Administrative Article

Communication Within Hospice Interdisciplinary Teams: A Narrative Review

American Journal of Hospice & Palliative Medicine® 1-17 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909115613315 ajhpm.sagepub.com

Angela R. Moore, MPH1, Randi Ginger Bastian, MPH1, and Bettye A. Apenteng, PhD1

Abstract Hospice care is coordinated through an interdisciplinary team (IDT), which assures that a holistic care plan based on the patient’s wishes is implemented. The extent to which an IDT provides quality care may be associated with how effectively they communicate within the team as well as with patients, caregivers, and families. This review seeks to characterize communication strategies among hospice IDT members and to determine how such strategies impact patient care. Although the existing literature sheds some light on communication within hospice IDTs, further research is needed. Inquiry into the communicative process of IDTs in settings other than team meetings, such as during patient visits or informal settings, would provide a more comprehensive representation of how communication influences IDT dynamics and overall team functioning. Keywords hospice, palliative care, end-of-life, interdisciplinary team, communication, collaboration, coordinated care

Introduction Approximately 1.6 million patients received hospice services from over 5000 hospices across the United States in 2013.1 Hospice care provides an environment that supports the physical, emotional, and spiritual needs of individuals approaching the end of life. Care is provided in a variety of settings such as the patient’s home, a nursing home, or hospital; however, the common element of hospice care, regardless of the care setting, is its focus on caring for the patient and enhancing their quality of life during this terminal phase.1 Four principles underpin the hospice care approach: (1) care is holistic and centered around the patient and their family; (2) care is self-determined, thus, the care provided is driven by patient and family values, culture, beliefs, and lifestyle; (3) care is focused on one’s quality of life rather than prolonging life through medical treatment; and (4) death is viewed and accepted as the final stage of the life cycle.2 Similar to other health care settings, hospice care is provided by an interdisciplinary team (IDT). There is mounting evidence to suggest that IDTs in health care can improve continuity of care, enhance quality of care, lower costs, and result in overall improvement in health.3-5 Per Medicare guidelines, the hospice IDT must include a nurse, medical doctor, social worker, and counselor.6,7 In the hospice setting, the IDT is responsible for the biomedical, psychosocial, and spiritual health care of the patient.8 The registered nurse (RN) usually serves as the case manager and is responsible for team coordination, assessment of patient and caregiver needs, and

implementation of the care plan.6,9 Despite the growing body of research on IDT functioning and its quality implications in health care settings such as mental health, palliative care, and intensive care units, there have been little empirical inquisition into IDT functioning and dynamics within the hospice setting. To ensure that the hospice care environment truly supports the patient physically, emotionally, and spiritually, IDT members must work collaboratively and in coordination. The degree to which optimal coordination and collaboration is achieved hinges on the extent to which team members communicate effectively with each other, their patients, and family members. The purpose of this review is to characterize communication strategies within hospice IDTs and to determine the extent to which these strategies impact patient care and hospice outcomes.

Methods An in-depth narrative review of peer-reviewed literature was conducted to address the following research questions: (1) 1

Department of Health Policy and Management, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA, USA

Corresponding Author: Bettye A. Apenteng, PhD, Department of Health Policy and Management, JiannPing Hsu College of Public Health, Georgia Southern University, Statesboro, GA 30460, USA. Email: [email protected]

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American Journal of Hospice & Palliative Medicine®

2 What communicative processes characterize IDT interactions, (2) how does effective communication contribute to team functioning, and (3) to what extent does effective communication among hospice team members impact the quality of hospice care. Databases searched included CINAHL, Medline, SocIndex, PsycINFO, Science Direct, Advanced Placement Source, and Communication and Mass Media Complete. The following Boolean search syntax were used: ‘‘hospice AND interdisciplinary teams,’’ ‘‘communication AND hospice interdisciplinary team,’’ ‘‘collaboration AND hospice interdisciplinary team,’’ and ‘‘hospice interdisciplinary team AND quality.’’ The results were then filtered to abstract-only peer-reviewed documents published from 2000 to June 2015 and available in English. Articles published in settings outside the United States were excluded due to the fact that the organization and delivery of hospice services differ across countries. Additionally, this review focused solely on communication among hospice health care professionals who are part of the IDT. It assessed communication between family members or caregivers and the IDT only to the extent that such communication influenced the communication practices of health professionals in IDTs. Although patients and the caregivers should be an integral part of the IDT, the existing literature suggests that they are often not involved in IDT deliberations, as it relates to care planning.10 After applying the inclusion and exclusion criteria and scanning reference lists for additional relevant articles, 34 relevant articles were selected and synthesized in this article. Thematic analysis was used to synthesize evidence in the qualitative, quantitative, and mixed methods studies. Three reviewers (all authors) independently read these articles and identified relevant themes using inductive coding. The research team resolved any disagreement or ambiguity by discussion, and themes were refined accordingly.

Results Figure 1 describes the article selection process. Collectively, the reviewed articles addressed the following broad themes: hospice IDT communication processes, content and quality, IDT dynamics and collaboration, technologies for enhancing hospice IDT communication, and hospice IDT communication and outcomes. The majority of the studies were conducted by a core group of researchers (24 of the 34, 70.6%; Table 1). The studies reviewed included descriptive quantitative (9 of the 34; 26.5%), qualitative (13 of the 34; 38.2%), mixed method (6 of the 34; 17.6%), and other types of studies (6 of the 34; 17.6%) and were published mostly in peer-reviewed hospice and social work journals (Table 1).

