Self-Learning Module: You the Learner, The Person in Your Care, in Care of the Elderly and Rehabilitation (CoE & R) At SCO Health Service

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1 Self-Learning Module: You the Learner, The Person in Your Care, in Care of the Elderly and Rehabilitation (CoE & R) & The Interprofessional Care Team At SCO Health Service Production of this document has been made possible through a financial contribution from Health Canada. The views expressed herein do not necessarily represent the views of Health Canada.

2 Self-Learning Module: You, the Person in Your Care & the Interprofessional Care Team This self-learning module has been developed by the Project Team & Steering Committee described in the diagram below: IECPCP & the Humanities Steering Committee Co-Chairs: Susan Brajtman: School of Nursing Pippa Hall: Faculty of Medicine, SCO Health Service & EBRI SCO Health Service Evaluation: Lynda Weaver SCO Health Service Project Team: Kevin Barclay Dawn Mullins Enkenyelesh Bekele Universities Clinical Programs: Complex Continuing Care (CCC) Palliative Care Unit (PCU ) Care of the Elderly & Rehabilitation (CoE & R) Long Term Care (LTC) Patients/Families From: CCC CoE & R PCU LTC Corporate Programs: Ethics Mission Effectiveness Office of Learning U of Ottawa: Social Sciences Human Kinetics Rehab Sciences Law School of Nursing Faculty of Medicine Saint Paul University Faculty of Human Sciences Students: U of Ottawa Saint Paul U Algonquin College Colleges La Cité collégiale With contributions from: Clinical preceptors and team members at SCO Health Service Faculty and teachers of the partner universities and colleges All of the learners who provided feedback on the module The Authors List can be found in Appendix 1. Pippa Hall, Susan Brajtman, Lynda Weaver 2008 Edition #2

3 TABLE OF CONTENTS INTRODUCTION 1 OBJECTIVES. 2 HOW TO USE THIS SELF-LEARNING MODULE.. 2 SECTION I: HOLISTIC CARE. 6 LEARNING ACTIVITY #1 - Knowledge of Holistic Care.. 7 LEARNING ACTIVITY #2 - Care Activities that support Holistic Care 16 SECTION II: THE INTERPROFESSIONAL TEAM. 20 LEARNING ACTIVITY #3 - Knowledge of the different definitions of teams Knowledge of different professional roles Observing the health care team and Aspects/Domains of Holistic Care Professions you least know about.. 32 LEARNING ACTIVITY #4 - Care Scenario LEARNING ACTIVITY #5 - Knowledge of Collaborative Practice and Team meeting 41 LEARNING ACTIVITY #6 Family meeting SECTION III: THE HUMANITIES FRAMEWORK 57 LEARNING ACTIVITY #7 Knowledge about the Humanities FOUR PILLARS OF THE HUMANITIES.. 60 HOLISTIC CARE MODEL SUMMARY. 69 HOLISTIC CARE MODEL EVOLUTION.. 70 SECTION IV: THE CREATIVE SUMMARY.. 72 EXAMPLES OF CREATIVE SUMMARY QUESTIONS AND EXPLORATORY ACTIVITIES FOR EACH PILLAR. 73 EXAMPLES OF A CREATIVE SUMMARY BIBLIOGRAPHY APPENDICES. 79 APPENDIX 1: AUTHORS.. 81 APPENDIX 2: ABBREVIATIONS AND GLOSSARY APPENDIX 3: INTERPROFESSIONAL TEAM MEMBERS - ROLE DESCRIPTIONS APPENDIX 4: CONSENT FOR PHOTOGRAPHS AND RECORDINGS.. 95 APPENDIX 5 A): TOOL # 1- KEY ELEMENTS OF COLLABORATION CHECKLIST APPENDIX 5 B): TOOL # 2 - FAMILY MEETING CHECKLIST APPENDIX 6: BLANK TEAM MAP APPENDIX 7: RESOURCES

