Professional Practice Building Capacity for Collaborative Leadership in Knowledge-Creating Teams PDF

P R O F E S S I O N A L P R AC T I C E Building Capacity for Collaborative Leadership In Knowledge-Creating Teams In the Fall 2012 résumé, the together to provide comprehensive and continuous care to a article, “Are you a kno...

P R O F E S S I O N A L P R AC T I C E Building Capacity for Collaborative Leadership In Knowledge-Creating Teams In the Fall 2012 résumé, the together to provide comprehensive and continuous care to a article, “Are you a knowledge- patient/client”.3 creating team member?”, Leadership Functions discussed how Registered As collaborative leaders, the role of dietitians is to help the Dietitians (RDs) have an IPC team develop synergy and engage in client-centred Carole Chatalalsingh, PhD, RD obligation to make practices to ensure that it operates safely within the IPC Practice Advisor & interprofessional collaboration Policy Analyst environment. To do this, a collaborative leader has two work by actively participating in functions: task orientation and relationship orientation.4 building effective knowledge-creating teams. RDs can do this effectively by recognizing the team stages of functioning, Task Orientation Function taking the actions needed to nurture their team at each stage, In the task-orientation function, the collaborative leader helps and taking responsibility for their own roles and functions others on the IPC team (interprofessional practitioners, clients, within the team. This article focuses on collaborative team their families, the circle-of-care, other teams and leadership which enables synergetic relationships and organizations) keep on task in achieving safe outcomes for effective working partnerships to achieve the common goal client care. This could involve tasks, such as, organizing and of effective client-centred dietetic services.1 defining roles, coordinating individual profession’s regulatory and professional obligations and setting goals. Other task- WHAT IS COLLABORATIVE TEAM LEADERSHIP? oriented responsibilities include:4, 5 The concept of “collaborative leadership” is identified as one l helping to maintain the integrity of the team’s of the six competency domains in the National governance and operating processes; Interprofessional Competency Framework. The competency l helping to achieve client-centred outcomes for quality statement says, “Learners/practitioners understand and can services; apply leadership principles that support a collaborative l establishing continuous monitoring and re-evaluations for practice model.”1 mitigating risks; and l carrying out daily administrative responsibilities, For dietitians, the collaborative practice model for health processes, and systems essential to managing the care in Ontario is defined by the IPC Charter developed by boundaries with the larger organization or with key HeathForceOntario (2009) to foster a common vision and stakeholders. language for interprofessional client-centred care in Ontario. (also see the back cover for information on the new IPC Relationship Orientation Function eTool developed in collaboration with the Federation of In the relationship orientation, the leader assists the IPC team Health Regulatory Colleges of Ontario).2 to work more effectively. This includes ensuring effective Collaborative leaders are expected to be skilled in enabling communication among members, providing support, collaboration, “a process that requires relationships and managing conflict, and building productive work interactions between health professionals regardless of relationships.6 These responsibilities include:5 whether they are members of a formalized team or a less l coaching, in a supportive role, by providing guidance formal or virtual group of health professionals working and acting as a sounding board; résumé WINTER 2013 College of Dietitians of Ontario 9  P R O F E S S I O N A L P R AC T I C E l energizing a group into action, which means enabling in order to function as a health care teams; breakthroughs where possible, being a change agent in l communication and decision-making; holding the team accountable for actions, making l clear expectations of the team based on client-centered unpopular observations; care; l facilitating the internal and external coordination of l the coordination of services to reduce risk to the client; activities among team members as mediator and catalyst, l negotiation skills to manage conflict, mediation, and facilitate building of partnerships; and by bringing people together, ensuring integrity in work continuous improvement of the health care system, relationships, and making necessary interventions; l particularly in the area of client safety by mitigating risks sharing responsibility for the success of the team; and increasing efficiency. l l actively participating in its activities; and nurturing the team’s development stages. Over time, collaborative IPC team leaders will help develop l knowledge-creating teams with a body of common COLLABORATIVE SHARED LEADERSHIP knowledge and effective team practices and approaches In a shared leadership model, IPC team members will that allow them to function collaboratively in a client-centred collaborate to determine who will be group leaders in environment. certain situations. Clients may choose to serve as the leader 1. A National Interprofessional Competency Framework, Canadian or leadership may move among practitioners to provide Interprofessional Health Collaborative, February 2010. opportunities for mentorship in the leadership role. In some 2. Oandasan. I., Robinson, J., Bosco, C., Carol, A., Casimiro, L., cases, there may be two leaders: one for practitioners to Dorschner, D., Gignac, M. L., McBride, J., Nicholson, I., Rukholm, keep the work flowing and the other who connects with E., & Schwartz, L. (2009). Final Report of the IPC Core Competency Working Group to the Interprofessional Care clients and their families, serving as the link between the IPC Strategic Implementation Committee. Toronto: University of team, clients and families. Toronto. 3. Canadian Health Services Research Foundation. Teamwork in Within collaborative or shared leadership, dietitians on the Healthcare: Promoting effective teamwork in healthcare in knowledge-creating IPC teams support the choice of leader Canada. www.chsrf.ca. and team decision-making. They will also assume shared 4. Heineman, G.D., & Zeiss, A.M. (2002). Team performance in accountability for the processes chosen to achieve outcomes. health care: Assessment and development. New York: Kluwer Academic/Plenum Publishers. This means that they will take responsibility for their scope of 5. Marshall, E. (1995). Transforming the way we work: The power practice, their roles and expertise and will work collaboratively of the collaborative workplace. New York: American with others to enable continuous quality improvement in work Management Association. processes for effective client-centred outcomes.1 6. Laiken. M. (1998). The anatomy of high performing teams: A leader’s handbook (3rd ed.). Toronto, Ontario, Canada: Collaborative leaders and supporters of leaders can enable: University of Toronto Press. l the coordination of services to ensure that the client is 7. Day, D., Gronn, P., & Salas, E. (2004). “Leadership capacity in teams”. The Leadership Quarterly, 15, 857-880. kept appropriately informed; l the treatment plan is executed by the right people with 8. Carroll, J. S., & Edmondson, A. C. (2002). “Leading organizational learning in health care.” Quality and Safety in appropriate continuity and with as little waste as Health Care, 11, 51-56. possible; l interprofessional team learning, synergy and collaboration; l the integration of professional knowledge, skills and attitudes into team practice; l support of organizational values that members will need 10 College of Dietitians of Ontario résumé WINTER 2013  P r o f e s s i o n a l P r ac t i c e ENHANCING CAPACITY FOR INTERPROFESSIONAL TEAM LEARNING Interprofessional team learning is sharing.ii Rather, pre-existing knowledge is simply a social learning activity that disseminated more broadly and information is spread across benefits the individual, the team, the team such that a greater number of team members now and most importantly, the client. have the information. As dietitians, we are applying specialized knowledge, skills and This form of knowledge sharing emerges through circle-of- attitudes to everyday work within care informal conversations, daily dialogue and social Carole Chatalalsingh, PhD, RD our interprofessional (IPC) teams. interactions of IPC team members, as well as more formal Practice Advisor & In addition, how can we help activities such as education, care rounds or team meetings. Policy Analyst create synergetic teams that learn, Pooling information is an important component of providing grow and innovate together for the benefit of clients? services to clients. RDs can