Collaboration underpins comprehensive palliative care and continuity of care. And good communication underpins collaboration.
Nurses can facilitate communication within the care team through:
Nurses can play a role in pulling together the various providers and ensuring that their points of view are heard, misunderstandings are prevented or resolved, and a comprehensive plan of care is created that reflects input from all. With experience and seniority a nurses' contribution towards this is likely to grow.
There are programs specifically developed to guide inter-disciplinary team collaboration and communication including:
Case conferences are also known as family meetings. These meetings usually bring together the health care team to discuss issues relating to clinical care and coordination of care. The person with life-limiting illness and their family may also be invited to ensure that the focus is on their needs and care preferences.
Case conferences can be of greatest value when:
Begin by asking what guidance and protocols your organisation already has in place. Tools such as ISBAR (Situation–Background–Assessment–Recommendation) model can help to guide discussions by:
As a person’s needs and priorities shift, nurses often communicate these to other members of the care team (internal and external to the same organisation).
It is often the registered nurse who will decide when to contact the person’s GP. They may also need to liaise with palliative care specialists.
Some approaches to facilitating conversation and involvement of an external care provider such as GP, other health professional or service include:
Visit ACSQHC Communication at Clinical Handover
Effective communication is essential when all or part of a person’s care is transferred between locations, clinicians, or different levels of care within the same location. This includes:
The context of the handover determines whether the handover is communicated verbally or in writing.
Tools that can be used to facilitate communication during clinical handover include:
What is included in a handover summary will depend on the context and reason for handover. For a person with palliative care needs, handover information is likely to include physical, social, psychological, and spiritual aspects of care. Handover notes might include preferred place of death, phase of illness, and functional ability (AKPS). In deciding where handover takes place, consideration should be given to what information has already been provided to the patient and their level of fatigue.
Practical Guide for Clinical Handover in Residential Aged Care Facilities
Download Guide (189MB pdf)
A handover, where appropriate, will include:
See Documentation for more on the list of minimum requirements for safe care for complex patients.
Interdisciplinary or multidisciplinary team meetings (MDT) aim to enhance collaboration within the MDT (medical, nursing, allied health and spiritual care). The composition of the team often varies. Meetings can include patient case discussions, decision-making, education and research. They may help a MDT coordinate care for people with complex needs, or discuss matters that are currently unclear or unresolved.
These meetings are usually facilitated by a nominated chair (105kb pdf) whose role is to:
This information was drawn from the following resources:
Read: How to Overcome Common Communication Challenges in Health Care (725kb pdf)
Read: ASCQHC's Transferred - Communicating at transitions of care
Access more Commnication within the Care Team Resources
Page created 26 September 2022