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Best practices on team communication

interprofessional practice in oncology

D’Alimonte, Lauraa,d; McLaney, Elizabethb,e,f; Di Prospero, Lisac,d

Current Opinion in Supportive and Palliative Care: March 2019 - Volume 13 - Issue 1 - p 69–74
doi: 10.1097/SPC.0000000000000412
COMMUNICATION IN CANCER: ITS IMPACT ON THE EXPERIENCE OF CANCER CARE: Edited by Elie Isenberg-Grzeda and Janet Ellis
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Purpose of review Good communication is the cornerstone of interprofessional care teams providing optimized quality patient care. Over the last decade, advances in technology have provided tools to improve communication; however, opportunities still exist for innovation and implementation.

Recent findings The literature suggests that interprofessional education and assessment of team communication are fundamental in supporting collaborative care. The literature favours an interactive, team-based approach (e.g. simulation) to learning about communication, in which communication competencies and behaviours are practiced explicitly in an open, feedback-rich environment.

Summary Key elements of excellence in communication are embedded in three priority recommendations: first, the team must adopt a practice strategy that leverages accessible and timely communication second, the team must be open to initial and ongoing training within the domain of ‘effective communication’ third, communication must be the cornerstone to producing a high-performing team that will provide the best care possible.

aDepartment of Radiation Therapy, Odette Cancer Centre

bInterprofessional Education

cPractice Based Research and Innovation, Sunnybrook Health Sciences Centre

dDepartment of Radiation Oncology

eDepartment of Occupational Science and Occupational Therapy, Faculty of Medicine

fCentre for Interprofessional Education, University of Toronto, Toronto, Ontario, Canada

Correspondence to Lisa Di Prospero, Practice-Based Research and Innovation, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Office Number D403b, Toronto, ON, Canada M4N 3M5. Tel: +1 416 480 6100x89513; fax: +1 416 480 5207; e-mail: lisa.diprospero@sunnybrook.ca

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INTRODUCTION

Cancer care is complex. From the initial diagnosis, through active treatment and into end-of-life care, patients receive the highest quality and seamless care when their healthcare team collaborates and learns about, from and with, each other [1]. When cancer care teams work together with the patient as the focus of care, there is a direct impact on improved patient quality of life, survival and outcomes and improved communication amongst the interprofessional team [2]. Effective and inclusive interprofessional communication within oncology care is critical for positive patient outcomes across the cancer care trajectory. Advances in technology over the last decade have aided in supporting communication amongst the interprofessional oncology team and the cared for patients, families and caregivers. Despite these successes, opportunities still exist to continue to improve in this domain. There are many communication tools that are integrated and leveraged within oncology clinical practice to help facilitate effective interprofessional communication; for example, electronic patient records. This article will identify interprofessional communication best practices and the role of interprofessional education (IPE) on embedding effective interprofessional communication strategies into practice. We will then explore oncology healthcare professionals’ perceptions of current state communication practices across the interprofessional team. Finally, current communication strategies will be explored and opportunities for improvement will be discussed, highlighting key recommendations that should be integrated into interprofessional oncology practice.

Box 1

Box 1

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INTERPROFESSIONAL COMMUNICATION: A CORE COMPETENCY FOR INTERPROFESSIONAL COLLABORATIVE PRACTICE

Interprofessional collaboration (IPC) is the process by which healthcare professionals from different professions work together with patients, families and caregivers to deliver the highest quality of care [1]. In 2010, the Canadian Interprofessional Health Collaborative developed a National Interprofessional Competency Framework highlighting best practices of IPC and education [1]. The framework consists of six competency domains which include the knowledge, skills, attitudes and values that frame interprofessional collaborative practice [1]. These six domains are interprofessional communication, person centred care, role clarification, team functioning, interprofessional conflict resolution and collaborative leadership [3]. The two domains that intersect and influence collaborative practice across healthcare teams are person-centred care and interprofessional communication [3]. These two competencies support and provide an overarching overlay for the entire interprofessional framework [3] across all points of care. By definition, interprofessional communication occurs when ‘learners/practitioners from varying professions communicate with each other in a collaborative, responsive and responsible manner’ [3] with the purpose of discussing individual patient cases and recommending treatment care plans [4]. In the context of cancer care, interprofessional communication is defined as a team of healthcare professionals working together using evidence-based medicine to guide clinical decisions and to deliver coordinated care throughout the care continuum [4,5▪]. Oncology lends itself, by nature of the complexity of the disease, to a broad ranging team. The interprofessional team includes (and is not limited to) the clinicians specialized in oncology (e.g. radiation oncologists, radiation therapists etc.), pathologists, pharmacists, and nurses, with the patient at the centre, driving the care [4]. Care teams who effectively communicate with each other and with the patient have been shown to positively impact the patient experience and key dimensions of cancer care, including; access to care, person-centred care, quality of care, continuity of care and results of care [4]. When healthcare teams communicate poorly with each other, patient safety is compromised, which can lead to medical errors, redundancy of work, delayed access to appropriate care and delayed management of symptoms [6]. It is therefore imperative that interprofessional teams communicate in an effective and timely manner. In recent years, there is greater emphasis on ensuring caregivers are included as partners in care, in addition to patients. For example, a decision to discharge a patient is often made, with the patient finding out last and the caregiver sometimes only finding out when they are called to pick up the patient. Yet the caregiver takes over the continuum of care at that transition. As such, it is imperative that the interprofessional team is more collaborative and supportive of caregivers, as their role is vital in safe transitions of care.

