Debra Gerardi, RN, MPH, JD, Chair of the Program
on Health Care Collaboration
and Conflict Resolution at
the Werner Institute for Negotiation and Dispute Resolution
at Creighton University School of Law
"Fragmentation
consists of false division, making a division where there is
a tight connection and seeing separateness where there is wholeness.
Fragmentation is the hidden source of the social, political,
and environmental crises facing the world."
--
David Bohm2
"Culture
matters. It matters because decisions made without awareness
of the operative cultural forces may have unanticipated and
undesirable consequences. . . . The argument for taking culture
seriously, therefore, is that one should anticipate consequences
and make a choice about their desirability."
--
Edgar Schein3
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Team Disputes
at End of Life
There
are persistent calls for improving end-of-life care in the United
States. Several recurrent issues make end-of-life care suboptimal,
including disputes among members of the health care team. Difficulties
in end-of-life care arise around issues such as: variability in
practice, poor communication among providers, lack of consensus
regarding plan of care, incomplete documentation, and differences
of opinion regarding the definition of futility. Despite documented
support for improved collaboration among health care providers,
the struggle to work together continues, often to the detriment
of patients and their families, and more profoundly to the caregivers.
The
system for delivering end-of-life care is fragmented and current
models for providing care are unsustainable. In a recent Hastings
Center report,1 Murray and Jennings cite three areas
that require rethinking assumptions regarding end-of-life care.
These include paying greater attention to the end-of-life care
delivery system, the approach to advance directives and surrogate
decision making, and managing conflict and disagreement. The disjointed
and complex system for providing end-of-life care is costly, confusing,
and invites legal intervention as the dominant response to anger,
mistrust, and unmet needs. This serves no one well.
Given
the likelihood of continuing to provide care within fragmented
and complex structures, we must look for and identify successful
patterns. Often, we are able to come together, reach consensus,
coordinate care, and resolve disputes, resulting in a respectful,
authentic, and compassionate caress; a concerted action aligned
with our common purpose to do no harm.
To
provide better end-of-life care, we are compelled to create a
normative ethic of collaboration, to transition toward more effective
engagement, toward a higher level of professional consciousness.
Our fragmented system has evolved to a level of complexity that
demands a rebalancing, a swing toward integration that enables
us to respond collectively to the overwhelming challenges in our
clinical environments. We can transform our approach to end-of-life
care by making conscious choices to work together, not just side
by side. Creating an ethic of collaboration as a foundation for
practice will allow us to better meet the needs of patients and
to fulfill our own desire to do meaningful work.
Toward
an Ethic of True Collaboration
True
collaboration is a way of being and a way of working. It requires
a personal commitment to self-awareness and development of skills
for interacting at multiple levels. Collaboration occurs at the
intersection between self-reflection and active engagement; it
is simultaneously a conscious act by individuals and the product
of group wisdom. It is the antidote to the epidemic of fragmentation
that runs throughout our organization and our system for providing
end-of-life care. Collaboration requires time and commitment;
in return for that investment we gain understanding, build trust,
discover common purpose, and expand possibility. An ethic of collaboration
provides a foundation for addressing paradox and ambiguity, and
for managing differences that, if left unaddressed, can lead to
moral distress and service fatigue.
Starting
From Where We Are
So
how far do we need to travel to find an ethic of collaboration
among health professions? Our dominant ethical principles of do
no harm, distributive justice, patient autonomy, and integrity
in practice do not expressly indicate an ethic of collaboration.
On closer examination, however, it is clear that the threads of
true collaboration are woven into our current ethos.
Collaboration
requires reflection on our effectiveness in negotiating with colleagues
on behalf of patients. Awareness of this and our ability to acknowledge
others is the first step in patient advocacy.
To
do no harm, the most fundamental of our ethical obligations, we
must work together. Complexity dictates that no one person has
enough information to care individually for the patient. Collaborative
practice underlies nonmaleficence. Coming together is the only
way to consistently prevent harm to patients.
