a qualitative analysis of communication between members of a hospital-based multidisciplinary lung...

A qualitative analysis of communication between membersof a hospital-based multidisciplinary lung cancer teamecc_12004 1..12

S. ROWLANDS, bappsc(mra), mqihc, phd, DIRECTOR, Health Information Management Services, Sunshine CoastHealth Service District, Nambour, Qld, & J. CALLEN, ba, diped, mph (research), phd, ASSOCIATE PROFESSOR AND

SENIOR RESEARCH FELLOW, Centre for Health Systems and Safety Research, Australian Institute of Health Innova-tion, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia

ROWLANDS S. & CALLEN J. (2012) European Journal of Cancer CareA qualitative analysis of communication between members of a hospital-based multidisciplinary lungcancer team

The aim of the study was to explore how patient information is communicated between health professionalswithin a multidisciplinary hospital-based lung cancer team and to identify mechanisms to improve thesecommunications. A qualitative method was employed using semi-structured in-depth interviews with arepresentative sample (n = 22) of members of a multidisciplinary hospital-based lung cancer team includingmedical, nursing and allied health professionals. Analysis was undertaken using a thematic grounded theoryapproach to derive key themes to describe communication patterns within the team and how communicationcould be improved. Two themes with sub-themes were identified: (1) characteristics of communicationbetween team members including the impact of role on direction of communications, and doctors’ dominancein communications; and (2) channels of communication including, preference for face-to-face and the subop-timal roles of the Multidisciplinary Team Meeting and the hospital medical record as mediums for commu-nication. Traditional influences of role delineation and the dominance of doctors were found to impact oncommunication within the multidisciplinary hospital-based lung cancer team. Existing guidelines on imple-mentation of multidisciplinary cancer care fail to address barriers to effective team communication. Thepaper-based medical record does not support team communications and alternative electronic solutions needto be used.

Keywords: cancer, communication, lung cancer, multi-professional communication.

INTRODUCTION

The incidence of cancer in developed countries is increas-ing: in Australia there were 108 368 new cases diagnosedin 2007 (Australian Institute of Health and Welfare 2010).Lung cancer is one of the most common types of cancers

with 9703 cases reported in 2007 and is the leading causeof cancer deaths in both men and women (AustralianInstitute of Health and Welfare 2010). In the UK lungcancer accounts for one in eight newly diagnosed cancerswith 40 806 new cases diagnosed in 2008 (CancerResearch UK 2008). Cancer patients receive care in hospi-tal from a range of health professionals including doctors,nurses and allied health professionals who make up themultidisciplinary cancer team (Clark 1981; Houssami &Sainsbury 2006; Victorian Government Department ofHuman Services 2007). Multidisciplinary care, where allmembers of the team work collaboratively and coopera-tively, is considered fundamental to the provision of safe

Correspondence address: Stella Rowlands, Director, Health InformationManagement Services, Sunshine Coast Health Service District, PO Box487, Nambour, Qld 4560, Australia (e-mail: [email protected]).

Accepted 1 July 2012DOI: 10.1111/ecc.12004

European Journal of Cancer Care, 2012

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Original article

© 2012 Blackwell Publishing Ltd

care and improving patient outcomes (Clark 1981; Depart-ment of Health 2000; National Breast Cancer Centre2005). Studies have shown that involvement of a range ofhealth professionals in the cancer care process results inhigh-quality diagnosis, evidence-based decision making,optimum treatment planning and, the best possibledelivery of care (Sainsbury et al. 1995; Chang et al. 2001;Fleissig et al. 2006). A critical element, which is essentialfor the success of hospital-based multidisciplinary cancerteams, is effective communication including verbal,written and electronic, among all members of the team(Tripathy 2003; Boyle et al. 2004; Rabinowitz 2004;National Breast Cancer Centre 2005; Fleissig et al. 2006;Wagstaff 2006; Queensland Health 2008; Sargeant et al.2008; Weaver 2008; Suter et al. 2009).

There are many challenges to effective communicationbetween health professionals including: the synchronousnature of communication, the diversity in the educationand training of health professionals, and the impact ofhierarchy (Bates & Lapsley 1985; Kenny & Adamson1992; Adamson et al. 1995; Coiera 1996, 2000; Wilson &Pirrie 2000; Gair & Hartery 2001; Leonard et al. 2004;Toussaint & Coiera 2005; Wagstaff 2006; Creswick et al.2009). The principal information repository in healthcare is in the minds of providers, and the largest infor-mation network is a complex web of conversations with50% of communication occurring face-to-face (Coiera2000, 2006). Additionally due to the highly mobilenature of the healthcare workers, particularly in hospi-tals, most communication is synchronous and thereforecharacterised by high levels of interruptions (Coiera1996, 2006). Health professionals are also trained to com-municate differently (Leonard et al. 2004) and those fromthe same professional group are more likely to commu-nicate with each other (Creswick et al. 2009). Doctors,nurses and allied health professionals are generally edu-cated separately with limited engagement with eachother and this gives rise to differing communicationstyles particularly between nurses and doctors: nursesare taught to ‘paint the big picture’ in broad termswhereas doctors are taught to be concise and get to the‘headlines’ (Leonard et al. 2004). Nurses relate that theyare taught during their training that they ‘don’t makediagnoses’ (Leonard et al. 2004). There is a perceivedpower differential between health professionals whichalso inhibits communication. This occurs both withinand between disciplines, with doctors generally in theposition of most power (Bates & Lapsley 1985; Kenny &Adamson 1992; Adamson et al. 1995; Wilson & Pirrie2000; Gair & Hartery 2001; Leonard et al. 2004; Wagstaff2006). It is important to understand the divergent

characteristics of healthcare communication whenassessing the effectiveness of communication within thecontext of multidisciplinary cancer care.

