Communication
What communication strategies would you recommend for conflicts between palliative team members?

Communication between team members requires ongoing attention and effort to make it work in the best way possible. Any conflict can create barriers to effective communication. This affects the team as well patients and their families.

A good place to start is with self-examination and reflection. Be aware of what you are thinking, how you are reacting and how you are feeling. Ask yourself:

  • What is going on for me?
  • What is going on for the other individual(s)?

With any kind of conflict, it helps to keep it out in the open. If you internalize it, your future interactions will be affected. Try to understand your differences and work to improve the situation. Assess not only what you are thinking and feeling and but also what the another person may be experiencing.

Cultivate dual awareness by being aware not only of what is happening for the patient, but what is happening for you and others in your work environment. Kearney et al. state that "self-awareness involves a combination of self-knowledge and development of dual-awareness … a stance that permits the clinician to simultaneously attend to and monitor the needs of the patient, the work environment, and his or her own subjective experience."[1]

Ultimately, we can only be responsible for ourselves and how well we are communicating. We might ask ourselves:

  • Is my assessment thorough?
  • Am I communicating the details clearly and concisely and in an organized fashion?
  • Is it clear what I am asking?
  • Am I over-reacting?
  • Am I respectful?
  • What is my intent?
  • How can I represent myself better?
  • How can I best advocate for the patient?
  • Am I open to discussing varying points of view?
  • Am I willing to seek a better understanding of other team members?

It is important to let the other people know that they are being heard. Be positive and curious. Acknowledge aloud what someone is saying. Arber points out the importance of asking questions in developing interdisciplinary team relationships and care planning for patients. It is a way of keeping the exchange of ideas and information flowing.[2] Arber states that "specialist nurses use questions in a strategic polite manner to achieve their professional agenda, to present their professional identity, and to manage the tensions involved in interprofessional working."[2]

If you feel frustrated, confused or concerned about a patient and wish that your team could do more to help him or her, communicate this in a positive, respectful way. Doing so can open the door to further exploration of what could be done or tried. The following examples may help you start the conversation:

"We are all trying to do our best here, and I am wondering how we can best work together on this?"
"I wish we could help this person feel better than he or she is currently feeling."
"Can you help me to understand how you decided on that medication (or approach)?"
"Do you remember when we tried this for Mr.___ and it worked?"
"I agree it's worth a try. Perhaps we could set a trial time frame and then revisit our decision. If this approach doesn't seem to be making a difference in 48 hours, maybe we could try this...?"
"In reviewing the situation with the patient, he would really like to give this a try." 

If the situation is one where you feel the need to advocate on behalf of the patient, keep the focus on the patient and how you as a team can work together to do your best for the patient and/or the family.

The “negotiation” of clinical options among members of a health care team is a learned skill, and it may require different communication strategies depending on the team members involved. Again, the key is to be open to both sharing your experience and being receptive to learning about the experience of others. We may not always get “our way,” and that is sometimes a good thing. There is often more than one way to achieve a desired outcome, and we can all learn from each other’s experience. Always remind yourself that the focus of discussions and decisions should be based on what the patient and family desire and what is in their best interests.

Here are some communication strategies you can try with team members:

1.    Organize your assessment findings. Sometimes we unfairly expect our colleagues to reach the same conclusion without having the same information as we do. Think about the objective and subjective findings, the context of the given situation, and patient/family perspectives when developing the narrative you want team members to consider.

2.    Consider your approach. Acknowledge and respect the knowledge and perspectives of other team members while sharing your personal view.

3.    Recall past successes with other patients. For example, start by saying:

“Remember when you did x, y, z for that woman we cared for under similar circumstances? That worked well. Do you think that may help this patient?”

Context is so important and in the above example, you present a possible solution as another person’s idea.

In some circumstances, speaking with a team member one-on-one may be effective. At other times, you may need to meet as a team to reach a consensus. Over time, you will learn for yourself which approach works best in which situation.

Turning to the evidence is an important starting point for guiding a team's decision making and resolving conflict. Recognizing the importance of research and evidence-based practice in palliative care is crucial, but often there are situations where the best approach to day-to-day care practice is not as straight forward. These situations usually require:

  • ongoing assessments and discussions with patients, families and team members;
  • revisiting decisions; and
  • adjusting care plans to address concerns, control symptoms and optimize comfort.

References

Kearney MK, Weininger RB, Vachon ML, Harrison RL, Mount BM. Self-care of physicians caring for patients at the end of life: “Being connected . . . a key to my survival". JAMA. 2009;301(11):1155-1164.

Arber A. Team meetings in specialist palliative care: asking questions as a strategy within interprofessional interaction. Qualitative Health Research. 2008;18(10):1323-1335.