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Abstract
Multiprofessional teams have become in recent years one of the distinguishing features of services, where professionals with different competences work together. The core of our interest is addressed to the équipe of a palliative care ward; in particular, to that series of working activities that consists of communicative acts, as équipe meetings, for instance. Our research focuses on the analysis of the process by which the development of knowledge in multiprofessional practice is built to establish more information on recurrent patterns in the interaction and connect them to the specific context that these are shaped by. In this sense we will underline how components of knowing are shared among team members in constructing medical prognosis and we will analyse the connection among language processes, cognitive activities and social structures. More specifically, we will study the role of language and the context in the definition of linguistic acts in cognitive activities and in hierarchies involved in decision-making processes by exploring and pointing out how it is organised and structured. In particular through the study of talk-in-interaction where interchange of information is realised, we will emphasise how, in the multiprofessional équipe meeting, the realisation of practices and the knowledge useful to collaborative management of ward working life are established. To reach this aim, we adopted an ethnographic approach connected to the analysis of the situated interaction.
- Concept of health
- healthcare for specific diseases/groups
- quality of healthcare
- attitudes towards death
- death education
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- Concept of health
- healthcare for specific diseases/groups
- quality of healthcare
- attitudes towards death
- death education
Introduction
During recent years multiprofessional teams have become one of the identifying elements within healthcare contexts where professionals such as doctors, psychologists and medical attendants work together. This situation has entailed a new way of communicating for the operators, as usually a significant activity of the team is team meetings where every single patient therapeutic project is periodically discussed and defined. Our attention has been focused on a special healthcare environment, a state-run hospice in the north of Italy, where the équipe represents the central element around which the daily work of those who operate within this structure is organised and run. The hospice is a welfare structure for incurable patients with a fatal diagnosis and a short time to live.
Scientific studies of hospices are few. They have been mostly carried out within Anglo-Saxon contexts and are mainly aimed either at analysing their clinic, structural, formative and ethical aspects or at understanding and explaining the psychological aspects of the people involved.1
In Italy, for example, the first book on Italian hospices was published only in 2007 as a result of the collaboration between the Italian Society for Palliative Care, the Ministry of Health, the Regions and the A.S.L.s (Local Health Services). The first ministerial enquiry for conducting a census of the hospices operating on Italian territory and for gathering data on their condition dates only to 2008.
The aim of this research is to analyse the discursive practices enacted in the équipe meetings of one of these structures.
Methodology
The research combines ethnographic study2 with discourse analysis as we are interested in showing ‘how things really develop’, beyond ideological prejudices and collective representations of any kind.
Our presence in the field was, from this point of view, and allowed us personally to observe and listen to real events and witness practices and discourses evolving.3 Doing this, the contingent dimension of these practices emerged as did the need for us to take into account the idea of a context formed by continually developing persons, social roles, interactions and interpretations which were dependent on each other. The research focus moved towards a communicative context within which we could identify the processes by which meanings were being socially constructed by the team members. In this respect and according to discourse analysis (ie, Austin4; Gubrium5; Potter6), conversations can be seen as real, natural, contingent and factual colloquial modes, by which the world can be interpreted and constituted and by which meanings can be built and shared, within the framework of given relationships. From this point of view, speech is interpreted as a text and as a conversation in social practice6 where language serves as a means of interaction with features which can be traced back to the rhetorical and argumentative structures expressed by the speakers. Language is therefore a symbolic and formal apparatus allowing people to express and share with others the meaning of what they do; researchers have the chance to investigate its performing dimension4—that is, language in its accomplishment. In this way conversations do not simply describe a state of affairs, but are full-blown actions performed by speakers. In particular, discourse in working environments performs professional acts, where people enact their expertise, and a team meeting must be seen as a segment in a system of professional activities. Discourse analysis is therefore the epistemological framework which, together with the ethnographic approach, allowed us to understand the conversational practices in the community.
After having been allowed by the director of the palliative care unit of a hospital in the north of Italy to take part in and record the team meetings which were held in the unit, our research started. Thanks to an observation period which lasted about a year, and to the subsequent transcription of the audio-recorded tapes and notes taken during the meetings (which were held weekly), we obtained the biggest part of the empirical material necessary for this analysis.
