35 - Place of care
Editors: Goldman, Ann; Hain, Richard; Liben, Stephen
Title: Oxford Textbook of Palliative Care for Children, 1st Edition
Copyright 2006 Oxford University Press, 2006 (Chapter 34: Danai Papadatou)
> Table of Contents > Section 4 - Delivery of care > 33 - Working as a team
33
Working as a team
Satbir Jassal S
Jo Sims
There has been extensive discussion in both business management and health literature surrounding team working, which has clearly been identified as effective, and is advocated by all. Indeed the World Health Organization affirms that primary health should involve all related sectors working together, including education and social services, in addition to health care, and that efforts should be made to co-ordinate these sectors [1]. It is the intention of this chapter to consider the issues around definitions in teamwork briefly and then concentrate on the practical application of team working and how it can be effectively achieved.
Defining teams
Prior to exploring teamworking in paediatric palliative care, it is essential to consider defining team . This may appear to be simple; however, there is still much debate, and there are contentious issues involved [2]. Handy [3] challenges many definitions by demonstrating that they could refer to people who do not even perceive themselves to be part of a group or team; for example, a number of individuals in a pub who are interacting, have a common objective and are aware of each other (often key points that are used in team definitions), by their actions of talking and drinking; however, they do not have the perception of being in a group or team. Others have suggested that following the belief that team', and teamworking are aspirational and aiming for co-operation, collaboration and co-ordination, each individual team should define what team means individually to them [2].
Despite difficulties we believe it is helpful and important to have a working definition even if this is viewed as a starting point. We propose to work with West's definition, relevant to the health environment, as a group of individuals who share goals and work together to deliver services for which they are mutually accountable [4]. Team working aims to stimulate group cohesion and co-operation towards professional and service objectives [2]; however a significant omission within these descriptions is the role of the service user, in this case the family and child.
Within health care teams a variety of terms are used relating to the structure and philosophy of the teams; these include multidisciplinary, interdisciplinary, and transdisciplinary. Some use these terms interchangeably, which is inaccurate and therefore confusing. They can be seen, more usefully, as being points on a joint working continuum which goes from professionals working alongside each other, to true partnership between professionals, agencies, the family and the child.
Multidisciplinary teamworking has been described as a progressive and beneficial strategy [5] with many writers demonstrating good practice in the work of multidisciplinary teams [6, 7, 8, 9, 10]. Pardess [11] identifies the advantages of multi disciplinary teamwork as reducing bias, enhancing validity and reliability, and offering a source of sharing and support. There are however criticisms of the approach, as it has been argued that multidisciplinary teams tend to concentrate on a specific task, and are often led by professional hierarchy [12].
Inter-disciplinary work is thought to be a development and advance from multidisciplinary working. It is being increasingly introduced in a wide range of settings, including palliative care. It is viewed as being unconstrained compared with the function of a multidisciplinary team, it is inclusive and is not ruled by professional roles, the aims vary over time as appropriate, and there is a continuing sense of working together. This type of working acknowledges the value of involvement of different agencies, including the voluntary and private sectors [12, 13].
Transdisciplinary team working is a newer term, still only featured minimally in the literature. This is perhaps because
P.514
its occurrence in practice is rare. This is where the focus and starting point is with the child and family's needs and how these needs can be met, rather than from the restrictions of existing services. It is believed that this form of working would be welcomed by families [14].
The family in teamworking
Teamwork cannot effectively occur unless the family and the child are viewed by all to be valid members of the team. The concept of family-centred care is fundamentally supported within the paediatric world [15]. However, Taylor [16] identifies that this has not necessarily led to the appropriate discussions with families, and the delivery of individualised care, that may have been presumed. Friction often remains between parents and professionals. Parents continue to cite problems with staff shortages, professional rivalry, numerous separate appointments, difficulty in distinguishing overlapping roles, confused communication of information and difficulty obtaining funding [17]. The professional can perceive parents reactions to these problems as those of difficult or over-demanding parents. The parents themselves may develop an adversarial attitude toward the professional, by questioning or refuting medical advice, fighting for limited financial resources, or deviousness in identifying what resources they have in fear of losing them. This conflict can be explained in part by the understanding that the family are in fact undertaking a dual role at this time; they are carers for their child and therefore part of the team, however they are also themselves in need of receiving care from other team members. These different roles may conflict and challenge their partnership with others, and certainly adds to the complexity of the situation. Taylor [16] calls for more research within this field to ensure that the obstacles to family centred care are identified and overcome, to enable the development of an equal partnership.