enhance team practice by paying close attention to Examples of knowledge shared within the team are: how they use, share, create and seek knowledge within the IPC team. The Use of Knowledge Framework (Figure 1, next Unidirectional passing of Information page) shows the three general categories of knowledge use A student asks, “What is the turnaround time on lab within the “circle-of-care”, the IPC team.i The framework results?” to which a team member responds, “We illustrates how knowledge is shared within the team, how could do a rapid response and get results right away knowledge is created by the team; and how knowledge is on this unit.” sought outside of the team. This article explains how IPC teams learn together, and how RDs can apply the Use of A dietitian reports in a team meeting that the new Knowledge Framework to manage information and food service computer system can now be interfaced knowledge to enhance capacity in IPC team learning. to capture client’s food allergies. kNOWlEDGE sharED WIThIN ThE TEam Collective pooling of Information A dietitian describes that the case managers for each Knowledge shared within the team describes circumstances individual client on social assistance have the Special when some members have a “self-sufficient” piece of Diet Allowance forms and will distribute them to information and others are lacking this information so the clients as appropriate. The clients are required to information is shared or pooled. Importantly, no new have the forms completed by an eligible health care knowledge is inserted into the team as a function of this provider (MD, Nurse Practitioner, RD, or Midwife). i. The 'Circle of Care' includes the interprofessional care team, the health information custodians and their authorized agents, who are ii. We recognize that knowledge is always altered, even if only permitted to rely on an individual's implied consent when slightly, in each new person’s incorporation of the information into collecting, using, disclosing or handling personal health their own perspective and understanding. For these purposes, information for the purpose of providing direct health care. See however, we have chosen to ignore this issue in order to R. Steinecke and CDO, The Jurisprudence Handbook for Dietitians distinguish the phenomenon described here from the category in in Ontario, Web Edition, 2011, p. 67. the next section entitled “knowledge-created”. 4 College of Dietitians of Ontario résumé SPRING 2012  Figure 1 “Use of Knowledge” Framework1, 2 How interprofessional team members learn within the circle-of-care, developing team processes and functions to enhance knowledge sharing, knowledge creation and knowledge seeking activities within the team for safe, ethical and competent client-centred services. Us e o f K n ow l e d g e kNOWlEDGE sharED kNOWlEDGE sOUGhT kNOWlEDGE CrEaTED WIThIN ThE TEam OUTsIDE ThE TEam Unidirectional collective recognition Better solutions team self-initiated greater empowered Passing of Pooling of of a than Knowledge Understanding Knowledge seeker information information larger Pattern Before seeker kNOWlEDGE CrEaTED by ThE TEam recognition of a larger pattern A dietitian reported that a client was worried about In situations where knowledge is created by the team, no hair falling out. A nurse reported that she also had a member of the team possesses the complete information patient with the same complaint. Collectively the needed to address a situation. When the knowledge is group realized that there were a few other patients on pooled, new knowledge emerges because: a particular drug that mentioned the same symptoms 1) a greater understanding than the team had before in the past. This led to a new concern regarding hair was achieved; loss as a consistent side effect of this drug. 2) a pattern not previously noticed was recognized by the team; or better solution Than before Team members were being asked to see clients in 3) a better solution not previously known was discovered by the members of the team. satellite offices away from the main office. One member asked about timing of making client’s Here are three examples of knowledge created by the team: records or expressed a concern about the theft of Greater Understanding of a situation information. Another team member indicated that it During team meetings, a dietitian reported the client would be ideal to document directly into the client’s loss of appetite, another team member noted the health record upon completion of the services, or client wanted to sleep all day, another professional shortly after. The manger reports that all team team member recalled the client’s report of loss of his members will be given access to the electronic sexual function, and yet another professional team documentation system. Another member indicated member indicated the client’s concern about losing that personal passwords could be used to access the his job. This pooling of information led the team to electronic documentation system and that the records consider that the client may be suffering from could be encrypted while at satellite. The team depression. together decides that the best solution to ensure the privacy and confidentiality of client health information résumé SPRING 2012 College of Dietitians of Ontario 5  when accessing and recording off-site is for everyone volunteers to explore the workplace training involved in to use passwords and encrypted documents, and that acquiring the skills to act as an evaluator in assessing the laptop or other mobile devices be kept with them capacity in addition to search the College website for at all times to avoid theft. resources. kNOWlEDGE sOUGhT OUTsIDE OF ThE TEam INTErprOFEssIONal TEam lEarNING This category of knowledge happens in circumstances where the team, as a collective, was not able to find solutions Effective team learning is as an integral aspect of synergetic within the team and is required to seek knowledge outside teams allowing team members to clarify practice the team through: expectations, optimize roles, set accountabilities and determine services for fulfilling client needs across the circle 1. a team empowered knowledge seeker, or of care. Learning to provide services in collaboration involves 2. a self-initiated knowledge seeker. team members from many backgrounds such as dietitians, The team empowered knowledge seeker is a team member physicians, nurses, social workers, therapists, and other empowered by the group to seek knowledge outside on healthcare professionals, all of whom are collectively behalf of the team. Empowered team members are given managing obstacles and coordinating efforts. Some team responsibility for feeding the information back to the team. members’ professional scope of practice, regulations and discipline-specific values are not explicit to other team The other form of knowledge seeking is the self-initiated members. knowledge seeker. This team member is not sanctioned by the team to seek knowledge; however knowledge sought is The Use of Knowledge Framework can be applied to solve directly related to team activity. These team members go team-related problems, improve team-related functions, and outside the team to find new knowledge on behalf of the promote the delivery of safe, ethical and competent dietetic team; however, they also seem emotionally motivated to services. By applying the Framework, RDs can further seek information on behalf of their clients, and for the anticipate, recognize and manage situations that enhance practice of client-centered care. interprofessional team learning and client safety. Examples of knowledge sought outside the team include: In the Fall résumé, I will focus on the role of teams in aligning Team Empowered knowledge seeker processes, structures and resources to foster learning in an IPC A dietitian is empowered to research new protein culture. supplements on the market for the team. The team noticed an increased number of amputations 1. Chatalalsingh, C., & Regehr, G. (2006). “Understanding teamlearning in a healthcare science center.” In L. English & J. in the dialysis population and empowered a nurse to Groen (Eds.), Proceedings of the Canadian Society for the Study collect data on the frequency and incidence, and to of Adult Education (CASAE) 25th Annual Conference (pp. 31 – compare this to other centres in terms of how they 36). Toronto, Ontario, Canada: York University. manage the amputation rates, then report back. 2. Chatalalsingh, C. (2007). Understanding team learning in a multiprofessional healthcare setting. Master's thesis, Ontario self Initiated knowledge seeker Institute for Studies in Education, University of Toronto, Toronto, Ontario, Canada. The team is unclear of how one is trained as an 3. McMurtry, A. (2007). “Reinterpreting Interdisciplinary Health Teams evaluator to assess capacity. Team members volunteer to from a Complexity Science Perspective”. Faculty of Education, review resources available on their