Exploring the Dynamics of Interdisciplinary Palliative Care Teams in Providing Psychosocial Care: “Everybody Thinks that Everybody Can Do It and They Can't”

Abstract

Background:

There has recently been a call for an analysis of the way in which professionals see their role and status in the context of palliative care and the interdisciplinary team. This is particularly salient in the provision of psychosocial care.

Method:

This study qualitatively explored team members' perceptions and experiences of team dynamics. An in-depth qualitative research design was adopted using semistructured interviews and was guided by a social constructivist framework. Seven palliative care team members were recruited from across three palliative care sites. Two palliative care nurses, a palliative care medical specialist, a consultant psychiatrist, a social worker, a counselor, and an occupational therapist comprised our prototypical interdisciplinary team. Analysis was conducted using a method of constant comparison.

Results:

Two major themes emerged from our research: “Lack of clear role boundaries” and “Strategies for maintenance of role boundaries,” which included: “Claiming access to specialist expertise and knowledge” and “Minimizing the knowledge of other professions and professionals.” It is argued that effective team functioning can be enhanced through the development of interdisciplinary team training programs and policies, resources and structures that provide support for the interdisciplinary team model.

Introduction

Interdisciplinary team work is pivotal in the practice of palliative care¹ with its emphasis on holistic care and the relief of physical, psychosocial, and spiritual suffering. The team approach is not only desirable but arguably, fulfillment of the philosophy of palliative care can only be achieved via interdisciplinary team care.² However, there is a call for a closer examination of how these teams function.³

Palliative care emphasizes facilitating one-on-one communication between health care professionals and patients.⁴ There is, however, a distinct lack of research on how health care professionals communicate with each other about patients, despite patient outcomes being dependent on team communication.³ For example, Higginson and Constantini⁵ examined end-of-life communication in three European countries and reported that communication problems between health care professionals in palliative care teams impacted negatively on patients' quality of life for between 10% and 20% of patients.

There are several explanations for these findings. The traditional medical model endows physicians with power and status, with allied held professionals playing a supporting role.⁶ This can result in the dominance of particular discourses and the exclusion of others. Differences in terminology may inhibit interdisciplinary team communication,⁷ promote miscommunication⁸ and may serve to constrain interdisciplinary collaboration. Palliative care interdisciplinary teams also frequently rely on informal communication, such as “personal approaches and goodwill rather than standardized processes and procedures.”⁴

This informality and fluidity may also impact on team roles. A role is an expected set of behaviors associated with a position; roles are negotiated and their synchronisation is necessary for effective team performance.⁹ In palliative care teams members do not usually work with distinctly defined roles and role boundaries are typically blurred.¹⁰ What one team member is “supposed to do” may overlap with the expectations of another team member.¹¹ Wittenberg-Lyles et al.¹² report that palliative care chaplains believe other team members lack understanding about their role and value, and that chaplains experience role conflict with other team members, particularly social workers. We know that conflict, as well as role confusion and ambiguity, can lead to tension and territoriality, both of which are difficult to resolve⁴ and may impact on optimal patient care.³

Psychosocial Care

Issues pertaining to team dynamics are particularly pertinent in the context of psychosocial palliative care. Physical needs are met by physicians and, to a certain extent, nurses, but psychosocial needs are privileged by all team members. Nurses see themselves as multiskilled professionals providing physical and supportive care^13,14; social workers claim special expertise in operating in this psychosocial space¹⁵ and want to strengthen their role¹⁶; and psychologists wish to limit the input of other professional disciplines in the provision of psychological support.¹⁷ Palliative care physicians also articulate a role for themselves in this psychosocial domain.¹⁸ This results in palliative care team members becoming engaged in a struggle where they are trying to differentiate themselves from other health professionals and promote their place in the team.^11,19

Aim of Current Study

In spite of its assumed importance, interdisciplinary teamwork has been neglected in palliative care research and education.^20,21 This is particularly salient in psychosocial palliative care where so many professionals are “staking a claim.” The aim of this hypothesis generating study, therefore, was to explore team members' perceptions and experiences of team dynamics in psychosocial palliative care.