If the family members are included in the team, it follows that some level of teamwork will be required in the care of all children with palliative care needs. It would appear reasonable to presume that a team working together will be more effective and efficient than individuals working independently [18]. The number of professionals and agencies that a family has contact with and the complexity of teamwork needed is dependent on that family's particular needs. On average a disabled child has contact with 10 different professionals and attends 20-clinic visits a year [19]. Equivalent data for palliative care in children has not been collected but it is likely to be of a similar order. This can be expressed diagrammatically, with the child and family firmly occupying the central position (Figure 33.1).
 |
Fig.33.1 Professional involvement in the care of a child. |
As well as each family being different, the range of conditions varies with different patterns of disease progression and palliative care. These will therefore present different challenges to achieving effective teamwork to meet the families' varying needs with time. Reflections on two clinical examples (scenarios 1 and 2) are presented to illustrate this.
Case
Jenny is 8 years old, and has Hurlers syndrome. She was admitted to the local district general hospital with a chest infection. Her parents also reported a general deterioration in Jenny's mobility, ability to feed and general condition.
Previously the family members had been eager to limit the number of professionals involved as they felt it was their responsibility to care for their child, and they wished to maintain as much normality as possible. However, they are now clearly very tired, and are expressing that they are unsure how they will cope once they take Jenny home.
Jenny was acutely unwell for a few days, requiring oxygen, suction and intravenous antibiotics. Although her respiratory condition improved, it became evident that she may require some oxygen and suction in the longer term. Also there was little improvement in Jenny's general condition, which led the ward staff and her parents to believe that these skills may not be regained.
In discussion with the parents, it was agreed that there was a need to involve other professionals prior to Jenny's discharge from hospital, as the family's needs had significantly changed. Jenny's parents were keen to keep those involved to a minimum, but appreciated that they would need support in certain areas. These included feeding, seating, mobility, minor adaptations to the home, benefit advice, support with oxygen and suction requirements and potentially respite care.
Invited to the discharge meeting were 12 professionals; however, the family had only met four of them previously.
P.515
Case
Jamie is 7 years old and has acute myeloid leukaemia, which was diagnosed when he was 5 years old. Jamie relapsed and is now requiring palliative care at home. He and his family have identified that they wish for him to remain at home. However they are concerned about how they will cope.
Jamie has received the majority of his treatment at a tertiary centre that is 30 miles away from his home; the family members have had minimal contact with the local District General hospital, and have not accessed other local services previously.
The specialist nurse at the tertiary centre has been a continuing contact for the family, always on hand with information, advice, and support. However the family members now require other professionals from their locality to become involved so they have support available, close by, 24h a day. The professionals and services in the locality have had experience of this type of palliative care before, but they acknowledge that they do not have the expertise that the specialist nurse has.
Despite the differences, in both these cases there is a sudden increase in the number of professionals the families are introduced to, at a time when they are faced with the deterioration in their child's condition and realisation of their impending mortality. Without careful and effective team work the increase of professional assistance and services will not necessarily have a positive impact on the care of the child and family.
A distinct difference between the scenarios is the expected trajectories of the conditions from this point. Jenny may continue to require palliative care for months to years, whereas Jamie is likely to die within a short time. Therefore in Jenny's case there is a need for the team work to be sustained over a long period of time fluctuating between times of stability and times of need for increase services and support; whereas for Jamie and his family the team has to become effective very quickly, and the care and support may be required to be very intensive throughout the palliative care.
It could be viewed by members of Jamie's family that their main support is becoming distant as others are becoming involved. However a sole worker based some distance away will be unable to meet the needs of the family. Good team working can address the issues of knowledge, time and availability of support that are evident in this scenario.
