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

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
Maggie.draper@nyypct.nhs.uk

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
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3. Individual Beliefs and values
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4. Individual Beliefs and values
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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
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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 ?
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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
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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”
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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)
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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)
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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
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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
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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
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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
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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 ?
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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
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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. 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

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