Issues
The first part of our analysis underlines the peculiar aspects of the hospices which make the weekly meeting one of the most important communicative moments on which the handling of situations within the unit depends. We consequently developed a parallel comparison between the concept of traditional medicine on the one hand, and the philosophy of palliative care (originating from the former) on the other, thus ending up with the description of the story of the hospice where we performed our research.
Getting closer to the end of life is an intensely personal event which can be very demanding from both an emotional and physical point of view.7 During this phase the patients and their relatives often need very quick support, and prompt answers about their increased needs are required from the medical and social helpers. These measures can help people live a dignified life until the end and can also support the relatives afterwards. Interest in the quality of life topic and the interpretation of the concept itself, are nevertheless very individual8 for all the participants in this process. Some of them are very worried by the physical symptoms such as pain; some others are afraid of the influence of the illness on their daily lives9; others can be distressed about the uncertainty of the situation, about religious beliefs or about the consequences of their illness on their relatives. The patients' concerns can moreover differ from those of the healthcare professionals and from those of the relatives taking care of them.
In Italy, even if the scenario is slowly changing, palliative care has not yet gained a high profile, nor any kind of formalisation in the theoretical and practical training programmes of health professionals in general. This can explain why the staff claims not to feel expert enough to cope with critical situations such as giving bad news, verifying prognosis and helping patients and relatives to make difficult decisions. For these professionals and above all for those who take care of patients in a terminal phase and who cope with the reality of daily practice, it is therefore very urgent to develop new techniques. Ethical questions are more and more complex in the field of patient care.
The team meeting, in a palliative context, should represent the situation where the principles of care and assistance arising from palliative care philosophy come into force. For this reason we decided to focus on this topic and to test if there exists a correspondence between the theoretical model foreseen by palliative care in general and the discursive practices set in force by the workers in the hospice.10 By observation we tried to verify in the field what we had learnt from manuals and, consequently, to check if there is a correspondence between theoretical and operative patterns. This part of the study refers, at a theoretical level, to the neo-institutionalism literature according to which the highly institutionalised environments which comprise the organisations.
In this sense, organisations are nevertheless not isolated from institutions which, on the contrary, constitute the social texture legitimating the organisations; an assumption that opens a new research perspective on the ways in which institutions and organisations interact and therefore influence each other.
The organisation, in our case study, the hospice, must therefore modify some of its targets in order to be socially legitimised. This implies the need for continuous negotiations between external influences and the organisation which needs to have its activities carried out in a certain way. According to this theoretical perspective, an organisation may survive in the long run only if it manages to limit those influences and to preserve its commitment to the multipurpose and effective handling of its internal structure aimed at reaching the original targets (the original targets can be found in the palliative care manuals). Obviously, team meetings also are influenced by institutions and, as we have noticed, the operators highlight this fact through their daily practices.
The operational pattern of the unit we have studied is actually influenced by theoretical aspects which are linked to the palliative care philosophy, among which are assisting the terminally ill patient and accompanying him towards death according to a holistic approach to the person. The ideological aspects are also linked to elements which characterise both the single operators and the hospice of north Italy itself. The mix of different aspects such as, for example, professional training, former working experiences of the single operators, their nature and social status, and the peculiar aspects of the national and local institutional framework, results in a different appreciation of the general principles of palliative care and therefore shapes also the discursive practices within the unit.
Our study also shows the existence in Italy of solid historical institutions such as those of the state and the church, influencing both individual and collective perspectives and behaviour. The theory of organisation explains this phenomenon with an institutional approach11 which has led hospices in Italy to surrender to the institutions in order to obtain legitimisation and increase their opportunities of long-term survival. In this respect we discovered in the hospice studied the persistence of those mainly symbolic aspects imported directly from the Anglo-Saxon culture on palliative care along with a certain hybridisation between the unit and local realities and issues. In this case institutions overcome the local reality of the hospice;
–in this specific case, we highlight the existence of Italian peculiarities governed by the influence of the national bureaucratic and politic system and of the Catholic Church on issues related to the end of life (such as the use or not of opium based drugs, the recourse to or the cessation of assisted feeding and hydration) with consequences on an ethic, moral and managerial level as far as the procedures used in the hospice are concerned. These arguments represent the bases of the palliative care philosophy (for which the respect of the patient's freedom of choice is a fundamental principle to be considered) and they are the result of the reciprocal influence between institutions and organisations, a theory proposed by the modern version of the Institutionalism, that is, the Neo-Institutionalism.
