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The role of the keyworker in breaking down professional culture barriers to providing high-quality palliative care: a literature review

Published online by Cambridge University Press:  04 September 2013

Carina Feuz
Carina Feuz*
Affiliation:
Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, 610 University Avenue, Toronto, Ontario, Canada M5G 2M9
*
Correspondence to: Carina Feuz, 610 University Avenue Rm 6-103, Toronto, Ontario, Canada M5G 2M9. Tel: 416-946-4501 × 3197. Fax: 416-946-2019. E-mail: carina.feuz@rmp.uhn.on.ca
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Abstract

Background

Palliative cancer care is by definition multi-professional in nature. An interdisciplinary approach to disease management emphasising continuity of care results in increased quality of life for patients and families. Complex disease management demands the provision of a full spectrum of high-quality care; requiring both specialist and generalist services. Appointed keyworkers are knowledgeable about patient preferences enabling effective coordination of care and promotes collaborative team-working. The need for diversity in the provision of palliative care is recommended but can challenge effective interdisciplinary collaboration by creating tension and limiting the interdisciplinary team (IDT) from reaching its full potential resulting in adverse outcomes.

Purpose

The purpose of this paper is to review the literature available regarding how IDTs and keyworkers influence high-quality palliative care; evaluate how professional culture barriers can influence team collaboration; discuss the keyworker role in minimising these barriers and clinical implications.

Methodology

A review of the English literature from 2003 to 2013 was performed using the databases PubMed (NML), OVID Medline and Google Scholar.

Results and conclusion

Keyworkers can help overcome professional culture barriers that result from ineffective team communication. Facilitating improved communication regarding professional roles fosters mutual understanding among team members. The dissemination of relevant and timely information minimises fragmentation, prompting team decision-making and promotes continuity of high-quality palliative care.

Keywords

advanced practicecancerinterdisciplinarykeyworkerpalliative careprofessional cultureradiotherapy
Type
Literature Reviews
Information
Journal of Radiotherapy in Practice , Volume 13 , Issue 4 , December 2014 , pp. 465 - 472
Copyright
Copyright © Cambridge University Press 2013 

Introduction

The World Health Organization 1 definition of palliative care states that patients facing the challenges associated with life-threatening illnesses, including cancer, can experience improved overall quality of life when there is access to early identification, assessment and treatment of all issues related to their disease.Reference Wittenberg-Lyles and Oliver 2 , Reference Wittenberg-Lyles, Oliver, Demiris and Regehr 3 In addition to quality of life, the definition emphasises an interdisciplinary team (IDT) approach to disease management, which is evident in current care initiatives including the National Institute for Clinical Excellence guidelines, 4 NHS End-of-Life Care Strategy 5 and the Cancer Care Ontario Palliative Care Strategy. 6 An IDT is comprised of two or more professionals, from different disciplines, working interdependently towards a common goal by actively communicating, sharing and coordinating information to produce a product that is a direct result of the team's collaborative effort and synergy.Reference Abbott, Townsley and Watson 7 – Reference Youngwerth and Twaddle 11 Interdisciplinary collaboration allows teams to achieve results that are superior in quality and not necessarily feasible by working separately. Leadership within IDTs is task dependent and non-hierarchical with emphasis placed on establishing an understanding and appreciation for the various roles and contributions of each discipline; in addition to incorporating team decision-making, planning and goal setting.Reference Pecukonis, Doyle and Bliss 10 , Reference Youngwerth and Twaddle 11

Practice guidelines recommend that palliative cancer care should be interdisciplinary with an emphasis on promoting continuity of care for patients, which may involve the appointment of a keyworker to act as a primary contact for patients and families, in addition to promoting collaborative team working and facilitating care across service providers. 4 , Reference Abbott, Townsley and Watson 7 , 12 Despite recommendations for the need for IDTs in the provision of high-quality cancer care, bringing various disciplines together, each with their own professional culture, varying in beliefs, values and customs, can introduce challenges to effective team working.Reference Hall 8 Lack of interprofessional understanding regarding roles and abilities can challenge effective communication and cause conflict; negatively impacting continuity of care and quality of life for patients.Reference Verhovsek, Byington and Deshkulkarni 13

This paper will critically explore how the IDT and keyworker influences holism in palliative care; evaluate how professional culture can be a barrier to effective team collaboration; discuss how the keyworker can minimise professional culture barriers and implications for practice, with an emphasis on the keyworker role within radiotherapy.