Given that multidisciplinary cancer care teams are rec-ommended it is important that they function efficientlyand effectively particularly in relation to sharing patient-related information. There have been few studies thathave focused on the fundamental role of communicationwithin this multidisciplinary cancer care paradigm. Ofthose studies undertaken, the focus has been on the Mul-tidisciplinary Team (MDT) Meeting (Lanceley et al. 2008;Fleming et al. 2009; Devitt et al. 2010; Lamb et al. 2011)and not communication and coordination between teammembers generally. The aim of this study is to undertakean in-depth exploration of how patient information iscommunicated between members of a multidisciplinaryhospital-based lung cancer team. The results will informpolicies and strategies to improve information sharingbetween health professionals and ultimately care deliveryto lung cancer patients.

METHOD

Design and research setting

A qualitative design was used as it enables detailed explo-ration of complex interactions and work processes(Denzin & Lincoln 1998). In-depth interviews were under-taken with a representative sample of members of a mul-tidisciplinary hospital-based lung cancer care team to gainan understanding of how patient specific information iscommunicated. This research forms part of a larger mixed-methods study exploring communication and informationflow within a hospital-based lung cancer team andbetween the team and the patient’s general practitioner(Rowlands et al. 2010). The study was conducted in a330-bed Australian public teaching hospital within acatchment population of 210 000 (Australian Bureau ofStatistics 2006), 36 777 annual discharges and 146 415annual non-admitted patient occasions of service (July2006 to June 2007) (Transition II Clinical BenchmarkingDatabase, Study Hospital). Table 1 presents statisticaldata on inpatients diagnosed with primary lung cancerat the study hospital.

Selection and sampling logic

The lung cancer team consisted of 42 health professionalsincluding doctors (medical oncologist, radiation oncolo-gist, respiratory physician, thoracic surgeon, palliativecare physician, pathologist and radiologist), nurses and

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© 2012 Blackwell Publishing Ltd2

allied health professionals (dietitian, pharmacist, psy-chologist, social worker). A purposive sample of represen-tative members of the team was interviewed to reflectviews from a range of perspectives. The study hospital waschosen based on convenience and it was considered rep-resentative of similar hospitals providing oncology andpalliative care services to patients with lung cancer.

Data collection

A single researcher (SR) undertook all interviews withparticipants, which were taped and transcribed. The inter-views were guided by a standard set of questions (Table 2).Prior to each interview the researcher outlined the aim ofthe study and each participant was given a study informa-tion sheet and asked to complete a participant consentform.

Data analysis

Analysis was undertaken using a grounded theoryapproach (Glaser & Strauss 1967) to derive initial catego-ries and then broader themes relating to communicationwith the multidisciplinary team. The constant compara-tive method of grounded theory analysis meant that datawere repeatedly studied and analysed. Categories weregenerated from this line-by-line analysis and re-analysisthat was inductive, allowing development of themes andrelationships rather than the themes being imposed priorto data collection. A memoing document including thecodes, field notes and reflections during data collection

and analysis (for example, observations in relation to non-verbal signals from the participants) was maintained.

Rigour of the qualitative data

Trustworthiness was enhanced by triangulation of dataanalysis and data source (Willms & Johnson 1993). Fourresearch assistants were added to the study group toanalyse interview transcripts and compare derivedthemes. Differences in analysis were resolved with discus-sion. Data source triangulation occurred as data were col-lected from members of each of the three professionalgroups (medicine, nursing and allied health) represented inthe lung cancer team to provide diverse perspectives.Member checking of results occurred by re-interviewingparticipants if clarification was needed with eight partici-pants re-interviewed to ensure accuracy of the data.

Ethics

Ethics approval for the study was obtained from the HumanResearch Ethics Committee of the study hospital and TheUniversity of Sydney, New South Wales, Australia.

RESULTS

Twenty-two members of the hospital-based multidisci-plinary lung cancer team were interviewed reflecting arepresentative cross-section of disciplines and roleswithin the team including eight doctors, nine nurses andfive allied health professionals (Table 3).

Qualitative analysis of interview data revealed two keythemes with subcategories:

Theme 1: Characteristics of communication between teammembers

(i) The role of team members determines the directionof communication

(ii) Doctors’ dominance in communications

Theme 2: Channels of communication between team members(i) Face-to-face communication preferred(ii) The suboptimal role of the MDT Meeting as a

medium for communication(iii) Failure of the paper-based hospital medical record as

a medium for communication

Table 1. Number of patients with lung cancer in the study hospital (July 2006 to June 2007)

Annualseparations

Occupiedbed days

Average lengthof stay (days)

Primary diagnosis* –lung cancer

Primary diagnosis –chemotherapy

Primary diagnosis –radiotherapy

Primary diagnosis –other

935 1993 2.13 92 (10%) 386 (41%) 249 (27%) 208 (22%)

*Primary diagnosis – is the diagnosis established after study to be chiefly responsible for occasioning the patient’s episode of carein hospital.Source: Transition II Clinical Benchmarking Database, Study Hospital.

Table 2. Lead questions asked of lung cancer team members

Interview questions

How do you communicate with others members of the team onmatters related to patient care? (For example – verbal,electronic, mail, etc.)

What information do you communicate?When and where do you communicate?Who do you communicate with?How could communication between members of the team

be improved?

