Communication Within Hospice Interdisciplinary Teams

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 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 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 task-oriented 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 al ²³ 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 Sontag ¹² 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 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 model ³⁹ 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 Oliver ³⁴ 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, Coopman ⁶ 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 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 meetings ³² 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 DeLoach ¹⁷ reported an association between collegial relationships with coworkers and job satisfaction. Interestingly, in another study of hospice IDTs, Coopman ⁶ 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 cost-effective 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.

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 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.