college’s website University of Alberta Newsletter, Volume 4, Issue 1. and share their findings with the team. A dietitian further 6 College of Dietitians of Ontario résumé SPRING 2012 Assigning Duties to Nutrition Support Personnel By Sarah Herd, RD, and Susan Tran, RD The College would like to thank Sarah Herd, RD, and Nutrition Management (CSNM) to be hired as a DT or DA. Susan Tran, RD, for authoring this article. It is with sincere The role and responsibilities assigned to nutrition support appreciation that we are able to incorporate their research1 personnel also depend on organizational factors, such as: as Dietetic Interns at St. Michael's Hospital into tangible l the facility’s RD human resource capacity; guidance for RDs when assigning tasks within dietetic l the roles, responsibilities and area of practice of the practice. RD; and l the facility’s patient population and care delivery needs. NUTRITION SUPPORT PERSONNEL (For example, nutrition support personnel in long-term In many healthcare facilities, support personnel in “assistant” care facilities often have different duties compared to positions contribute to a number of health disciplines, such those in urban hospitals and/or community settings.) as physiotherapy, occupational therapy, speech language A survey of hospitals across Canada and the United States pathology, optometry, dentistry, and pharmacy. Diet revealed that tasks carried out by DTs and DAs range from technicians (DTs), dietitian assistants (DAs), and those with collecting and entering patient food preferences and menu equivalent unregulated nutrition designations often support selections to providing individual education to patients, Registered Dietitians (RDs). These healthcare providers are conducting calorie counts, and screening.1 Many of the essential members of the healthcare team, especially as organizations surveyed indicated that DTs/DAs typically human resource shortages demand increased efficiency. interact with low-risk patients and occasionally dealt with moderate-risk patients while supervised by an RD. Nutrition support personnel play a key role in Generally, DTs/DAs were not directly involved in the interprofessional collaboration (IPC). IPC can provide clients nutritional care of high-risk patients.1 with greater access to healthcare providers and improved client outcomes.2 Clients may also be more satisfied with ACCOUNTABILITY OF RDS IN ASSIGNING TASKS the enriched level of high-quality care that they receive. As regulated health care professionals, RDs are accountable to their clients, colleagues, employers and to ROLE AND RESPONSIBILITIES OF NUTRITION SUPPORT the College. Accountability consists of taking responsibility PERSONNEL for decisions and actions, and ensuring practice is In many facilities, RDs assign tasks to support personnel consistent with professional standards, guidelines and (e.g., DTs and DAs) to assist with nutritional care.The type of relevant legislation.3 While support personnel are tasks assigned to nutrition support personnel depends on responsible for their own actions, RDs are accountable for an employee’s: assigning tasks to adequately trained and competent l level of education; employees. As outlined in the College’s Professional l training/qualifications; Misconduct Regulation, (www.cdo.on.ca > Resources > l years of experience; and Regulations) RDs may be found to be in misconduct if they l competence to perform assigned tasks. are: Education qualifications required by institutions for nutrition “17. Assigning members, dietetic interns, food support personnel vary. Some institutions require membership service supervisors, dietetic technicians or other or eligibility for membership into the Canadian Society of 6 College of Dietitians of Ontario résumé WINTER 2011  P R O F E S S I O N A L P R AC T I C E health care providers to perform dietetic functions for role of the regulated health professional in delegating and which they are not adequately trained or that they assigning tasks to support personnel.3-8 are not competent to perform.” CDO will be examining the need for developing similar Failure of RDs to ensure competence of an employee documents to support RDs to work collaboratively with receiving a direct assignment may compromise client safety nutrition support personnel and others while maintaining and negatively affect client outcomes. client safety and client-centred care. CDO will communicate the availability of additional resources to RDs as they become available. In the meantime, RDs can refer to the EVALUATING COMPETENCE information contained in this article as well as the resources It is not enough to rely solely on the knowledge that support in the reference list ,below, that are available from other personnel have completed an appropriate education program. health regulatory colleges in Ontario. Both RDs and support personnel need to be aware of the competencies of the support workers to feel confident that they can perform the assigned tasks. Initially, an accurate 1 Herd S., Tran S., Keith M., McLaughlin J., Fletcher H. (2010). An internal and external examination of the responsibilities of a assessment of the competencies and skills of support staff is dietitian assistant. Dietitians of Canada poster research critical. The verification of competency is normally specific to presentation abstract. the facility and the assigned tasks. It may include asking http://www.fcrd.ca/dloads/2010_abstracts.pdf support personnel to demonstrate the skills necessary to perform 2 HealthForceOntario. (2010). Implementing Professional Care in Ontario. tasks and/or asking scenario-based questions. To ensure that http://www.healthforceontario.ca/upload/en/whatishfo/ipcproj tasks will be carried out appropriately, orientation to the facility ect/hfo%20ipcsic%20final%20reportengfinal.pdf and training on specific tasks should also be provided. 3 College of Nurses of Ontario. (2010). Working together: RNs, RPNs and UCPs. Unpublished manuscript. It is good dietetic practice to continually re-evaluate the 4 College of Occupational Therapists of Ontario. (2004). Practice competency of support personnel to ensure client safety. guideline – support personnel. Ongoing open communication between the RDs and http://www.coto.org/pdf/P_G_Eng.pdf support personnel is necessary to maintain competency, 5 College of Physiotherapists of Ontario. (2010). Physiotherapists clarify their roles and responsibilities, and foster IPC within working with physiotherapist support personnel: Guide to the the healthcare facility. Nutrition support workers should be standards for professional practice. http://www.collegept.org/LiteratureRetrieve.aspx?ID=61166. encouraged to practice continual self-evaluation to determine 6 College of Audiologists and Speech-Language Pathologists of whether they feet competent to perform new tasks assigned Ontario. (2007). Use of support personnel by speech-language to them and to ask for help when needed. They should pathologists. understand that client issues and outcomes need to be http://www.caslpo.com/Portals/0/positionstatements/supportper sonnelfinal.pdf. reported to the RD as appropriate. 7 College of Optometrists of Ontario. (2005). New policy on delegation and assignment. http://www.coptont.org/docs/Optom%20Delegation%20Policy% RESOURCES 202005.pdf In Ontario, various health disciplines have support personnel 8 The College of Dental Hygienists of Ontario. (2009). Dental documentation including: Hygiene Standards of Practice for Delegation: Limited to clinical competency preparatory courses in schools accredited by the 1) Decision tree models to help determine whether CDAC. http://www.cdho.org/PracticeGuidelines/StandardsofPracticeDel delegation of a task to support personnel is appropriate3,4 egation.pdf 2) Standard guidelines or policies which help determine the résumé WINTER 2011 College of Dietitians of Ontario 7 Winter2012 résumé mar7 2012_Layout 1 07/03/2012 5:37 PM Page 5 P R O f e s s i O n a l P R aC T i C e Enhancing Interprofessional Collaboration The integration and "work co-operatively with colleagues, other professionals, coordination of the and laypersons”. What does collaborative practice mean interprofessional health care within the IPC environment? (IPC) team is increasingly recognized as a key factor in CoLLABoRATIvePRACTICe safe, effective and efficient Carole Chatalalsingh, PhD, RD health care delivery. Health- Collaborative practice is seen as members going beyond just Practice Advisor & care providers are expected to working in a team to synergistically learning to practice Policy Analyst engage in collaborative together as a team to influence the client/patient centered practice and share their expertise within the IPC environment. care. “It involves the continuous interaction of two or more Dietitians partnering in health care teams are seeking professionals or disciplines, organized into a common effort guidance from the College as they recognize that working in to