Content and Processes of Communication Within Hospice IDTs Although communication among hospice IDT settings can take place in both formal and informal settings, the existing literature has predominantly evaluated the content, processes, and quality of communication during IDT team meetings. These

Records idenfied through database searching (n = 373 )

Records restricted to peer-reviewed arcles (n = 363 )

Records aer duplicates removed (n = 245 )

Records screened (n = 245 )

Full-text arcles assessed for eligibility (n = 52 )

Studies included in synthesis ( n = 34 )

Records excluded (n = 193 ): published outside the US, lack of direct relevance to the study

Full-text arcles excluded, with reasons: focused on palliave care in sengs other than hospice; addressed hospice IDT-caregiver communicaon with lile or no emphasis on intra-team communicaon (n = 18)

Figure 1. Process for selecting articles.

studies have mostly been descriptive in nature and have often assessed team and caregiver interactions within these team meetings to gain insight into common communication strategies used by IDT members. Two predominant themes emerged from the review of the literature, regarding the content of communication during IDT meetings: (1) hospice team members’ profession and role in the IDT team influence the level and nature of communicative contributions and (2) the content of communication during IDT meetings largely focuses on the biomedical aspects of the patient’s care. In several studies on communication within hospice IDTs, Wittenberg-Lyles and colleagues have demonstrated that the profession of a hospice IDT member determines their level of participation during meetings as well as the content of their communication.2,13,19 Nurses and medical directors were found to be the most dominant communicators during team meetings, with social workers and chaplains being the least involved.19,20 One study assessing communication processes within IDT meetings found that nurses did the majority of talking, accounting for 63% of all message transmission. The medical director was the second most active speaker and contributed to formal reporting and requests for clarification, whereas the chaplain had the least active communication role, only accounting for 5% of message transmission and primarily offering impressions or information.20 Findings from a similar study on communicative processes during hospice IDT meetings revealed

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3

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None stated

John A. Hartford Social Work Faculty Scholars Program

Oliver et al14 Journal of Palliative Care

Quantitative—survey; response rate: not stated

Methodology

Assess perception of collaboration Quantitative evaluation of among members of hospice collaboration using the MIIC IDTs Instrument; response rate: not stated

Describe the role and experiences Quantitative—semistructured of hospice chaplains within phone survey; response rate: hospice IDTs. 24%

Evaluate the relationship between Quantitative—survey; response social worker involvement in rate: 20% hospice care and hospice service delivery and outcomes

None stated

Social Work

Purpose

Jonas Center for Nursing Assess nurse-perceived Excellence communication and collaboration challenges in interprofessional care teams

Funding Source

Journal of Hospice and Palliative Nursing

Journal

Wittenberg- Journal of Palliative Medicine Lyles et al13

Reese and Sontag12

Quantitative Wittenberg et al11

Author(s)

Table 1. Summary of studies included in the review. Key Findings

Purposive sample of 193 nurses The majority of participants attending 1 of 5 End-of-Life identified nurse leaders (43%) Nursing Education Consortium and physicians (18%) as team programs members responsible for setting meeting agendas and taking on leadership roles. Nurses reported more difficulties in dealing with conflicts arising within the IDT compared with conflicts with patients and family members. Accordingly, nurse respondents fared poorly on collaborative skills related to team building NHPCO-membership Social worker experience and representative sample of 66 having no other duties outside hospices across the United hospice social work were States associated with greater involvement in team processes and better team functioning. Greater involvement in hospice service delivery processes (participation in intake and more client contact) was associated with better hospice outcomes and reduced costs Purposive sample of 100 hospice Chaplains perceived that their role chaplains within the hospice IDT was not clearly defined, often resulting in role conflicts with team members from other disciplines. They reported having to often take on group maintenance roles during IDT meetings, including managing team conflicts. In an informal capacity, they also reported that they comforted and provided spiritual guidance for team members experiencing stress Convenience sample of 95 staff There is more variation in from 5 hospices in Nevada, perceived collaboration across California, New York, and hospice team than within Missouri hospice teams

Sample Description

(continued)

IDT dynamics and collaboration

IDT dynamics and collaboration

Impact of hospice IDT communication and collaboration on patient care and hospice outcomes

IDT dynamics and collaboration

Theme

4

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Methodology

Assess difference in job satisfaction Quantitative—survey; response among hospice IDT members rate: 90% from different disciplines

None stated

Key Findings

Theme

(continued)

Hospice social workers reported IDT dynamics and high levels of collaborations collaboration and within their IDTs. No impact of hospice IDT association was observed communication and between either total collaboration on interdisciplinary scores or patient care and subscale scores and hospice hospice outcomes quality or social workers’ demographic and practice characteristics Purposive sample of 126 hospice All 4 disciplines reported high levels IDT dynamics and professionals of interdisciplinary collaboration collaboration. Using the MIIC, no significant difference was observed in the level of perceived collaboration based on professional discipline. Results from the Influences on IIC show differences among disciplines with respect to the following: history of collaboration, perceived level of trust among team members, liking other professionals on team, and other team members’ understanding their personal values and perspectives. Similarly, differences were observed with respect to job satisfaction, with social workers reporting lower job satisfaction Convenience sample of 76 hospice Overall, respondents reported high Impact of hospice IDT IDT members from 4 hospices levels of job satisfaction. communication and in the Midwest Subscale analysis revealed collaboration on differences with satisfaction in patient care and distributive justice (perceived hospice outcomes fairness of how penalties and rewards are distributed in organization), autonomy, and job opportunity. Compared with other professionals, nurses reported the highest levels of autonomy and the highest level of satisfaction with the degree of distributive justice in the organization. Social workers, on the other hand, reported having the least opportunity

Sample Description

Explore the correlates of Quantitative evaluation of Purposive sample of 77 social interdisciplinary collaboration in collaboration using the IIC workers in 1 state hospice teams Instrument; response rate: 53%

Purpose

Monroe and Omega DeLoach17

None stated

Funding Source

Michigan State University Compare and contrast the Quantitative evaluation of Dissertation perceived level of collaboration using the MIIC, Completion interdisciplinary collaboration the Influences on IIC, and the Fellowship and job satisfaction among the Job Satisfaction Scale; response following hospice professionals: rate: 27.5% physicians, nurses, social workers, and chaplains

Health and Social Work

Journal

American Journal of Kobayashi Hospice and and Palliative McAllister16 Medicine

ParkerOliver et al15

Author(s)

Table 1. (continued)