A particular challenge for members of Jenny's family could be the conflict between realising that they require more assistance and support to care for Jenny and their principles of addressing issues as a family without outside influences; good teamwork in this situation can empower this family members to ensure that they retain control over their lives.
All the children who require palliative care will have different requirements but in common they need everyone to work together and be clear of their roles and responsibilities, to ensure the child's and the family's needs are met in a supportive and timely manner.
Teamworking across agencies
Teamwork to ensure that provision and delivery of care is optimal for an individual child and family is clearly identified, There is also a need to look at joint working at broader levels, including strategic planning and service commissioning [8, 11, 12].
Consider the situation when, more than one team is involved. To return to both Figure 1 and the clinical scenarios, it is evident that there is a core team around the family, but it is likely that most members of this are also members of other teams. For example, a staff nurse from a hospital ward may be a member of the core team, but will work with the family within a nursing team on the ward, and cannot be present at all times. Also there may be an extended team attached to the ward, for example play specialists, hospital teacher and others so creating another team. These teams within teams are replicated in other services, where even those who appear to be individual workers will have extended teams that may impact on the family. For instance, a family doctor has other doctors in a practice, and also other members of a surgery team (nurses, receptionists). Each of these teams will be required to work effectively, otherwise there is potential for a detrimental effect on the family and child [20]. The requirement for good communication needs to be both within each agency and also between them.
Organizational culture
The carers involved with children with complex needs come from many organisations and each of these have their own way of working, hierarchy, pay, funding, geography and training [14]. This tends to generate different ideologies, culture and attitudes [5]. Organisational rigidity leads to ineffective team working [13]. Different levels of commitment to the care required can lead to frustration and fragmentation of the team. Time factors often mean key personnel not being able to attend meetings and decisions are put off. Linked to this are the personal and organization's perceptions of the value of liaison and communication in team meetings. Differing attitudes towards leadership can mean that the team lacks direction, or conflicts develop as infighting for power within groups. Many team leaders have little or no training in team working or leadership skills. Power struggles develop between organisations, linked to control and funding issues. Funding for equipment is repeatedly seen as an issue between health and social services. Funding for time, and training for team development are overlooked. The issue of justice in the allocation of limited resources can lead to team tension and frustration. Control is often related to how individuals and organisations value their status and who is the most important rather than being held by the key worker on behalf of the family.
P.516
Team theory
All those working together in teams need to develop an understanding of how the success of a team can be achieved. Various authors have suggested models for team formation and development (Table 33.1). The key points that emerge from all these papers, are that teams do not magically appear, gel and work immediately. All teams go through stages of development, as individuals learn about each other's skill and knowledge, roles are defined and responsibility is delegated. Conflict appears to be a natural event in the evolution of the team. Role change and mutual respect develops within the team as individuals learn to value the work of their colleagues and the team. The situation is fluid and patterns and aspects of team behaviour may emerge, resolve and then recur with time.
Factors of a successful team
After recognizing that teams do not just occur but take hard work to achieve, many writers have contributed to identifying the factors that can influence the development and work of a team. Handy [3] separates them into the givens, the intervening factors and the outcomes (Table 33.2).
Table 33.1 Models for the development of teams | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
Table 33.2 Factors for a successful team, Handy [16] | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
Some of these factors, for example productivity , may seem unrelated to teamwork in palliative care and risk being dismissed as irrelevant. However, a family that feels supported and has access to appropriate and timely services should be the productivity that is being sought by all. Madge and Khair [23], writing from a paediatric care perspective, have also identified a number of factors the most important being:
team membership
group dynamics, clear objectives
awareness of colleagues both within and outside the team
an agreed team philosophy
It is clear that although factors identified by different writers may vary, effective teamwork does not just occur; there are many areas that require consideration and attention. How we take the theory and put it into practice in the real world of organ-isations, individuals and children with life limiting illness is the great challenge.