explore and solve common issues, with the best possible IPC teams does not necessarily mean that they are practising participation of the client. It is designed to promote the collaboratively or that their team approach is client-centred. active participation of each discipline in client care. It enhances client- and family-centered goals and values, To support dietitians to be safe, competent and ethical provides mechanisms for continuous communication among within interprofessional health care teams, the College of caregivers, optimizes staff participation in clinical decision- Dietitians of Ontario is expanding its professional practice making within and across disciplines, and fosters respect for program to create new direction and education to promote disciplinary contributions of all professionals.”1 (See Figure 1, a better understanding of collaborative dietetic practice. page 6.) As a new Practice Advisor and Policy Analyst for the College, I am thrilled to have the opportunity to make a INTeGRATINGTHeoRYINToPRACTICe difference by facilitating learning and creating educational Evidence shows that, when health care professionals work opportunities for dietitians to discover and transform their and learn together to share their knowledge and skills, the skills as they take on new roles in IPC environments. quality of client care improves.2, 4 There is increasing Dietitians have an ethical obligation to seek new ways to interest in working in an interprofessional manner and many achieve the goal of safe and high quality client care. In the health care organizations place high priority in educating Code of Ethics for Dietitians in Canada, dietitians pledge to and training novice health care professionals and students. However, support for and models of interprofessional care approaches remain relatively new to more experienced Interprofessional Care health care professionals. The provision of comprehensive health In the spirit of improving care and developing an services to clients by multiple health care understanding of how to best engage in interprofessional collaboration and learning at the level of the team, the professionals who work collaboratively to College’s educational opportunities for dietitians will focus deliver the best quality of care in every health on integrating education theories into collaborative dietetic care setting.5 practices.3 This will involve 1) offering and implementing a professional development webinar series, 2) creating blogs résumé WINTER 2012 College of Dietitians of Ontario 5 110357 - Winter2012 résumé mar7 2012.qxp:Layout 1 15/03/12 4:52 PM Page 6 Interprofessional Collaboration and forums for dietitians including seeking input from members, and assessing needs, as well as partnering with An interprofessional process of dietetic, academic and practice leaders in the community communication and decision-making that and 3) a developing a series of résumé articles. enables the separate and shared knowledge and skills of care providers to synergistically ENHANCING INTERPROFESSIONAL HEALTH CARE TEAMS influence the client/patient care provided. 6 Dietitians have already been exposed to interprofessional collaborative concepts through the College workshops held IPC ON A DAY-TO-DAY BASIS in 2009. A webinar series will be developed in 2012 The College will be publishing a professional practice blog based on the work started in those workshops. The for dietitians which will include topics focused on client- webinars will focus on client-centred care and centred care and interprofessional care within teams on a interprofessional care within teams on a day-to-day basis. day-to-day basis. The primary objectives of the blog will be The primary objectives of the webinars will be to: to: 1. Introduce common issues and challenges of 1. provide a collegial venue for sharing ideas, questions interprofessional collaboration in dietetic work. and expertise about the changing landscape of dietetic 2. Engage in critical reflections about dietetic/health and interprofessional practice environments; standards in caring for clients and the values 2. to engage in point-of-care information sharing and underpinning them. decision-making; 3. Identify opportunities for future directives, innovation and 3. to elicit feedback from members and professional change. associations in enhancing interprofessional innovations and to develop a plan to enhance the knowledge of Figure 1: Synergetic Team organizational leaders. Interprofessional team learning is a social learning activity Information about the professional practice blog will that benefits the individual, the team, and most importantly, the client. be sent to you by email shortly. Look for it in your email box. AWARENESS, LEARNING AND POSITIVE ATTITUDES While the scope of practice statement set out in the Dietetics Act describes in broad terms the focus of our profession as individual practitioners, IPC describes team expectations and focuses on a collaborative approach to health care. Within the IPC environment, dietitians are often faced with learning new roles and procedures. Developing a more in-depth understanding of the role of dietitians as collaborators is needed. Dietitians have a professional obligation to examine themselves and their practices with a view to expanding the profession of dietetics.The résumé articles will help dietitians develop critical thinking and problem-solving skills in using their knowledge, skills and judgment effectively in the IPC © College of Dietitians of Ontario environment. 6 College of Dietitians of Ontario résumé WINTER 2012 Winter2012 résumé mar7 2012_Layout 1 07/03/2012 5:37 PM Page 7 P R O f e s s i O n a l P R aC T i C e “Use of Knowledge” Framework within the context of interprofessional collaboration 7, 8 Us e O f K n OW l e D g e kNoWLeDGeSHAReD kNoWLeDGeSoUGHT kNoWLeDGeCReATeD WITHINTHeTeAM oUTSIDeTHeTeAM Unidirectional Collective Recognition Better solutions Team self-initiated greater empowered Passing of Pooling of of a than Knowledge Understanding Knowledge seeker information information larger Pattern Before seeker INTeRPRoFeSSIoNALTeAMLeARNING 1. Oandasan et al. (2006). Teamwork in health care: Promoting effective teamwork in health care in Canada. Policy synthesis and Interprofessional care is not static. IPC teams are dynamic recommendations. Ottawa: Canadian Health Services Research and create synergy by learning together and discovering new Foundation. knowledge, growth and innovation. Interprofessional team 2. Barr, H. (2005). Interprofessional education. Today, yesterday learning is a social process involving a community of client- and tomorrow. A review. UK Centre for the Advancement of Interprofessional Education. Oxford, UK: Blackwell Publishing Ltd. centred care providers including health professions, staff 3. Reeves, S., Suter, E., Goldman, J., Martimianakis, T., & members, students and trainees, and family caregivers. The Chatalalsingh, C. (2007). A scoping review to identify IPC team is focused on communication, mutual respect, organizational and education theories relevant for interprofessional interaction and participation. IPC teams not only deliver practice and education. Calgary Health and Queen's University Inter-Professional Patient-Centered Education Direction project. effective health care together, but also learn together in their 4. Oandasan, I., Gotlib Conn, L., Lingard, L., Karim, A., Jakubovicz, daily practice. D., Whitehead, C., Miller, K-L., Kennie, N., & Reeves, S. (2009). “The impact of time and space on interprofessional teamwork in When health care professionals work and learn together Canadian primary care settings – Implications for health care sharing their knowledge and skills, the quality of client care reform.” Primary Health Care Research and Development; 10:151- improves.1 Team learning is a process through which 162. knowledge is shared, created and sought in order to benefit 5. Interprofessional Care Steering Committee. Interprofessional Care: A Blueprint for Action in Ontario, July 2007. Available at: the individual, the team, and most importantly, the client. www.healthforceontario.ca/upload/en/whatishfo/ipc%20blueprin With health care moving from health profession silos to IPC t%20final.pdf. teams, it seems only natural that dietitians should also be 6. Way, D., Jones, L., Baskerville, B., & Busing, N. (2001). “Primary making a concurrent shift of focus from individual self-directed health care services provided by nurse practitioners and family physicians in shared practice”. Canadian Medical Association learning models to models of interprofessional team learning. Journal, 165(9), 1210. In the spring résumé, we will examine the “Use of 7. Chatalalsingh, C., & Regehr, G. (2006). “Understanding team learning in a healthcare science center.” In L. English & J. Groen Knowledge” Framework, above, within the context of (Eds.), Proceedings of the Canadian Society for the Study of Adult synergistic teams in practice. The