Integrated Care Through Supervision and Mentorship

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Integrated Care Through Supervision and Mentorship

• Lorraine J. Breault, Ph.D., R. Psych
• Director of Equity
• Faculty of Medicine and Dentistry
• University of Alberta

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Office of EquityFaculty of Medicine and
DentistryUniversity of Alberta

• Missionto create a healthy, respectful,
  working and learning environment achieved largely
  through education and training at the individual,
  group, and institutional levels focusing
  professional behavior.

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Terminology

• Interprofessional Practice-Focus on
  practitioners-Boundary clarification becomes the
  most salient concern
• Integrated Care-Focus on delivery of
  care-Quality and organization of care become
  the most salient concerns

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Integrated Health Care

• Health care is (currently) characterized by
  high levels of differentiation between
  professionals and organizations and low levels of
  integration. To provide coordinated care, the
  level of integration must be increased rather
  than decreasing differentiation of
  specialization.
• Integrated care is an organizational process
  that seeks to achieve seamless and coordinated
  care tailored to the patients needs, and based
  on a holistic view of the patient.
• Wijngaarden et. al., Health Policy (79) 2006

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Integration of Care

• The right care, by the right professional, at the
  right moment , in the right place.
• Integrated care requires direct communication
  stimulated by-physical proximity (situated
  close to each other)-task proximity (work on
  same tasks)-formal organization
  proximity-social proximity (established social
  contacts)-professional proximity (similar
  professional backgrounds including values,
  mental images, status and jargon) Cott, C.
  1997 (45) Social Science and Medicine

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Integration of Care

• Integrated care requires that professional
  boundaries be clear and explicit rather than
  expanding the scopes of practice.
• Professions must share information on-what body
  of knowledge supports practice?-what training is
  required to be competent?-how is competence
  maintained?-how are they accountable to patients?

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Integrated Care Requires an Ethics of Competence
for each Profession

• An obligation to function competently
• Goal to protect from harm
• Interest in an area does not qualify as
  competencefor practice
• Competence requires education, training,
  supervision, and/or consultation
• The burden of demonstrating competence rests with
  the practitioner.

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Changing and Emerging Areas of Health Care

• Health care is a rapidly expanding field
• Health professionals must gather and interpret
  information, problem solve, and take appropriate
  action on a continual basis.
• This requires both individual learning and
  collective learning.
• Collective learning requires the sharing of both
  explicit and implicit or tacit knowledge and is
  achieved through networks.

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Integration of Care is based on Network Learning

• Def. the capacity to maintain or improve
  performance based on experience within a network.
  (knowledge creation and sharing, feedback,
  learning)
• Interprofessional care is provided within a
  network of specialized care providers, not a
  group of similar providers.
• Expanding and overlapping scopes (increased
  homogeneity) of practice is not Interprofessional
  Care.

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Interprofessional Practice

• Health professionals providing services that are
  based on a distinct and relevant body of
  knowledge, who collectively make decisions and
  solve problems supported by evidence, who are
  accountable to the public for their actions, who
  act in a network, and who utilize an often
  unarticulated shared background of experiences
  and circumstances to improve the quality of care.
  (Breault, 2007)

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Implications for Supervisors and Mentors in
Integrated Health Care

• Learning is the mechanism for changing the way in
  which professionals work.
• Managers, supervisors, administrators have great
  difficulty changing the work of professionals.
• Through network learning, professionals give
  direction to the change process which increases
  compliance.
• Knowledge sharing and feedback, aspects of
  network learning, sustain integrated care.

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Implications for Supervisors and Mentors in
Integrated Health Care

• Interdisciplinary education throughout training
  provides standardization of knowledge (explicit
  curriculum) experience provides tacit knowledge
  (hidden curriculum).
• Effective supervisors regularly create
  opportunities for sharing information and
  expertise.
• Mentors share tacit knowledge.

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Tips

• Meet regularly to share information and
  experiences (physical proximity)
• Solve problems collectively (task proximity)
• Meet with related organizational units (formal
  organization proximity)
• Celebrate events (social proximity)
• Regularly discuss and assess values, goals,
  visions, language (professional proximity)

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Tips

• Use authority only in urgent situations
• Facilitate learning, achieved through the sharing
  of knowledge and expertise of all professionals,
  to sustain integrated care.
• View yourself as a strategic net worker rather
  than a teacher or problem solver.

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Performance Evaluation

• Ensure that all professionals agree with goals
  and objectives
• Focus on process and outcomes not on individuals
• Establish safe mechanisms for feedback
• Include all participants in evaluations
• Use learning as the mechanism for change
• Recognize contributions

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Personal traits impact relationships

• Arrogance/humility
• Narcissism/Selflessness
• Fear/Trust
• Dominance/submissiveness
• Negativity/ positivism
• Introversion/extroversion
• Etc.
• Traits are not the problem nor do they cause or
  solve problems or conflicts.

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Two Wolves
One evening an old Cherokee told his grandson
abouta battle that goes on inside people. He
said, "My son, the battle is between two
"wolvesinside us all. One is Evil. It is anger,
envy, jealousy, sorrow, regret, greed,
arrogance, self-pity, guilt, resentment,inferiori
ty, lies, false pride, superiority, and ego. The
other is Good, It is joy, peace, love, hope,
serenity, humility, kindness, benevolence,
empathy, generosity, truth, compassion and
faith." The grandson thought about it for a
minute and then asked his grandfather "Which
wolf wins?" The old Cherokee simply replied,
"The one you feed."
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Relationship Conflicts

• Typically arise when needs are threatened
• Examples of needs include-Basic needs (food,
  shelter)-Safety needs-Belongingness
  acceptance-Prestige and esteem
  needs-Achievement of potential(Maslow 1987)

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Workplace Well-Being

• A sense of belonging (relatedness)
• Competence
• Autonomy (responsibility and authority)
• Deci and Ryan, 2000 Self-determination
  Theory

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Strategies for successful interactions

• Care with words
• Share information not gossip (Have an answer when
  someone says what is your evidence?)
• Speak the truth and dont add colour
• Use words to support. No cutting, sarcastic
  banter
• Share ideas and do not believe that you are right
  100of the time.

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Strategies for successful interactions

• Do not make assumptions about the other persons
  position or beliefs. Ask them!
• A common and disastrous behavior is to make
  (biased or far fetched) assumptions and then act
  on the basis that those assumptions are correct.
• Do not interpret the actions of the other person
  as if they were the enemy
• Never try to recruit those not involved, to your
  side of the argument

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Strategies for successful interactions

• Gather all possible solutions and select the best
  or take parts of some to create a more complex
  imaginative solution
• Create an agreement Who will do what?
• Retrace any steps you need to

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Strive for Win-Win outcomes

• Deal with the PROBLEM not the person
• Do not resort to a personal attack, or scold or
  judge
• Do not impose a solution against the others
  wishes, even if you have the required authority
• Listen more than talk
• Meet do not try to solve any but the most
  trivial conflicts by e-mail

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Pearls

• Accept the fact that you will mess up sometimes
• Learn to lose with good grace and try to learn
  from the experience
• Admit mistakes and turn them into opportunities
  for growth
• Be aware of everyones personal valuesand
  beliefs
• Recognize the benefits of reflection and
  validation
• Distinguish between venting (emotional
  evacuation) and a complaint.

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Pearls

• With positive intentions, you dont need to fear
  mistakes
• View conflicts as a fascinating challenge
• Have a sense of humor
• Sit beside a person to solve problems and face
  the problem together.
• Ask for support
• Keep issues on the front burner What you resist,
  persists