The challenges of the team working
Considering the complexity of care that needs to be provided in paediatric palliative care and the emotionally powerful nature of the work, it is perhaps not so surprising that conflicts and problems can occur when people and organizations attempt to work together. The difficulties encountered come in many forms, ranging from conflicts between groups and individuals, to problems of organization within the team. Conflict itself should not be considered a good or bad thing in itself. It is the outcome of the conflict on an individual or group that determines its effect [5]. Thus unchecked conflict can paralyse individuals or divide groups and organizations, whereas providing a forum for expression of differences of opinions can create an environment for shared ideas and openness [24] and in the best of worlds constructive progress.
Interprofessional relationships
Health, education, and social services
The needs of children with life-threatening illness can only be fully assessed and managed by the input of care health, education and social services [25]. However, certainly in the United Kingdom, each of these organizations have different hierarchical structures, management and funding [20, 26]. This can lead to differences in service priorities, in aims and objectives of team members, in competing targets for different agencies, disagreement over funding, confusion over accountability, and incompatible exchange of information [13, 18]. In addition it has been suggested that the core ideology ingrained in
P.517
education and training of individuals in the groups is different with medicine founded on a pathophysiological paradigm, nursing on a holistic problem solving framework, and social work on an individual paradigm [5]. Unless individuals from the triad of organisations are able to recognise previously held biases and lay their prejudices to one side and acknowledge each others's strengths conflict is bound to occur [12, 27].
Hospital, community, and hospices
The traditional model of care in the United Kingdom of primary care led by family doctors in the community with occasional input from secondary and tertiary centres is inadequate for children with terminal illness. Most family doctors will only look after one or two children with life-threatening illness in their lifetime and therefore most feel they have insufficient training and experience to look after dying children. However, it is generally accepted that most children with life-limiting conditions spend the majority of their time being cared for in the community, and that being at home is the children's and the families'preference. Some of the barriers and prejudices between hospital and community care need to be broken down to enable this to be successful [28]. Some of this has been pioneered very effectively in the care of children with malignant disease through the paediatric oncology outreach nurses and their work in collaboration with children's community nurses. However, the care of children with often more uncommon non-malignant diseases has lagged behind.
The children's hospice movement in the United Kingdom, which developed particularly with these children's needs in mind, has grown greatly in the last ten years. The initial scepticism by hospital paediatricians about their role and value is no longer significant and the benefits of hospice care for children with non-malignant disease are clearly recognised. However their input adds an additional team and approach in the communication network and also difficulties still need solving in relation to issues of competition for staff and resources locally.
Health care professionals
The very interdependency, reliance and need to share information and responsibilities particularly between doctors and nurses, but also other therapists, highlight the need for good close relationships. The belief that one's own profession is superior to the others is the commonest sited obstacle to joint working [12]. Conflict can occur when either party does not complete their expected role and responsibilities or blocks completion of goals set by others [29]. It may result, for example, when doctors assume leadership roles in teams when they may have neither the skill nor the knowledge to lead. Their views may be based on traditional expectations or concern regarding the medico-legal implications for them in cases of complaint or litigation [30]. More often problems occur due to a lack of understanding of the skills and roles of each other's profession [31]. Unfortunately it has been shown that this type of conflict has significant effects, not only on parents perceptions of the health care professionals [17], but also on patient mortality and morbidity [24].
Communication
Communication at all levels continues to be the most common problem associated with difficulty in team working and little appears to have changed over time [21]. Poor communication can inflict profound, long-term and personal damage on the child and the family [32]. It is particularly relevant as children with life-limiting illness often have complex needs and require support from different agencies. One example of a group which can suffer from poor communication within the wider team is the one involved in a child's education. Health staff often assume that parents act as go-between and convey the necessary information, yet the reality is that teachers may be left in the dark about the needs of the child [20] and are fearful about managing medical problems in the school [25] especially as the child's condition changes.
The way language is used by professionals is often a key to good or bad communication. The use of complex medical terms has the potential to cause confusion for other members of the care team as well as the family. At worst it can be seen as a way of asserting status, power, and knowledge over others [13]. However, the different interpretations of common language by different professionals, for example, patient-centred', collaboration', or advocacy can lead to an illusion of uniformity of attitude and be just as damaging.