Communication between members of a lung cancer team

© 2012 Blackwell Publishing Ltd 3

Table 3. The demographics of doctors, nurses and allied health respondents interviewed from the lung cancer team (n = 22)

Healthprofessional Description of role

Years workingin cancer care

Years withteam

Duration ofinterview (min)

DoctorsMedicalOncologist

Patient care 27 3–4 40Haematologist and Palliative Care PhysicianChair – Lung Cancer Multidisciplinary Team Meeting

Palliative CarePhysician

Patient care 30 2 40*Clinical Director – Palliative Care

RespiratoryPhysician

Patient care 17 2 25Visiting Medical Officer†

MedicalOncologist

Patient care 10 3 30Clinical Director – Oncology – part-time

Pathologist Indirect patient care related to the histological diagnosisof cancer

N/A 1.5 5

MedicalOncologist

Patient care 11 0.2 28*Registered Palliative Care Physician

MedicalRegistrar –Oncology

Patient care 0.2 0.2 25

Radiologist Indirect patient care related to the radiological diagnosis ofcancer

N/A Notreported

12

NursesNurse UnitManager –

Oncology

Management role – responsible for the Day Chemotherapy Unitand outpatient clinics

7 4 35*

Limited hands-on nursingClinical NurseConsultant –Oncology

Staff education – including orientation, training, assessment ofcompetencies

12 7 40*

Maintenance of clinical standardsLiaison with inpatients and clinicians on patient care and staff

educationResearch Nurse Management of clinical trials 3 3 40*

Nursing research and acts as resource person for nursesundertaking tertiary studies

Assist medical officers in quality activitiesCancer CareCoordinator(Nurse)

Patient care – coordination role 20 2.5 60*Facilitation – Lung Cancer Multidisciplinary Team Meeting

Clinical Nurse –Palliative Care

Patient care – assessment, coordination and patient advice 25 Notreported

20Occasional hands-on nursing

Clinical Nurse –Oncology

Patient care – chemotherapy day unit and outpatients 8 8 15

Clinical Nurse –Oncology

Patient care – chemotherapy day unit and outpatients 4 4 15

Nurse UnitManager –Palliative Care

Management role 1.5 1.5 30Limited hands-on nursing

Clinical NurseConsultant –Palliative Care

Staff education 5 1 30Coordination, liaison and consultancy roleLimited hands-on nursing

Allied HealthClinicalPsychologist

Patient care 3 2 20

ClinicalPsychologist

Patient care 0.2 0.2 25

Pharmacist Patient care – including supply of pharmaceuticals andpatient education

6 2 55*

Dietitian Patient care 2 2 45*Social Worker Patient care 3 3 30

*Respondents interviewed twice – duration represents length of two interviews combined.†Visiting Medical Officer – maintains a private practice and provides a consultancy service to the hospital.

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Theme 1: Characteristics of communication betweenteam members

(i) The role of team members determines the directionof communication

Most communication within the team occurred betweenmembers of the same professional group. It was evidentthat ‘like to like’ communication was influenced bytraditional referral patterns particularly in relation todoctors. For example, once the diagnosis had been estab-lished and the care pathway determined the respiratoryphysician would refer the patient to the medical oncolo-gist. The involvement of oncology nurses and allied healthprofessionals commenced only after the medical oncolo-gist had assumed the care. However, communication withallied health professionals from doctors were often limitedas illustrated by the following quotes: ‘Most of the time,in terms of the psychologist, dietitian and anybody else onthe team I don’t have a lot of direct contact with them andmost of the contact is in terms of trying to encouragethem to say something maybe at the meeting to drawthem in there’ (Medical Oncologist); ‘In terms of thingslike psychosocial support it shouldn’t actually be themedical consultant who is making the decision, itshould be more of multidisciplinary focus’ (Cancer CareCoordinator – Nurse). In circumstances where patientmanagement was palliative rather than curative the com-munication pattern was from the palliative care physicianto medical oncologist or respiratory physician. The pallia-tive care nurse’s communications were restricted to thepalliative care physician. The role of the pathologist andradiologist in information communication was related tofeedback and clarification of pathology and radiologicdiagnostic tests and this communication was limited todoctors.

The nurses on the team held a central role in the com-munication process with high levels of interaction withnurses from both doctors and allied health professionals.Doctors communicated with nurses within the context ofthe delivery of planned care, for example, the administra-tion of chemotherapy. The two Clinical Nurses (Oncol-ogy) reported their communication with doctors wouldcommence with more junior doctors initially (residentand registrar) and escalate if required – ‘if I thought it wasa complex problem and I didn’t think the resident wouldbe able to respond to it or they didn’t know the patient. . . then I would possibly go directly to the consultant’.Allied health professionals’ communication with nursesusually resulted when an allied health intervention wasrequired, for example, patient weight loss requiring refer-ral to a dietitian. One Clinical Nurse (Oncology) reported

‘we either refer them (the patient) to dietitians or psy-chologists or social workers depending on what theirneeds might be’. The limited communication of theresearch nurse with the allied health professionals wasdue to the parameters of their role, which focuses on themanagement of clinical drug-trials that follow strictprotocols managed by doctors.

(ii) Doctors’ dominance in communications

Standard patterns of communication based on role werefurther reinforced, in the opinion of some members of theteam, by the influence of medical dominance in commu-nications between team members. This influence wasparticularly seen at the MDT Meeting where mostcommunication occurred between doctors.

When asked how communication could be improved anumber of participants suggested that all team membersneeded to understand their role and the roles of others. Itwas suggested that breaking down barriers such aspatient ownership was important if communication wasto improve. Patient ownership was seen as the reluc-tance of one health professional to handover care toanother and was manifested by withholding of informa-tion. For example, a nurse commented that ‘there are alot of territorial attitudes based on ownership of patient-s . . . and people not feeling that they want to handpatients over and that actually effects communication’(Nursing Unit Manager – Palliative Care Service). Thiswas particularly evident with members of the palliativecare service where they considered that there waslimited understanding by other health professionals oftheir role. The nursing unit manager of the palliativecare service thought that others perceived their servicesas simply an end-of-life service. Another suggestion bynurses and allied health professionals was the creation ofanother multidisciplinary forum to discuss complexpatients. ‘By no means do we feel that we have coveredall of the bases because there isn’t a forum for discussionabout patients who are having radiation in any sort offorum’ (Social Worker). It was considered that there werea group of patients, with identified issues that had arisenduring treatment, where there was no forum for multi-disciplinary care planning, particularly on issues of anon-medical nature. An example of this type of patientwould be one who was experiencing profound psycho-logical distress due to their diagnosis and was subse-quently experiencing weight loss as a result. Thismeeting would be additional to the MDT Meeting whereonly newly diagnosed patients and those whose progno-sis had changed would be discussed. This forum would



serve an important function in educating team memberson the role and contributions of their colleagues.