Interprofessional communication in oncology care is informed and driven by best practices. Effective communication is composed of four key integral elements. Routine, reliable, timely and secure forms of communication with an emphasis on technology are shown to facilitate interactions and improve team efficiency; as timely communication can decrease and/or avoid serious harm and prevent medical errors from occurring. Communication must include all members of the team including the patient, family and caregivers. There must be a strong emphasis on good listening skills and mutual respect for all team members across all discussions. Finally, team members must feel comfortable and safe providing constructive feedback to one another in an environment of confidence and trust [7]. Essentially, the best practices focus on core domains of accessibility, inclusivity, respectful listening and reciprocal constructive feedback.

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INTERPROFESSIONAL EDUCATION: THE CORNERSTONE IN IMPROVING COMMUNICATION PRACTICES AMONGST THE INTERPROFESSIONAL TEAM

It is well established and recognized that IPE is essential to prepare healthcare students to engage in collaborative practices once they enter into the clinical care setting either pre or post licensure [8]. In 1988, the WHO called for a need for collaboration across medical healthcare professions and published the pivotal report: ‘Learning Together to Work Together for Health Report’ [9]. They defined IPE as a way to enhance collaboration and interprofessional teamwork through different professional groups coming together to learn with, from and about each other, working towards a common goal of providing optimal patient care, using the skills and expertise of each profession [9]. Through IPE, learners have the opportunity to improve their collaboration, teamwork and communication skills and prepare trainees for future collaborative practice [10,11]. Several recent publications have shown the benefit of structured IPE learnings on developing communication skills [8,10,12]. Embedding interprofessional learnings, like development of effective communication skills, is an important first step towards the development of a culture that supports and fosters interprofessional teamwork in clinical practice, in particular fostering collective interprofessional competencies of interprofessional communication, role clarification, team functioning, interprofessional conflict and resolution [3].

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ASSESSING COMMUNICATION: THE TEAM AND PATIENT PERSPECTIVES

Interprofessional teamwork and collaboration is critical in the management and care of people living with cancer, a highly complex integrated disease, with a number of clinicians interacting to care for any one patient at any one time [13▪]. Understanding healthcare professionals’ perceptions of communication and teamwork can aid in developing tools to improve communication skills. There are several published works on the topic but no standardized way of assessing teamwork and communication. Survey-based assessments and focus groups are most frequently cited. One commonality is the linkage between the assessment tool outcomes and patient outcomes or care experience. Lam et al. used an internally developed 10 question survey, designed to understand the perceptions of the Radiation Therapy team's level of satisfaction communicating with the Radiation Oncology team (consisting of Radiation Oncologist, Medical Physicist and Registered Nurse). Face-to-face interactions or phone calls were rated as the most preferred communication pathway, followed by check lists in a patient electronic medical record [14]. E-mail was the least preferred communication strategy. This is an interesting finding given the expanded and more formalized role E-mail communication plays in our current healthcare environment. Timeliness and clarity of communication was rated highest with nursing and lowest with physicians [14]. Clear communication prevents the need for further clarification, redundancy of work and delays in the workflow and care of the patient. Goh and Di Prospero [5▪] conducted focus groups of Oncology Nurses and Radiation Therapists to understand the perceptions of IPC as it relates to role clarity and communication. Improvements in communication were identified by both professions, with insufficient time and high workload noted as the most significant barriers to effective communication. Utilization of a good communication tool was cited as a way to overcome these barriers [5▪]. Many healthcare organizations are moving to full integration of electronic patient charts accessible not only by the healthcare team within the organization but also accessible by healthcare teams outside of the organization, as a way to enhance communication regarding care of common patients.