Communication of information still appears to be inadequate between families and children and the healthcare professionals. Families feel that the information they need to arrive at decisions regarding care is lacking. The information they are given is often poor, conflicting, or couched in language they do not understand. There is poor recognition by the professionals of the knowledge and expertise that the families have acquired themselves of looking after their child [25].
The complexity and rarity of the types of medical conditions that children with life-limiting illness have, mean that knowledge about specialist care for the underlying problem may be in the hands of a limited number of experts in tertiary centres who see the child only for short periods of time. Day to day care and ongoing observation of the individual child occurs in the community by general healthcare staff. Both sets of knowledge are essential and unless good communication can occur between the different professionals holding them,
P.518
through appropriate liaison and discharge arrangements, conflicts and poor healthcare for the family continue to arise [25, 28, 33].
The family members themselves cross all these geographic and group boundaries and can act as a valuable link between them. However this can also lead to potential problems as the family can have increased stress if they feel too much responsibility is placed on them to support poorly communicating professionals. They can be drawn into taking sides with groups of professionals who are not working and communicating together effectively and occasionally the family themselves can undermine the effective cooperation of other members of the team.
Too many cooks!
Large numbers of professionals can be involved in looking after an individual child and a family, particularly within the first year of diagnosis [17]. The repeated contact by all these workers puts a major strain on family and child in terms of coordination, communication, understanding roles, developing relationships and assessing which services are available [34]. Parents will often complain that they feel swamped and suffocated by the number of people from the caring professions they have to meet. The number of people involved can lead to inertia and confusion over care and responsibilities. In contrast, the reverse of this may happen after the death of the child, parents can feel isolated, particularly the prime carer, when their social contact with all the different healthcare professionals finishes abruptly.
Successful teamworking
Planning ahead and careful consideration of the specific issues involved in the needs of children with life-limiting illness and their families is vital when planning a team who will be undertaking care. This falls on the managers of the various organisations who will be contributing so that the design and membership of the team will be appropriate. Time and funds need to be allocated not just for the work of the group, but also for training and development towards team building. The team's location, facilities, resources and the structure and timing of meetings should be planned to reflect the needs of the team and its members. Systems also need to be developed for internal and external audit of the group's work.
Within the team it is essential to develop good leadership, based not on perceived status, but on the skills of the individuals and the role that they play in understanding the needs of the child and the family. The position of leader may need to change as the needs of the child and the family change. The leader will need to take the responsibility for co-ordinating the individuals from separate organisations and locations, to developing the ways of working across boundaries that is so fundamental [26]. If necessary, team members should attend courses on team work and team management.
Members of the team need to understand their own and other member's roles and respect those with different knowledge and experience. This leads to focused allocation of responsibilities and workload [12]. However it needs to be combined with flexibility and compromise. The balancing act between maintaining professional identity and blurring professional boundaries [13] remains one of the key challenges to team working. If the professionals do not understand each other's role then there is a risk that the parents may also uncertain who to communicate their needs to, and feel clear in their own roles in the team too.
Team meetings require structure and co-ordination [35]. Aims need to be set by formulating clear goals, which are appropriate, specific and measurable. The goals must be in tune with the needs of the parents and the child. Information presented in the meeting should be clear and concise and in a language that is understood by all present [36]. By the end of the meeting, individuals should know what they need to do and in what time frame. Information needs to be given to the parents and the child in a clear manner, sensitive to their culture and language.
Communication both between team members and with families appears to be one of the keys to successful work together. It is important to recognise the need to share professional information between all the individuals looking after the child and the family. This involves dedicated time and good listening skills as well as open, honest provision of information in a form that all will understand.
Service co-ordination and key workers
The identification of an appropriate person to act as key worker and as a coordinator is one suggestion to achieve effective teamwork to meet the palliative care needs of the child and the family. This has been strongly recommended within palliative care documents [37]. It is believed that this role is important to support the family and act as a link and advocate to the rest of the professionals involved. This approach is supported by other writers, in the field of children with disabilities and complex needs (of which many may also have palliative care needs). Recent work in this area is now beginning to address the challenges of implementation of this model [19]. One such model, The Team around the Child [38] is an example concentrating on pre-school children with
P.519
complex needs which could be extended to all children with palliative care needs.