Methodology

The search strategy for this review used the databases PubMed (NML), OVID Medline and Google Scholar. Key words used, alone or in combination, for this review were:

interprofessional, interdisciplinary, multidisciplinary, collaboration, collaborative practice, team-working, keyworker(s), holism, professional culture, barriers, challenges, communication, team, service providers, radiation therapy, allied health, palliative care and clinical implications.

The literature was limited to journal articles written in English and published after 2003 to ensure that the literature being reviewed was recent and up-to-date. There were no restrictions on the country of origin where the publications were produced, which helped to provide a range of opinions and experiences.

Searches of the online databases using ‘interdisciplinary’, ‘interprofessional’ and/or ‘multidisciplinary collaboration’ produced large results and were refined further when used in combination with other key words. Articles identified from the refined search were further reviewed on an individual basis for content. Inclusion criteria consisted of interdisciplinary collaboration, coordination of care, keyworkers, professional culture barriers, effective communication strategies and clinical implications.

Interdisciplinary collaboration and holism

Palliative cancer care is a complex and dynamic process whose patient care requirements cannot be fulfilled by one discipline; requiring a collaborative interdisciplinary approach to care.Reference Bainbridge, Brazil, Krueger, Ploeg and Taniguchi 14 – Reference Chan and Nichols 16 Practice guidelines 4 , 12 have recommended IDTs be the standard of care to promote and ensure continuity of care for palliative patients. Wittenberg-Lyles et al.Reference Wittenberg-Lyles, Oliver, Demiris and Regehr 3 supported the use of IDTs by identifying them as a core element in the collaborative practice in palliative care and hospices. Chan and NicholsReference Chan and Nichols 16 also supported the guidelines by recognising that team-working is an essential component to providing an effective holistic approach to care, which has increased quality of life for patients. Having a healthcare team that is diverse in its composition of providers and services enables provision of care that is responsive to a range of ongoing and changing patient care needs.Reference Crooks, Castleden, Hanlon and Schuurman 17 The IDT approach has also been noted as being a cost-effective method to providing care in a demanding healthcare system while creating a holistically caring environment.Reference Beales, Walji, Papoushek and Austin 18 – Reference Nugus, Greenfield, Travaglia, Westbrook and Braithwaite 20 VytReference Vyt 21 stated that interdisciplinary collaboration provided better service and yielded better healthcare and patient outcomes, which was echoed in several other studies.Reference Pecukonis, Doyle and Bliss 10 , Reference MacDonald, Bally, Ferguson, Murray, Fowler-Kerry and Anonson 19 , Reference Gagliardi, Dobrow and Wright 22 Youngwerth and TwaddleReference Youngwerth and Twaddle 11 also supported these findings and added that IDTs were the most effective method to complete complex tasks, which maximised patient care delivery and was recommended as a ‘comprehensive approach for healthcare teams to provide patient-centred care; combining skills, experience and knowledge to produce superior outcomes’.

Practice guidelines identify that a key element in providing quality palliative care, while working within IDTs, is the ability to provide comprehensive and well-coordinated care that will enhance patients’ overall quality of life. 4 , 6 , 12 Pollock et al.Reference Pollock, Wilson, Porock and Cox 23 also identified that knowledge and access to timely and appropriate palliative care services provided patients with support that assisted in decreasing unscheduled admissions and emergent use of acute care facilities, improving both healthcare and patient outcomes. Studies have demonstrated the importance of the keyworker role in coordinating care by ensuring patients and families are informed of appropriate palliative care services and resources, in addition to promoting collaborative team-working and facilitating care services.Reference Abbott, Townsley and Watson 7 , 12 , Reference Brogaard, Jensen, Sokolowski, Olesen and Neergaard 15 , Reference Chan and Nichols 16 , Reference Payne, Kerr, Hawker, Hardey and Powell 24

