Cross Cultural Practice at the End of Life


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Presented by Maggie Draper at the Hospiscare conference 'Dignity of Difference' 5th November 2010.

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Cross Cultural Practice at the End of Life

  1. 1. The Dignity of Difference – Cross cultural practice at the end of life When beliefs conflict: cohesion and conflict in teams Maggie Draper NHS North Yorkshire and York 07961 834942
  2. 2. Dignity of difference Cross cultural practice in Teams What do we bring to our practice ? Individual belief systems and influences Culture of Professional roles Culture of teams Culture of Institutions Beliefs about service users and end of life care Conflict and Cohesion in Teams 2
  3. 3. Individual Beliefs and values 3
  4. 4. Individual Beliefs and values 4
  5. 5. 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 5
  6. 6. 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 ? 6
  7. 7. 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 7
  8. 8. 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” 8
  9. 9. 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) 9
  10. 10. 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) 10
  11. 11. 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 11
  12. 12. The “challenging” patient and family Medical views: Patient – is she dying or stable disease ? Pressure on beds Unreliability of reporting of symptoms Concern re manipulation Unfettered permission to stay 12
  13. 13. 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 care Non compliance and patient complaint Right to refuse all care - and then not to complain about lack of care 13
  14. 14. the “challenging” patient and family Social Worker Angry with team for being “punitive” re moving out of side room Inability 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 14
  15. 15. 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 ? 15
  16. 16. 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 16
  17. 17. • 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
  18. 18. Characteristics of effective teams 18 • 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
  19. 19. Institutional Abuse and “culture of niceness” in end of life care 19
  20. 20. “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 20
  21. 21. Culture of Niceness Is there pressure on staff to do more than is reasonable? /“donate” extra time Lower rates of pay/Tolerate poor working conditions / generational expectations Bullying and Harrassment in small work groups Avoidance of conflict – and emphasis on “cultural sensitivity rather than race equality” - Because - “Its a charity - they are dying – tomorrow will be too late” 21
  22. 22. 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 22
  23. 23. 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 23