Methodology

Design

This study adopted an in-depth qualitative research design using semi-structured interviews and was guided by a social constructivist paradigm. This paradigm acknowledges that people's unique experiences are valid and explores the ways in which people view the world and construct meaning as they engage in everyday activities and interactions.²² Multiple versions of the world are legitimate and there can be multiple readings of reality, which are defined and redefined through interactions with others.²³

Participants and recruitment

Seven palliative care team members were recruited from across three palliative care sites. We selected three sites in order to maintain anonymity of participants. Our virtual and prototypical interdisciplinary team comprised: two palliative care nurses, a palliative care medical specialist, a consultant psychiatrist, a social worker, a counselor, and an occupational therapist. We recruited three males and four females aged between 35 and 56 years (mean, 46.4 years); palliative care experience was between 7 and 20 years (mean, 12 years). Two participants were recruited from two of the sites and three from the remaining site.

In Australia, palliative care services are provided in designated palliative care units such as hospices, in dedicated and nondedicated palliative care beds in acute hospitals, and in the community^24,25 where patients receive care in their own home or other community-living facilities such as aged care facilities.²⁶ Teams vary in their composition but usually include physicians, nurses, and social workers. Counselors, occupational therapists, physiotherapists, and chaplains may be part of the team or consulted regularly by team members. Psychiatrists are usually in a consultant liaison role. The three sites in this study included a stand-alone hospice, a tertiary teaching hospital, and a community-based palliative care service.

Information regarding the research was distributed to the three sites with an invitation to participate. Once contact was made a mutually convenient time and location for the interview was arranged.

Data collection

The participants were interviewed once in their workplace, with duration times ranging from 40 minutes to 95 minutes (average time was 60 minutes). Participants were interviewed by two experienced interviewers. An interview schedule was used with a schedule of themes, some central questions and prompts such as: “Tell me about how you work.” “You have mentioned the palliative care team—can you tell me how this works?” “What do you mean by … .?” “Can you give me an example of … .?” Where possible, participants from the same site were interviewed consecutively to avoid participants sharing information about the study. Participants were reminded that their involvement was voluntary and that they were able to withdraw at any time without consequence. Written consent to take part in the study as well as record the interview was obtained from all participants. Ethical approval was provided by the Human Research Ethics Committee of Edith Cowan University to undertake the study.

Data analysis

All interviews were transcribed verbatim. Transcribed interviews were then entered into the qualitative computer-based data analysis program QSR N6 to facilitate analysis.

Constant comparison described by Glaser and Straus²⁷ and Glaser,²⁸ and operationally refined by Lincoln and Guba²⁹ was used for the analysis. Units of meaning were identified in the transcripts and coded through line-by-line reading. As the analysis proceeded, these units of meaning were coded into major categories of meaning. These categories were then refined with the aim of maximizing both internal homogeneity and external heterogeneity. Scientific rigor for the data analysis was ensured using the criteria recommended by Beanland et al.²⁵ The researchers discussed the findings in order to explore different perspectives on the data and reach consensus on the final themes.

Discussion and Findings

Two overarching themes emerged from our research: “Lack of clear role boundaries” and “Strategies for maintenance of role boundaries,” which included: “Claiming access to specialist expertise and knowledge” and “Minimizing the knowledge of other professions and professionals.”

Lack of clear role boundaries

Reflective of the literature suggesting that many interdisciplinary team members provide psychosocial support to patients, some participants in our study suggested that any team member can provide support for psychosocial issues. Team members stated:

Usually one or a number of members of the team will, in some way, get addressing that side, the psychosocial side of things, if other members of the team are more focused on the physical problems. (Nurse 1)

… a lot of people … they're very happy to divulge that sort of information if it's a nurse at the bedside or the occupational therapist in the activities room running a group or the therapy assistant … (Occupational therapist)

… if there was [a psychosocial] issue we could just ring the GP or the hospice doctor and get them to actually sit down and talk it through with them, or a counselor. But for myself personally, I don't feel I have a problem dealing with that. (Nurse 2)

Well, I wouldn't mind being more available [to discuss psychosocial issues with patients] definitely. (Doctor)

These findings contradict the literature on teams generally, where it is argued that team members need to be clear about their own roles and boundaries, to know what they can offer and, in turn, know what they can rely on others to provide.³¹ The necessity for the clarification of team roles, boundaries and procedures in palliative care has been highlighted in the literature.⁴

Interestingly, it is those team members who are not specialist psychosocial team members who advocate this approach with a “preparedness to do things … . do a little bit of everything … [with] a lot of overlap …” (Nurse 1).

