The team approach is crucial to palliative care, but there has been little research on the optimal structure and function of an interdisciplinary team that is responsible for caring for those with a life-threatening illness. The interdisciplinary team approach to care is not unique to palliative care. Other disciplines that emphasize teamwork include rehabilitation, critical care, mental health, and geriatrics. Interdisciplinary teams include professionals from multiple disciplines (e.g., nurses, physicians, social workers) who work collaboratively and make group decisions about patient care. The primary difference between multidisciplinary and interdisciplinary care is the role of collaboration and consensus building that is present in interdisciplinary care. Regular meetings serve as the forum for this collaboration and consensus building, and each member contributes the knowledge and skills drawn from his or her own unique training and education. This optimal approach to care, incorporating collaboration and interdependence, has been an historical cornerstone for hospice and palliative care and is the focus of this chapter.
Differences do exist regarding the definition of the interdisciplinary team, the criteria for an effective team, and methods for building and strengthening teams. A Medline search using the term “interdisciplinary” yields more than 17,000 citations; “multidisciplinary” generates more than 27,000 references. Nevertheless, significant overlap and confusion exist regarding the meaning and use of these and other related terms, such as transdisciplinary, interprofessional, and integrative teams. Multidisciplinary teams may consist of multiple disciplines, optimally working toward a common goal. Each individual team member performs his or her role within a formally defined scope of practice. The team members may function in parallel and, in less than ideal circumstances, with undefined or diverse goals. To add to the confusion, this term has also been used to describe teams that consist of multiple specialties within the same discipline who work together to provide patient care. An example of this model is the multidisciplinary pain clinic that includes an anesthesiologist, a neurologist, and a psychiatrist, all of whom work to address the complex needs of individuals with chronic pain. Another example is a team of internists and gynecologists who work to provide the health care needs of women. These individuals are all of the same discipline (physicians), but they are trained in different subspecialties.
Other terms have been used which may result in confusion. Interprofessional is synonymous with interdisciplinary and has also been proposed as an alternative to avoid the confusion associated with teams that include collaboration among medical specialties. Transdisciplinary is used to denote a system in which one team member acts as the primary clinician and other members provide information and advice. The integrative model consists of an interdisciplinary team approach that incorporates conventional medicine with complementary and alternative health care. For purposes of this chapter, the term interdisciplinary is used to describe a team composed of members from multiple disciplines who work collaboratively to provide palliative care.
Despite the confusion regarding terminology, there is strong agreement that an interdisciplinary team approach is needed to address the complexities of today’s health care system. The 1999 Institute of Medicine report, To Err is Human: Building a Safer Health System, identified “promoting effective team functioning” as one of several key principles necessary to create a safe health care environment. The Institute of Medicine’s subsequent report, Crossing the Quality Chasm: a New System for the 21st Century , reiterated the critical need for collaboration to respond to the complex demands inherent in the current health care system and recommended that better opportunities be provided for interdisciplinary training. A recent appraisal of the progress made in this area acknowledged the slow pace of change and continued to endorse the need for team training as a means to improve patient outcomes. The Joint Commission (TJC) issued their 2006 National Patient Safety Goals, which include a critical objective to improve communication among caregivers. Additionally, this organization endorsed the need for interdisciplinary participation as teams and organizations develop a patient safety plan in the clinical setting.
Professional organizations support the role of interdisciplinary teams. The Society of Critical Care Medicine includes “integrated teams” and states that “Multiprofessional teams use knowledge, technology, and compassion to provide timely, safe, effective, and efficient patient-centered care” in their mission statement. The American Geriatrics Society also espouses the role of interdisciplinary care in their mission and goals statement. Although not explicitly stated in their mission statements, interdisciplinary care is clearly endorsed by the primary professional organizations devoted to palliative care. Such organizations include the American Academy of Hospice and Palliative Medicine, the Hospice and Palliative Nurses Association, the International Association for Hospice and Palliative Care, and the National Hospice and Palliative Care Organization.