purpose will be to show Education (CASAE) 25th Annual Conference (pp. 31 – 36). how team-related knowledge and interprofessional team Toronto, Ontario, Canada: York University. learning promotes the delivery of safe, ethical and competent 8. Chatalalsingh, C. (2007). Understanding team learning in a multiprofessional healthcare setting. Master's thesis, Ontario quality client care. Institute for Studies in Education, University of Toronto, Toronto, Ontario, Canada. résumé WINTER 2012 College of Dietitians of Ontario 7  How do you know you are communicating well? Carole Chatalalsingh, PhD, RD Practice Advisor & Policy Analyst [email protected] "The two words information and communication are often used interchangeably, but they signify quite different things. Information is giving out; communication is getting through." Sydney Harris In its broadest sense, communication is the deliberate or received by the other. The ability to adapt our accidental transfer of meaning: One person does or says communication style and methods to the needs of the other something, while others observe what was done or said and person in the relationship is essential for getting through to attribute meaning to it. Whenever you observe or give them and to create a positive communication environment. meaning to behaviour, communication is taking place.1 The client-RD relationship is an example of interpersonal Communication is an essential dietetic practice competency. communication. Since the goal of the communication is a In the competency standard for Registered Dietitians in mutual understanding of client-centred nutrition services, RDs Canada, it is one of the five broad areas of dietetic practice need interpersonal skills and techniques to communicate required for entry-to-practice.2 This applies to developing effectively with clients. These include establishing rapport, professional competency in both oral and written skills for speaking clearly, listening, having empathy and knowing communicating information, advice, education and how to give and receive feedback and making sure clients professional opinion to individuals, groups and communities understand treatment options for informed consent. in all practice settings. However, it is important to constantly Interpersonal communication skills also means developing an improve your communication skills through continuous awareness of how much information a client can handle. learning and reflection.3 Being an effective communicator This requires identifying barriers in communication by means being acutely aware of whether your professional listening to clients and carefully observing how they react. By communication is done well. Are you getting through? It also listening, you can be responsive to clients by modifying your means being aware of the various forms of communications speech and tone to match different communication styles, — interpersonal, interprofessional and intrapersonal language needs and literacy levels. You can also respond communication — and how they impact dietetic practice. appropriately to non-verbal communication signals. To verify if a client has understood your message, ask for feedback INTERPERSONAL COMMUNICATION and clarify or re-phrase your message if necessary.1 Interpersonal communication is one person interacting with another person within a relationship, either face to face, through technology or any form of social media. INTERPROFESSIONAL COMMUNICATION Interprofessional communication is when a professional Interpersonal communication involves the recognition of how interacts collaboratively with members from different words and actions (including touching) are used and 4 College of Dietitians of Ontario résumé SPRING 2015  P R O F E S S I O N A L P R AC T I C E professions, either one-on-one or in groups. Effective INTRAPERSONAL COMMUNICATION communication is vital to the functioning of an interprofessional Intrapersonal communication is communication with oneself. care (IPC) team. This applies to both oral and written Thinking, speaking to yourself and journaling are forms of communications. It also applies when using technology for intrapersonal communication. Reflective practice is also a form team communications (email, Skype, intranets, social media or of intrapersonal communication. Reflective practitioners are any other online group communications). encouraged from early on to reflect on their values, attitudes, To communicate within an IPC environment, RDs need some how they think and learn, and to understand, appreciate and of the same skills as those described above for interpersonal practice alternative ways of knowing and learning.5 A relationships: establishing rapport with team members competent reflective dietitian repeatedly reflects on experience individually or in groups (e.g., rounds, team events, lunches or and is capable of reflecting-in-action and reflection-on-action, learning together), speaking clearly, listening, and knowing continually learning from experience to the benefit of future how to give and receive feedback from others for the benefit actions.6 They reflect on their interpersonal or interprofessional of the team and for client-centred care. communications to gain awareness of how well they communicate by: Effective communication skills will allow a dietitian to Challenging and examining personal assumptions. contribute knowledge to the team in a collaborative way and n also to draw on the expertise of others on the team. n Being mindful that the effective interpersonal communicator Interprofessional communications includes sharing knowledge is guided by awareness and ability to adapt. with other members of the team, pooling information and n Identifying what changes are needed during interpersonal participating in team discussions for shared decision-making. and interprofessional relationships to improve It also means informing your team about the nutrition treatment communication outcomes. you are giving to clients. Where health records are shared Not taking others for granted or allowing stereotyping with other professions, effective written communication skills n to get in the way of communicating. ensure that the documentation is clear, well-written and relevant. n Recognizing that without feedback and open-dialogue, there is a risk that reflection may be introspective. The How the RDs perform their roles, follow protocols for reflective process requires different sources of feedback. communication or how good they are at sending and receiving information within the team depends on what they Competent reflective dietitians repeatedly reflect bring to the team relationship. Communication skills, dietetic on their interpersonal or interprofessional knowledge and skills, how they feel about themselves, their attitudes, values, and goals, all contribute to the quality of communications to gain awareness of how well their communications within the team. These elements they communicate with clients and their team influence how well a dietitian encodes thoughts, feelings, members. emotions, and attitudes by putting them into a form others can relate to, and how the receiver decodes the thoughts, feelings, SEVEN KEY ELEMENTS OF COMMUNICATION 1 emotions, and attitudes of the sender by interpreting them into messages.1 The IPC Ontario Charter, states the importance of How well we are able to exchange messages and negotiate interprofessional communication to be understood, for seeking or share meaning during professional encounters depends on input and listening to others to foster a collaborative team how well we handle the essential elements active in the culture.4 communication process. For example, depending on the situation, patting someone on the back may be perceived as friendly and supportive or it may also be felt as a form of résumé SPRING 2015 College of Dietitians of Ontario 5 Table 1: The Essential Elements of Communication1 PEOPLE Senders and receivers of communication messages. MESSAGES The content of communication. CHANNELS The media through which messages travel. NOISE Interference with the ability to send or receive messages. FEEDBACK Information received in exchange for messages. CONTEXT Environmental, situational, or cultural setting in which communication takes place. EFFECT Result of the communication episode. sexual harassment. There are seven key elements that could and attitude in your communications; these might damage influence how this action is interpreted. The better we your professional relationships. Instead, approach everyone understand these essential elements of communication, the respectfully. Use tact and objectivity when talking to the diet more likely we are to improve and determine if we are technician and the manager. communicating well. Table 1, above, provides a description Also, respect clients by not putting them in the middle of the of each of the elements of communication. discussion and lobbying them for your position on the