Coordination of care by a keyworker is considered an essential task.Reference Brogaard, Jensen, Sokolowski, Olesen and Neergaard 15 The preferred team member identified within the literature to take on the role of the keyworker is the Clinical Nurse Specialist or general practitioner. 4 , Reference Lamb, Taylor and Lamb 25 , 26 However, it has been argued that the coordination of care is within the scope of all healthcare professionals (HCPs) and the responsible individual can be any HCP with the knowledge, skills and judgement to support the patient and integrate care. 12 The core responsibilities of a keyworker are summarised in Table 1. In addition to being a point of contact for patients and families, the keyworker can help maintain a holistic care plan, which is based on patients’ specific values and end-of-life goals.Reference Abbott, Townsley and Watson 7 , Reference Herbert 27 Keyworkers are able to build trusting relationships with patients and therefore can obtain a better understanding of patient preferences regarding care. Building relationships allows the keyworker to engage the patient in shared decision-making processes, which help to maintain autonomy and fosters service user engagement.Reference Ryder, Beattie, O'Hanlon and McDonald 28

Table 1 Core responsibilities of the keyworker 4 , 26 , 51

Due to the multi-professional nature of providing holistic palliative care services, fragmentation of information is often a challenge to providing coordinated, integrated and seamless care.Reference Bainbridge, Brazil, Krueger, Ploeg and Taniguchi 14 , Reference Chan and Nichols 16 , Reference Payne, Kerr, Hawker, Hardey and Powell 24 Often, no one person is fully acquainted with the patient's history or preferences and therefore cannot effectively coordinate the transfer of information among IDT members.Reference Payne, Kerr, Hawker, Hardey and Powell 24 However, studies have shown that the keyworker can play a vital role by acting as a patient advocate and share patient-specific information with the IDT.Reference Wittenberg-Lyles and Oliver 2 , Reference Chan and Nichols 16 After obtaining this information, the IDT can develop a better working relationship with the patient and family, improving the quality, efficiency and coordination of care by providing a comprehensive holistic shared-care plan, leading to increased patient satisfaction and improved overall quality of life.Reference Abbott, Townsley and Watson 7 , 12 , Reference Chan and Nichols 16 , Reference MacDonald, Bally, Ferguson, Murray, Fowler-Kerry and Anonson 19 , Reference Vyt 21 , Reference Gagliardi, Dobrow and Wright 22 , Reference Payne, Kerr, Hawker, Hardey and Powell 24 , Reference Salhani and Coulter 29

Treatment advancements and increased survivorship of palliative cancer patients has put pressure on generalist and palliative specialist teams to produce high-quality cancer care.Reference Fennell, Das, Clauser, Petrelli and Salner 30 , Reference Mitchell, Burridge, Colquist and Love 31 The multidimensionality of healthcare, as identified by Verhovsek et al.Reference Verhovsek, Byington and Deshkulkarni 13 and Vyt,Reference Vyt 21 has resulted in increased numbers of specialised healthcare providers and a decrease in interdisciplinary exchange. However, HallReference Hall 8 argues that the complexity of disease management deems IDTs necessary to provide a full spectrum of high-quality care. There is therefore a need for both specialist and generalist roles and services. Available care should be based on the particular needs of the patient and a patient-centred approach can assist the blending of generalist and specialist services.Reference Axelsson and Axelsson 32 , Reference Manca, Breault and Wishart 33 Effective collaboration between these two groups can be mutually beneficial as it allows the team to achieve goals not otherwise possible by providing opportunities for accessing resources and services that are integrated for the specific benefit of the patient.Reference Pecukonis, Doyle and Bliss 10 , Reference Youngwerth and Twaddle 11 , Reference MacDonald, Bally, Ferguson, Murray, Fowler-Kerry and Anonson 19 , Reference Badger, Plumridge, Hewison, Shaw, Thomas and Clifford 34 , Reference Groot, Vernooij-Dassen, Crul and FGrol 35