Some specific roles of a key worker have been identified which include:
information provision
identifying and addressing the child and family's needs
co-ordinating timely services
emotional support
acting in the role of advocate.
As with all services, the balance of these roles is dependent on the individual needs of the family and the child [19]. The key worker could be seen as taking on the role of team leader for that child and family.
Some have suggested that a drawback of key working systems is that the key worker tends to co-ordinate current services and is not involved in the synthesis of services which are required in the long term to truly meet a family's needs [14] as demonstrated in transdisciplinary team work; however others believe that effective service co-ordination can lead to changes in systems involved. It also must be anticipated that a key worker is unlikely to be constant. Families needs may change and professionals will generally not remain in the same role for more than a few years, therefore families need to be prepared for possible changes [39]. Key working appears to be a model worth continuing to explore to enable effective teamwork that is family and child focused. It is believed that key worker systems with good care co-ordination [40] have positive effects [36], but there is still only limited evidence.
Summary
In any discussion of team working in paediatric palliative care it is important to recognize and keep returning to the core concept that the centre to all our work is the family and child [16]. We must look towards the family's concerns and perceptions of need and at the same time recognize the natural expertise the family have acquired [36]. This family centred holistic care will allow interdisciplinary team care to function for the benefit of the life-limited child. Much of this can be achieved through the use of key workers who co-ordinate, advocate and communicate with and on behalf of the family. The enhanced communication this will generate leads to improved relationships between the child, the family and the professionals [41]. Despite all the problems that can potentially arise, the benefits of team working to all concerned are so great that the work involved in achieving an effective team is more than rewarded by the successes that the team can accomplish.
Acknowledgements
We would like to thank Dr Clare Hale for proofreading and correcting our manuscript, and our families for putting up with us whilst we sat endlessly in front of the computer writing this chapter.
References
1. WHO. Declaration of Alma-Ata. New York: World Health Organization, 1978.
2. Payne, M. Teamwork in Multiprofessional Care. London: Macmillan Press, 2000.
3. Handy, C. Understanding Organizations (4th edition). London: Penguin, 1993.
4. Vanclay, L. Teamworking in primary care. Nurs Stand 1998;12(20):37 8.
5. Rowe, H. Multidisciplinary teamwork myth or reality? J Nurs Manag 1996;4(2):93 101.
6. Pinkerton, CR. Multidisciplinary care in the management of childhood cancer. Br J Hosp Med 1993;50(1):54 9.
7. Esenyel, M. and Currie, D.M. A child with spina bifida, cerebral palsy and juvenile rheumatoid arthritis: rehabilitation challenge. Disabil Rehabil 2002;24(9):499 502.
8. Chalkiadis, G.A. Management of chronic pain in children. Med J Aust 2001;175(9):476 9.
9. Blake, K.D., Russell-Eggitt, I.M., Morgan., D.W., Ratcliffe, J.M., and Wyse R.K. Who's in CHARGE? Multidisciplinary management of patients with CHARGE association. Arch Dis Child 1990;65(2):217 23.
10. Watson, A.R. Strategies to support families of children with end-stage renal failure. Pediatr Nephrol 1995;9(5):628 31.
11. Pardess, E., Finzi, R., and Sever, J. Evaluating the best interests of the child a model of multidisciplinary teamwork. Med Law 1993;12(3 5):205 11.
12. Boone, M., Minore, B., Katt, M., and Kinch, P. Strength through sharing: Interdisciplinary teamwork in providing health and social services to northern native communities. Can J Commun Ment Health 1997;16(2):15 28.
13. Barr, O. Interdisciplinary teamwork: Consideration of the challenges. British Nurs 1997;6(17):1005 10.
14. Norah Fry Research Centre. Working together? Multi-agency working in services to disabled children with complex health care needs and their families. Birmingham: Handsel Trust, 2002.
15. Marshall, M., Fleming, E., Gillibrand, W., and Carter, B. Adaptation and negotiation as an approach to care in paediatric diabetes specialist nursing practice: A critical review. J Clin Nurs 2002;11(4):421 9.