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5 INTRODUCTION WHO IS THIS MODULE FOR? This module has been created for all healthcare learners coming to SCO Health Service for clinical placement in any of the four programs of care: Complex Continuing Care; Rehabilitation & Care of the Elderly; Palliative Care; Long-Term Care. At SCO Health Service, we strive to use a team approach that is person-focused when providing care to our people and their families. This approach requires a great deal of collaboration amongst the different healthcare providers in order to deliver care that addresses the unique needs of each person in your care at SCO Health Service. We consider it very important to teach a team approach when learners come to SCO Health Service to receive training from our clinicians. WHAT S THE PURPOSE OF THIS MODULE? The overall purpose of the learner s module is to provide a self-instructional guide that will help you learn the interprofessional collaborative team approach to providing person-centred care. You will have the opportunity to learn with, from and about other health professionals throughout the module. This will help you to develop your clinical skills as team members while you work with the people in your care along with the SCO health care team. It is our hope that by providing these learning opportunities to you early in your clinical career, you will acquire the knowledge, attitudes and skills necessary for a holistic, interprofessional collaborative team approach and will use this approach when you become the next generation of health care providers in your particular profession. The ultimate goal is that the person in your care will benefit greatly from this holistic and humanistic approach. WHAT WILL YOU FIND IN THE MODULE? This module contains interprofessional collaborative learning activities that can be adapted to any level of training and expertise. That is, you will benefit from doing the learning activities and Creative Summary whether your clinical stay is short (e.g., two weeks) or long (e.g., many months) and regardless of your chosen profession. A Humanities framework is used in this module to focus on all aspects of a person s well-being, which is important to all professions. HOW LONG WILL THIS MODULE TAKE TO COMPLETE? The learning module is intended to be used as a self-learning guide and is therefore self-paced. As the learner, you choose when you want to do the learning activities in the module, the level of detail you wish to explore and the areas you want to reflect on in depth. It is a resource to support your own interprofessional learning goals, use it wherever it helps you to gain new information and insights that advance your learning goals. If you know a section well already, you may wish to go on to the next section. Aim to have the module completed (including the Creative Summary) by the end of your clinical placement. The module is designed for placements of 10 days or longer. 1

6 OBJECTIVES The overall objective of this Learning Module is to increase your knowledge of interprofessional education, collaborative person-centred practice, aspects/domains of holistic care, elements of collaborative practice, interprofessional team maps, and the Humanities. More specifically, by the end of this module, you will be able to: 1. List at least four aspects/domains of holistic care of the persons you are caring for and their families after completing Section I. 2. Describe the roles of the different members of the interprofessional health care team where you are working after completing Section II. 3. Identify the seven elements of collaborative person-centred practice after completing Section II. 4. Discuss the framework of the four pillars of the Humanities after completing Section III. 5. Demonstrate your understanding of practicing holistic collaborative personcentred care through the foundation of the Humanities by the completion of your Creative Summary in Section IV. HOW TO USE THE SELF-LEARNING MODULE The module is divided into four sections: Section I contains information and learning activities about holistic care Section II contains information and learning activities about interprofessional teamwork Section III contains information and learning activities about the Humanities Section IV contains information describing how to do your Creative Summary The information in Sections I and II may be a quick review for some, whereas Section III may introduce some new ideas into the care you are providing. All three Sections are important for your Creative Summary. We hope you find the module informative and fun. Travel through the module the way it suits you best! 2

7 Each learning activity offers: A question inviting you to identify your initial knowledge and understanding of the concept Information intended to add to your initial knowledge and understanding. If your initial knowledge and understanding of the concept is complete according to the objectives of the section, you may want to move on to the next section. A reflective question to reinforce your learning and expand upon your knowledge: You should begin the learning module a couple of days into your placement at SCO Health Service. Reading and actively engaging in each learning activity will help you learn the material and apply it in your practice. Your responses within the module are not going to be evaluated. However, your fellow team members on staff are expecting you to discuss your ideas and these concepts with them. We encourage you to do so. We also include: Abbreviations and Glossary of Terms (See Appendix 2) CPCP Domains of Holistic Care Elements of Collaboration Definitions for Teams and Interprofessional Team Map Humanities IPE The icon represents the two tools: Key Elements of Collaboration Checklist and Family Meeting Checklist. 3