Barriers to effective interdisciplinary collaboration: professional culture

The need for diversity in the provision of high-quality palliative care has been recommended in practice guidelines from Canada and the United Kingdom. 4 , 5 , 12 Although the literature also recognises the benefits of interdisciplinary team-working, a recognised strength of palliative care, it identifies that effective IDTs must also have the desire to work together to achieve a common goal, which provides a holistic and patient-focused approach to disease management.Reference Hall 8 , Reference Crooks, Castleden, Hanlon and Schuurman 17 , Reference Suter, Arndt, Arthur, Parboosingh, Taylor and Deutschlander 36 It is this need for diversity in team-working, which can be a barrier to effective interdisciplinary collaboration,Reference Bainbridge, Brazil, Krueger, Ploeg and Taniguchi 14 , Reference Salhani and Coulter 29 , Reference Pype, Symons and Wens 37 in particular, the impact of professional culture.

Each healthcare profession has its own unique culture consisting of specific norms and expectations regarding values, beliefs, customs, behaviours, attitudes, language and approaches to problem solving.Reference Pecukonis, Doyle and Bliss 10 , Reference Verhovsek, Byington and Deshkulkarni 13 , Reference Fennell, Das, Clauser, Petrelli and Salner 30 HallReference Hall 8 stated that ‘a long history of class differences and gender issues underlies current challenges to collaborative teamwork in healthcare’. Traditional roles and barriers to collaboration, such as professional hierarchy, between professions can create tension and limit the IDT from reaching its full potential.Reference Beales, Walji, Papoushek and Austin 18 , Reference MacDonald, Bally, Ferguson, Murray, Fowler-Kerry and Anonson 19 , Reference Baxter and Brumfitt 38 For example, physicians are often considered by other professions to be leaders and ultimate decision makers due to the extent of their education and scope of practice.Reference Fennell, Das, Clauser, Petrelli and Salner 30 Each culture is re-enforced through education, often delivered in silos, and socialisation, which begins early during training and transcends into the workplace.Reference Hall 8 , Reference Verhovsek, Byington and Deshkulkarni 13 , Reference Liston, Wagner and Miller 39 These firmly entrenched beliefs and values will often result in lack of interprofessional understanding, leading to misconceptions, stereotyping and communication barriers.Reference Hall 8 , Reference Verhovsek, Byington and Deshkulkarni 13 , Reference MacDonald, Bally, Ferguson, Murray, Fowler-Kerry and Anonson 19 , Reference Chung, Manga, McGregor, Michailidis, Stavros and Woodhouse 40 , Reference Powell and Davies 41 As Chung et al.Reference Chung, Manga, McGregor, Michailidis, Stavros and Woodhouse 40 acknowledged, professional cultural constraints can challenge effective IDT collaboration. Several studies have identified some adverse patient outcomes, which can occur as a result of the impact of professional culture on collaboration and communication. These can include: delayed treatment planning or implementation, which compromises overall care and patient safety, duplication of work and incomplete patient follow-up, which can cause increased anxiety; negatively influencing patient satisfaction and quality of life.Reference MacDonald, Bally, Ferguson, Murray, Fowler-Kerry and Anonson 19 , Reference Fennell, Das, Clauser, Petrelli and Salner 30 , Reference Suter, Arndt, Arthur, Parboosingh, Taylor and Deutschlander 36 , Reference Chung, Manga, McGregor, Michailidis, Stavros and Woodhouse 40