Quotes from the interviews with the members of themultidisciplinary hospital-based lung cancer team in rela-tion to Theme 1 are presented in Table 4.

Theme 2: Channels of communication betweenteam members

(i) Face-to-face communication preferred

The preferred mode of contact between most members ofthe lung cancer team was synchronous, verbal, face-to-face communication. For example, the research nursereported visiting the oncology unit several times a day justin case another member of the team wished to talk withher; such was her preference for face-to-face communica-tion over other forms of communication (for example,telephone). The pharmacist reported that the physicallayout of the oncology unit with team members workingin close proximity with one another within the outpatientclinic and chemotherapy unit was conducive to face-to-face communication ‘I absolutely prefer face-to-face

communication. The environment invites that’ (Pharma-cist). The respiratory physician reported that he generallymade referrals verbally and then followed these up with awritten referral.

Although verbal face-to-face communication was pre-ferred there were other modes of communication usedsuch as telephone, documentation in the health record,e-mail and less frequently the hospital paging system. Itwas apparent that communication channels were influ-enced by office location. For example, the respiratory phy-sician reported relying on the telephone, as his office wasremote from the hospital. The use of e-mail for commu-nication of patient-related matters among the team waslimited to non-urgent matters.

(ii) The suboptimal role of the Multidisciplinary TeamMeeting as a medium for communication

The MDT Meetings were held weekly and they were theprincipal decision-making forums for planning carefor patients with lung cancer. Most members of themultidisciplinary hospital-based lung cancer team

Table 4. Sample quotes from the interviews by Theme 1 – characteristics of communication

Sub-themes Quotes from the interviews

The role of team membersdetermines the directionof communication

‘I don’t have a great deal on a day to day basis . . . (respiratory physicians)’ (Pharmacist)‘The social workers . . . I certainly talk with them you know informally on the ward round’

(Respiratory Physician)‘I don’t have a lot of reason to communicate with them (allied health)’ (Research Nurse)‘. . . respiratory physicians . . . the oncologists . . . radiologists’ (Pathologist)‘Mainly respiratory physicians and oncologists . . .’ (Radiologist)‘Not so much with the consultants because they – the nurses would relate to the consultants

normally’ (Clinical Nurse – Palliative Care)‘. . . if we, if they’re actually having palliative chemo at the same time then there’s probably

more communication’ (Clinical Nurse – Oncology)

Doctors’ dominance incommunications

‘So yes there is a pecking order – I could see that for instance registrars – I can see theregistrars are nervous when they’re presenting’ (Medical Oncologist)

‘Ah – yeah – I think, I think it’s certainly in – I think that’s certainly probably the case inforums – may be in places like the multidisciplinary meetings. Yeah – I think that’s alwaysthere but I think I would like to believe that ultimately that if it’s the patient’s – if it’s apatient clinical decision, then I think people would speak up – I wouldn’t think – I’d hate tothink – I don’t think in our organisation that would be an issue. I think it might well be thatyou respect the person within the meeting and that you would talk to them afterwards’(Clinical Nurse Consultant – Oncology)

‘No – but I can appreciate that others might be. I think I am quite fortunate that my nursingposition is quite senior within this department but I could imagine that others could feelthat they weren’t able to do so. But I am happy to be their advocate if they feeluncomfortable’ (Nursing Unit Manager – Oncology)

‘. . . I probably doubted myself and – was a bit intimidated’ (Pharmacist)‘I think medically we still have a bit of an aura about us whether it is warranted or not that

allows us to say some things that get more importance placed upon them by the patient thanthey would coming from the other health professionals’ (Medical Oncologist)

‘. . . in terms of things like psychosocial support it shouldn’t actually be the medical consultantwho is making the decision on that, it should be more of a multidisciplinary focus’ (CancerCare Coordinator)

‘So I think it is a mixture of personality and where you sit on the ladder’ (Research Nurse)

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attended this meeting except the clinical nurses. If theclinical nurses had concerns regarding a particular patient,the nursing unit manager or the clinical nurse consultantwould present these to the meeting. All newly diagnosedcases of lung cancer and some existing patients whosedisease status had changed (from curative to palliative) orwere not responding to a treatment regime were presentedfor discussion at the MDT Meeting. The presentationincludes a summary of the patient’s medical history, stageof cancer and investigations that have led to the diagnosisof lung cancer. Rigorous discussions were then heldamong the doctors on the various options for patient man-agement and a treatment plan was recommended. Nursesand allied health professionals are present at the meetingbut their involvement was limited. ‘I think my, the alliedhealth level of communication is quiet low at those meet-ings. I think we have a presence but we don’t have asmuch interactions as the oncologists and the various keyconsultants and . . . mainly to be seen but personallyI’d say I don’t interact as much as I think is possible’(Dietitian). On rare occasions allied health professionalsand nurses may be asked for an opinion or if they thoughtit was of crucial importance they would offer an opinionwithout being asked. Therefore, the meeting whiledeemed multidisciplinary was primarily a decision-making forum for doctors. The failure of the MDTMeeting as a communication forum was acknowledged bysome doctors and as articulated in the following quotefrom one medical oncologist ‘medically dominated . . . insome ways it kind of has to be to get the medical decisionsmade that need to made – but I think that is potentially anissue as to whether there is enough openness for otherpeople to contribute to the discussion and even othermedical people’.

The complexity of communication at the MDTMeeting was heightened by the use of a myriad oftechnologies. Members of the team who could not bephysically present linked into the meeting by videocon-ference. The written presentations relating to the patientunder discussion were projected for viewing from anelectronic database. This database is updated by thecancer care coordinator and projected for viewing asfurther information is provided by members of the teamand the management plan developed. Medical imaginesstored online were projected for viewing while otherfilms were presented using a radiology viewing box.Those members of the team who linked by videoconfer-ence must be able to view all medical images displayedover the video link if they were to actively participate inthe planning of care. Sometimes this was problematicdue to the number of imagines being displayed.