Distributive
justice by its nature involves a broad view of the needs of a
community. Through discussion and consensus we are better able
to determine just and equitable solutions in the face of competing
interests and limited resources.
Patient
autonomy, respect for an individual's capacity for self-determination,
reflects the personal responsibility patients carry and underscores
the fiduciary duty of each practitioner to provide a framework
built on trust from which patients can make decisions. Trust is
the determining factor that enables collaboration.
True
collaboration blends individual commitment with group action.
Integrity in practice through truth-telling, reliability, equanimity
and fidelity, has long been an expectation of practitioners and
goes to the heart of our individual commitment as professionals.
Without a commitment by each individual to contribute and participate
with integrity, there is no collaboration.
The
guidelines found in the ethics codes of various professional groups
range across the collaboration continuum. The levels of ethical
responsibility fall into five categories: professional conduct
(citizenship), acknowledgment, cooperation, collaboration, and
active conflict engagement. The categories reflect a progression
in professional engagement and provide a glimpse into the attitudes
each profession holds toward collaborative practice. A look at
the words used within these codes reveals the stories each profession
has crafted to define their role including respect for hierarchy,
expectations of cooperativeness, acknowledgment of alternative
points of view, and collaboration for the sake of the patient's
well-being. Each code is distinct and provides insight into the
assumptions that lie at the heart of each professional culture.
Professional
Cultures
Underlying
our ability to engage with each other in resolving differences
are professional cultures that reinforce fragmented approaches
to end-of-life care and impact our ability to appreciate the contribution
of others, to integrate ideas, to communicate effectively, to
problem solve holistically, and to make sense of complexity. Structural
and professional divisions create containers that make connection
and collaboration difficult.
Professional
cultures are composed of those things we see and what we do not
see. Below the surface are unconscious assumptions that drive
professional behavior. Within each profession are assumptions
that can sabotage efforts to communicate clearly and collaborate
effectively. Surfacing these assumptions and testing their validity
is the key to building understanding and managing differences
between professions.
Tools for
Expanding Capacity to Collaborate
The
field of alternative dispute resolution offers a number of processes
and techniques to improve individual skills and enable groups
to come together. Facilitation and mediation have traditionally
been used to manage conflict and build agreement, particularly
when there is a loss of trust or perceived differences that impede
decision making or problem solving. Dialogue is a process that
enables groups to establish common purpose, test assumptions,
and collectively develop deeper meaning. Coaching and mentoring
processes create clarity and promote self-awareness by providing
structured feedback in a supportive environment. Appreciative
inquiry helps groups to identify patterns of success. Through
positive inquiry into stories of success, groups can move forward
by envisioning solutions that build on what is already working.
Integrating these tools into clinical practice is a practical
means for advancing collaboration.
Enhancing
Our Delivery Systems
Most
health care organizations have a need to redefine their processes
for responding to conflict and for resolving disputes. System
designs that enable productive engagement is a special application
in the field of dispute resolution. Drawing on principles of emergence
and self-organizing behavior, organizations can identify reliable
methods for fostering collaborative problem solving and effective
dispute resolution enhancing the ability of health care professionals
to work together and truly live out their ethical obligations.
Conclusion
End-of-life
care is fragmented and requires that we examine our commitment
to work collaboratively as a means for improving end-of-life care
and managing team disputes. Techniques used by conflict specialists
can enhance the capacity of health care professionals to transition
their practice toward a culture of collaboration.
Presented
March 2006 at the Northern California Kaiser Bioethics Symposium,
San Ramon, CA.
References
-
Murray TH, Jennings B. The quest to reform end of life care:
rethinking assumptions and setting new directions. Hasting Cent
Rep 2005 Nov-Dec;Spec, No.:S52-7.
-
Bohm D, Edwards M. Changing consciousness: Exploring the hidden
source of the social, political, and environmental crises facing
our world. 1st ed. San Francisco: Harper Books; 1991.
-
Schein E. The corporate culture survival guide: sense and nonsense
about culture change. 1st ed. San Francisco: Jossey-Bass; 1999.
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