5

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None stated

Journal of Hospice and Palliative Nursing

Baldwin et al18

Wittenberg- Journal of Gerontological Lyles et al2 Nursing

NIH National Cancer Institute R21 C 120179

None stated

None stated

The Journal of Business Communication

Coopman, 20016

Qualitative Wittenberg- Qualitative Health Lyles19 Research

Funding Source

Journal

Author(s)

Table 1. (continued) Methodology

Quantitative—survey; response rate: 20%

Key Findings

Theme

Convenience sample of 52 hospice A positive association was IDT dynamics and IDT members from 3 hospices observed between participation collaboration and in decision making and impact of hospice IDT perceived team cohesiveness, communication and productivity, and job collaboration on satisfaction. The relationship patient care and between participation in hospice outcomes decision making and job productivity was mediated by team productivity. An association was observed between team productivity and satisfaction with hospice organization (as measured by turnover intention) Purposive sample of 145 hospice About two-thirds of hospices IDT dynamics and agencies across the United reported training IDT members collaboration States to work collaboratively in team settings. Structures and processes to appraise the adequacy of these training programs were lacking

Sample Description

(continued)

Explore how case managers This study uses ethnographic Town hospice meetings, 30.5 hours Psychosocial information is relayed Content, processes, and negotiate the addition of patient observation to assess the extent of fieldwork, and 23 pages of as part of care goals. Case quality of psychosocial information into to which IDT meetings provide field notes managers were compelled to communication within IDT meetings insight on communication about share psychosocial information hospice IDTs psychological, social, and if an instance of inadequate care spiritual elements of care was discovered Investigate IDT communication and Videorecorded sessions were 81 Hospice team meetings were Nurses dominated in message Content, processes, and evaluate the use of relational transcribed and analyzed using coded from video recordings transmission, largely due to quality of communication within message control the Family Relational their role as a reporter. The Communication Control most frequent kind of hospice IDTs Coding System interpersonal communication were those aimed at gaining control of the information exchange

Assess the level of preparation hospice IDT members have in team collaboration

Assess the perception of hospice Quantitative—survey; response IDT members regarding rate: 74% participation in decision making, team outcomes, satisfaction with team, and overall satisfaction with hospice organization

Purpose

6

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Dugan Day8

Oliver and Peck7

Author(s)

Funding Source Gain insight into hospice team collaboration by exploring the experiences of hospice social workers in IDTs

Purpose

Journal of Social National Cancer Institute Explore interactions between Work in End-Ofhospice team members as it Life & Palliative relates to using processes to Care address multidimensional pain

Journal of Social John A. Hartford Work in End-OfFoundation Social Life & Palliative Work Faculty Care Scholars Program

Journal

Table 1. (continued)

Qualitative study to explore 2 processes in team pain palliation: communication and collaboration. Team members were interviewed individually, and the author observed and kept notes of team treatment planning meetings over a year

This qualitative study uses interviews to further explore social workers’ perception regarding IDT collaboration

Methodology

Key Findings

Theme

(continued)

Factors that facilitate collaboration Content, processes, and Random sample of 77 social workers stratified by IIC scores include good communication, quality of (high, medium, and low), 27 trust, understanding the role of communication within social workers were team members in the process of hospice IDTs and IDT interviewed communicating, joint home dynamics and visits (visiting a patient with collaboration colleagues from another discipline), and formal and informal opportunities for team building, respect, and administrative support or interest. Factors that act as barriers to collaboration include excessive caseloads, overemphasis on clinical or medical issues, and interpersonal conflicts Convenience sample of 1 IDT from In relation to pain management, IDT dynamics and 2 hospices (rural nonprofit and communication and collaboration rural for profit) collaboration were experienced as 2 independent processes. Communication about pain management was more routine compared to collaboration. Communication about pain management occurred outside the IDT meetings. Nurses usually saw their role as providing patient education on pain, whereas chaplains and aides reported wanting to empower patient to express experiences of pain. Although all discipline-specific perspectives regarding pain were valued, the findings revealed a lack of clarity about each team member’s specific role in pain management

Sample Description

7

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Journal

None stated

Funding Source

National Institute of Nursing Research R01NR022472

Journal of Hospice & NIH National Cancer Palliative Nursing Institute R21 CA 120179

Wittenberg- Health Communication Lyles et al22

Demiris et al21

Wittenberg- Journal of Housing Lyles et al20 For the Elderly

Author(s)

Table 1. (continued)

Using ACTIVE meetings with at least 1 family member virtually participating in IDT meetings explores how family participation affects communication

Understand the interactions of hospice providers during IDT meetings and to explore how these meetings contribute to team functionality

Explore how discipline-specific roles of IDT members impact communication processes

Purpose

Randomized controlled trial (randomly assigned to either standard meetings or ACTIVE meetings) that assesses caregiver clinical outcomes associated with participation in ACTIVE meetings

Thematic analysis of transcribed video-recorded IDT meetings based on the time, interaction, performance theory

Key Findings

Theme

(continued)

In the absence of patient and Content, processes, and caregiver participation, the most quality of frequent ‘‘backstage’’ communication within communicative messages during hospice IDTs IDT meetings included formal reporting, offering impressions, and requesting clarification. Nurses did the majority of talking in IDT meetings, accounting for 63% of all turns. Nurses engaged in formal reporting and offering suggestions. The medical director was the second most active speaker and contributed to formal reporting and request for clarification. The chaplain had the least active communication role, with only 5% of turns 81 Patient cases on 24 patients The majority of team meetings Content, processes, and focus on team production, served by 4 hospice teams in 1 quality of rural Midwestern hospice assuring that goals are well communication within program defined and that the team is hospice IDTs making an effort to attain goals. Team member well-being also plays a role in how well the team members can perform and coordinate tasks. Results indicate that team support occurs sparingly. Chaplains contributed to team support despite limited participation in team member well-being and team productivity Subset of a larger randomized Caregiver presence influenced the Content, processes, and control trial and recruited from content of communication as quality of 2 hospices. Caregivers had to be well as the extent of communication within older than 18 years, primary participation from IDT hospice IDTs caregiver, and have Internet members. Caregiver presence increased participation of social access workers and chaplains and fostered relationship building among meeting participants