Improving the MDT Meeting was recommended by anumber of participants who focused on the lack of inclu-siveness of the current meeting format. That is, ensuringthat all members of the team are present at the meeting andencouraging participation from nursing and allied healthteam members in care planning for the patient. The CancerCare Coordinator saw the role of the chair as integral tomultidisciplinary engagement. ‘Different chair personshave differing perspectives on the value of allied healthinput . . . so you will find that some meetings have fargreater allied health input and it’s almost directly corre-lated to the personal perceptions of the chair person’(Cancer Care Coordinator – Nurse). No specific suggestionswere made by the participants, on how to develop multi-disciplinary engagement. The duration of the meeting wasseen as an inhibitor by the registrar who felt that if every-one’s opinions were listened to the meeting would loosemomentum and become unworkable. However, the dieti-tian considered that a 5- to 10-min extension of the meetingwould be sufficient time for allied health input.

(iii) Failure of the paper-based hospital medical recordas a medium for communication

Participants commented that the paper-based hospitalmedical record was not always used to record clinicalinformation and documentation in the record was oftenincomplete. The following statements reflect the doubts inthe minds of those on the team as to whether or not thehealth record was actually read. ‘I would communicate bywriting in the patient’s progress notes under the assump-tion that people would read them’ (Clinical Nurse Consult-ant – Oncology). ‘I would like to think they do (read thehealth record) because I wouldn’t want to think that I amwriting my notes for nothing’ (Clinical Psychologist). Thedietitian reported that they could not always access thepaper-based hospital medical record when required whichnecessitated them having a separate departmental patientrecord, which was stored in the dietitian’s office. ‘In thepast it was difficult for me to always get my hands on thehealth record so we have actually developed our owndepartmental record – a specific oncology record which Ikeep on me and I just put a notification in the chart that Iam involved with patient and don’t file the notes untilpatient discharge’ (Dietitian). The respiratory physicianalso reported that he did not read the medical recordbecause as a Visiting Medical Officer he had limited timeat the hospital. The respiratory physician kept separatepatient information such as summary notes and copies ofoutpatient letters in his office. The social worker consid-ered there were many conversations that occurred



informally which were not documented in the hospitalmedical record. ‘Also many conversations I have with staffare not documented, just acted upon’ (Social Worker).

Participants suggested many improvements in relationto the use of the hospital medical record as a means ofcommunication between members of the lung cancerteam. For example, they suggested that standard policiesfor documentation, screening tools, improved access andan electronic medical record (EMR) would improve com-munication between team members. It was suggested thatdocumentation standards should focus on when to docu-ment, as it was considered that documentation of everypatient encounter was not occurring. The dietitian recom-mended the development of an allied health-screeningtool to identify those patients requiring allied health pro-fessional intervention thus eliminating the reliance on areferral. Generally an allied health-screening tool wouldbe self-administered by the patient once they had accepteda planned course of treatment. This tool, using evidence-based criteria, would provide triggers to the allied healthprofessionals as to whether or not an allied health inter-vention was required. As discussed, access to the paper-based hospital medical record, particularly by thedietitian, was problematic and resulted in the creation ofa separate departmental record by the dietitian. An EMRwas seen as a mechanism for improving access as an elec-tronic record would enable access, from various pointswithin the hospital, by multiple health professionals, in atimely fashion.

Table 5 includes quotes from the interviews with themultidisciplinary hospital-based lung cancer team in rela-tion to Theme 2.

DISCUSSION

The results of the interviews provided new perspectiveson how patient information is exchanged betweenmembers of a multidisciplinary hospital-based lungcancer team. Communication was strongly influenced bythe role of health professionals and face-to-face verbalcommunication was preferred. The MDT Meeting wasdescribed as a complex forum with limited engagement incare planning by nursing and allied health professionals,and with most communication occurring betweendoctors. However, the importance of the MDT Meeting asa communication forum was recognised by all partici-pants. The paper-based hospital medical record was notalways used to document clinical care and was sometimesreplaced by profession-specific departmental records.Many participants saw an EMR as a mechanism for facili-tating communication. This study provides new informa-

tion to assist in the development of an understandingabout how patient related information is communicatedamong members of a multidisciplinary cancer team andhow this team-based communication could be improved.

The impact of doctors’ dominance in communications

The study revealed limited communication between somemembers of the cancer care team, which was particularlyevident in the MDT Meeting where nursing and alliedhealth professionals did not actively participate and hadlimited involvement in the development of patient man-agement plans. The assignment of the role of chairpersonto a doctor could be seen as a barrier both to the flow ofinformation and the inclusion of all members at the MDTMeeting. The seniority of some health professionals onthe team enabled them to overcome the dominance ofdoctors at the MDT Meeting; however, this study showedthat the impact on multidisciplinary decision making waslimited. The findings are consistent with the research ofFleissig et al. (2006) who could find no empirical evidenceto support the notion that simply bringing health profes-sionals from different disciplines together improvescommunication. The dominance of traditional models ofcommunication where the doctor is responsible forpatient care and dominates discussion and decisionmaking are well documented in health care (Bates &Lapsley 1985; Kenny & Adamson 1992; Adamson et al.1995; Gair & Hartery 2001; Coombs & Ersser 2004). Gupta(2007) reports that within the context of multidisciplinaryclinics in oncology the influence of hierarchy is generallyunseen and, therefore, represents a hidden pitfall to thesuccess of multidisciplinary cancer care.