Although professional culture can be a barrier to effective interdisciplinary collaboration, it can be overcome by one key element: improved communication. The Canadian Hospice Palliative Care Association's Pan-Canadian Gold Standards for Palliative Home Care guidelines 12 states that communication is essential for interdisciplinary collaboration and case management. Communication allows team members to better understand and respect the distinct roles of other professions; encourages the development and sharing of common goals and philosophies; permits individuals to work to their full scope of practice and enhances collaboration to ensure continuity of care for patients. The literature supports the guideline by acknowledging that communication demonstrates respect for each discipline's contributionsReference Youngwerth and Twaddle 11 and commitment to sharing responsibility for patients’ overall care plans.Reference Youngwerth and Twaddle 11 , Reference Groot, Vernooij-Dassen, Crul and FGrol 35 Team members are obligated to act within their scopes of practice, which must be communicated to the team to clearly define professional responsibilities and minimise role overlap and misconceptions. 12 , Reference Beales, Walji, Papoushek and Austin 18 , Reference MacDonald, Bally, Ferguson, Murray, Fowler-Kerry and Anonson 19 Clarification of roles and responsibilities, through formal interprofessional education and experiential learning, fosters trust and mutual understanding among team members, which positively impacts patient care and quality of life. Despite the growing popularity of electronic communication methods, several studies have identified that in-person IDT meetings and communication are more effective in breaking down traditional discipline boundaries within teams and fostering mutual respect and collaboration.Reference Wittenberg-Lyles and Oliver 2 , Reference Neergaard, Olesen, Jensen and Sondergaard 42 In addition to team meetings, King et al.Reference King, Thomas, Martin, Bell and Farrell 43 determined that structured programs, such as the Gold Standards Framework (GSF), utilising a GSF coordinator, helped to improve communication between IDT members and services. The GSF was found to reinforce good practices and strengthen collaborative relationships between generalist and specialist palliative care services, ensuring improved quality and continuity of care. In addition to the GSF, the Liverpool Care Pathway was also identified as helpful in coordinating non-specialised care.Reference Payne 44

As previously discussed, the coordination of palliative care services is challenging and the keyworker can play a vital role to ensuring care is patient-centred, well-coordinated and integrated. Keyworkers can help overcome professional culture barriers that result from ineffective team communication. Guidelines 4 , 12 recognise keyworkers as an essential member of the healthcare team who have the flexibility and opportunity to collaborate with various disciplines to develop care pathways, which optimise team skills and competencies that would best benefit patients’ overall care needs. Keyworkers are also valuable information resources who can provide education to generalist team members about available specialist services. 12 , Reference Pollock, Wilson, Porock and Cox 23 By being a source of extra information, keyworkers play an active role in collaborative communication during IDT meetings.Reference Wittenberg-Lyles and Oliver 2 , Reference Abbott, Townsley and Watson 7 The IDT will gain a better overall understanding of the patient's needs by having a keyworker who can disseminate and provide access to timely and relevant information that will result in prompt clinical decision-making and healthcare outcomes.Reference Chan and Nichols 16 The keyworker can facilitate team collaboration and keep care focused and well-coordinated by communicating to the IDT the distribution of roles and responsibilities; minimising the fragmentation of information, role overlap and duplication of tasks, which will ensure well-integrated high-quality care.Reference Brogaard, Jensen, Sokolowski, Olesen and Neergaard 15

Clinical implications

Working within the IDT can have several clinical implications impacting both patients and HCPs. An IDT approach will improve the efficiency and effectiveness of healthcare services through increased interdisciplinary collaboration. This will not only enhance patient-related outcomes but will reduce healthcare costs due to more effective and timely use of available resources by patients. 12 , Reference Nugus, Greenfield, Travaglia, Westbrook and Braithwaite 20 , Reference Salhani and Coulter 29 The IDT is an example of a shared-care approach to providing high-quality palliative care. Through collaboration, teams develop common goals and objectives that are driven by being patient-focused and sharing responsibility for care.Reference Spruyt 45 This requires equal involvement and cooperation between team members and demands knowledge and acceptance of each other's abilities and roles, including professional culture, in the delivery of care.Reference Vyt 21 , Reference Neergaard, Olesen, Jensen and Sondergaard 42 , Reference Petri 46 Interprofessional understanding is necessary to decrease conflict and to prevent HCPs from retreating back into their own professional culture.Reference Beales, Walji, Papoushek and Austin 18 Although IDTs enhance information exchange,Reference Zwarenbstein, Goldman and Reeves 47 it also requires compromise from all team members.Reference Pecukonis, Doyle and Bliss 10 Programs such as the GSFReference King, Thomas, Martin, Bell and Farrell 43 , 48 and the Ontario Family Health Team Initiative 49 help guide HCPs in the standardisation and delivery of interdisciplinary care by providing tools to improve transfer of information, which can include assessment and care planning protocols, electronic or common patient records, case conferences and regular team/family meetings. 12 , 26 These standardisations ensure quality and continuity of care and improve satisfaction among patients and HCPs.