Strategies for maintenance of role boundaries

Claiming access to specialist expertise and knowledge

The lack of role boundaries in the psychosocial realm leads to professionals claiming special expertise. One of the nurses in our study stakes a wide-ranging claim regarding psychosocial care of the patient:

[I'm involved in] talking with the patient and the family, psychosocial support, frequent follow-up, family meetings, referrals to other sources, that sort of thing … [Assisting in] adjustment to diagnosis, adjustment to big issues of prognosis, concerns about loss of independence, loss of control … image issues … sexuality … bereavement counseling. (Nurse 1)

The special expertise of nurses is claimed through their centrality to the team—by directing and taking charge:

We have lots of family meetings and I think that really helps, just to give the family, patients, the situation, where they're at with things, be up front with them, just be very supportive, make ourselves available … they have our pamphlet, they can ring us at any time … Getting the social worker involved or the OT … those sorts of things. And obviously managing their symptoms … sometimes we've involved psychiatrists … depending on their state really. (Nurse 2)

By positioning him/herself as central, operating in both the medical and psychosocial realm, the nurse becomes indispensable to the operation of the interdisciplinary team. The nurse is able to provide psychosocial care and constructs his/her professional knowledge accordingly:

Lately we've [palliative care nurses] talked a lot about people in denial, and I wouldn't be hitting them [patients and family] over the head with the news [of their terminal prognosis] everyday … because they're obviously using denial as some sort of mechanism that helps, and I feel if they know what the score is and they choose to be in denial, then so be it … (Nurse 1)

For the counselor in our study special knowledge and expertise is the ability to see the person in the system and he/she also emphasizes his/her therapeutic background:

… being able to be circumspect without being pulled emotionally … to understand systems and how they interact and operate … [my practice] is backed up by family therapy. (Counselor)

It is possession of these particular professional attributes and access to established family therapy expertise that delineates his/her profession from others. The counselor also draws upon psychological constructs, which positions him/her as having knowledge and ownership of the psychological realm:

When I'm working with people around death, death and dying is one thing, but the core issue that I tend to begin to help them focus toward is separation and that's where birth and death are very similar. We all separate at birth and we all separate at death … (Counselor)

The social worker also claims special expertise through being able to see patients in their social context and to be able to listen carefully and interpret what people mean:

I think we [social workers] do look at the person in their environment … I think a lot of time that's where other people get it slightly wrong because they don't look at the broader picture and then just see the person in isolation and you can't do that. And a lot of times that's where I come in … it's not that everybody doesn't have to listen and give support or can't do some part of the social history but they really don't have the time or the expertise to really see the broader context. (Social worker)

And:

So if you don't really listen with, with your third ear about what [the patient's talk] actually means then you're not hearing. (Social worker)

The occupational therapist also draws upon unique specialised skills:

I think that as an O[ccupational] T]herapist and running an activities programme, we're uniquely able to do that [psychological/emotional support] in terms that, a lot of what we do, does revolve around reminiscence, and that's really important … we do a life review and we encourage people to do that in whatever form they might like to do it. (OT)

Team members who identify themselves very clearly as providing psychosocial support find the overlap frustrating and unhelpful:

… I think the social worker, social work, has a defined role and that there are times when people you know can be seen by everybody but they really need to see a social worker because of the expertise of social work. And I've been frustrated by that in palliative care, because everybody thinks that everybody can do it and they can't. (Social worker)

I am concerned at times that a little information is often more damaging with how people intervene … [families are] very complex and, you know, you can influence families quite subtly in a very unhelpful way without even being aware of it. (Counselor)

In an ideal world the psychological needs of patients will be met by having at least a psychologist if not a psychiatrist involved in liaison in the home services and each of the [palliative care hospital] units. (Psychiatrist)

It is through access to professional knowledge and discourse that professionals are able to exercise power.³² The various palliative care team members claim special expertise by virtue of access to professional knowledge and expertise. It is through this unique access to knowledge that members are able to separate themselves from other palliative care professionals who also operate in the psychosocial realm. We argue that, in our study, interdisciplinary team members are struggling to register a legitimate presence within the psychosocial realm of patient care.