The results identified that role also impacted on com-munication within the lung cancer team, with commu-nication occurring more frequently between members ofthe same professional group. Limited communicationwas noted across professional groups and in particularbetween doctors and allied health professionals. Com-munication based on role is consistent with the modelsof communication in health care as described by Coiera(2000), Leonard et al. (2004) and Creswick et al. (2009).Creswick et al. (2009) describe communication as beingmore likely to occur along professional lines due to acommon identity, training and practice, and closer ide-ologies and attitudes. These results contrast to thenotion of an effective team where the roles of all healthprofessionals on the team are known and respected asdescribed in the literature by Sargeant et al. (2008),Weaver (2008) and Suter et al. (2009). This finding isimportant as it identifies that the team was not

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functioning as a multidisciplinary unit but rather oper-ating within professional silos.

The traditional models of communication that exist inhealth care, contrast with a multidisciplinary model ofcare. The multidisciplinary care model requires an inte-grated team approach to patient care characterised byeffective communication among team members. The mul-tidisciplinary care model aims to harness the collective

knowledge of medical, nursing, and allied health profes-sionals to develop a management plan for the patientcovering the clinical and social aspects of care (NationalBreast Cancer Centre 2005). Results from this studyshowed that within the lung cancer team the traditionalmodel of medical dominance and role persists. Theresults are important as they highlight deficiencies inAustralian and international guidelines for implementing

Table 5. Sample quotes from the interviews by Theme 2 – channels used for communication

Sub-themes Quotes from the interviews

Face-to-facecommunicationpreferred

‘Mostly my mode of communication would be verbal’ (Clinical Nurse Consultant – Oncology)‘Through multidisciplinary team meetings; through team meetings; weekly team meetings; one-to-one

contact . . . I prefer to use one-on -ne contact’ (Clinical Psychologist)‘Generally verbal, face-to-face – occasionally I talk on the phone, ring someone back’ (Clinical Psychologist)

The suboptimalrole of the MDTMeeting as amedium forcommunication

‘I think it’s quite off putting when it’s just mainly consultants presenting – sometimes the consultantsabbreviate because they have done it so many times before and it’s not such an educational process’ (MedicalOncologist)

‘. . . there are a whole lot of people that are only listening and there are people who never have any inputwhatsoever’ (Research Nurse)

‘Well if I thought that the whole forum needed to hear that I would say it’ (Social Worker)‘I can see scope for psychology input on a bit more of a regular basis but yeah not quite at that point yet to

push that the moment’ (Clinical Psychologist)‘. . . very strongly opinionated individuals and it does tend to inhibit your ability to communicate . . .’

(Respiratory Physician)‘Yes, ideally regular multidisciplinary meetings should take place so that all aspects of a patient’s care can be

discussed at several points in time. In reality this is likely to be too time consuming given the number ofpatients that come through’ (Clinical Psychologist)

‘Some would have on certain occasions yes (response when asked about input of non-medical healthprofessionals to MDT Meeting)’ (Research Nurse)

‘. . . it would be much better if we could have everyone sort of sitting around facing each other’(Cancer Care Coordinator)

‘And unfortunately we don’t have any support from the radiation oncologist’ (Medical Oncologist)

Failure of thepaper-basedhospital medicalrecord as amedium forcommunication

‘Generally the documentation is done by a resident or registrar but occasionally if I think it’s very importantthat what I want to say is recorded faithfully I would actually write in the notes myself’ (RespiratoryPhysician)

‘For me because medical notes in the hospital it is a little more difficult because my time at the hospital islimited and the notes you know I can’t tuck the notes under my arm and take them home and peruse themso it perhaps become less useful. . . . but yeah generally I would take a brief summary. The other I guesssource of information that I have is the letters that I write in the outpatient clinic a copy gets sent to myrooms’ (Respiratory Physician)

‘I read a lot of health records so it’s hard for me to say whether or not other people read records. I must admiteven as a nurse I am guilty of reading more of the doctors input than the nurses input’ (Research Nurse)

‘I would only use the diary as a back up with the same info as in the chart’ (Clinical Nurse – Palliative Care)‘. . . I now print – so send it via Medical Objects – I print it out – we file that . . .’ (Medical Oncologist)‘. . . we minute the meeting . . . then a copy of those gets put in the chart which is then available to all

members of the team’ (Cancer Care Coordinator)‘I actually think that doctors document more in the charts than nurses do. The nurses have got this little short

hand that of initials and numbers and it doesn’t really mean very much and I hate to say it but I tend towhiz through the nursing staff and glean most of the information that I need from what the doctors havewritten because they write more’ (Research Nurse)

‘. . . we need a standardised level of documentation’ (Cancer Care Coordinator)‘The clarity is not there’ (Clinical Nurse – Consultant – Oncology)‘It’s what you write and it’s accuracy of what you write’ (Clinical Nurse Consultant – Oncology)‘Most cases I will get it sometimes I don’t (health record)’ (Dietitian)‘I don’t know if the answer, if an electronic health record that people can access you know from various points

in a timely fashion’ (Cancer Care Coordinator)‘. . . an allied health screening tool – a wider screening tool’ (Dietitian)

MDT, Multidisciplinary Team.



multidisciplinary cancer care. The guidelines are deficientin presuming that barriers to multidisciplinary care arerestricted to: lack of representation of all disciplines; work-force and caseload; lack of support by health service execu-tives; lack of diagnostic services; lack of physical facilitiesand administrative support; resistance to quality auditing,and the medico-legal implications of team decision making(Victorian Government Department of Human Services2007). The Department of Health (2000), National BreastCancer Centre (2005), Victorian Government Departmentof Human Services (2007) and Queensland Health (2008) allfail to identify traditional models of healthcare deliveryand known patterns of communication among health pro-fessionals as being inhibitors to multidisciplinary cancercare. The challenge is to change communication behaviourand associated policies (Coiera 2000) thereby eliminatingthe communication pitfalls of multidisciplinary cancercare (Boyle et al. 2004; Wagstaff 2006; Gupta 2007).