The institutional reality, together with economic reasons oriented towards rationalisation, political reasons, religious beliefs and the peculiarities regarding our hospice (including its operators) meet and determine, according to us, the birth of a hybrid hospice model, which creates new demands and values for the institutions, thus giving birth to a relationship of reciprocal exchange and not only of influence between the two. In this respect we are assisting in Italy the foundation of ad hoc ministerial commissions also composed of palliative care specialists aimed at representing different local experiences appointed to the study and evaluation of new legislation proposals.
In the second part of our study we have focused on teamwork within a specific hospice. The core of our interest was talking work: that series of working activities which are mainly constitute by discursive acts,12 in particular the team meeting. These meetings are the fulcrum of decision-making on which the interdisciplinary handling of the patient and his relatives within the unit completely depends.
The communicative practices which are aimed at reaching a final choice are the basis of all other activities, because of the peculiarities of this context where the average stay is a little more than 12 days and where the patients and relatives' needs are very diversified. Our frame of reference for this study phase is the sociocultural models of communication (Duranti and Goodwin13; Sarangi and Roberts14). In these models human action is considered as a social action, where meanings are interactively and discursively built (talk-in-interaction) through practices (Wenger15) which are shared with other individuals within intersubjectivity environments. We carried out this study to explore the possibility that work practices are shaped by contingent aspects of unfolding situations more than by the theoretical model of palliative care. Considering the different facets of the team meetings through observation and subsequent transcription of some of them, we identified the key aspects regulating the communicative practices. As a result, we found that the latter mainly consist of routines which are necessary for supplying and granting the certainties that allow the proper daily running of the unit. This can be strongly connected to the institutional framework and to the local context within which the analysis was performed.
The transcript analysis, which is the core of our research, was carried out through three different dimensions of analysis. These dimensions reflect the choice of studying the weekly team meeting according to the theoretical perspectives which guided the whole cognitive path of the research. This was meant to provide a dynamic and in situ observation of our studied object, based on a constructivist approach towards the world.
–Through the language analysis, we tried to understand which role is played by language in situations of decision-making. With reference to a study carried out by Hugh Mehan16 on the possibilities of placing students in special educational programmes, we aimed at demonstrating that extraordinary persuasion patterns exist in language and can influence the decision-making process.
–Through the process analysis, we highlighted what is referred to as disparity of interaction power. This involves asymmetric interactions, that is, the communication interactions where there are no real communicative equal rights and duties among the speakers but the participants are characterised by an unequal access to the handling powers ruling the communicational exchange. This has obviously strong consequences on the final decision-making.
–Finally, through the structural analysis, we studied the meeting format, that is, to verify the existence of a structural format common in all our recordings.
Conclusion
In conclusion, the équipe meeting turned out to be inconsistent with the original theoretical model from which it is derived, ruled by an unequal conversation and where recurrent clichés linked to breaking points can be found. Taken together the three analysis dimensions have allowed us to suggest that: there is no sharing of meaningful information during the weekly meetings and that this is the reason for the lack of an operative process. Moreover, meetings are the space within which emotional or private events of those who work in the hospice are manifested. These results reveal the inadequate professional role of the health operators in a context where a high level of operational and moral responsibility is required thus increasing the complexity and the contradictions that the individuals must face from an institutional point of view and also as human beings with subjective personal experience.
After outlining the historical, political and cultural context within which the members of the studied team are working (thanks to the identification of its peculiar cognitive and organisational elements) we have highlighted the critical points and, in the meantime, the innovative aspects making the hospice the place where the fundamentals of traditional medicine are put under discussion as a consequence of the holistic approach to the person that is considered in his whole entirety and complexity.17
By doing so we highlighted the influence exerted by the institutions in the hospice on communicational practices among the health operators during the weekly team meeting and also aimed to show that communication among the operators is definitely not the result of joint activities as foreseen by the theoretical reference model.