Assessing interprofessional team function provides an opportunity to improve communication across the healthcare team. Relational coordination is a concept or framework developed to measure teamwork and collaboration between different healthcare professionals with a focus on communication and relationships among the care team [13▪,15,16]. A pilot study conducted to measure perceived relational coordination among 12 oncology care teams was correlated with patient's perceptions of care received by the team [13▪]. The care team comprised of Medical Oncologists, Nurse Coordinators and Clinical Secretaries. Nurse Coordinator roles were the strongest and most positively correlated to patients’ perceptions of good care [13▪]. Azar et al. attribute this finding to the fact that the Nurse Coordinators are able to communicate effectively with both their colleagues and the patients. They further conclude that given these observations, Oncologists may benefit from more training in relational team-based care practices [13▪].

Given the importance of communication, identifying opportunities for improvement in communication amongst the care team is essential for improved care delivery. Identifying weaknesses and opportunities in communication amongst the care team may provide gaps in which quality improvement may be beneficial [17]. The Communication Assessment Tool-Team (CAT-T) is a patient satisfaction survey focused on the quality of communication received from the healthcare team during a visit to an emergency department (ED) [18]. Although not specifically used in the oncology context, the CAT-T survey has been shown to be an effective tool to assess strengths and weaknesses of ED team communication with patients [18].

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CURRENT STRATEGIES AND OPPORTUNITIES

The management of cancer is complex and requires a collaborative, evidence-based approach to care to optimize therapeutic outcomes and quality of life [19]. Multidisciplinary cancer conferences (MCC) are regularly scheduled meetings where the interprofessional team comes together to make shared decisions about the best treatment options for each patient [20]. Patient cases reviewed in this manner are more likely to receive treatments that are aligned with guidelines and improved overall survival [21–23]. Evidence supports care teams coming together within such a collaborative forum, as it improves communication amongst the team, drives efficient and effective use of resources, ensures that referral pathways are better streamlined, standardizes patient management protocols and provides an excellent learning opportunity for student learners and trainees [24]. Advances in technology, such as videoconferencing capabilities, have allowed for healthcare teams to connect across institutions and discuss patient cases. This is particularly helpful when oncology cases are cross managed (e.g. chemotherapy treatment provided in one organization and radiation therapy treatment provided at another). Current literature is further exploring the expansion of the interprofessional team within the MCC context. Pype et al. sought to understand the general practitioners (GPs) role in MCC meetings. They report that GPs feel that this is part of their scope of work, particularly with respect to challenging cases and to ensure continuity of care [25▪]. More recently, involvement of patients (themselves) within these MCC events is also being trialled. Massoubre et al. explored the influence of the patient's presence on therapeutic decisions at MCC meetings. Although they found no benefits in improved therapeutic decision-making amongst the health professional care team, there may be benefits from the patient, family and caregiver lens that require further study [26].

Continuing professional development explicitly focused on interprofessional communication is a strategy that could be employed to improve communication and teamwork amongst the interprofessional team. Oncology team members, whilst highly skilled in clinical care, may be ill-prepared to work effectively as members of a collaborative care team, frequently having little or no training in key competencies that foster highly functioning team development [27]. A recently published comprehensive Cochrane Systematic Review suggests that communication skills training for healthcare professionals caring for cancer patients using learner-centred, experiential education methods by experienced facilitators, can improve communication skills [28]. The reviewers highlight that the long-term efficacy of these communication skills training are not well understood and remain a recommended area of continued learning [28]. Team training using simulated cancer care scenarios to enhance collaborative practice skills within clinical oncology, similar to other clinical care environments, have been highly effective as part of competency-based curriculum [29▪]. Clinician learners who consisted of Oncology Nurses and Clinical Fellows, valued the simulation-based team training scenarios and acquired new knowledge, skills and attitudes to enhance teamwork and communication [29▪]. Consideration of incorporating these types of training sessions into interprofessional collaborative practice has the potential to transform cancer care by creating high-performing teams, resulting in improved patient outcomes, enhanced clinical effectiveness and higher levels of satisfaction among patients, families and healthcare providers [29▪].