matter. Developing strategies for enhanced interpersonal, This situation can be appropriately handled without involving interprofessional and intrapersonal communication can make clients in a discussion or dispute that could break their trust a difference on how well you communicate with clients and in the care team.8 with members from other professions in your practice. Communication represents the key to safe, competent, ethical Clear Client-Centred Message High-functioning professional relationships are the outcome dietetic practice, and involves not only professional of clear communication: how well information is competence but also developing collaborative professional communicated, received and processed by the parties and interprofessional relationships. involved. The main concern, here, is client safety. Your communication to the diet technician and to the manager CASE SCENARIO ONE — INTERPERSONAL should be clearly focussed on mitigating risk of harm to COMMUNICATIONS clients. You can use the College’s Framework for Managing A diet technician has been assigned a task by the Risks 7 to help identify the degree of risk to the client and department manager. You observe that the diet technician is work together to find the proper protective factors to mitigate not competent to perform the task. You explain to the diet that risk. The appropriate protective factors could include technician that he should ask the manager for training and education or training for the diet technician, altering the job that he should not be attempting to perform the task without description so that the diet technician is no longer the necessary skills. You also explain that you will discuss the responsible to perform the task, or that supervision is matter with the department manager. In being a good required to ensure clients are safe from harm. Using the communicator, what factors do you need to consider? Framework will help you state your message clearly and objectively to remain focused on safe client outcomes.7 Collaborative, Respectful Communications In this scenario, your interpersonal communication skills will What the diet technician or the manager thinks is important be critical to protect the client from harm and to maintain or harmful to clients may not necessarily be what you think is collaborative relationships with the diet technician, the important or harmful to clients. An RD cannot expect to have manager and any others on the team involved in the full agreement in every case. Being a collaborative decision-making.7 Refrain from using a reprimanding tone professional communicator means providing evidence-based 6 College of Dietitians of Ontario résumé SPRING 2015  P R O F E S S I O N A L P R AC T I C E information, asking questions, listening to understand It may be very appropriate for a qualified team member to another’s reasoning, clarifying intentions and expectations, support a diet plan by focusing on other matters, for and working on a resolution, if possible. It may also mean, example, behavioural issues that may impede adherence to that once you have done all you can to communicate your nutrition plans. Such a discussion may give the RD an concerns about the diet technician and client safety, the opportunity to share knowledge to optimize client outcomes manager can decide to handle the situation going forward and team functioning. In keeping with the objects given to without your input. And, you would have to accept that health professions colleges in the Regulated Health decision. Professions Act, the College promotes inter-professional collaboration. CASE SCENARIO TWO — INTERPROFESSIONAL Communication represents the key to safe, competent, ethical dietetic practice, and COMMUNICATIONS An RD at a bariatrics assessment and treatment centre works in an interprofessional team. A non-RD team member has involves not only professional competence but been giving nutrition advice to some clients. The RD also developing collaborative professional and suggested that this non-RD team member refer the clients to the RD. Further the non-RD team member was heard giving interprofessional relationships. advice that was not based on evidence. In being a good communicator, what factors do you need to consider? RESOURCES Sometimes communicating with our colleagues in other n Ask yourself, “Am I a good communicator?” If you’re not professions can be more difficult than speaking with clients. It sure, take this online self-assessment: all depends on the communication skills of the team www.mindtools.com/pages/article/newCS_99.htm members: how good they are at sending and receiving For an extensive list of communication skills resources see: information and what they bring to the team relationship. n www.mindtools.com/page8.html Dietitians do not have the full responsibility for successful communication. All healthcare professionals have a mutual 1. Gamble, T.K. & Gamble, M. Chapter 1-Interpersonal Communication, and shared duty to communicate effectively. Under the Code retrieved March 10, 2015 from http://www.sagepub.com/upm- of Ethics, dietitians have a duty to be collegial. They also data/52575_Gamble_%28IC%29_Chapter_1.pdf have the obligation, in serving their clients’ interest, to make 2. Partnership for Dietetic Education and Practice (2013). The Integrated Competencies for Dietetic Education and Practice, p. 2. interprofessional relationships work. To support having the 3. Canter, M. (2000). The assessment of key skills in the workplace. conversation with the other team member, the RD should be Journal of Cooperative Education, 35(2/3), 41-47. prepared by:8 4. Oandasan. I., Robinson, J., Bosco, C., Carol, A., Casimiro, L., Knowing the facts, review the situation with an open mind. Dorschner, D., Gignac, M. L., McBride, J., Nicholson, I., Rukholm, E., & Schwartz, L. (2009). Final Report of the IPC Core Competency n n Approaching the health professional in a collaborative Working Group to the Interprofessional Care Strategic Implementation way: avoid criticizing and engage your colleague in a Committee. Toronto: University of Toronto. discussion of options that might best serve the client; 5. Miley, F. (2004). Peer Teaching for Life-Long Learning. Academic Education Quarterly 8(2): 254-259. n Avoiding putting the clients in the middle or to ‘lobbying’ clients for your own position; 6. Schon D.A. 1983. The reflective practitioner: How professionals think in action. New York: Basic Books. Documenting the discussion and results; 7 College of Dietitians of Ontario, A Framework for Managing Risk in n n Adhering to organizational policies regarding this matter. Dietetic Practice, résumé, Fall 214, pp. 4-8. http://www.collegeofdietitians.org/Resources/Publications- CDO/resume/resume-(Fall-2014).aspx Consider this situation as an opportunity for program policy 8. Steinecke, Richard, LLB and the College of Dietitians of Ontario. The and planning, specifically around how professionals on the Jurisprudence Handbook for Dietitians in Ontario. Online version, team can best use their knowledge and skills to serve clients. 2014, pp 17-19. résumé SPRING 2015 College of Dietitians of Ontario 7 GUIDELINES COLLABORATIVE CARE PROFESSIONAL PRACTICE GUIDELINES FOR REGISTERED DIETITIANS IN ONTARIO Approved by Council December 7, 2018 GLOSSARY Collaborative Care: a style of care that involves a team of health providers and a client who work in a participatory, collaborative and coordinated approach to share decision- making around health and social care. Collaborative Care Team: clients and their healthcare providers work together to achieve the optimal health outcomes. It could refer to situations where the team is located in the same practice setting and interact closely, or it could refer to providers who work independently and/or externally, but are providing care to the same client. Collaborating: an active ongoing partnership based on sharing, co-operation and coordination in order to solve problems and provide a service, often between people from very diverse backgrounds. Interprofessional: more than one health care profession on a health care team who work together and learn from each other. Interprofessional Care (IPC): is the provision of comprehensive health services to clients by multiple health caregivers who work collaboratively to deliver quality care within and across settings. Interprofessional Collaboration: the process of developing and maintaining effective interprofessional working relationships with learners, practitioners, patients/clients/ families and communities to enable optimal health outcomes. INTRODUCTION The purpose of the Collaborative Care Professional Practice Guidelines for Registered Dietitians in Ontario (Guidelines) is to set out the knowledge and behaviours that a dietitian must demonstrate when working in Collaborative Care Teams and in Collaborative Care environments. The Guidelines also help dietitians integrate knowledge, skills, attitudes and behaviours in utilizing their