Identification of the team meeting as one of the most important activities of the organisation and a crucial one for the functioning of the hospice (since it implements the paradigm upon which the philosophy of palliative care is based) has then led us to detect some critical areas. The routine, that is mostly expressed within the meetings, does not suit a context where emerging aspects are more emphasised as relevant than standard ones (such as rounds, checking the patients temperature, the meal served at a given time, and so on) and results in a wrong outcome. Routine is in fact a rigid net of meanings and cannot therefore fit the dynamism characterising the end of life phases. If on the one hand, routine is the answer to the uncertainties linked to the topic of death, on the other it inhibits the discursive practices of the operators who remain therefore stuck in it.
The consequences are the difficulty in the sharing of meaning during a team meeting and, as a consequence, non decision-making; the inhibition of any reflective activity among the members of the team; a widespread attitude towards self-referentiality among the operators; the continuous reference to the ideal philosophy of palliative care; and the need of re-defining the concept of interdisciplinarity in the hospice context.
The fact that there is no sharing of meanings within discursive practices is proved by the predominance of individual perspectives together with routine elements which make the hospice a unique and particular reality, which cannot be generalised.
The failure to structure choices demonstrates that even if death is the sole certain perspective of the acts and mission of the health operators (ie, accompanying patients towards death with the vision of a ‘sweet death’) the instinct to live keeps on prevailing in them. If there is no remedy to death, life always introduces other scenarios and the fact that no final decision is ever made confirms, according to us, this conclusion. From this point of view the fact of not deciding can also be interpreted as a refusal of death.
The inhibition of thoughtful activities among the team members is the direct consequence of activities which are mainly routine and individually planned and therefore linked to pre-existing meanings. The discursive practices to which operators often refer during the daily handling of life (and death) in the hospice have a repetitive, foregone and a priori nature which contributes to reducing the possibility that cognitive and explorative mechanisms may develop for coping with the difficulties dictated by the experience of assisting those who will soon die. The operator is also prone to praise his role through continuous references to his skills (which should be in line with the philosophy of palliative care). This is aimed at underlining his own function in the hospice, even if he might feel death as a personal failure and in order to ease himself from the difficulties caused by his actions. Notwithstanding the fact that the philosophy of palliative care proposes a new attitude towards the end of life, we think that in everyday work the feeling of deception is in some way emitted by one's own feeling of existing. The continuous reference to the philosophy of palliative care reflects a potentially idealistic projection of what should be done but is in reality very difficult to do owing to all the reasons we have analysed previously.
The importance given to the concept of interdisciplinarity proposed by palliative cares led us to consider the possibility that, within the team, it is also necessary to safeguard and preserve the individual skills in view of a holistic approach to the patient and his relatives. This approach should not go beyond the individual skills since, within this context, it is very important to be able to cope with the complexity of the situations thanks to a responsible attitude, which is also in line with the duties deriving from everyone's professional role. In this sense, the situation-sharing could be made explicit through a negotiation of competences, without having to disregard the relevant responsibilities and from a point of view of mutual exchange and support (in compliance with the interdisciplinary model).
The strength of the interdisciplinary team lies in the gathering and fusion of different points of view which could give birth to an overall vision able to respond to the concreteness of the situations and in coherence with the professional points of view of every member. Every operator should therefore develop a higher disposition towards responsibility and personal self-government in order to verify, during the meetings, if his own objectives in relation to those of the team have been attained. The advantage of this attitude would result in the possibility of implementing, in a flexible and coherent way, single competencies to face the specific cases to be handled and in relation to the goals to be reached. The role separation, the acknowledgement of all specificities and the demarcation of responsibilities would therefore represent the enriching elements useful for realising models and organisational ways aimed at implementing the idea of an efficient therapeutic continuity.
The purpose of this research is to enrich the current knowledge on a specific social and health reality of palliative care, the hospice of a hospital in the north of Italy, by helping to define the possible formative paths for the healthcare operators working in similar contexts. According to us, the definition of universal and universally shared rules cannot be attained through an empirical generalisation, but only through a continuous comparison among different experiences, different contexts and different professions, in theory and also on the job. For this reason it would be helpful to organise meetings, round tables and seminars in order to offer real formative occasions along with relevant and specific literature in the field. The contribution offered by humanistic disciplines to holistic approaches such as that of palliative care, must be seen as complementary in order to encourage an analytic investigation, without forgetting the specificities of every reality.
Footnotes
Patient consent Obtained.
Provenance and peer review Not commissioned; not externally peer reviewed.