The limitations of the paper-based hospital medicalrecord as a communication tool

The study raised critical questions regarding the use ofpaper-based hospital medical records. The reliance placedon the paper-based hospital medical record as the primarycommunication tool was found to be compounding com-munication problems within the multidisciplinary team.The study revealed a failure to document all clinical carein the hospital’s paper-based medical record, the existenceof separate departmental medical records, and a failure bysome health professionals to use the hospital medicalrecord. A failure to document in the medical record can beattributed in part to the synchronous nature of communi-cation in health care as described by Coiera (2006), namelya reliance on face-to-face communication with high levelsof interruption. This study described a preference by theteam for verbal communication based on urgency andopportunity, and it found that frequently, conversationswere not translated into documentation in the medicalrecord. The integrity of the hospital’s medical record as acomplete and accurate record of patient care was thereforecompromised. These results highlight a risk to patientsafety related to potential errors of omission in the ‘offi-cial’ hospital medical record.

The study highlighted problems with access to clinicalinformation when using paper-based medical records.Access to the hospital medical record was reported as soproblematic that some health professionals were forced tocreate separate records to document care provided. Themaintenance of satellite medical record systems limitedaccess by the cancer care team to all health professionals

documented care delivery. The effectiveness of multidis-ciplinary care is therefore compromised, as a holistic viewof the patient cannot be established when the hospitalmedical record is incomplete.

The study identified support for electronic solutions toimprove access to clinical information by multiple healthprofessionals. The desire expressed by the lung cancerteam for electronic solutions is important, as barriersassociated with the change from paper-based to electronicrecords should be minimised. Within the context of thejurisdiction of the study the person-controlled healthrecord (National Health and Hospitals Reform Commis-sion 2009), a form of Personal Health Record (PHR), andthe EMR to be rolled out by Queensland Health in Aus-tralia under the eHealth Strategy, offer electronic solu-tions. The EMR offers a solution for the lung cancer teamthat would enable access to patients’ health informationby multiple users at their desktop thereby eliminating thecurrent problems associated with access to the paper-based medical record. Additionally the linkage betweenthe EMR and the PHR will mirror the patient-centric EMRas described by Hesse et al. (2010) enabling personalisedsurveillance and enhanced care coordination and thusimproved outcomes in cancer patients.

It is important to note that this study was confined to alung cancer team in one hospital and, therefore, theresults may not be applicable to other tumour streams,nor to other hospitals. However, a key strength of thestudy is the representativeness of professional groupswithin the study sample. Opportunities exist for furtherresearch into communication and information transferbetween members of cancer care teams, for example, theenabling of multidisciplinary engagement at the MDTMeeting. Strategies for improving communication need tobe elicited from health professionals involved in cancercare and evaluated in a broad range of clinical settings.

CONCLUSION

This study has shown that members of a hospital lungcancer team were not communicating effectively andchanges are essential if multidisciplinary care is to bedelivered efficiently and effectively. Multidisciplinarycancer care is a relatively new model of service deliveryfor patients with lung cancer. While guidelines exist onthe formation of cancer care teams they do not take intoaccount the need to integrate this new model of servicedelivery with the existing medical model. Furthermore,the study highlights the necessity to develop and imple-ment EMRs to facilitate communication between allhealth professionals caring for patients with cancer.

ROWLANDS & CALLEN


ACKNOWLEDGEMENTS

The authors wish to acknowledge the contribution ofmembers of the multidisciplinary hospital-based lung

cancer team. The contribution of Professor Johanna West-brook co-supervisor on this research study is alsoacknowledged.

REFERENCES

Adamson B.J., Kenny D.T. & Wilson-Barnett J.A. (1995) The impact of per-ceived medical dominance in theworkplace satisfaction of Australianand British nurses. Journal of AdvancedNursing 21, 172–183.

Australian Bureau of Statistics (2006) 2006Census Data by Location. Available at:http://www.censusdata.abs.gov.au/ABSNavigation/prenav/LocationSearch?ReadForm&prenavtabname=Location%20Search&&&navmapdisplayed=true&textversion=false&collection=Census&period=2006&producttype=&method=&productlabel=&breadcrumb=L&topic=& (accessed 18 July 2007).

Australian Institute of Health and Welfare(2010) Cancer in Australia: An Over-view, 2010. AIHW, Canberra, Australia.Available at: http://www.aihw.gov.au/publication-detail/?id=6442472459&tab=2 (accessed 3November 2011).

Bates E. & Lapsley H. (1985) The HealthMachine. Penguin Books, Vic., Australia.

Boyle F.M., Robinson E., Heinrich P. &Dunn S.M. (2004) Cancer: communica-tion in the Team Game. ANZ Journal ofSurgery 74, 477–481.

Cancer Research UK (2008) Lung cancer –UK incidence statistics. Available at:http://info.cancerresearchuk.org/cancerstats/types/lung/incidence/(accessed 12 February 2012).

Chang J.H., Vines E., Bertsch H., FrakerD.L., Czerniecki B.J., Rosato E.F.,Lawton T., Conant E.F., Orel S.G.,Schuchter L., Fox K.R., Zieber N., GlickJ.H. & Solin L. (2001) The impact of amultidisciplinary breast cancer centeron recommendations for patient man-agement: the University of Pennsy-lvania Experience. Cancer 91, 1231–1237.

Clark R.L. (1981) The control of cancerthrough the interaction of communityphysicians and regional comprehensivecancer centres. Cancer 7, 7–10.

Coiera E. (1996) Clinical communication –a new informatics paradigm. In: Proceed-ings American Medical InformaticsAssociation Annual Fall Symposium,pp. 17–21.

Coiera E. (2000) When conversation isbetter than computation. Journal of theAmerican Medical Informatics Associa-tion 7, 277–286.

Coiera E. (2006) Communication systemsin healthcare. The Clinical Biochemist.Reviews 27, 89–98.

Coombs M. & Ersser S.J. (2004) Medicalhegemony in decision-making – a barrierto interdisciplinary working in intensivecare? Journal of Advanced Nursing 46,245–252.