Sample Description

Videotaped IDT meetings were 15 Hospice IDT members at a reviewed, and interactions were hospice facility in the Midwest. coded using Ellingson backstage IDT members included a communication processes medical director, nurses, social workers, home health aides, chaplains, a hospice director, and volunteer coordinator

Methodology

8

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Sample Description

Randomized control trial that Sample was taken from 88 explores communication within recordings of ACTIVE team ACTIVE meetings and evaluates meetings within 2 hospice the use of VALUE principles agencies operating within a among teams through the Midwestern state analysis of video and audio recordings

Methodology

National Cancer Institute Identify hospice medical director role during IDT case reviews

Oliver et al26 Journal of Palliative Medicine

Characterize experiences of medical directors working in IDTs

Purposive sampling of case reviews A sub sample of 24 patients and 68 to identify roles of medical case discussions involving 4 directors. Between 2006 and teams, and 6 medical directors 2008, as part of a larger study, a sample of 244 case discussions was reviewed. The study had 2 phases, a control phase, which included traditional hospice team meetings, and an intervention phase, which included the caregiver. Deductive coding was used, based on Vandenberg list of medical director roles to ensure consistent interpretation of the role of hospice medical director

Descriptive study addresses 17 Physicians were interviewed as research questions related to follow-up from a larger study collaborative experiences of medical directors, characteristics of hospice collaborations, factors that mark successful medical directors, and benefits and challenges for medical directors. Hospice medical directors were interviewed

Determine information flow of IDT To determine information flow of IDT staff (physicians, nurses, social workers, bereavement meetings with focus on IDT meetings, video recordings information access, exchange, of hospice team meetings were counselors, chaplains, volunteer observed and analyzed coordinators, and home health and reporting (documentation) aides) who were part of 4 teams operating in the Midwest

Curtis W. and Ann H. Long Department of Family and Community Medicine and the University of Missouri School of Medicine

NIH National Cancer Institute R21 CA 120179

Journal of Interprofessional Care

Demiris et al24

Assess the extent to which IDTs use VALUE principles and to explore communication in ACTIVE meetings that involve caregivers

Purpose

Oliver et al25 American Journal of Hospice and Palliative Medicine

National Institute of Nursing Research R01NR011472

Funding Source

Journal of Palliative Medicine

Journal

Washington et al23

Author(s)

Table 1. (continued)

Although clinicians used VALUE principles in communication during ACTIVE meetings, the majority of communication was of moderate or poor quality due to its task focus and lack of emphasis on the emotional concerns of patients and families 12.3% of all discussions were focused on an absent team member who could have provided additional information, 8.6% of all discussion featured information that was conveyed 3 times or more, and 5% of all discussions on patient cases focused on soliciting information from team members who had access to the patient’s chart, illustrating challenges to efficient information flow Medical directors described successful or good directors as those who had an understanding of psychosocial issues, an ability to work well in team, good communication skills, and an ability to advocate for their patients. Medical directors also indicated that time and opportunities for professional development could further improve collaboration The medical director usually spoke on average 9.5% of the team case review time. Medical director did not always participate in case review. When they did, they assisted the team with care planning; educated members of the team; and to a lesser extent played a role in connecting the team with the attending physician, participating in quality assurance discussions, determining if hospice was appropriate for the patient, and discussing the budget

Key Findings

(continued)

IDT dynamics and collaboration

IDT dynamics and collaboration

Content, processes, and quality of communication within hospice IDTs

Content, processes, and quality of communication within hospice IDTs

Theme

9

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Journal

Funding Source

Purpose

Methodology

Sample Description

Key Findings

Wittenberg- Progress In Palliative National Cancer Institute Investigate the use of niceness Descriptive study that utilizes video 43 members of 2 hospice IDTs who Strategies used by IDT members to Lyles et al27 Care RA-CA-05-013 message strategies by IDT were nurses, social workers, recordings of case discussions initiate the telling of atrocity members to tell atrocity stories among IDT meetings to chaplains, medical directors, stories include indirect criticism during IDT meetings determine strategies used to tell volunteer coordinators, medical (56%), direct criticism (36%), atrocity stories within a hospice students, bereavement and inverted comma criticism setting coordinators, and home health (8%). These strategies were aides used to share criticism about patients, other health care professionals, or caregivers Journal of Social None stated Identify interdisciplinary Qualitative national telephone 14 Coordinators from 11 state Prison hospice also work within a Bronstein Work in End-ofcollaboration between social survey with the coordinators of prison hospice were chosen traditional IDT model and and Life & Palliative work and criminal justice 14 prison hospice programs in from a list generated from the report high-quality Wright28 Care 11 states Department of Justice collaboration on the team Mixed methods Qualitative—verbal behavior Convenience sample of 43 hospice Video technology is a feasible way Wittenberg- Journal of Computer- National Cancer Institute Present a theoretical framework Medicated R21 CA120179 and evaluate the use of video coding. Quantitative assessment IDT members and 25 caregivers to enhance caregiver Lyles et al29 Communication technology to enhance caregiver of video quality using a validated participation in hospice IDT participation in hospice IDT instrument deliberations meetings Assess the impact of caregiver Qualitative—participant 226 Video recorded meetings from Inclusion of caregivers in IDT Wittenberg- Palliative Medicine None stated enhances team outcomes, participation on the structure, observation. The Team 2 groups: hospice IDT without Lyles et al30 processes, and outcomes of Observation Scale was used to caregiver participation (N ¼ including increasing the IDTs generate quantitative data to 152) and hospice IDT with discussion of biopsychological assess the impact of caregiver caregiver participation (N ¼ 74) problems and enhancing interdisciplinary care planning participation Telemedicine and National Institute of Assess the quality of Randomized clinical trial. 200 Video-recorded hospice team Web-based videoconferencing is Demiris eHealth Nursing Research R01 videoconferencing to enhance Qualitative—participant meetings (114 Web-based superior in technical quality to et al31 NR011472 caregiver participation in IDT interviews; quantitative— videoconferencing and 86 POTS-based videophones. meetings and to compare POTS quantitative assessment of video POTS-based videophones). 19 Overall, caregiver participants and Web-based quality using a validated Caregivers in the Web-based perceived Web-based videoconferencing on the instrument as well as participant videoconferencing group were videoconferencing as a valuable quality of telehealth interactions ratings interviewed tool for facilitating team communication AMIA 2009 National Cancer Institute Assess how the technical quality of Qualitative—content analysis of 70 Videotaped meetings between Sessions with higher technical Demiris Symposium R21 CA120179 POTS-based videophones verbal utterances of 30 caregivers and 43 hospice quality were associated with et al32 Proceedings impacts the style and content of participants. Quantitative— more time spent on general IDT members from 2 rural communication between video quality using a validated hospice in the Midwest informal talk, discussion of hospice team members and instrument psychosocial issues, and family caregiver education

