Difficult Conversations

Transcription

1 Difficult Conversations Providence Health Care Ethics Seminar An Introduction to Health Care Ethics April 29 th, 2015 Hilary Pearson, MA, PhD, CCC Paul Whitehead, MA, PhD, CCC, R.Psych Centre for Practitioner Renewal Providence Health Care / University of British Columbia

2 Centre for Practitioner Renewal (CPR) Health care is about curing and healing; art and science, mind and heart, skills and knowledge, technology and compassion Health care is based on a business model of efficiency, the work we do is about relationship relationship with self, other and Other Relationship is often sacrificed to action and efficiency

3 Centre for Practitioner Renewal Objectives How do we sustain health care providers in the work place? What is the effect of being in the presence of suffering? What would be reparative, healing or restore resilience for health care providers? Efficiency through relationship

4 Our Experience at CPR Sustaining Healthcare Providers in the workplace: Burnout / Compassion Fatigue / Vicarious Trauma / Moral Distress / Grief / Depression / Anxiety and Lateral Stress among colleagues Centre for Practitioner Renewal

5 Lateral Stress: Accumulated stress discharged between colleagues Irritability, frustration, lack of patience Intolerance of difficult emotion Silencing response Scapegoating/bullying/incivility Centre for Practitioner Renewal

6 Relationship-centered Health Care An approach that recognizes the importance and uniqueness of each health care participant s relationship with [one s self and] every other, and considers these relationships to be central in supporting: high-quality care high-quality work environment superior organizational performance Safran, DG, Miller, W. and Beckman, H Organizational Dimensions of Relationship-centered Care J Gen Intern Med 2006: 21:S9-15

7 Relationship-centered Health Care Principles: 1. Relationships in healthcare ought to include the personhood of the participants 2. Affect and emotion are important components of relationships in health care 3. All health care relationships occur in the context of reciprocal influence 4. The formation and maintenance of genuine relationships in health care is morally valuable Beach, MC, Inui, T, Relationship-Centered Care Research Network. Relationship-centered Care: A Constructive Reframing J Gen Intern Med 2006; 21:S3-8

8 Objectives to help participants: Identify the importance of being mindfully aware of self and others in order to co-create a space for dialogue Review key skills in having difficult conversations Understand the importance of dialogue in maintaining team cohesion, optimizing patient care and sustaining healthcare provider resilience

9 The Fundamental Steps Understand ourselves Understand others Use our communication skills to foster civility, engagement, and creative problem solving

10 Guidelines C onfidentiality E qual airtime N on-judgemental listening T imeliness R ight to pass E ngaged

11 Reflection: Your experience of an ethically challenging situation Think of a situation which you experienced as ethically complex and which required you to make a decision or take an action (or refrain from action) that made you uncomfortable.

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13 Transference Transference is an unconscious displacement of feelings, attitudes, expectations, perceptions, reactions, beliefs and judgments that were appropriate to former figures in our lives onto people in the present.

14 Transference and Mindfulness Transference can be baggage (impedimenta). Unconscious transferences give power to the past. They fuel the potential of engaging in repetition in the false hope of completion. Awareness of our transferences gives power to the present. It can act as a guidepost to growth, a signal of what needs healing or integration.

15 Impact of Patient/Resident and Family Suffering on Team Dynamics Every family has dysfunction in it! Serious illness and patient suffering exaggerate anxiety and exacerbate family dysfunction. Patient/Resident and Family anxiety impacts individual team members and team dynamics We each bring our own family history, expectations and assumptions into the process

16 The importance of maintaining supportive relationships with self, other and Other Commitment to self knowledge and team cohesion will optimize patient and family centred care. Collegial support promotes resilience and mitigates anxiety, moral distress, compassion fatigue, and burnout Pausing to engage in dialogue promotes inter-personal understanding and ethical practice Spiritual Connection

17 Dialogue Dialogue does not require people to agree with each other. Instead, it encourages people to participate in a pool of shared meaning that leads to aligned action. - Jaworski, 2011

18 Complexity of Relationship

19 The Interpersonal Gap

20 THE PERSONAL ICEBERG METAPHOR OF THE SATIR MODEL BEHAVIOUR (action, storyline) COPING (stances) FEELINGS (joy, excitement, anger hurt, fear, sadness) FEELINGS ABOUT FEELINGS (decisions about feelings) PERCEPTIONS (beliefs, assumptions, mind-set, subjective reality) EXPECTATIONS (of self, of others, from others) YEARNINGS (loved, lovable, accepted, validated, purposeful, meaning, freedom) SELF: I AM (life force, spirit, soul, essence) See: Satir, V, Banmen J., Gerber, J., and Gamori, M. (1991). The Satir Model of Family Therapy and Beyond. Palo Alto, CA: Science and Behaviour Books, Inc.

21 Window of Tolerance 21

22 Window of Effective Empathic Engagement Empathic Over-Arousal * Identification vs. Empathy * Extreme sense of personal responsibility * Loss of boundary between self and other E M P A T H Y Zone of effective empathy Empathic 'Silencing'(Baranowsky, 2002) * Blocked Compassion * Cynicism * Avoidance of clients' suffering Centre for Practitioner Renewal

23 Exercise Imagine that the inter-disciplinary team you are part of is facing an ethically complex situation, and difficult conversations are needed.

24 Sabotage! Take a moment to reflect individually, then brainstorm at your table to identify the best strategy you could possibly use to ensure that these conversations FAIL in the most dramatic way possible.

25 Key Communication Skills Identifying what works

26 Common Pitfalls to Communication Meeting an emotional need with a cognitive response Mis-matched expectations regarding task versus process focus Assumptions and interpretations Defensive professionalism Conflict avoidance Smiling Rage

27 Communication Template A ttend B ridge C omment D evelop Relationship/Agreement

28 Communication Template: Attend Context: What is happening right now? Self: What am I experiencing? Other: What do I sense the other person is experiencing? Intention: Is my motivation to enhance respectful dialogue or to be right?

29 Communication Template: Bridge Introduce Topic Ask if it is a good time to talk Remain aware of both verbal and non-verbal relational cues

30 Communication Template: Comment Deliver message Check for mutual understanding Open space for dialogue

31 Communication Template: Develop Relationship / Agreement Acknowledge impact on other person Establish time-line/follow-up

32 Implications: The vital need for supportive relationships Adults remain social animals in some important ways, people cannot be stable on their own not should or shouldn t be, but can t be. This prospect is disconcerting to many, especially in a society that prizes individuality as ours does. Total self-sufficiency turns out to be a daydream whose bubble is burst by the sharp edge of the limbic brain. Stability means finding people who regulate you well and staying near them. Lewis, Amini & Lannon. A General Theory of Love. (2000).

33 Community Community is not an arrangement of people; it is a form of love. It is felt, enjoyed, and enacted in service and celebration. If you can achieve agape, communal love, in your feeling and attitude, you are a long way to finding your life work. - Thomas Moore: A Life at Work: The joy of discovering what you were born to do. (2008)

34 TGIF What am I Trusting? What am I Grateful for? What Inspires me? How am I practicing my Faith? (Faith = a place of mystery, where we find courage to believe in what we cannot see and strength to let go of our fear of uncertainty. Brene Brown)

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