professional judgement when working with interprofessional colleagues, participating in and contributing to decisions that affect the wellbeing of clients. Much of this Guideline document provides suggestions for enhanced or best practices and relates to clinical and other care-based contexts with clients. However, many of the concepts can be applied to other interprofessional areas of dietetic practice. The Guideline statements are interrelated; each informing and qualifying the other statements. They are not intended to be applied in isolation, nor are they intended to provide an exhaustive or definitive list of collaborative behaviours required of members. Rather, they are to be used in combination with other College documents such as the Code of Ethics and Standards of Practice and relevant legislation, policies and any other applicable organizational guidelines or policies in the workplace. SECTION 1: ROLE, RESPONSIBILITY AND DECISION- MAKING Dietitians must have an understanding of their role and responsibilities in collaborative care- based contexts that enable respect, trust, shared decision-making, and partnership, including the following: 1.1 COLLABORATIVE CARE SHOULD BE CLIENT AND FAMILY CENTRED i. In addition to the professional members of the collaborative health care team, clients and family members are integral as active participants across the spectrum of care. ii. The client/substitute decision-maker is a key participant in the collaborative care team. iii. Whenever possible, the client should be treated as a member of the team. iv. Based on context, if the client is capable, and has expressed the desire to, they may even act as the team leader to become an active participant in their own care. 1.2 CLARIFY TEAM MEMBERS’ ROLES AND RESPONSIBILITIES AS PART OF EACH CLIENT’S CARE PLAN i. Understand who is capable and authorized to perform which aspects of treatment is the starting point for role clarity in a team. In many cases, there may be more than one provider sharing roles and tasks (including authority mechanisms) to best service clients. ii. Members of a collaborative care team should clearly understand: who is on the team; the team members’ roles and responsibilities; and which task(s) each team member will perform (this is especially important when there is overlapping scope or shared authority for the performance of controlled acts). iii. Dietitians recognize that the authorities, roles and responsibilities in the team may differ depending on the specific needs of the client, the practice setting, or other relevant factors. iv. Dietitians exercise professional judgment within the limits of individual competence and collaborate with others, seek counsel, and make referrals as appropriate. v. There should be mutual respect and trust in the team, based on a clear understanding of each team member’s competencies. vi. It may be beneficial to document team members’ roles and responsibilities as part of each client’s care plan. This will include members in the circle of care such as dietitians in food- service, community, public health, management etc. 1.3 DIETITIANS ARE ACCOUNTABLE FOR DIETETIC SERVICES DELIVERED IN COLLABORATIVE ENVIRONMENTS i. Dietitians have a professional obligation to maintain individual accountability when practising dietetics within collaborative environments. ii. Dietitians should use critical thinking, problem-solving skills and good judgement when practising dietetics in diverse collaborative care environments. iii. Dietitians must ensure that a comprehensive client health record is maintained when individual nutrition assessments and treatment/intervention are provided (this can include shared appointments whereby another provider documents nutrition services that were provided which are then verified and signed by the dietitian). iv. Records provide clear accountability of what was done and by whom. Keeping appropriate records is important for client care and is critical to ensuring accountability for services. The quality of a dietitian's records can be a good barometer of the quality of their practice. 1.4 SHARED EVIDENCE-INFORMED DECISION-MAKING FOR SAFETY AND QUALITY CARE i. Dietitians are encouraged to work in a participatory and coordinated approach when providing collaborative care. This includes evidence-informed decision-making through the use of best practices and resources to support the safe delivery of collaborative care. An evidence-informed decision-making approach should enable the separate and shared knowledge and skills of care providers to synergistically influence the client care provided. ii. Decisions should be made based on the client’s informed choices and health care professionals working together to ask, access, appraise and act on the research evidence. SECTION 2: COMMUNICATION, CONFLICT MANAGEMENT AND EVALUATION Dietitians must have an understanding of how to work effectively in teams, including the following: 2.1 EFFECTIVE COLLABORATION REQUIRES EFFECTIVE COMMUNICATION i. The team should establish a clear process for communicating within the team, and have a shared language/lexicon. ii. Being an effective communicator means being acutely aware of whether your professional communication is done well. Are you getting through? It also means being aware of the various forms of communications — interpersonal, interprofessional and intrapersonal communication — and how they impact dietetic practice. iii. Communication is an essential dietetic practice competency, so it is an important area for continuous learning and reflection. iv. Sometimes the only form of communication between health care providers is through the client health record. The team should develop both a process and format of how record keeping will occur in the team. v. Timely and clear record keeping not only facilitates communication between the health team members, it helps to prevent gaps, errors and duplication, and enhances collaboration and coordination to optimize safe, effective and efficient health care. vi. Sometimes communicating with our colleagues can be more difficult than speaking with clients. Dietitians do not have the sole responsibility for successful communication; all healthcare professionals have a mutual and shared duty to communicate effectively. Dietitians have a duty to be collegial. vii. Active listening skills facilitate information sharing, seeking and decision-making. 2.2 THERE SHOULD BE A STRATEGY FOR CONFLICT MANAGEMENT i. The team should establish a clear process for conflict resolution and decision-making. ii. Team members should be able to identify conflict when it occurs. iii. In the interest of client-centred care, dietitians should strive to work collaboratively with the other health professions caring for their clients. If dietitians have concerns about the safety of a nutrition treatment recommended by another dietitian or practitioner from another health profession, address these concerns with the individual practitioner and collaborate to find the best course of action for the client. iv. Dietitians have the obligation, in serving their clients’ interest, to manage conflict and advocate for the client’s best interest. To support interprofessional collaborative practice, dietitians need to consistently address conflict in a constructive manner as discussed in How do you know you are communicating well? (p. 7): a. Know the facts; review the situation and go in with an open mind; b. Approach the health professional in a collaborative way. For example, instead of criticizing, engage your colleague in a discussion of what options might best serve the client; c. Try not to put the client in the middle or to ‘lobby’ clients for your own position; d. Document the discussion and results; and  e. Adhere to your organization’s policies regarding these matters. 