16. Taylor C. The partnership myth? Examining current opinions. J Child Health Care 1998;2(2):72 5.
17. Bridge, G. A personal reflection on parental participation: How some mothers of babies born with disabilities experience interprofessional care. J Interprofessional Care 1993;7(3):263 7.
18. Enderby, P. Teamworking in community rehabilitation. J Clin Nurs 2002;11(3):409 11.
P.520
19. Sloper, P. National Service Framework for Children, External working group on Disabled Children Background work on Key Workers. London: www.doh.gov.uk/nsf/children/externalwgdisabled. htm, 2002.
20. Mukherjee, S., Lightfoot, J., and Sloper P. Communicating about pupils in mainstream school with special health needs: the NHS perspective. Child Care Health Dev 2002;28(1):21 7.
21. Lowe, J. Conflict in Teamwork. Soc Work Health Care 1978;3:323 30.
22. Roelofsen, E.E., The BA, Beckerman, H., Lankhorst, GJ., and Bouter, LM. Development and implementation of the Rehabilitation Activities Profile for children: Impact on the rehabilitation team. Clin Rehabil 2002;16(4):441 53.
23. Madge, S., Khair, K. Multidisciplinary teams in the United Kingdom: problems and solutions. J Paediatr Nurs 2000;15(2):131 4.
24. Forte P.S. The high cost of conflict. Nurs Econ 1997;15(3):119 23.
25. Watson, D., Townsley, R., and Abbot, D. Exploring multi-agency working in services to disabled children with complex healthcare needs and their families. J Clin Nurs 2002;11:367 75.
26. Hudson, B. Joint working. Prospects of partnership. Health Serv J 1998;108(5600):26 7.
27. Lavelle, J. Education and the sick child. In L. Hill, ed. Caring for Dying Children and Their Families. London: Chapman & Hall, 1994 pp. 87 105.
28. Chambers, E.J. and Oakhill, A. Models of care for children dying of malignant disease. Palliat Med 1995;9(3):181 5.
29. Hill, L. The role of the children's hospice. In L. Hill, ed. Caring for Dying Children and Their Families. London: Chapman & Hall, 1994, pp. 177 183.
30. Robinson, C. and Jackson, P. Children's Hospices A lifeline for families? London: National Children's Bureau, 1999.
31. Nelson, B. Dealing with inappropriate behavior on a multidisciplinary level: A policy is formed. J Nurs Adm 1995;25(6):58 61.
32. Dombeck, M. Professional personhood: Training, territoriality and tolerance. J Interprofessional Care 1997;11(1):9 21.
33. Nuckles, M. and Bromme, R. Knowing what the others know: A study on interprofessional communication between nurses and medical doctors. Klin Padiatr 1998;210(4):291 6.
34. Ledbetter-Stone, M. Family intervention strategies when dealing with futility of treatment issues: A case study. Crit Care Nurs Q 1999;22(3):45 50.
35. Hooker, L. and Williams, J. Parent-held shared care records: Bridging the communication gaps. Br J Nurs 1996;5(12):738 41.
36. Sloper, P. Models of service support for parents of disabled children. What do we know? What do we need to know? Child. Care, Health Dev 1999;25(2):85 99.
37. Yerbury, M. Issues in multidisciplinary teamwork for children with disabilities. Child: Care, Health Dev 1997;23(1):77 86.
38. Roelofsen, E.E., Lankhoorst, G.J., and Bouter, L.M. Team conferences in paediatric rehabilitation: Organization, satisfaction and aspects eligible for improvement. Int J Rehabil Res 2000;23(3):227 32.
39. ACT. A guide to the development of Children's Palliative Care Services. Bristol & London: Association for Children with Life Threatening or Terminal Conditions and their Families and the Royal College of Paediatrics and Child Health, 2003.
40. Limbrick, P. The team around the child. Manchester: Interconnections, 2001.
41. Himid, K.A, Zwi, K., Welch, J.M., and Ball, C.S. The development of a community-based family HIV service. AIDS Care 1998;10(2):231 6.
EAN: 2147483647
Pages: 47