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

When beliefs conflict: cohesion and conflict in teams

Maggie DraperNHS North Yorkshire and York

07961 834942Maggie.draper@nyypct.nhs.uk

Dignity of differenceCross cultural practice in Teams

What do we bring to our practice ?

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

Conflict and Cohesion in Teams 2

Individual Beliefs and values

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Individual Beliefs and values

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Individual Beliefs and values

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

professional identity, health hierarchies• Palliative care myths and culture

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Where individual beliefs might conflict

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

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

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Team culture and differences

Literature on organisation culture, power and performance and changing cultures

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

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

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

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

Institute of Health Care Management:

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

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Problems in teams include:

• Debate and confusion over what is palliative care

• Lack of understanding of contribution of others

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

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

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Why do teams get into difficulties ?

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

(King, 2005)

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The “challenging” patient and family

How did it make the staff feel ?

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

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

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The “challenging” patient and family

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

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the “challenging” patient and family

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

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

about lack of care

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the “challenging” patient and family

Social WorkerAngry with team for being “punitive” re moving

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

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

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How did it make the team feel ?

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

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

Who has responsibility ? Does everyone want it ?

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Cohesion in teams- case review

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

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

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

Successful teams:

– Members share a common language

– Do not feel threatened by other professional groups

– Individuals value the different contributions made by team members

– Professional values and cultures shared

Characteristics of effective teams

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

• Acknowledging and valuing patients and staffs diversity

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

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“Culture of Niceness”

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

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

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

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

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

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

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

be too late”21

What helps us work with difference ?

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

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

• User involvement - focussing on patient experience and outcomes

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What helps us work with difference?

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

• Clinical Case review – way of safe reflection and challenge

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

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