Interdisciplinary Teams in Palliative Care
Interdisciplinary team membership is loosely defined in palliative care. Palliative care team members can comprise a variety of disciplines, including art therapists, chaplains, home health aids, nurses, nurse aides, nutritionists, pharmacists, physical and occupational therapists, physicians, psychiatrists, psychologists, social workers, and speech therapists. The hospice core team members must include at least one physician, a nurse, and one other member from a psychosocial discipline. Unique settings or populations may require specialized members. These may include, for example, a neonatologist when providing palliative care in the special care nursery or an infectious disease specialist when addressing the needs of patients with human immunodeficiency virus infection.
Other members of the interdisciplinary team in palliative care can include volunteers and informal caregivers. Even though both hospice and palliative care team members and patients and families find volunteers to be invaluable, few studies have evaluated the common or optimal role of these individuals within the team. In a survey of palliative care volunteers, investigators found the primary motivations for volunteering included the ability to ease the pain of those with a life-threatening illness. Other studies of palliative care teams reveal that volunteers were the least likely (37%) to consider leaving hospice work, compared with nurses (60% had considered leaving) and physicians (40%).
Informal caregivers include family members and friends of the patient who provide physical, emotional, and spiritual support. Numerous studies have documented the physical and psychological impact of providing care for loved ones who are dying. These include time constraints, physical tasks, financial costs, emotional burdens, and physical health risks. Rabow and colleagues suggested ways in which physicians can address the needs of informal caregivers, including good communication, encouraging appropriate advance care planning and decision making, supporting care within the home, demonstrating empathy, and attending to grief and bereavement needs. Although directed to physicians, these recommendations apply to all interdisciplinary team members. Much research is needed to articulate fully the way informal caregivers optimally work together with the interdisciplinary team and how the team can best assist in meeting the caregivers’ needs.
Although difficult to investigate, some evidence correlates improved outcomes with palliative care provided by interdisciplinary teams. One controlled clinical trial of an outpatient palliative medicine consultation service revealed significant improvements in dyspnea, anxiety, sleep, and spiritual well-being when compared with patients who received standard care. Furthermore, patients who received palliative care from this interdisciplinary team experienced fewer visits to their primary care physician or at an urgent care setting. Other studies indicate improved relief of symptoms, improved use of advanced directives, more time at home, and reduced costs when care is delivered by interdisciplinary palliative care teams. A comprehensive review of the literature related to palliative care teams who care for dying patients in the intensive care unit (ICU) revealed high levels of family and staff satisfaction, as well as cost savings to the institution.
Criteria for Effective Team Functioning
As a result of limited research, few clear criteria are available to guide those attempting to build a strong and successful palliative care team. Experience suggests, however, that collaboration and communication are critical components to effective team functioning. Goals and roles must be clear and focused on the patient and family, and trust must be established. Leadership functions may be shared, and the strengths and contributions of all team members must be fully incorporated. The functioning and cohesiveness of the team should be viewed as more important than the individual identities of team members. Accepted signs of effective team function include strong rates of retention and satisfaction, trust among all members, participation by all members in leadership decisions, consistent attendance at meetings, successful attainment of quality indicators, and high satisfaction scores by patient and families.
Threats to Team Functioning
There are inherent internal threats to the successful functioning of any group. Turnover of group members, along with role overload and conflict, can jeopardize team performance. This situation can be exacerbated by the stress of providing care to vulnerable patients and families with complicated needs, in a complex environment that may not provide sufficient fiscal and other support to allow effective team function.
Instability of Team Membership
In the optimal situation, there is little staff turnover on an interdisciplinary team, but membership still changes at some point. Staff members may decide to leave for positive reasons (e.g., academic advancement or a partner who relocates out of town) or negative reasons (e.g., burnout). The program may decide that additional roles and positions are needed, and the resultant newcomers can produce temporary team instability. Furthermore, diverse settings present unique challenges to team solidarity. For example, when instituting palliative care in an ICU, some team members are based in the ICU, some visit the ICU, and some are consulted on a case-by-case basis. This arrangement also occurs in dedicated palliative care units, where there may be a core interdisciplinary team based on the unit, personnel who visit the unit (e.g., the hospice chaplain whose patient is admitted for respite care), and members who are consulted for their expertise (e.g., psychiatry for assisting with a patient with complex mental health disorders). In each of these situations, the composition of the team changes in subtle ways, and team function may be altered.
