Interprofessional communication in the care of adults with cancer: exploring clinicians’ perceptions of team rounding

Abstract

Interprofessional communication (IPC) is important for the inpatient oncology team due to the complexity and acuity of oncology patients. One intervention used to improve IPC is team rounding, yet few researchers have explored experiences of team members with team rounding. In this study, 12 interviews were conducted with providers from five different professions: Nursing Assistant, Registered Nurse, Pharmacist, Advanced Practice Provider, and Physician. We aimed to identify communication barriers and explore providers’ perceptions of team rounding and IPC through semi-structured interviews on the adult inpatient oncology unit. Interviews were coded and conventional content analysis used. Facilitators identified were: effective team communication: (a) including interprofessional stakeholders in rounding and communication; (b) the importance of “real-time” communication; and (c) team dynamics. Barriers identified were: effective team communication: (a) workflow-related issues and (b) team dynamics. Findings from this study indicate each profession had unique perceptions, but all had a positive outlook on the necessity of IPC in the delivery of optimal cancer care.

Introduction

Interprofessional communication (IPC) is fundamental to the delivery of safe, effective, patient-centered care that promotes teamwork and boosts cost efficiency (Foronda et al., 2016; Interprofessional Education Collaborative [IPEC], 2016). Rounding includes all or as many members of the interprofessional team as possible in reviewing a patient’s plan of care, priorities, and patient updates (IPEC, 2016). Inpatient oncology requires ongoing effective IPC to ensure reduction of communication breakdown and increase patient safety (Blough & Walrath, 2007). Oncology care can benefit from the improved inter-professional relationships associated with team rounding. To advance understanding of effective IPC using team rounding, we proposed a pilot study to address this gap. Our institution implemented a team rounding initiative in May 2018. At the time of implementation of this new protocol on the inpatient adult oncology unit, several barriers impeded the process. The purpose of this study was to identify communication barriers and explore clinicians’ perceptions of team rounding and IPC on the adult inpatient oncology unit after the implementation of team rounding.

Methods

Setting and sampling

A 53-bed oncology unit at a large academic medical center in the Southeastern United States. The unit has 3 medical teams, 4 or more pharmacists, 2 physician assistants and 2 nurse practitioners, Advanced Practice Providers (APPs), 18 registered nurses (RNs), and 4 nursing assistants on any given day. This pilot, qualitative, convenience sample recruited oncology team members via unit nurse managers’ e-mails to uncover communication barriers and explore clinicians’ perceptions of team rounding and IPC. Eligible participants had at least 1 year of experience in their role and worked alternating shifts. Participants received a $10 gift card for participation.

Data collection

Interviews were semi-structured and conducted by (second author) in January and February 2019. Interviews lasted approximately 10 minutes on average, were audio recorded, and were transcribed by a professional transcription company. Written consent to participate was obtained, and interviews occurred during their workday. We stopped recruiting and interviewing because of similar comments from participants. The Nursing Research Council and Institutional Review Board at the University of North Carolina at Chapel Hill approved this study (IRB #18-3136).

Data analysis

Twelve transcribed interviews were coded and conventional content analyzed (Hsieh & Shannon, 2005) to identify barriers and facilitators to IPC including team rounding. Four broad codes were determined a priori (barriers, facilitators, communicating with team, and understanding roles), with additional codes emerging throughout the coding process. Two members of the research team independently coded the first transcript, meeting afterward as a group to discuss codes and update the codebook. Any disagreements were discussed until consensus was reached. This process was repeated for the second and third transcripts. One team member then coded the remaining transcripts, updating the codebook as needed. After coding was complete, the other coder reviewed the coded transcripts, adding an additional code to two coded segments. Coding was managed in Atlas. ti (Atlas.ti Version; Berlin, Germany) query and “super code” functions were used to further refine the data for this analysis to focus on barriers and failitators to IPC and team rounding. Code reports were used to develop reports that further summarized major facilitators and barriers. Aggregate findings were shared with the participants without mention of profession for participant check.

Results

Twelve individuals completed an interview: three NAs, 2 RNs, 3 PharmDs, 2 APPs, and 2 MDs. We were unable to report years of experience without violating confidentiality due to the small number of subjects. There is variation between professions in terms of formal education, roles, and responsibilities, and there is variation within professions. For example, new graduate nurses have a different comfort level than those who have been practicing for years. Likewise, physicians experience changes throughout their residency, fellowship, and years of practice.

Facilitators

Facilitators included (a) interprofessional stakeholders in rounding and communication, (b) the importance of “real-time” communication, and (c) team dynamics.

Interprofessional stakeholders in rounding and communication

Participants emphasized the importance of including the inter-professional stakeholder in both team rounds and communication efforts. In particular, one participant noted the importance of consistently including nurses in team rounds, highlighting intentional efforts to include nurses as interprofessional stake-holders in rounding and communication.

They made a huge initiative for us to page the nursing staff … It’s mostly been effective. I think it it’s always going to be impossible to get everybody in the same place at the same time every time, but generally speaking, I think we’ve done decent with paging them, and they’ve done well with being available, or if they’re not available, following up with us after

(APP).

Importance of “real-time” communication

Participants described how team members in different roles may hold different types of information about patients. When stakeholders in multiple roles are present at the same time, this information can be communicated to everyone, leading to a clearer picture. This is the importance of “real-time” communication. One participant echoed this perspective:

I think rounds when all of the different disciplines are around or present for the discussion are more productive … I find that what the nurses are telling us about what the patient reports is usually very insightful because they don’t always report the same thing to the providers.

