologist confirmed the diagnosis of prostate cancer and ordered a battery of tests to determine the stage of the disease. A week after completion of the tests, Sam and Vera had heard nothing from the oncologist’s office. They eventually went and waited in the doctor’s office until the oncologist agreed to see them. Together they learned that Sam had stage IV prostate cancer. The oncologist recommended that Sam seek no treatment. Vera found a prostate oncologist who offered to treat Sam with a renegade hormone treatment unique to his practice. For three years, Sam’s PSA has remained at normal levels and he is pain free and fully functioning.

Vera’s Profile: Vera works feverishly to document Sam’s care. She also believes strongly that their children should not have to participate in decision-making or be bothered by updates on his treatments. Both Sam and Vera agree that their children have not been affected by his diagnosis. Vera explains, “We don't want the children to be bothered with the details of his care. Sam is comfortable and we can manage treatment by ourselves.” Vera never admits to fatigue or her own caregiver needs and has not relinquished any aspects of her coordination of Sam’s treatment. She is present at all of his appointments and Sam acknowledges that she is his “mommy” in the care of his cancer.

12

Sample Case Group Debrief Questions

1. Describe a time when you opted to self-censor your participation in a group. What circumstances or factors led to your decision?

Instructor Guide: Self-censorship is one of the dominant indicators of Groupthink, a process in which group cohesion takes the place of varying perspectives. Think about the factors that pushed you in the direction of self-censorship. Also consider the outcomes for the patient/family in this particular instance. Was the planning and delivery of care dissatisfactory in any aspect? If you could go back in time and make a different communication choice, what would it be?

2. How could you influence your team to adopt ongoing evaluation and assessment of their operational practices?

Instructor Guide: Reflective practice is the most powerful variable in improving team function. If your team does not practice assessment, evaluation, and planning, you could influence the practices of the team by suggesting a change in the way the team functions. Example: Speak to team members from varying disciplines about changing the team’s way of working. Bring up your idea to the team once they are all together. You might also consider sharing a resource from this module that provides evidence of the benefits of team evaluation and assessment.

3. What might influence you to become more flexible in your role within the team and the ways in which you might flexibly assist other disciplinary specialties to provide the best patient/family care?

Instructor Guide: Interdisciplinary collaboration is an experience that requires team members to reach beyond the expected border of his/her specialty across the disciplines to facilitate creative care solutions for patients/families. This means you might find yourself, as a social worker for example, discussing pain medicine with a family member; or a chaplain might be positioned best to share ideas about place of care with a patient. However, no team member will feel empowered to share responsibilities creatively unless there is an open practice of collaboration in the team at large.

13

Role Play ActivityObjectives:

1. Practice identifying family caregiver types.2. Identify caregiver specific team interventions.3. Engage in role-play activities informed by interdisciplinary collaboration.4. Extend team module learning for practical communication application.

How to Proceed-Introduction & Discussion: (20 minutes)

Review objectives for group activity and facilitate introductions of group members to one another.

Ask group participants to read case. Facilitate discussion of caregiver type and indicators.

How to Proceed-Role Play: (20 minutes)

Roles: There are several roles to be played in this case; remaining participants can observe

Facilitator: Keep time (20 minutes MAX for this part of group activity, as divided below): 5 minutes for role players to read roles and arrange seating for conversation 10 minutes for role play 5 minutes for de-brief and discussion.

14

Family Meeting Role Play

Situation:A geographical move prompted by both Sam and Vera’s professional demands required they find a new oncologist in another state. He prescribed Sam a different treatment. Within 2 months, Sam’s PSA crept up to 9 and he complained for the first time of pain in his most affected shoulder. As with his previous oncologist, Vera suggested male castration as a solution but was ignored. Sam and Vera decided to continue seeing this new oncologist, but secretly began administering treatment from the previous oncologist. One weekend Sam became dehydrated/was experiencing horrible shoulder pain and was admitted overnight. When bone scans showed a reduction of affected cancer areas, Sam and Vera share with their current oncologist what they had been doing in terms of their treatment plan. A damaged rotator cuff and the flu were the source of Sam’s recent health scare. Enact the meeting in which this discussion took place:

Present: Vera (Sam’s wife), Sam (patient), Sally (social worker), Brian (first-year RN taking care of Sam), Dr. Coone (oncologist)

Sam: Remains quiet and contemplative.

Vera: Is elated to hear that scans show a reduction of affected cancer areas and boasts that their own secret treatment plan has been successful. She is most interested in securing the next decision regarding Sam’s discharge and continuation of the renegade treatment. She never mentions other family members.

Ms. Sally: Encourages team to find ways to support Sam’s desire take a break from treatment, despite Vera’s plan to continue renegade hormone therapy. Vera has a high-power job at a fortune five hundred company and the couple has three children. Sally has noted the friendships Vera has made with other family members at the Cancer Center.

Mr. Brian Vitale, RN (first year RN caring for Sam): Believes Sam is tired of the renegade hormone treatment and is only continuing with the protocol to please Vera. Brian has cared for Sam throughout his three-year illness and has shared several long talks about the side effects of this treatment.

Dr. Coone: Feels betrayed by Sam and Vera and feels that urgent decisions need to be made regarding do-not-resuscitate/allow-natural-death and status, especially given their omissions of treatment information and uncertainty about side effects. She feels strongly that her recommended treatment protocol is the way to go, but wants to support Sam’s decisions and practice patient-centered care.

15

Reflective Writing Activity

Geraldine is a social worker having recently celebrated her 10th year of practice in a

community hospital. Today she is caring for Joseph who has been hospitalized for

infections in both lower legs and feet. He is a diabetic in addition to a 2-month old

diagnosis of liver cancer. Joseph also recently lost his wife after 50 years of marriage.

Geraldine sits quietly with Joseph, listening as he recalls the details of his wife’s final

days. She charts this conversation and also sends an email to the bereavement coordinator

working with hospice families. Geraldine makes special note of her concerns for Joseph

as he has a previous history of depression. It will therefore be important to assess

Joseph’s depression and how it is influenced by the loss of his wife as well as his own

failing health.

Questions:

1. What can your disciplinary specialty directly lend Joseph in light of his depression?

2. What skills and flexibility could you offer another disciplinary specialty in light of Joseph’s

depression?

3. How would you talk about the importance of Joseph’s depression with a team member who is

more focused on Joseph’s physical rather than his psychosocial distress?

Instructor Debrief

Clinical communication necessitates interdisciplinary collaboration among health care

professionals in order to develop holistic care plans that address the psychological aspects of

care. Interdisciplinary collaboration is a dynamic communication process that relies on sharing

resources, mutual dependence between team members, and sharing and respecting positions of

power afforded by credibility or expertise. Interdisciplinary team members are united by

16

psychospiritual care, the underlying care required to meet the needs of patients’/families’

personal labor with terminal illness that often brings psychological suffering and spiritual

realities (Grey, 1996). Psychospiritual care is complex, ambiguous, and cannot be attended to

best by any individual team member.

17