Author(s)

Table 1. (continued)

(continued)

Technologies for enhancing hospice IDT communication

Technologies for enhancing hospice IDT communication

Content and processes of communication within hospice IDTs

Technologies for enhancing hospice IDT communication

IDT dynamics and collaboration

IDT dynamics and collaboration

Theme

10

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Journal

None stated

None stated

Health & Social Work

Reese and Sontag12

John A. Hartford Social Work Faculty Scholars Program

Journal of Hospice and Palliative Nursing

American Journal of Hospice and Palliative Medicine

Fine et al36

Other Parker Oliver et al35

Purpose

Methodology

Sample Description

Patient chart review

Psychometric testing of an instrument

Review the literature on barriers to Literature review successful interprofessional collaboration on hospice IDTs from the perspective of social workers

Describe a novel approach to assessing time and cost variability in hospice IDT meetings relative to patient outcomes

Psychometrically test a modified version of the IIC—the MIIC

Identify the collaborative aspects of Mixed methods: qualitative— collaboration in hospice IDTs ethnographic observations; and to extend the theoretical quantitative—survey evaluating framework of interdisciplinary collaboration using the MIIC. collaboration to the hospice setting

Theme

Collaborative communicative IDT dynamics and process was defined based on collaboration the Bronstein model to include interdependence and flexibility; newly created professional activity; and reflection on process and collective ownership of goals. Despite being perceived as occurring frequently, interdependence and flexibility were the least enacted communicative practice. The presence of caregiver participants was associated with less reflection on processes. Overall, collaborative participation was enhanced in the presence of caregivers Interdisciplinary collaboration IDT dynamics and occurs within hospice and is collaboration sustained through communicative processes

Key Findings

(continued)

The MIIC is a valid and reliable IDT dynamics and instrument for assessing collaboration collaboration in hospice IDTs. Rating of interdisciplinary collaboration among hospice professionals was high 2025 Patient reviews from 7 Application of the novel approach Impact of hospice IDT satellite sites of 1 not-for-profit reveals variation in normalized communication and hospice in Washington DC cost per IDT meeting. The most collaboration on cost-effective hospice satellite patient care and site was identified based on hospice outcomes optimized costs relative to patient outcomes N/A This review identifies barriers of IDT dynamics and successful interprofessional collaboration collaboration to include among others, differences in theoretical underpinning and values of disciplines, role blurring, negative team norms, and administrative issues. Potential solutions to these barriers are presented

Convenience sample of 95 staff from 5 hospices in Nevada, California, New York, and Missouri

Ethnographic observations: 5 hospice teams in 1 hospice located in the West Region of the United States; survey: 18 hospice team members from the 5 IDTs

62 Video-recorded IDT meetings National Cancer Institute Explore the relationship between Qualitative—verbal behavior coding. Quantitative— from 2 IDTs in 1 hospice. 20 R21 CA120179 IDT members’ perception about evaluation of collaboration using hospice IDT members team collaboration and actual the MIIC completed the MIIC collaborative communicative practices during meetings

Funding Source

Wittenberg- Progress in Palliative None stated Care Lyles34

Wittenberg- Journal of Lyles et al33 Interprofessional Care

Author(s)

Table 1. (continued)

11

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American Journal of Hospice and Palliative Care

Group Work

Rock9

Olshever38

None stated

None stated

National Institute on Nursing R21 NR010744 and R01 NR011472

Funding Source

Methodology

Review the literature on hospice Systematic literature review IDTs, focusing on teamwork and the role of social workers

Discuss IDT work in palliative and Perspective hospice settings

Describe the utilization of health Literature review information technologies in the hospice and palliative setting

Purpose

N/A

N/A

N/A

Sample Description

Theme

Telecommunication tools can be Technologies for effective tools for enhancing enhancing hospice IDT caregiver participation in IDT communication deliberations and engaging them in the delivery of hospice care The evolution of IDTs is discussed, IDT dynamics and and its role in the delivery of collaboration hospice and palliative care is highlighted This review identifies a general lack IDT dynamics and of empirical research on the collaboration and group dynamics of hospice IDTs impact of hospice IDT communication and collaboration on patient care and hospice outcomes

Key Findings

Abbreviations: IDT, interdisciplinary team; IIC, Index of Interdisciplinary Collaboration; MIIC, Modified Index of Interdisciplinary Collaboration; N/A, not available; NHPCO, National Hospice and Palliative Care Organization; NIH, National Institutes of Health; POTS, plain old telephone service; VALUE, value, acknowledge, listen, understand, and elicit.