Creswick N., Westbrook J.I. & BraithwaiteJ. (2009) Understanding communicationnetworks in the emergency department.BioMed Central 9, 1–9. Available at:http://www.biomedcentral.com/1472-6963/9 (accessed 10 May 2010).

Denzin N.K. & Lincoln Y.S. (1998) Collect-ing and Interpreting Qualitative Materi-als. Sage Publications, London, UK.

Department of Health (2000) The NHSCancer Plan. Department of Health,London, UK. Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4014513.pdf (accessed 30June 2008).

Devitt B., Philip J. & McLachlan S. (2010)Team dynamics, decision making,and attitudes toward multidisciplinarycancer meetings: health professionals’perspectives. Journal of Oncology Prac-tice 6, e17–e20.

Fleissig A., Jenkins V., Catt S. & FallowfieldL. (2006) Multidisciplinary teams incancer care: are they effective in the UK?The Lancet Oncology 7, 935–943.

Fleming M., Byrne J. & Szer J. (2009) Howwell are we doing multidisciplinary care?An audit of multidisciplinary meetings inWestern and Central Melbourne.Available at: http://www.wcmics.org/documents/Posters/MDM%20Audit.pdf(accessed 22 May 2011).

Gair G. & Hartery T. (2001) Medical domi-nance in multidisciplinary teamwork: acase study of discharge decision-makingin a geriatric assessment unit. Journal ofNursing Management 9, 3–11.

Glaser B.G. & Strauss A.L. (1967) The Dis-covery of Grounded Theory: Strategiesfor Qualitative Research. Aldine,Chicago, IL, USA.

Gupta T. (2007) Multidisciplinary clinics inoncology: the hidden pitfalls. Journal ofOncology Practice 3, 72–73.

Hesse B.W., Hanna C., Massett H.A. &Hesse N. (2010) Outside the box: willinformation technology be a viable inter-vention to improve the quality of cancercare? Journal of the National CancerInstitute. Monographs 40, 81–89.

Houssami N. & Sainsbury R. (2006) Breastcancer: multidisciplinary care andclinical outcomes. European Journal ofCancer 42, 2480–2491.

Kenny D. & Adamson B. (1992) Medicineand the health professionals: issues ofdominance, autonomy and authority.Australian Health Review 15, 319–334.

Lamb B.W., Sevdalis N., Mostafid H.,Vincent C. & Green J.S.A. (2011) QualityImprovement in Multidisciplinary CareTeams: An Investigation of Teamworkand Clinical Decision-Making andCross-Validation of Assessments. Avail-able at: http://www.annsurgoncol.org/journals/abstract.html?v=0&j=10434&i=-1&a=1773_10.1245_s10434-011-1773-5&doi= (accessed 30 July 2011).

Lanceley A., Savage J., Menon U. & Jacobs I.(2008) Influences on multidisciplinaryteam decision making. InternationalJournal of Gynecological Cancer 18, 215–222.

Leonard M., Graham S. & Bonacum D.(2004) The human factor: the criticalimportance of effective teamwork andcommunication in providing care.Quality and Safety in Health Care 13,85–90.

National Breast Cancer Centre (2005) Mul-tidisciplinary Meetings for Cancer Care –A Guide for Health Service Providers.Australian Government Department ofHealth and Ageing, Canberra, Australia.

National Health and Hospitals ReformCommission (2009) A Healthier Futurefor All Australians – Final Report June2009. Available at: http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/nhhrc-report (accessed 19January 2010).

Queensland Health (2008) QueenslandStatewide Cancer Treatment ServicesPlan 2008–17. Available at: http://pandora.nla.gov.au/tep/108541 (accessed16 February 2009).

Rabinowitz B. (2004) Interdisciplinarybreast cancer care: declaring and improv-ing the standard. Oncology 18, 1263–1267.

Rowlands S., Callen J. & Westbrook J.(2010) What information do generalpractitioners need to care for patientswith lung cancer? A survey of GPsperceptions. The HIM Journal 39, 8–15.

Sainsbury R., Hayward B., Johnston C. &Round C. (1995) Influence of clinicianworkload and patterns of treatment on



survival for breast cancer. Lancet 345,1265–1270.

Sargeant J., Loney E. & Murphy G.(2008) Effective interprofessional team:‘contact is not enough’ to build a team.The Journal of Continuing Educationin the Health Professions 28, 228–234.

Suter E., Arndt J., Arthur N., Parboosingh J.,Taylor E. & Deutschlander S. (2009) Roleunderstanding and effective communica-tion as core competencies for collabora-tive practice. Journal of InterprofessionalCare 23, 41–51.

Toussaint P.J. & Coiera E. (2005) Support-ing communication in health care.

International Journal of Medical Infor-matics 74, 779–781.

Tripathy D. (2003) Multidisciplinarycare for breast cancer: barriers andsolutions. The Breast Journal 9, 60–63.

Victorian Government Department ofHuman Services (2007) Achieving BestPractice Cancer Care: A Guide for Imple-menting Multidisciplinary Care. Mel-bourne, Victoria. Available at: http://docs.health.vic.gov.au/docs/doc/6675BC2B37531110CA2578E80005F63F/$FILE/multidisciplinarypolicy0702.pdf(accessed 30 June 2009).

Wagstaff A. (2006) The dream team: whenwill we make it a reality? Cancer World(May to June), 16–26.

Weaver T.E. (2008) Enhancing multiple dis-ciplinary teamwork. Nursing Outlook56, 108–114.

Willms D.G. & Johnson N.A. (1993) Essen-tials in Qualitative Research: A Note-book for the Field. Mc Master University,Hamilton, ON, Canada.

Wilson V. & Pirrie A. (2000) Multidisci-plinary Teamworking – Beyond theBarriers? A Review of the Issues. TheScottish Council for Research inEducation, Glasgow, UK.

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a qualitative analysis of communication between members of a hospital-based multidisciplinary lung...

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