Minimizing the importance of other professions and the legitimacy of their professional knowledge

Claiming special expertise is one part of a two-pronged strategy that professionals appear to engage in. A parallel strategy is to attempt to minimize legitimacy of the professional knowledge of other team members.

For example, a nurse critiques other team members for continually seeking patient acceptance of impending death:

What I've found is that a lot of people [team members] want to keep telling them [patients] that they're gonna die so they get this repeated barrage of, somehow they don't understand. So people … not so much us [nurses] ’cos we perhaps can see more what's happening, but the team want to keep saying this is what's happening to you so you're gonna die soon … (Nurse 1)

The counselor refers to a lack of professional qualifications in psychology and allied disciplines to question the appropriateness of psychosocial support from other professions. One particular concern of the counselor is that those who are attempting to intervene do not have the qualifications or the skills, to do so:

I do have a concern that … people [team members] might do a couple of [psychology] units in their training, but a couple of units doesn't equate to four years of therapeutic training and exposure in terms of what goes into depth in a field. (Counselor)

Furthermore, a stronger point:

I get a bit concerned when I see some of the interventions happening that I think are contraindicative to the benefit either to the patient or to their surviving family member, and that fits in the context of grief and understanding the whole processes at a psychological level of the impact of grief. (Counselor)

The argument in terms of professional qualifications is further addressed by a consultant psychiatrist. He/she also suggests that it comes down to specialized training and it is only those who are trained who have all the skills necessary:

I'm talking from the psychological perspective and I reckon that what we lack is that sort of psychological input. Now I'm not saying a social worker couldn't provide such input, they can. Some of them can. Not all of them can. It depends on their training and their interest. (Psychiatrist)

In the process of legitimizing professional knowledge, it appears that there is some cleavage between professionals; particularly between those who have specialist knowledge and training in psychological care and those without such training. Previous seminal literature examining organizations or teams that have a democratic or flat structure suggests that informal hierarchies do develop around access to specialized knowledge and cleavages and alliances emerge.^33–37 This was evident among those members of our virtual palliative care team who had training in psychological knowledge and those who did not.

Limitations and Future Research

The small sample size was a limitation of the current study. As such the findings are not generalizable to other palliative care teams. Rather, the results offer insights into tensions facing teams that may impact on team effectiveness. Further, as the participants were recruited from three different palliative care sites, any differences between participants could be due to differences across the different sites.

Future qualitative research could address these limitations using an in-depth study with more participants and exploring these issues longitudinally. Discourse analysis could also be usefully used to analyze what is said and how psychosocial issues are discussed in team meetings. Alongside this exploratory work we need robust quantitative studies examining the impact of interventions, such as educational programs, on outcome measures such as team members' satisfaction and/or patients' quality of life.

Conclusions and Recommendations

Interdisciplinary teamwork is presented uncritically in the palliative care literature. However, there has recently been a call for an analysis of the way in which professionals see their role and status in the context of the interdisciplinary palliative care team and, in particular, in the provision of psychosocial care.³ This current study qualitatively explored team members' perceptions and experiences of team dynamics.

A salient finding was that the blurring of role boundaries and the provision of psychosocial care by members of the team was perceived as being positive by nonspecialist psychosocial team members and as unsatisfactory, frustrating, and even potentially harmful, by specialist psychosocial team members. This forms a cleavage within the team and leads to what we term a “contested realm,” i.e., team members struggling to find a niche and a valuable and valorized role in the provision of psychosocial care and support. Team members endeavor to find this niche and articulate their importance by claiming specialist expertise and knowledge and by questioning the expertise and knowledge of other team members.

We need to move beyond the assumption and rhetoric that all palliative care interdisciplinary teams operate effectively to a position of critical evaluation of teams to enhance patient care and, importantly, to support team members. Our key argument in this article is that effective and efficient functioning of the interdisciplinary team is pivotal to palliative care practice. However, effectual functioning does not occur without awareness and effort. At the individual and team levels effective functioning can be enhanced through the development of interdisciplinary team training programs; and at the organizational or systemic level we need policies, resources, and structures that provide support for the interdisciplinary team model.

Footnotes

Acknowledgments

We would like to thank all participants for giving their time and sharing information.

Author Disclosure Statement

No competing financial interests exist.

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