(Pharmacist 1)

Team dynamics

Participants emphasized open communication between stake-holders in different disciplines as a strength of their unit. They noted that team members feel comfortable speaking up and asking questions or seeking out additional information when needed which describes team dynamics. One participant stated: “ … Throughout the day, nurses are very comfortable with coming and finding us, and paging us, and calling us, and figuring out however else to get a hold of us. They’re very good at figuring out how to get their answers.” (APP 1)

Barriers

Barriers were (a) workflow-related issues and (b) team dynamics, discussed next.

Workflow-related issues

Some participants shared that having multiple duties, high workloads, and busy schedules, can prohibit clinicians from joining rounds at all. Two quotations characterizes workflow-related issues as a barrier:

I know it’s hard for people always to make it to rounds. So obviously nurses have a million things to do, so like actually getting them there can be hard … I know we had tried to do more of a multidisciplinary rounding in the morning with case management, and their schedule is prohibitive of that … It’s just timing and scheduling and getting all the prices involved, especially when people are covering multiple services or multiple patients.

(Pharmacist 2)

Participants also noted that within the changing workflow, or as one participant said, “chaos” of rounding, providers often forget to call the nurse to join the team is at their patient, or rounding is delayed as the team is waiting for the nurse to join when the team is at their patient’s room, or rounding is delayed as the team is waiting for the nurse to join.

I remember there was a big push to try to call the nurses before we were going to round on the next patients so that they could be involved, which I think is really important, but it’s also so hard to do, and the chaos of rounds and especially if one of the interns is off, then it’s hard to delegate that task to somebody.

(Physician)

Team dynamics

As described during the discussion of facilitators, having good rapport was recognized as one of the factors that can promote effective team communication and team dynamics. In particular, participants highlighted the ways in which frequent clinician turnover on the unit can lead to lack of rapport and familiarity with team members, as well as discomfort or lack of understanding when communicating.

I think some of the challenges are that we have interns and residents who filter in and out. They change services. So, you get to know them and then you become comfortable communicating with them and vice versa. And then they’re gone, you know? They get to know you by name, you’re taking care of their patients regularly, and then in six weeks they’re gone. So then you get new people.

(RN)

Many participants in this study spoke to the central role nurses play in patient care, and the importance of including them in team rounding and communication. At the same time, some described a role-based chain of communication with nurses being the central link; this chain can be inefficient – at times, information is lost, or the chain’s structure stands in the way of direct communication. Team dynamics was described earlier as a facilitator and can be viewed as a barrier as well as noted by the participant.

I’ve found a few residents who really talk to me and let me know what’s going on and what needs to be done, and I really appreciate when they do that, but … they usually just go straight to the nurse, and the nurse will usually tell me what we need to do … instead of going through them, I feel it could be better if they could just tell us, and we could get to it faster.

(NA)

Discussion

Members of each profession acknowledged in some way that they lacked understanding of the nature of other roles. Our findings support that interprofessional teams work better when members have shared values and a similar work (IPEC, 2016). Additionally, having opportunities for members of the team to get to know each other, build trust, and understand others’ communication styles are strategies that were identified to enhance team communication. This is especially true in units where team members change frequently. These findings reiterate importance of the IPEC competencies and the need to build these competencies into the current workforce, and educational environments.

Although participants recognized the value of having team members present during rounds, the ability to communicate effectively is an important skill that must also be addressed. If a team member does not feel empowered to speak up, or does not feel confident in their communication skills, communication breakdowns can occur. Our findings support that effective communication must be clear, intentionally focused on understanding each other’s roles, and use strategies to sustain effective harmonious communication. Strategies to promote team communication such as Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS^®), standardized communication tools such as Situation, Background, Assessment, and Recommendation (SBAR), and restructuring of team rounds to stimulate team processes and function can be helpful tools to provide all members of the team with the same language, building self-efficacy and empowerment to engage with interdisciplinary team rounds (Buljac-Samardzic et al., 2020).

Team rounding can enhance IPC as it allows for inclusion of interprofessional stakeholders and promotes real-time communication (Vatani et al., 2020). Using real-time communication among interprofessional team members to collaborate on the plan of care for the patient ensures that each member’s contribution has a greater chance of being heard and integrated into the plan of care. It was acknowledged that various team members held different information about the patient, their needs, and response to therapy; when shared, these provided a more holistic view of the patient and provided information necessary for coordination of care. Importantly, the IPEC competency of roles and responsibilities was challenging for the team rounding members. Although team rounding provided glimpses of roles and responsibilities, team members lacked depth and breadth of understanding of other disciplines necessary to be a highly functioning team, and logistics of team rounding presented the greatest challenge. Multiple teams round on this unit at unpredictable times, and the mechanisms of alerting nurses prevented timely notifications. Even with timely notifications, the team members had competing patient care responsibilities when they were trying to integrate within multiple rounding teams.

To our knowledge, ours is one of the first pilot studies to explore IPC and team rounding on an inpatient adult oncology unit. The study was focused at one site. It is difficult to generalize findings to all oncology care settings. Another limitation was time. All 12 interviews were conducted on days that the participants were working and thus were relatively short. The study was designed this way to enhance participation. However, because individuals were interviewed during the workday, there were job pressures such as pages and telephone calls, and many other distractions that arose through the course of the interviews. Furthermore, the sample was small from selected professions. The pilot was not designed to achieve saturation within the subgroups. We are unable to draw conclusions about interactions between professional status and the findings. The small sample limits generalizability of the findings. Future studies could be designed to recruit enough participants to achieve saturation in subgroups and could explore issues more in-depth by scheduling longer interviews with the clinicians outside of their workday.

Conclusion

The value of team rounding is acknowledged, but the operationalization of it is complex and challenging. Our work illuminates benefits as well as complexities of team rounding with effective team communication described as both a facilitator and barrier. A need exists to review current processes and team functioning for effective communication and coordinated care. Future researchers should work to create an IPC model that can be as effective and efficient as possible for care of individuals with cancer.