Seminal Oncology Nursing

Journal

Demiris37

Author(s)

Table 1. (continued)

American Journal of Hospice & Palliative Medicine®

12 that as part of their dominant communicative role during team proceedings, nurses and medical directors often dictated the sequence of meeting activities as well as how much time was spent on each activity.21 The communication content during IDT meetings naturally takes on a biomedical and taskoriented emphasis, since physicians and nurses have a professional focus on the biomedical aspects of the patient’s care. They are the most active participants during IDT meetings, and are generally regarded as leaders of the team.9,19,20,21 Given that the IDT team consists of team members with a professional focus on the emotional aspects of the patient’s care and the hospice philosophy places equal emphasis on addressing both the physical and psychosocial needs of the patient, the dominance of biomedical discussions during team meetings often results in dialectical tensions in the team.19 For a nurse, for example, such dialectical tensions arise from the negotiation of their own background and bias toward biomedical aspects of patient care, with a recognition of the importance the hospice philosophy ascribes to addressing patients’ psychosocial needs. One study describing the experiences of social workers in hospice IDTs noted that an overemphasis on the physical aspects of care to the detriment of the psychosocial aspects of care often results in some team members feeling disregarded and disengaged from the group process.7 Findings from another study suggest that given the limited involvement of chaplains during IDT meetings, specifically as it relates to discussions on the patient’s care, they often find themselves engaging in group maintenance roles (often as conflict mediator) rather than their prescribed role within the IDT team structure.13 Interestingly, there is evidence to suggest that the content of communication as well as participation from individual team members vary depending on team membership. Specifically, research shows that when family members or caregivers are present during IDT meetings, communication on the psychosocial aspects of care increases.30 Additionally, team members who are traditionally less active during team meetings, like chaplains and social workers, tend to participate more in the presence of caregivers and family members.22 Caregiver participation in IDT meetings has also been shown to foster collaboration and relationship building among IDT members,33 increase meeting durations, and increase patient-centered communication content.22

Quality and Effectiveness of Communication Within Hospice IDTs Beyond accurate information transmission, effective communication can be used as a vehicle for trust building and role clarification within hospice IDTs.7 Applying the value, acknowledge, listen, understand, and elicit (VALUE) communication principles in an evaluation of the quality of communication in hospice IDT meetings with caregivers present, Washington et al23 generally found communication to be of low quality. This was evidenced by a disproportionate prominence of task-focused communication and less emphasis on

patient-centered communication that seeks to attend to the emotional and psychosocial needs of the patient (a fundamental component of the hospice philosophy). Although there is generally a dearth of literature assessing the quality and effectiveness of communication among hospice IDTs, there is some evidence that the overall communication effectiveness during IDT meetings may be limited by structural factors such as the lack of meeting agendas, the absence of a clearly designated facilitator or leader during meetings, and general gaps in information flow.24 According to Demiris et al,24 deficits in information flow reduce the efficiency of team meetings, therefore, resulting in longer meeting duration and an overall decline in productivity during meetings. The authors suggest that such deficits could be addressed, and the quality and effectiveness of communication improved by designating a leader or facilitator for meetings, ensuring that all team members have access to patient charts during meetings, documenting meeting proceedings as well as decisions made, and using appropriate communication technologies to facilitate communication.24 In addition to structural factors, communication effectiveness may also be hampered by role conflicts and other sources of interpersonal tensions. For example, evidence suggests that due to their similar focus on the psychosocial and emotional aspects of the patient’s care, the roles of social workers and chaplains are often in conflict.13 In their study, Reese and Sontag12 discuss these role conflicts: ‘‘just as social workers may compete with nurses for the provision of psychosocial services, chaplains may view social workers as encroaching on their professional turf.’’12(p168) Interpersonal tensions arise as a result of several related factors including (1) lack of knowledge about the expertise and scope of other professional disciplines, (2) overlap of professional roles resulting in role blurring, (3) differences in the theoretical underpinning and values of different disciplines, (4) power differentials on the IDT, (5) inequities in the way work is shared among team members, and (6) lack of commitment by individual team members to team processes.12 The IDT members’ general lack of training in interpersonal communication is often blamed for these tensions and has been noted as an important delimiter of effective communication and optimal team functioning.21

Interdisciplinary Team Dynamics and Collaboration Communication and collaboration are intertwined mutually reinforcing concepts. Indeed, in as much as effective communication is vital to fostering collaborative relationships, enhanced communication could also be a product of collaboration within teams. Interdisciplinary collaboration has been defined in the existing literature as ‘‘an interpersonal process that leads to the attainment of specific goals, which are otherwise not attainable by one team member alone.’’25(p537) Despite the apparent deficits in communication effectiveness within hospice IDTs, team members generally rate collaboration within their teams as high,7,14-16,35 with chaplains identified

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as playing a central role in managing team conflicts and fostering collaboration among team members.13 Indeed, one study found more variation in the perceived interprofessional collaboration between hospice IDTs than was found within hospice IDTs.14 Bronstein’s model39 has been widely used as the conceptual framework to evaluate interdisciplinary collaboration in hospice IDTs. The model integrates 4 theories—multidisciplinary theory of collaboration, services integration, role theory, and ecological systems theory—to describe successful team collaboration.35,39,25 Bronstein’s model consists of the following 5 components: interdependence, flexibility, newly created professional activities, collective ownership of goals, and reflection on the collaborative process.7,35 Interdependence refers to the notion of team members relying on each other in order to achieve shared goals. Flexibility refers to the capacity of the team to blur professional roles as needed and still function effectively. Newly created professional activities refer to collaborative acts or programs that allow for the accomplishment of activities or goals requiring collective effort. Collective ownership of goals refers to the extent to which team members share the responsibility of identifying, defining, developing, and achieving shared goals. The final component, reflection on the collaborative process, requires team members to be introspective about team processes as well as the outcomes of the team effort.7,39 Communication processes shape the extent to which team members successfully engage in the aforementioned activities. Research findings suggest that the Bronstein model has broad applicability to hospice IDT collaboration. Indeed, Wittenberg-Lyles and Parker Oliver34 note that within the hospice setting, flexibility (or the ability to deviate from an individual’s professional boundary) fosters interdependence among team members. As a result of this mutual dependency among team members, newly created collaborative professional activities emerge. A study that examined hospice team members’ perception of collaboration found that IDT members’ most positive perception of collaboration were related to ownership of goals, interdependence, and flexibility.33 Another study that assessed the extent to which hospice team members address multidimensional pain within their practice found high levels of interdependence, flexibility, and collective goal setting among members.8 Interestingly, in this study, participants divorced collaboration from communication, noting that although communication occurred on a regular basis, collaboration occurred more sparingly. In another qualitative study, social workers provided examples of positive and problematic issues regarding interdependence, newly created professional activities, flexibility, ownership of goals, and reflection on process as components for collaboration.7 The findings from this study highlighted the potential for hospice teams to exercise interdependence and role flexibility in order to create synergies that facilitate quality care. A study examining decision-making processes in hospice IDTs found that although members perceived that everyone’s opinion was listened to, there was unequal participation by