One benefit of interdisciplinary collaboration identified in the literature is the concept of role expansion.Reference Abbott, Townsley and Watson 7 , Reference Hall 8 , Reference Petri 46 By working as individual professions, it is a challenge to remain knowledgeable and current about available resources both within the community and at tertiary care facilities. HCPs benefit from consulting with each other at team meetings and tumour boards or via patient records and online cancer care registry networks, such as the Uniting Primary Care and Oncology Network, in Manitoba, Canada.Reference Mitchell, Burridge, Colquist and Love 31 , Reference Sisler and McCormack-Speak 50 Collaboration enables professionals to expand their role within the group by gaining different knowledge and skills, which may not have been originally feasible by working independently.Reference Abbott, Townsley and Watson 7 , Reference Hall 8 This provides opportunities for development of potentially new service initiatives, which will benefit patients. Sharing care responsibilities has also shown to increase HCP's job satisfaction and minimise burnout.Reference Youngwerth and Twaddle 11 , Reference Vyt 21 , Reference Petri 46

Radiation therapists in the role of the keyworker

The keyworker has been established as beneficial to effective IDT working. Practice guidelines 4 , 26 , 51 identify that care needs change and recognise the individual in the keyworker role will also change as the patient transitions through various treatments and stages of disease. A radiation therapist can effectively act as a keyworker while the patient is undergoing radiotherapy; provided that the individual has the knowledge, skills and judgement to coordinate appropriate and well-integrated care. 12 Radiation therapists are currently major contributors in providing information to patients regarding the radiotherapy process.Reference Halkett and Kristjanson 52 , Reference Halkett, Merchant and Jiwa 53 In addition to having excellent communication skills, radiation therapists are already working in consultant roles with good outcomes; helping to minimise wait times by providing additional resources.Reference Shi, Cox, Atyeo, Loh, Chuong and Back 54 Current practice at the author's institution and a suggestion for future practice would be for individuals to remain site specific and become specialists for one particular site group to assist in developing the necessary breadth and depth of knowledge required for working within the keyworker role. 12

The development of professional frameworks for practice is also required to support development of the specialised skill sets required for undertaking this particular role. Professional guidance, such as the NHS Knowledge and Skills Framework pertaining to the responsibilities of the keyworker, have already been established within the United Kingdom and provides institutions with an outline recommending the specific knowledge and skills necessary to fulfill the role. 26 , 51 The development and implementation of keyworkers will have implications on institutional resources should organisations wish to incorporate the position into current clinical practice. Institutions should provide individuals with initial training, continuing education and support, in addition to on-going monitoring and evaluation of the keyworker by both the IDT and patient (i.e. patient satisfaction surveys). 12 , 51 Regardless of the individual's profession, the focus of the keyworker is to facilitate effective collaborative team-working and decision-making while coordinating care by informing patients about available resources and services, which will deliver high-quality palliative care. Thereby, positively impacting the patient experience and improving their overall quality of life.

Conclusion

The IDT is a key element in providing high-quality palliative cancer care. Due to the complexity of palliative disease management, the IDT is needed to provide patients with a full spectrum of care, which has been shown to increase patient satisfaction and improve quality of life. Teams with the desire to work together will develop a well-coordinated and comprehensive shared-care plan comprising common goals and objectives. As a member of the IDT, keyworkers are fundamental in the promoting the facilitation and coordination of palliative care services; ensuring care is patient-centred and well-integrated.

Despite the known benefits of working within an IDT, professional culture and a lack of interprofessional understanding is considered to be a barrier to effective collaboration. Professional culture barriers are often overcome by increased communication regarding professional roles and abilities that fosters respect and mutual understanding among team members. The keyworker can play an important role in overcoming professional culture barriers that result from ineffective communication by disseminating relevant and timely information, which minimises fragmentation and duplication of tasks. Open and effective communication is essential to address patients’ needs and promotes continuity of high-quality palliative care; resulting in increased patient satisfaction, improved healthcare and patient outcomes and overall quality of life, which is considered the primary goal of palliative care.

Acknowledgements

None.

Sources of Support

None.

References

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Figure 0

Table 1 Core responsibilities of the keyworker4,26,51