8 LEARNING ACTIVITIES When working through the module during your clinical placement, use the guidelines below to help you make the most of the learning activities: 1. Document that you have discussed with at least one of the team members their professional role. This should be a role about which you knew very little until you had this discussion (QUESTION 3.2b in the module) 2. When you attend Team Meetings, complete Tool #1 7 KEY ELEMENTS CHECKLIST (Appendix 5A) and discuss your observations with one of the health care team members. 3. When you attend Family Meetings, complete Tool #2 FAMILY MEETING CHECKLIST (Appendix 5B) and discuss your observations with one of the health care team members. 4. Complete a CREATIVE SUMMARY at the end of your clinical placement that reflects your experiences with, and learning about, interprofessional teamwork and holistic person-centred care through the use of the Humanities framework. Your summary may be an individual or a group project. You are asked to share your Creative Summary with SCO Health Service s Office of Learning so that it might be included in the next Learner s Showcase 1. To keep track of your completed work, use the checklist on the following page and submit this with your Creative Summary. 1 The learner s showcase will be hosted once a year to celebrate the creative expression of the learners. Creative Summaries will be displayed at the showcase and other students, faculty and staff will be invited to view and reflect on the work of the learners. 4

9 LEARNING ACTIVITIES TRACKING SHEET Please put a mark in each box as you complete your learning activities: Section II 1. QUESTION 3.2b: Explored at least one professional team member s role that you know least about 2. 7 ELEMENTS CHECKLIST Completed: Week 1 Discussed with a team member Week 2 Discussed with a team member Week 3 Discussed with a team member Week 4 Discussed with a team member 3. FAMILY MEETING CHECKLIST Completed Discussed with a team member Section IV 4. CREATIVE SUMMARY Completed Interprofessional Team Map (see template in Appendix 6) Completed Creative Summary Shared Summary with SCO s Office of Learning Date: The Office of Learning would be pleased to receive your Creative Summary. Please contact one of the individuals below to share your Creative Summary with the Office. If you have any questions about the module, you may contact one of the following people: Margaret Lehre Tel.: ext Dr. Susan Brajtman Tel.: ext Dr. Pippa Hall Tel.: ext Lynda Weaver Tel.: ext

10 SECTION I: HOLISTIC CARE Section 1 contains information and learning activities about holistic care. Learning Objectives At the end of this section of the module you will be able to: 1. List the four aspects/domains of holistic care of the persons you are caring for and their families. 2. List at least four care activities for each of the four domains of holistic care. 3. Reflect on the care activities other professionals do (for the people in your care) and compare them to the care activities done in your profession. 6

11 Learning activity #1 Working at SCO Health Service requires you to be involved with individuals who have complex illness experiences and their families which result in multiple complex needs. These needs affect multiple aspects/domains of their health and well-being. No single health care provider can meet all of these needs. Identify your initial knowledge and understanding of holistic care: Question 1.1 Holistic care includes more than just the physical aspect/domain of a person s illness. Think of a person in your care, and think of the whole person. Identify some different aspects/domains of holistic care that you think are important for the person you are caring for and his/her family: 7

12 The following information is intended to add to your initial knowledge and understanding of holistic care. A model to categorize the many needs and issues of persons living with complex illnesses has been developed through a national consensus building strategy by the Canadian Hospice & Palliative Care Association ( CHPCA A Model to Guide Hospice Palliative Care: Based on National Principles & Norms of Practice, Ottawa, ON). The model is applicable to all persons with an illness. The following diagram is one way of describing the aspects/domains of holistic care. The sphere, or pie, represents the whole person. Aspects/Domains of Holistic Care Physical, e.g. -Disease management -Pain & other symptoms -Function -Nutrition habits -Physical activity Psychological, e.g. -Personality -Psychological symptoms -Emotions -Control & dignity -Cognitive function -Coping responses -Self image/ self esteem -Loss & Grief Social/Cultural, e.g. -Finances -Relationships -Personal routines -Recreation -Vocation -Rituals -Legal issues -Family caregiver support -Practical Spiritual, e.g. -Meaning & values -Existential issues -Beliefs -Spirituality -Rites & rituals -Symbols & icons -Loss & Grief -Life transitions -Religions Adapted from: Domains of Issues Associated with Illness and Bereavement in A Model to Guide Hospice Palliative Care: Based on National Principles and Norms of Practice. CHPCA, March 2002, page 15. 8