members in the team decision-making processes.6 Another exploratory study examining IDT members use of relational control messages found more instances of one-up messages, which are defined as messages aimed at gaining control of exchange of information.2 According to the study, one-across messages that neutralize control of the exchange are needed to facilitate collaboration. Collectively, the findings from the extant literature on IDT interactions suggest that there is a power dynamic due to team member composition, which may stymie both shared decision making and collaboration. The IDT approach lends itself to the exchange of different perspectives, which could in turn lead to more effective ways of providing care. However, if IDT members are unable to equally take part in decision making, this cross-pollination of ideas is lost. Failure to assure that each IDT members’ perspectives are equally weighed and considered will negatively impact the extent to which the team can engage in shared decision making and collaboration. Beyond decision making, other facets of collaboration, such as input sharing, listening, and provision of support have received less attention. A review of the literature showed a lack of studies assessing the effectiveness of hospice IDT teams in providing social support for team members. One qualitative study found that team member support occurred rarely during IDT meetings.21 In the only empirical exploration of the relationship between input sharing and listening on IDT outcomes, Coopman6 reported that although input sharing and listening were weakly associated with positive satisfaction with team communication, they were not associated with team productivity and overall team satisfaction. Similarly, only one study examined how IDT meetings facilitate the provision of social support. The authors suggested that by providing a platform for sharing bad experiences IDT members had with patients or other professionals with other team members, IDT meetings served as an avenue for ‘‘venting’’ and the release of emotional labor.26 In general, the existing evidence suggests that less than optimal attention has been paid to enhancing interprofessional collaboration among hospice IDTs, despite the importance of interdisciplinary communication on team functioning. In a recent study assessing collaborative skills, nurse IDT members fared poorly on collaborative skills related to team building.11 In a survey of 145 hospices across the United States, approximately one-third of hospices reported that they did not provide training that emphasized team building and interdisciplinary collaboration, despite the documented need for such training.37

Technologies for Enhancing Hospice IDT Communication The integration of health information technologies in the delivery of hospice and palliative care services is still in its infancy.37 Few studies have evaluated the use of communication technologies in end-of-life care, and these have largely focused on the utilization of telehealth and videoconferencing technologies as a means to bridge the geographic divide between hospice health care providers, patients and their

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14 caregivers.10,29,38 Previous studies have also shown that videoconferencing may be an effective way to involve family member or caregiver in hospice IDT deliberations and to improve team functioning.22 The visual component of videoconferencing is noted to enhance communication effectiveness by improving information flow and facilitating the transmission of nonverbal cues.31 However, beyond facilitating the involvement of family members in team meetings, they have been no studies examining the use of technologies to facilitate communication among hospice health care professionals who are part of the IDT. Communication technologies, such as videoconferencing, can facilitate the documentation and retrospective assessment of the content and quality of communication during IDT meetings32 and can also allow hospice health care professionals to attend team meetings virtually, when needed.

Impact of Hospice IDT Communication and Collaboration on Patient Care and Hospice Outcomes It has been suggested that collaboration among hospice team members can enhance patient care outcomes as well as foster a positive organizational culture that is characterized by caring, collegiately and respect and facilitated by a shared goal of providing humane and dignifying care at the end of life.28 However, the effect of IDT communication and collaboration on patient and organizational outcomes largely remained uncharacterized. Although a handful of studies have attempted to characterize the relationship between IDT effectiveness and patient and organizational outcomes, the generalizability of their findings is limited due to their sampling design or other methodological limitations. One such qualitative study of 11 prison hospices in the United States reported a positive impact of hospice team collaboration on dying prisoners, as evidenced by the delivery of more humane and dignifying patient care.28 Similarly, although it is anticipated that effective team communication would result in increased IDT members’ satisfaction with team processes and with their jobs in general, the evidence in support of this assertion has been inconclusive. In one study of hospice IDTs, Monroe and DeLoach17 reported an association between collegial relationships with coworkers and job satisfaction. Interestingly, in another study of hospice IDTs, Coopman6 found no association between satisfaction with team communication and overall job satisfaction. Another study, conducted in 1 not-for-profit hospice and palliative care program, attempted to assess the characteristics of IDT membership and processes that optimize cost benefit from an organizational perspective. The study compared IDTs across 7 different satellite sites and identified the most costeffective IDT as being composed of 4 to 3 RNs, a licensed practical nurse, a physician, 2 social workers, a chaplain, and a volunteer staff, with team meetings lasting for 2.5 hours. In this time frame, the team reviewed 55 patients and also allocated a 15- to 30-minute block of time for announcements, continuing education sessions, or in-service training.36 Undoubtedly, further empirical research is needed to characterize the

relationship between collaborative communication between hospice IDT members and patient and organizational outcomes.

