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Multiprofessional collaboration in children's cancer care: believed to be a good thing but how do we know when it works well?

2009; Wiley; Volume: 18; Issue: 4 Linguagem: Inglês

10.1111/j.1365-2354.2009.01131.x

1365-2354

Faith Gibson,

Ethics and Legal Issues in Pediatric Healthcare

Collaborative working, where care is delivered through teams of professionals working together, has become a central characteristic of services within children and young people's cancer care. The opportunities to share expertise and experience within the healthcare team throughout a child's care pathway have the potential to positively influence patient outcomes. Working within the field we can be certain of two important factors: (1) that no single profession can treat the complex physical and psychosocial needs of this population; and (2) that the multiprofessional team is a vital component of quality care for children and young people with cancer and their families (Baggott & Kelly 2002). The need to share expertise, pool knowledge and cross traditional boundaries has been portrayed not as a choice, but as a necessary ingredient for the delivery of high-quality care (Department of Health 2001). However, in espousing collaboration as a ‘good thing’, we must be clear what we are talking about. Multiprofessional teams must not be confused with groups of professions who work independently but happen to liaise with one another over a period of time (Scholes & Vaughan 2002). Instead, teamwork should be regarded as the central component of multiprofessional collaboration, where professionals are being urged to learn from and about each other so that they might effectively work across professional boundaries for the benefit of the patient (Kenny 2002). It may well be that only the people involved can determine whether collaboration has occurred or not (Kenny 2002), leaving the thorny issue of ‘how do we know when it works well’ to be subjectively examined. Multiprofessional working is increasingly emerging through research collaborations. Mirroring clinical care, it is widely assumed that collaboration in research is a ‘good thing’. Thus, we are using evidence informed by contributions from a range of professions, namely health and the social sciences. But how collaborative is the research being undertaken? In a previous editorial in the European Journal of Cancer Care, O’Connor (2009, p. 220) commented, ‘the majority of papers published in the journal were unidisciplinary in focus and monoprofessional in their authorship’. This cannot be said of this special edition of the journal, which is an excellent example of the collaborative nature of emerging research revealing the sharing of expertise to answer clinically important questions. For example, Crawshaw et al. (2009) and Jackson et al. (2009) present collaborative studies between social scientists and paediatric oncologists, and Maurcie-Stam et al. present a study involving psychologists and paediatric oncologists. But in labelling these publications as collaborative, co-authorship is the only measure available to the reader to judge collaborative activity, a measure that Katz and Martin (1997) suggest be used with caution. Co-authorship must not be confused with research collaboration. Collaboration in this context concerns the working together of researchers to achieve the common goal of producing new scientific knowledge that most benefits patients (Ream & Gibson 2007). Attempting to measure this relationship through co-authorship is clearly inadequate. In cancer care and research we might all agree that collaboration is in fact a ‘good thing’. But clearly collaboration and multiprofessional working is less than straightforward. Differences in training, knowledge skills and values all have an impact on how professionals relate to and work with each other. It requires all members of the team share common aims and objectives, and work together towards a common goal. This requires commitment and the active involvement of each of the parties engaged. It requires creating environments of trust and respect enabled through good listening skills, an ability to articulate individual contributions and well-refined negotiation skills. Real collaboration derives from, and depends upon cultural growth, professional confidence and belief in the skills and knowledge that professionals possess (Kenny 2002). However, it is naive to think that these ways of working develop spontaneously or through good will alone. A project entitled ‘collaboration between nurses and doctors in paediatric oncology’ aims to improve the way doctors and nurses in paediatric oncology centres work together to improve patient care. It seeks to do this by describing and measuring the level of integration between these two professions in several areas of care and by promoting exchange of theoretical and technical knowledge between nurses who care for children and doctors in the same working environment. Two member societies of the European CanCer Organisation (ECCO), the European Oncology Nursing Society (EONS) and the European Branch of the International Society of Paediatric Oncology (SIOP), promoted the study that was awarded funding in 2005. The project was organised around three weekend seminars held in Europe over a period of 2 years, with ongoing support between meetings from a designated mentor. The aim during the seminars was: (1) to promote the implementation of theoretical content; (2) to provide an opportunity to discuss and receive feedback on methodologies to be used to manage and sustain change; (3) to analyse the issues encountered in clinical practice; and (4) to discuss implementation in the real world of clinical practice, using learned models of analysis and planning. The project participants have been active members of this appreciative inquiry project: an approach described as an exciting way to embrace organisational change (Cooperrider et al. 2005). Participants have planned and implemented a project in their own environment to promote the integration and collaboration of doctors and nurses drawing on theory and facilitation provided in the seminars. The project began with 15 pairs representing the UK (two centres), Estonia (two centres), Switzerland, Belgium, Greece, Lithuania, Serbia, Poland, Germany, the Netherlands, France, Spain and the Czech Republic (one pair each). Eleven pairs continue in the scheme, and are working on a range of projects. Examples of projects include: collaboration between doctors and nurses in providing information to the patients and their families during the course of treatment; improving telephone communication between parents, medical and nursing staff in a paediatric oncology unit; and implementation of a paediatric pain protocol in the paediatric haematology/oncology ward (see EONS Winter 2008 Newsletter for examples http://www.cancerworld.org/CancerWorld/moduleStaticPage.aspx?id=6857&id_sito=2&id_stato=1). Further funding has been awarded by ECCO to facilitate a fourth seminar prior to the ECCO congress in 2009 Berlin, enabling project participant's time to embed change and to put in place factors that would sustain their project over time. The project has achieved its main aim, in that the participants will have developed and implemented a project to explore and enhance collaboration between doctors and nurses in paediatric oncology. All those working on the project believe such collaboration to be a ‘good thing’. But the question remains ‘how do we know when it works well’? If we agree with Kenny (2002) that only the people involved can determine whether collaboration has occurred or not, then we need to find ways to capture the essence and defining features of collaboration from those who describe their role as collaborative both in clinical care and research. It is not enough to believe that collaboration is a ‘good thing’, where we mentally tick the box ‘collaborative working’. In order for real improvements in the quality of care delivered to children and young people with cancer and their families to be fully achieved we must focus on measuring integration and multiprofessional working, and learning to better articulate what works and when. The rapid advancement of clinical knowledge and the development of multiprofessional working, together with the evolution of patients’, and their families', expectations and needs have challenged nurses and doctors to re-think their current practices. This organisational change recognises that a single profession or individual can no longer deliver complex cancer care. To sustain this change within health care we need to know much more about when collaboration works well. I would like to acknowledge participants in the European Branch of the International Society of Paediatric Oncology/European Oncology Nursing Society European CanCer Organisation project who have helped me to understand collaboration more clearly, and know what it means to clinical teams. I would also like to acknowledge my colleagues working with me on this project: Alison Arnfield, Paola Di Giulio, Martin English and Momcilo Jankovic.