The research was conducted over a 9-month period with observations undertaken in chemotherapy treatment areas, waiting rooms, consultation and other multipurpose areas (n = 135 h approximately). These common (non-private) areas are primarily serviced by nursing staff but can act as a hub for many different professional groups. Ad hoc, unsolicited discussions with professionals occurred naturally during this fieldwork. Care coordinators, tumour-specific specialist nurses, cancer nurse specialists and senior clinical staff participated in formal navigator interviews (n = 13), totalling six and a half hours. Notably, many of these key informants had worked across more than one of the hospitals, and in various roles such as multi-tumour or tumour-specialised care coordination and oncology nursing.
Analysis: multidisciplinary care in real-world OPC practice
Analysis of these data resulted in the identification of six themes which captured OPC work as done: the care delivery team; professional identity and scope of practice; institutional expertise and capital; design and use of space; communication and flow of information; and negotiating patient-centred care.
Theme 1. Care delivery team
Working as part of a team was regarded as valuable, with staff members describing a shared respect and being in “awe” of their colleagues (key informant (KI)). The concept of “team” was at times taken to refer to a local professional disciplinary grouping (e.g., “chemotherapy nursing”) or to a cluster of different professionals working in a specific location.
The idea of flexible team membership was often discussed in relation to MDTMs. In response to issues that arose, staff members self-organised into teams comprising clinical and non-clinical professionals needed to best address the issue presented.
Administrative staff and other non-clinical staff, such as interpreters, frequently support care delivery, acting as communicators between nursing staff and doctors and in some cases even making efforts to advocate on behalf of patients. (Fieldnote p47)
In discussions, “team” was quite a fluid concept, especially where “we” and “they” (or equivalent) was used to identify oneself and others. “We” was not only employed to identify acts by the professional area of expertise (e.g., “We educate them …” KI9), but was also used to direct cross-disciplinary collaboration:
The doctor was sent for, due to issues arising during pre-chemotherapy checks. The doctor comes to the nursing station and immediately begins speaking: “Right, what we’ll do is… [tasks for the nursing staff to undertake].” (Fieldnote p92)
These terms also highlighted distinctions between professional groups or groups with specific roles: “we’re a very close team” (KI2). “They” terms were often heard in situations where boundaries and responsibilities were negotiated, such as when a senior nurse discussed a patient with colleagues: “he [patient] is not supposed to be there—they put him here because they needed the space. Phone them.” (Fieldnote p280).
Notably, the representation of “team” was carefully enunciated in patient-facing interactions (discussion with or in front of the patient). “We” was used to extend the local team to encompass a broader multidisciplinary expertise (e.g., “here we have a psychologist, who is great” KI12), and to present a united approach:
Oncology nurse: “We were a bit worried about you” (referring to a concern of the doctor and the impetus for the change in care). (Fieldnote p256)
In patient-facing interactions “we” appeared to aid a sense of continuity across professionals and offer reassurance. Staff members attempted to shield patients from conflicting information or concerns about the continuity of care. Where there was potential for discord in this united approach, this was cautiously explored, often involving gentle probing for further information:
Where a patient complains about an ongoing side effect of treatment and felt it was not being taken seriously, the oncology nurse looks concerned and responds: “Did you tell the doctor? What did he say?” The oncology nurse confirms that the date of their next appointment with the doctor is soon and guides the patient on how to raise this issue with them again. (Fieldnote p174)
Theme 2. Professional identity and scope of practice
Professional identity, scope of practice and how individuals negotiate these issues with their colleagues emerged as salient for understanding MDC. Interviewees’ descriptions of their roles, their sense of identity, the associated professional values, as well as the passion they had, was expressed in the comment: “I love what I do, love the patients that I work with” (KI11). The application of professional expertise was observed even in the rare departure from the united approach often presented to patients:
The oncology nurse takes the decision not to administer chemotherapy and the patient voices their dissatisfaction. The nurse responds “you’ll need to go to [hospital], this is not safe anymore. I’ll talk to [doctor]. We are not comfortable to give you this.” (Fieldnote p98)
The respective roles and duties of differing professional groups tended to be cited in the context of potential conflicts. On occasion, a lack of mutual understanding of roles was noted.