2.3 SHOULD HAVE A CLEAR LEADER i. Collaborative care does not happen automatically. In addition to any formal team leader, the “collaborative leadership” model means that team members understand and can apply leadership principles that support a collaborative practice model. Together the team determines who will provide group leadership in any given situation. The leader may change or alternate from time to time based on the client’s priorities and model of care. The leader helps the team develop synergy and engage in client-centred practices to ensure that it facilitates effective collaborative care. To do this, a collaborative leader has two functions: task orientation and relationship orientation. a. In the task-orientation function, the collaborative leader helps others on the team keep on task in achieving safe outcomes for client care. Task oriented responsibilities include helping to maintain the integrity of the team’s governance and operating processes and helping to achieve client-centred outcomes for quality services. b. In the relationship orientation function, the leader assists the team to work more effectively. This includes ensuring effective communication among members, providing support, managing conflict, and building productive work relationships. ii. The team should consider when it would be beneficial to document who is the team lead as part of each client’s care plan. iii. The team leader can be a dietitian or another member of the team. 2.4 TEAM FUNCTIONING AND EVALUATION i. Teams that respect the definition of collaboration should establish clear group expectations and a clear process to evaluate whether the team is meeting its goals, and how well the team is functioning. ii. An evaluative measure can be formal or informal, and should be based on context and the best interests of the health care system. Given that resources are constrained, how best can collaborative environments maximize productivity of each team without increasing costs (human or financial) or sacrificing safety and quality? iii. Team functioning is enhanced when team members learn about, from and with each other to practise in the interest of client-centred care. iv. Team functioning should reflect standards of respect and civility so as to enable collaborative teamwork, effective conflict management, andshared decision making. v. Teams function best when they have shared team values (e.g. integrity, compassion, stewardship, safety) 2.5 EDUCATION AND TRAINING i. Collaborative care includes continuous individual and collective learning and training. Where relevant, dietitians can reflect on their practice and professional competence to identify any gaps and develop plans for professional development which can include education and training for how to work effectively in a team. ii. Each profession brings its own set of competencies through education, training and experience. Health-care professionals working in collaborative environments should seek out opportunities to learn from each other in ways that can enhance the effectiveness of their collaborative efforts. iii. There may also be opportunities for team members to connect with and educate each other based on their respective knowledge bases and expertise to enable the best possible outcomes. REFERENCES AND RESOURCES World Health Organization. (2010). Framework for action on interprofessional education and collaborative practice. Geneva: Author. Retrieved from http://whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.3_eng.pdf Canadian Interprofessional Health Collaborative: National Interprofessional Competency Framework (2010). The College has developed several resources to assist dietitians and others in enhancing IPC within their professional practice. Refer to the following resources: Enhancing Interprofessional Collaboration Effective Use of Knowledge in Interprofessional Teams Interprofessional Collaboration e-learning module Interprofessional Collaboration Addressing Conflicts Between Health Care Professionals COMMUNICATING WITH A CLIENT VIA EMAIL AND FACEBOOK A client asks a dietitian specific questions about her nutrition care plan by email. She also asks a question on the dietitian’s professional Facebook page. What are the dietitian’s obligations for obtaining consent to communicate client personal health information via email and on social media? A dietitian cannot assume that a client understands all the risks involved in disclosing personal health information online or posting it on social media. It is the dietitian’s responsibility to obtain an informed and knowledgeable consent from the client that would allow sharing their personal health information in an email or on social media (Refer to the Professional Practice Standard, Consent to Treatment, Standards 2). The dietitian should clearly explain the security issues surrounding communicating via email and the measures they have in place to protect the client’s personal health information (encryption, password protection, etc.). Still, communicating over the internet is never 100% secure (Refer to Telephone & Web-Based Counselling) The dietitian can also explain the possibility for miscommunication online and the limits to communicating via email versus in person visits and conversations over the phone. With regards to social media, the dietitian should make sure that the client understands that the Facebook page is public and any personal health information posted there can be viewed by everyone. The dietitian may offer a private method of communication as an alternative. If the client understands the risks and consents to communicate via email or on social media, then the fact that the dietitian obtained an informed express consent to communicate online can be documented in the client's health record. OBTAINING CONSENT IN INTERPROFESSIONAL TEAMS A pre-term infant has been admitted to the Neonatal Intensive Care Unit (NICU). The infant requires Total Parenteral Nutrition (TPN). Mom is unconscious and being treated at another hospital due to severe blood loss. The baby’s father is at his wife’s bedside. The physician you work with has proposed TPN treatment to the infant’s father. What is the role of the RD to obtain consent in an interprofessional team? The role of the dietitian for obtaining consent depends on who is proposing and providing the treatment. In this scenario, the physician has proposed and ordered the treatment. The dietitian can assume that the physician has also obtained informed consent for the treatment and should be able to verify this by looking at the physician’s documentation in the client’s health record. The College's Standard of Consnet 1 (V), states that , "When another health care practitioner proposes nutrition treatment and obtains informed consent, RDs must: a) Be reasonably confident that the practitioner obtained informed consent; b) Obtain informed consent if it is determined that the informed consent process for treatment was incomplete; and c) Answer any additional questions that clients/substitute decision-makers may have regarding the nutrition treatment being proposed. Had the dietitian proposed the treatment and had parenteral nutrition ordering authority in the NICU, then the RD would be responsible for obtaining informed consent from the father. Whenever an RD obtains express consent, they must document this in the client health record. Informed consent is required for all treatment unless there is an emergency as defined under the Health Care Consent Act, 1996 (HCCA). There is an emergency if the person for whom the treatment is proposed is apparently experiencing severe suffering or is at risk of sustaining serious bodily harm if the treatment is not administered promptly (HCCA, 1996). Dietitians would need to consult with their health care team and/or organization’s legal counsel to determine what components of nutrition care, if any, present as an emergency situation for incapable clients under the Health Care Consent Act, 1996. If deemed an emergency, then nutrition treatment can be provided without consent (College of Dietitians of Ontario, Standard of Consent 8 ). Informed consent can be given for a multi-faceted treatment plan and course of treatment. The HCCA, 1996 specifies that a health care practitioner is entitled to presume that consent includes adjustments to the treatment that are not significantly different from the original treatment. If adjustments are needed during the course of the TPN treatment, the dietitian can use professional judgement to assess whether the expected benefits, risks or side effects of the TPN adjustments (e.g. rate or formula changes) warrant further consent from the baby’s father. For more information on obtaining consent in an interprofessional environment, please refer to the Guidelines (Collaborative Care Professional Practice Guidelines) which outline the knowledge and behaviours that a dietitian must demonstrate when working in Collaborative Care Teams and in Collaborative Care environments. In addition, the Standards (Professional Practice Standard: Consent to Treatment and for the Collection, Use and Disclosure of Personal Health Information) outline professional responsibilities to obtain informed consent for nutrition treatment. This video reviews dietitian responsibility to obtain consent in three different collaborative care practice settings. NON-CUSTODIAL PARENT Robert calls wanting to see you right away about his 8-year-old daughter Olivia. Olivia is with him for the day and has to be returned to her mother the next morning. Robert is concerned that Olivia is not being adequately fed by her mother and wants you to assess Olivia. You learn that Robert is not the custodial parent; he just has access rights. He says there is no provision in their separation agreement about his right to authorize medical care for Olivia. What do you do? To determine whether Robert can provide consent, you need to know if , as an a non- custodial parent, he has the authority to do so. Note that the Substitute Decision-Makers Ranked Highest to Lowest below, ranks the custodial parent higher than the access parent. If the higher r