In his classic studies of team function, Tuckman described four phases of team development: forming, storming, norming, and performing. Forming describes the setting of goals and objectives as the team begins its task. Storming occurs when group members express discord in their approach to the task. Interpersonal conflicts may become apparent at this stage. Norming occurs when effective communication results in cooperation. Performing is achieved when the task is accomplished through collaboration and conflict resolution. Each time a new member is introduced to the team, some level of forming and storming takes place, and norming and performing follow these stages. Frequent staff turnover and repeated substitutions can be a significant burden and a threat to the stability of the team and its function.
Role Conflict
Disparities and conflict among clinical disciplines are common, but little research specific to palliative care has been conducted. Furthermore, most of the existing literature focuses on physician and nurse conflict and neglects potential sources of conflict among other members of the palliative care team. For example, in a survey of 90 physicians and 230 nurses who worked in the ICU setting, 73% of physicians rated collaboration and communication with nurses as high or very high. Conversely, only 33% of the nurses rated the quality of collaboration and communication with physicians at the same level. Specifically, the nurses in this study reported difficulties in speaking up to physicians, complained that conflict was often not resolved, and felt that their input was not valued. The investigators concluded that some of this disparity in perceived effectiveness in collaboration and communication may be the result of differences in gender (most of the nurses were female and most physicians were male), status, authority, training, and responsibilities.
In a study of the role of various professionals working within a team, second-year postgraduate residents, advanced-practice nurses, and master-level social work students participated in the Geriatric Interdisciplinary Team Training. They were asked to respond to a survey regarding their beliefs about the roles of all team members. Interprofessional differences appeared to be greatest for beliefs about the physician’s role. For example, 73% of residents, but only 44% and 47% of social work and advanced practice nurse trainees, respectively, agreed that the team’s primary purpose was to assist physicians in achieving treatment goals for patients. Compared with the advanced-practice nurses and social work students, twice as many residents believed that physicians had the right to overturn care plans developed by the team. As in the previous study, differences in age, ethnicity, and gender among these groups may have correlated with the inconsistencies.
This theme of divergence and assumptions as a possible cause of impaired team functioning was echoed in another study of geriatric interdisciplinary team training. The authors call the phenomenon “interdisciplinary split” and believe that attitudes and cultural traditions are important contributory factors. Physician trainees were the least enthusiastic about the interdisciplinary training. Specifically, physicians who were farther along in their training were more likely to perceive other team members as incompetent. The nature of the problem, according to the authors, was not incompetence but rather the clinical inexperience of some of the trainees. Thus, successful interdisciplinary training may need to consider the level of education and experience of the team members from different disciplines.
Other investigators have also identified cultural differences as threats to interdisciplinary care. The Council on Graduate Medical Education and the National Advisory Council on Nurse Education and Practice held a joint meeting to discuss collaborative education models to support patient safety. They defined culture as the language, ideas, beliefs, customs, codes, institutions, and tools used by physicians and nurses in their practices. The panel members concluded that existing professional cultural norms do not support the interdisciplinary team approach and believed that cultural change will be a critical factor in fostering interdisciplinary care.
Cultural differences exist among other disciplines as well. For instance, some disciplines are action oriented and focus on fixing a problem or performing a task. Medicine and nursing generally fall into this category. Other disciplines are more relationship oriented, processing interactions and interpreting their meaning. Social work and psychology provide examples of this approach. Similar divergent approaches may occur between members of one discipline. Teams may need to consider these cultural differences when analyzing specific instances of role conflict.
Role blurring refers to overlapping competencies and shared responsibilities. This blurring can serve as a potential barrier to effective team function, particularly if resentment occurs because the skills of some team members are underutilized. Staff nurses, in particular, experience role blurring in interactions with advanced-practice nurses. Blurring also occurs when a physician’s expectation of the nursing role differs from the nurse’s expectation. Role blurring can be countered with clarification of the function of each team member. Williams and colleagues found that a clear definition of the roles and responsibilities of hospice chaplains was associated with less perceived stress. Conflict resolution and unambiguous communication within a team can address this confusion regarding roles. Other strategies to address role blurring are listed in Box 38-1 .
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