13 More detail of the contents of each piece of the pie is in the list below. *Extra bullets are inserted to indicate that this is not an exhaustive list. Please add to the list if you think something is missing. Physical: Disease Management Primary diagnosis (main disease) & general prognosis (i.e., what do we expect to happen with this illness for this person) Appropriate management (medications, investigations, treatments, etc.) Other co-morbidities & diagnoses (other diseases the person has) e.g., dementia, old stroke, heart disease, chronic obstructive lung disease, psychiatric diagnosis, diabetes Acute illnesses causing complications & more illness (e.g., pneumonia, delirium) Adverse events (e.g., drug side effects) Allergies Pain & other symptoms Cardiorespiratory: e.g., breathlessness, cough, edema, hiccoughs, apnea Gastrointestinal: e.g., nausea, vomiting, constipation, diarrhea, dyspepsia, dysphagia, cachexia Genitourinary: incontinence Mouth and skin care issues Neurological: e.g., cognitive changes, balance & coordination, weakness, paralysis Difficulty swallowing or eating/chewing food Hearing and speech difficulties Other: e.g., fatigue, insomnia, bleeding, syncope (i.e., fainting), sweats Functional, safety, aids to optimize function Motor function Sensory function Physiological function e.g., breathing & circulation Sexual function Physical activity Hobbies Activities of Daily Living Nutrition Habits & Hydration Smoking, alcohol 9

14 Psychological: Cognitive Functioning Ability to reason Ability to remember Affects personality, motivation, emotions Personality Strengths, behaviour Motivation Behaviour that generates positive effect Behaviour that generates negative effect Psychological symptoms Depression, anxiety Emotions Anger, distress, hopelessness, loneliness Fears Abandonment, burden, loss of home, death Issues of control, dignity, independence Conflict, guilt, stress, coping responses Self-image, self-esteem Loss, Grief Loss of past (e.g., dementia), loss of present (anticipated and actual if cognitive impairment), loss of future Grief : acute, chronic, anticipatory When death is imminent Bereavement planning Mourning 10

15 Social/Cultural: Culture Cultural values, beliefs and practices Cultural norms related to communication (e.g., eye contact, voice level) Financial issues Resources, expenses Relationships Roles and relationships with the family, friends and community Safe environment Hazards, vulnerabilities Need for privacy, intimacy Personal, family Personal routines Recreation Vocation Activities, roles Rituals Formal, informal Legal Power of Attorney for business, for health care Advance Directives Wills Guardianship, custody issues Family caregiver Support//protection Practical Activities of Daily Living (e.g., personal care, household activities) Care of dependents, pets Access to telephone, transportation 11

16 Spiritual: Foundations Meaning of, value in life Existential, transcendental issues Values, beliefs, practices, affiliations Spiritual advisors, rites, rituals Symbols, icons Religions Life Transitions Adjusting to major shift in life experiences (i.e., from being well and independent to requiring 24/7 care and supervision in a facility such as SCO Health Service) Preparing for life closure, when appropriate In this learning module, we suggest considering the physical, psychological, social/cultural and spiritual domains as the four main pieces of the pie that represent the suffering and needs of the person in your care. 12

17 The needs in each domain have to be addressed through our holistic approach to care. The Holistic approach considers the domains of care as well as the environment including the care setting and the community where the person is living and receiving care. We suggest that you need all the pieces of the puzzle before you can see the whole! So far we only have some of the pieces. This is represented in the illustration below: Holistic Care and Environmental Influences Physical Psychological Social/Cultural Spiritual Adapted from: Domains of Issues Associated with Illness and Bereavement in A Model to Guide Hospice Palliative Care: Based on National Principles and Norms of Practice. CHPCA, March 2002, page

18 Question 1.2 How did your answers in Question 1.1 (page 7) compare to the domain pie? How did they compare to the list on pages 9-12? 14

19 REFLECTION 1: To reinforce your learning and build upon your knowledge, reflect on the following question: What could you do to learn more about the aspects/domains you don t know much about? 15

20 Learning Activity #2 Identify your initial knowledge and understanding of the care activities required to provide holistic care: Question 2.1 Think of some of the care activities that other health care team members do at SCOHS when caring for a person and their family. What aspects/domains of care do these activities fit into? Physical: Psychological: Social: Spiritual: Environmental context: 16