While professional remit and duties may have been clear in theory, the scope and boundaries became less so in practice. The desire to prevent patients from “falling through the cracks” (KI13) appeared to contribute to staff members taking on duties which they did not believe was in their job description. This included where other services were overloaded, as illustrated: “I mean it should go totally to them [referring to a service outside of the hospital]. It doesn’t work that way though, it hasn’t for a long time because their staffing is so poor.” (KI5). In many cases the roles of staff members and teams appeared to adapt in response to the capacities of others and the demands made of them:
In response to the needs of the clinic, flexibility in clinicians’ tasks and role was observed. This appeared to be commonplace and expected. Further, staff were observed to go beyond their roles to facilitate care delivery, often becoming involved in other areas such as pharmacy, or even helping with parking issues. (Fieldnote p65)
This adaptability of roles and scope of practice illustrates the potential gap between work-as-imagined and work-as-done in the ambulatory setting.
Theme 3. Institutional expertise and social capital
In addition to professional expertise, a complementary form of “institutional expertise” was observed. Comprising organisational, cultural and social knowledge, this was a valuable resource, often deployed to navigate difficult situations:
Senior nursing staff who had worked in the district or the hospital for a number of years were often called upon where there was uncertainty or an issue. Their memory, history and experience were drawn upon to help navigate challenges. For example, where a patient might need to be admitted, the experienced staff would source information about the status of beds on wards and identify which specific staff members were occupying gatekeeping positions at that time. This was followed by negotiation and sometimes compromise with the relevant stakeholders/parties. (Fieldnote p122)
Because of professional and departmental interdependence, ‘bridges’, or staff who were familiar with or who moved between different areas of strategic importance, relayed information between the settings. These staff members (often senior or managing clinicians) were relied upon to relay status updates and real-time information, which informed near-term planning. As noted:
An experienced oncology nurse worked between the OPC and the ward. They were able to report on how busy other departments were, if there were any issues and the whereabouts/availability of key staff members who might be needed. This information was then factored into decision-making around securing staffing levels and patient transitions between areas. (Fieldnote p220)
Social capital (derived from status and position within social networks) formed another resource for front-line practice. This proved beneficial for navigating cross-disciplinary and interdepartmental issues and was most readily seen where senior nurses were approached by junior colleagues for help. For example:
The oncology nurse reported to the senior nurse that they had been waiting quite a long time for a surgical consultant to visit the patient and could not proceed until this happened. The senior nurse then phoned the consultant, and this request was framed within a humorous exchange, with the senior nurse declaring that the consultant owed the nursing staff coffee at the end of the call. (Fieldnote p256)
Relationships were recognised as vital in MDC practice, with staff members from across disciplinary areas investing in forming and sustaining interpersonal dynamics. At times, this simply involved an explicit commitment to cooperation, such as when a consultant confirmed to a senior nurse: “If he [patient] wants to see me again, page me and I will come down.” (Fieldnote p234).
These efforts could also be seen in the management of potentially tense situations, for example where a doctor was not satisfied with the way in which a nursing colleague had completed a form:
Oncology nurse: “With the form, do we need to fill out another?”
Doctor: “Yes, it’s the strictest thing, so we have got to make sure it’s perfect. Maybe hand do it.”
Oncology nurse: “Thanks [nickname for doctor].” (Fieldnote p134)
Maintenance of relationships, judicious deployment of social capital and the employment of institutional expertise supported formal care processes, and appeared vital for mitigating and resolving issues.
Theme 4. Design and use of space
Multi-site research permitted exploration of services with different treatment capacity (e.g., chemotherapy chairs/beds ranged from 10 to 21), on-site services (e.g., radiation therapy), and location of services such as allied health and oncology pharmacy. Features in the design and layout of OPCs emerged as important contextual mediators of MDC.