Communicating effectively with the team when stakes are high is critical to ensure optimized patient care and to minimize medical errors [30]. Palliative and paediatric medicine represent oncology specialties with unique communication challenges due to high stakes of end of life decisions and high emotions of parents. Palliative care in the oncology setting represents an area of care that utilizes successful and effective interprofession communication [31]. Palliative care has developed standards of practice and evidence-based knowledge related to interprofessional communication, collaboration and techniques (such as giving bad news and conducting family meetings). In paediatric oncology, communication can be complex and emotionally charged [32]. In addition, the traditionally paternalistic medical hierarchical structure within units and departments contributes to breakdowns in communication across the care team [33]. Hierarchical structure often leads to siloes of information which is not uniformly shared with the ‘full’ team [33]. A recent phenomenological report [33] published on the experience of parents of ill hospitalized children described five main communication challenges first, holding troublesome knowledge; second, the need for diplomacy; third, conciliation; fourth, every man and his dog in family meetings; and fifth, systems and processes presenting a brick wall. These challenges provide empirically derived examples of how communication occurring within interprofessional health teams and between individual clinicians and parents can act to diminish or enhance their experience of care for their hospitalized child. Identifying these types of challenges may help to inform practical strategies to ensure communication between individual clinicians and the patient; and within interprofessional teams. Although the dynamic of a parent–child scenario is unique, there is transferability of the challenges of communication that transcend granularity of the clinical details, reminding us of the importance of the key elements of respectful and effective communication.

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CONCLUSION AND FINAL THOUGHTS

The current review of the current literature highlights the importance of ‘good’ interprofessional communication that not only enhances the care of the patient and family but also provides the best shared decision-making amongst the interprofessional care teams. The literature suggests that IPE and assessment of team communication are fundamental in supporting effective, safe, timely collaborative care. The literature favours an interactive, team-based approach (e.g. simulation) to learning about communication, in which communication competencies and behaviours are practiced explicitly in an open, feedback-rich environment.

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Acknowledgements

None.

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Financial support and sponsorship

None.

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Conflicts of interest

There are no conflicts of interest.

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REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as:

  • ▪ of special interest
  • ▪▪ of outstanding interest
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REFERENCES

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3. Canadian Interprofessional Health Collaborative, Canadian Interprofessional Health Collaborative. A national interprofessional competency framework. 2010; Available at: https://www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf. [Accessed 1 October 2018].
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The prospective qualitative study explored the perceptions of Radiation Oncology Nurses and Radiation Therapists related to interprofessional collaboration within a Radiation Therapy Department. This article explores the benefits of shared teaching and learning amongst the interprofessional care team.

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The pilot study aimed to measure the relationship of teamwork with patients’ perceptions of care within an outpatient oncology setting. This article reports the benefits of teamwork within cancer care.

14. Lam J, Ng B, Shen S, Wong C. How is interprofessional collaboration applied by Radiation Therapists in the Radiation Therapy Department in British Columbia? J Med Imaging Radiat Sci 2015; 46:S43–S51.
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The qualitative study explores general practitioners perceived roles in multidisciplinary case conferences. This article highlights the value of communication with the broader interprofessional care team.

26. Massoubre J, Lapeyre M, Pastourel R, et al. Will the presence of the patient at multidisciplinary meetings influence the decision in head and neck oncology management? Acta Otolaryngol 2018; 138:185–189.
27. Lanham HJ, McDaniel RR Jr, Crabtree BF, et al. How improving practice relationships among clinicians and nonclinicians can improve quality in primary care. Jt Comm J Qual Patient Saf 2009; 35:457–466.
28. Moore PM, Rivera S, Bravo-Soto GA, et al. Communication skills training for healthcare professionals working with people who have cancer. Cochrane Database Syst Rev 2018; 7.
29▪. James TA, Page JS, Sprague J. Promoting interprofessional collaboration in oncology through a teamwork skills simulation programme. J Interprof Care 2016; 4:539–541.

The work explored the benefits of interprofessional team training in communication using simulated cancer care scenarios to enhance collaborative practice. Communication training needs to continue beyond the undergraduate education and into the clinical environment.

30. Raley J, Meenakshi R, Dent D, et al. The role of communication during trauma activations: investigating the need for team and leader communication training. J Surg Educ 2017; 74:173–179.
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32. Delany C, Richards A, Stewart H, Kosta L. Five challenges to ethical communication for interprofessional paediatric practice: a social work perspective. J Interprof Care 2017; 31:505–511.
33. Odeniyi F, Nathanson PG, Schall TE, Walter JK. Communication challenges of oncologists and intensitivits caring for pediatric oncology patients: a qualitative study. J Pain Symptom Manage 2017; 54:909–915.
Keywords:

best practices; communication; interprofessional collaboration; teamwork

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