21 The following information is intended to add to your initial knowledge and understanding of holistic care: The list below offers some of the care activities that health care providers may do when working with the person in their care with complex needs and their families. It is grouped by the four main aspects/domains of care. What else do you do? Add some care activities beside the empty bullets. 1. The physical domain: o Manage & monitor the complex diseases o Manage pain and other symptoms that result from the disease, medications and environmental restrictions of living in an institution o Optimize functional abilities, safety o Provide aids to optimize functional abilities o Optimize nutrition and hydration needs o o o 2. The psychological domain: o Recognize that when cognitive ability is impaired, you may only be able to change the environment to meet the person s needs (there may be no medications to help and no improvement is anticipated) o Recognize & support individual personalities and their strengths, behaviours, motivations o Manage depression, anxiety and other psychiatric disorders o Recognize normal emotional reactions to illness and institutional living conditions o Optimize control, dignity and independence o Assist with the re-establishment and maintenance of self-image & self-esteem o Facilitate healthy behaviour choices o Recognize issues related to stress, coping styles, conflict o Support the person in your care and their families in their experiences of grief and loss o o o 17

22 Some of the care activities in domains (continued): 3. Social/Cultural domain: o Assist with financial concerns o Recognize the need for relationships, roles of family members, dependents, community connections o Identify additional supports e.g., pets o Provide appropriate privacy, intimacy o Prevent isolation, sense of abandonment o Insure safety and comfort o Respect routines, rituals, hobbies etc. o Attend to legal needs o Optimize social functioning e.g., care of dependants; transportation o Optimize communication e.g., telephone access o o o 4. Spiritual domain: o Find meaning and value in life o Address existential/transcendental issues o Explore values, beliefs, symbols, icons o Support religious needs o Support decisions during periods of life transitions o o o 5. Environmental context: o Establish pleasant atmosphere o Foster a sense of community o Ensure access to appropriate equipment/resources o Ensure safety and security o o o 18

23 REFLECTION 2: To reinforce your learning and build upon your knowledge, reflect on the following questions: A) How would your answers to Question 2.1 compare to those of other professionals? Share your answers with other members of the team! B) How can other professionals help you enhance person-centred holistic care? 19

24 SECTION II: THE INTERPROFESSIONAL TEAM Context At SCO Health Service you will work alongside many other professionals providing a team of care with the person in your care at the centre. Team-based care requires a clear understanding of the functions of each team member and the skills to collaborate effectively. Learning Objectives By the end of this section you will be able to: 1. Define interprofessional team 2. Identify your interprofessional team at SCO Health Service 3. Describe the basic roles of at least four different members of the interprofessional health care team where you are working 4. Identify at least three activities undertaken by five different members of the interprofessional team in the context of a care scenario 5. Draw an interprofessional team map (see template in Appendix 6) 6. Identify the seven elements of collaborative person-centred practice 7. Complete a Collaboration Checklist using a video with two examples of team meetings. 8. Complete a Family Meeting Checklist using a video of a family meeting 20

25 Learning Activity #3 To identify your initial knowledge and understanding of different types of teams, write a brief description for: Question Multidisciplinary team 2. Interdisciplinary team 3. Interprofessional team 4. Transdiciplinary team 5. Interprofessional education 21

26 DEFINITIONS Multidisciplinary A multidisciplinary team (also can be known as a multiprofessional team): Members of the team work on the same project, but can have different goals. They work on their own part, and do not share decision-making. There is usually one leader who makes the key decisions. Members of the team work independently or in parallel to each other. Interdisciplinary Members of this team may represent different sub-specialties of the same profession (e.g., an internal medicine specialist, an obstetrician and a pediatrician working together to care for a woman with a complicated pregnancy). Interprofessional Members of this team represent different professions working together to achieve a common goal. Both interdisciplinary and interprofessional teams work together to reach a common goal and share a common decision-making process to enhance the achievement of this goal. The goal in health care is to work in a common effort with patients and their families to enhance their goals and values. Transdiciplinary Members of this team work so closely together that the boundaries between their professions can become blurred and even vanish. Any team member can take on the tasks of another. Interprofessional education (IPE) is defined as occasions when two or more professions learn with, from and about each other to improve collaboration and the quality of care (Centre for the Advancement of Interprofessional Education (U.K.) rev. 2002). * Reference : D Amour, D., Ferrada-Videla, M., Rodriguez, Leticia S. M. & Beaulieu, Marie-Dominique. (2005). The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks. Journal of Interprofessional Care, Supplement 1:

27 Definitions Discipline There can be several disciplines within one profession Profession Professions have different roles, functions Family Doctor MEDICINE Surgeon NURSING Oncologist MEDICINE VOLUNTEER Multi Disciplinary Inter Professional Trans Professional Pt P Pt P Pt P Team members work in parallel Communication is minimal, through chart and leader Leader is often the physician Team members work together Communication is frequent, through chart, meetings Leadership changes as issues change Team members roles overlap Communication is frequent, through chart, meetings Leadership changes as issues change 23

28 Learning Activity #3 To identify your initial knowledge and understanding of the roles of different professionals, answer the following questions: Question 3.2 A) At SCO Health Service, you have observed health care providers on your team doing some of the things identified in the previous section when caring for a person and his/her family. Who does what? B) If you don t know which team member provides which aspect of care, how can you find out? 24

29 The following information is intended to add to your initial knowledge and understanding about members of the team and their roles (see Appendix 3 for more complete details): Interprofessional Team Members - Role Descriptions Person in care at SCO Health Service & his/her family: Are active partners in the care team goals Play a central role in identifying goals and making decisions. Learners: Represent all the professions. Contribute to the care of the people they are responsible for and their families Are important colleagues on our teams. Advanced Practice Nurse Works to improve clinical outcomes through an advanced and expanded role in nursing that includes program planning and delivery, consultation, education research, efficient resource utilization and effective leadership. Chaplain/Spiritual Care Worker Allows patients and families to ask the difficult questions which often trouble ill persons. Enables patients to search for meaning and purpose in what they are living Ensures that spiritual as well as religious needs are responded to for all persons. Client Relations Advisor Relates effectively to patients/families and staff at all levels and have an in-depth understanding of human behaviour Works in highly emotional situations bringing a sense of empathy, professionalism, realism and hope Interacts effectively to bring diverse groups together as a team, including patients/families, physicians, managers, employees Clinical Manager Plans, organizes, directs, controls and evaluates all activities of their unit in order to provide high quality patient care. Dental Hygienist Provides oral health care within the dental hygiene scope of practice to treat and prevent oral diseases and conditions. Provides oral health care education to patients and caregivers for the maintenance of oral tissues and promotion of the important relationship of oral health to general health and well-being Makes referrals to and communicates with inter-professional team members as appropriate Dietitian Provides individual attention and support to patients and residents in the hope of improving/maintaining quality of life by providing dietetic counselling and favourite foods Plays an important role in education of team members 25

30 Is available as a resource person for the community. Occupational Therapist (OT) Works within the interprofessional team to maintain or enhance a patient s autonomy Works in close collaboration with the physiotherapist to assess the patient s capacity, assists with positioning and mobility (e.g., using a wheel chair) Works in close collaboration with the physician to create appropriate splints and assists with pressure-relieving approaches through positioning Assists with ADLs such as feeding and personal care in order to maintain a sense of control but also facilitate temporary discharge home (e.g., weekend leave of absences). Occupational Therapy Aide Reports to the Clinical Manager Provides and assists with occupational therapy treatments according to the policies, procedures and standards of the SCO Hospital Functions as a member of the occupational therapy team. Personal Care Assistant (PCA) Provides aspects of personal care and basic nursing care as assigned by a Registered Nurse or Registered Practical Nurse. Examples may include personal hygiene, dressing, grooming, feeding, toileting, ambulation and transfers Promotes the autonomy and the independence of patients/residents according to their functional abilities in the activities of daily living such as: bathing, dressing, grooming, feeding, toileting, mobility Acts as a preceptor to Personal Support Worker (PSW) students and newly hired and novice Personal Care Assistants (PCAs). Pharmacist Provides drug therapy for the purpose of achieving definite outcomes (good symptom control) that improve the patient s quality of life (pharmaceutical care) Collaborates with the patient and/or team to identify drug-related problems and makes every effort to resolve them Counsels patients and family about medication, discharge planning, or leave of absence 26

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