Discussion This review article sought to describe communicative processes occurring within hospice teams and to assess the impact of effective communication on team functioning and outcomes. A review of the literature revealed a need for further research inquiry into hospice IDT communication in order to better characterize its effect on team functioning as well as patient and organizational outcomes. Although there is little evidence on IDT communication within the hospice context, research on IDTs in other health care settings, including nonhospice palliative care settings, indicates that effective communication is a vital requisite for optimal team functioning.4 Evidence from these studies suggests that effectively functioning interdisciplinary health care teams can improve health outcomes and reduce organizational costs.3-5 In the palliative care setting, collaborative communication within IDTs results in team synergy, which is theorized to result in improved symptom management, improved care coordination, and enhanced quality of care.4,40 Collaboration is a product of positive communicative practices characterized by collegiality and mutual respect. Collaboration is considered an indicator of IDT effectiveness and is thought to be fostered by interprofessional education (IPE), role awareness, interpersonal relationship skills, and individual and organizational support.3 The findings from the review of the literature intimate that interpersonal tensions among IDT members can hamper effective communication and collaboration. Previous research on IDT teams in other health care settings suggests that interpersonal tensions may arise among team members as a result of role conflict, turf wars, misunderstanding of other professions, or lack of a clear delineation of roles and responsibilities.41,42 These findings are consistent with what has been reported in the hospice literature. According to Connor et al,41 highly functional IDTs are those successful in effectively managing conflicts and realizing that team conflict presents an opportunity for learning and growth. The authors add that despite the ubiquity of conflicts in a team environment, IDTs must take precaution to ensure that such conflicts do not lead to the ‘‘development of dysfunctional alliances or subsystems within the team.’’41(p348)

Gaps Identified in the Literature A noteworthy gap identified was the paucity of empirical inquiry into communication within hospice teams. Many of the studies reviewed have been exploratory and descriptive in nature. These studies have described threats to external validity as an important limitation. Specifically, although appropriate study designs were chosen, the sampling strategy and small sample sizes limited the generalizability of the findings reported. The studies evaluated in this review also largely used

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qualitative methodology to address their respective research questions. Although qualitative inquiry has tremendous potential for providing rich insights into the inner working of hospice teams, the hospice literature would also greatly benefit from quantitative studies on nationally representative samples that empirically evaluate the quality and effectiveness of IDT communication. Additionally, existing studies have almost exclusively focused on communication during IDT meetings. Inquiry into the communicative process of team members in other settings, such as during patient visits or in informal settings, would provide a more comprehensive representation of how communication influences IDT dynamics and overall team functioning. Furthermore, more research is needed to evaluate the effectiveness of health information and telecommunication technologies in enhancing IDT team structure, processes, and outcomes. There is indeed a potential to enhance team functioning and patient care using other technologies such as e-mails, text messaging, social media, and electronic health records. Research on the impact of technology on communication that extends beyond videoconferencing is therefore warranted.

Recommendation for Further Research and Practice Recommendations for a research agenda that examines communication tactics and its impact on collaboration and hospice care should have the following overarching aims: (1) inclusion of large-scale studies that utilizes mixed methods to study the communication strategies used by different members of the IDT, (2) further exploration of collaborative activities that are aligned with all components of the Bronstein model, (3) policy evaluation that identifies guidelines and regulations that either facilitate or hinder constitutive communication within hospice care teams, (4) analysis of the effectiveness of various communication channels in fostering communication effectiveness in hospice care teams, and (5) in-depth exploration of the relationship between IDT functioning and hospice outcomes. This research agenda would significantly contribute to the evidence base as well as serve as a basis for the development of policies that remove structural and institutional barriers to effective IDT communication and collaboration. A research agenda of this kind could also provide greater insight into critical success factors of effective IDTs that can be used to inform clinical practice. Research studies that truly explore each IDT member and uncover unique tactics used to influence care delivery and communication would provide great insight into team interactions and work. Further, evidence linking communicative practices to care delivery and patient outcomes is lacking. More research is therefore needed to fill this important gap in the literature. Hospice practice can be further enhanced through efforts to bolster the current workforce, disseminate best practices, and establish guidelines for professional interaction amongst hospice team members. The IDT members are exposed to varying levels of education and experiential training prior to beginning their hospice career. The theories and foundations of each

program are vastly different from one to the next. The IDT members, thus, come to the team with discipline-specific communication styles and cultures. To ensure hospice teams function at optimal levels, educational training should emphasize training team members in interpersonal communication, especially as it pertains to IDTs and the delivery of palliative care. Further, IPE should become more prominent in the educational curricula of all medical, nursing, and allied health schools. Furthermore, in order to retain the collective wisdom of members of the workforce who provided quality hospice care, a mechanism must be in place to ensure knowledge transfer of best practices among hospice health care professionals, including those relating to interdisciplinary communication and collaboration. Establishing guidelines for professional interaction among hospice team members that facilitate trust, team cohesion, and conflict resolution would strengthen the IDT relationships as well as the relationships they have with caregivers and patients.

Limitations of the Review Although this review addresses an important yet often overlooked aspect of hospice care—IDT functioning—there are some limitations to the study. In order to better define the scope of this review and to describe the available empirical evidence on IDT communication, the authors narrowed their search terms and focused on articles published in peer-reviewed journals. This approach may have resulted in the omission of some other evidence, including, best practices in the field, that may have provided more insights into IDT communication. Another important limitation is the fact that most of the articles reviewed in this study were completed by a core group of researchers using similar methodologies and samples and thereby resulting in some bias. The findings from these studies are thus limited in the extent to which they can be generalized beyond the populations studied. However, the lack of diversity of researchers examining hospice interdisciplinary dynamics is an unfortunate testament to the fact that there has been relatively little research inquisition into this process of hospice care. It is hoped that this review will initiate a discourse on the importance of research examining interprofessional dynamics and its impact on hospice quality as well as spark research interest in the area.

Conclusion Hospice provides comfort and care to individuals as they prepare for the last stages of life. The provision of effective hospice care requires that biomedical, social, emotional, and spiritual needs are met. Given the complexity of needs, a coordinated response from an IDT is needed. Interdisciplinary teams offer varying perspectives to quality care. When these perspectives are equally considered, the result is the provision of quality hospice care that is holistic, patient driven, and comforting. In order for hospice teams to function optimally, they must engage in communication strategies that facilitate

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16 interdependence, role flexibility, creation of collaborative professional activities, reflective thinking on processes, and collective ownership of goals. This literature review provides preliminary evidence of strengths and threats to the adoption of communicative practices that enhance collaboration; however, findings suggest opportunities for improvements in IDT communication practices and for continued research in this area. Authors’ Note All authors contributed equally to this article.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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