Sole and multi-purpose treatment areas created different opportunities for MDC interactions. In one OPC, the space and resources were organised to reflect the steps involved in chemotherapy preparation and administration; over the course of the observations, interactions with inter-professional colleagues were less frequently observed in this setting. In contrast, another OPC with a similar number of chemotherapy treatment spaces contained overlapping functional areas (e.g., it is necessary to walk through the chemotherapy suite to reach allied health) and parts of this space were thoroughfares to the ward and offices. Consequently, this OPC served as a meeting point to share information, find staff members and discuss concerns.
In the two smaller OPCs with multipurpose spaces, it appeared easier for allied health, treating physicians and other professional disciplines to casually visit patients while they were attending the clinic. This led to introductions, informal chats and consultations being undertaken while patients were waiting for or undergoing treatment (Fieldnote p57). In reality, even where spaces were not obviously multipurpose, they often functioned as such. For example, nurses working at the station of the chemotherapy treatment area were observed to field questions about a wide range of coordination issues, such as explaining parking and giving directions.
Where space was limited, staff adapted and used available free areas, including corridors and waiting areas; during fieldwork it became apparent that attempts to map key locations for multidisciplinary interaction in OPCs was futile as it occurred wherever staff met. Some staff members recognised the difficulties of working within limited space: “it is just that the work environment is quite small so it can be difficult to see patients and to deal with things that are coming up and changing” (KI8). Staff also highlighted the ways in which they tended to anticipate each other and act proactively to ensure consistent workflow given the confines of a small space.
The physical co-location of services and professionals influenced access to various expertise and input, as well as workflow in the chemotherapy treatment area. This was best seen in the interaction between pharmacy and chemotherapy staff. In one OPC, nursing staff could “just pop your head through” (Fieldnote p101), for immediate, in-person discussion with the pharmacist; this was valuable where there were schedule changes or when less common drugs were involved.
While at first glance the potential immediate access to inter-professional colleagues could be highly beneficial, a distinction was made between staff members being “present” and being “available” (KI9). For example, a common source of delay occurred where input from a doctor was needed to advise on whether chemotherapy should proceed, but the physician was not immediately available (e.g., in a consultation with a patient). Sometimes nursing or administrative staff spent time trying to track down the doctor in person. There was a recognition that doctors were attempting to prioritise and manage their, often multi-location, workloads. As one oncology nurse put it “you don’t own their time” (KI9).
Theme 5. Communication and flow of information
Co-location of consultation, treatment and other service areas was viewed as aiding communication “because you have all those prompts that you wouldn’t normally have” (KI13). This enabled opportunistic conversations, which staff found useful in situations “where you just need a quick, ‘yep that’s fine’” (KI13). Pursuing ad hoc communication, facilitated by physical co-location, was carefully exercised, taking into account urgency and appropriateness. Staff members were attuned to particular nuances, such as catching the doctor “between patients” or only calling in when the “door was ajar” (KI11). Unwritten/informal rules shaped communication practices:
[Discussing the delay that occurs when input is needed from a doctor to progress chemotherapy]
KI10: “Yeah. I guess a pager, but we don’t page them.”
Interviewer: “Is that because it's easier just to try and grab their attention?”
KI10: “I’m not sure. I’ve just been told just find them. If they are not there, just wait. I guess if they're in a meeting or with a patient you would only page them if it was an emergency.”
Drawing on institutional knowledge, methods of communication were often individually tailored, for example: “no, she won’t check that for ages, email her, she’s quick on that” (KI6).
It was not possible to observe electronic communication, such as emails or the oncology information system firsthand in the fieldwork; nevertheless, as this was a frequent topic of conversation, these discussions are pertinent in this theme. The potential benefits of centralised and shared oncology information systems for MDC were recognised by staff members. As one professional put it: “the psychologist will have documented that [they’ve] seen the patient and different things that need to be noted around that and we can pop in and we can see that” (KI8). Conversely, electronic documentation was noted as not always being well-integrated in the workflow. As one staff member reported: “So you might go, ok everyone is actually okay, so I’m going to… I will quickly sneak in [to the electronic system] and do this and catch up with the documentation that’s required” (KI8).
Electronic documentation could also provide a sense of protection for staff by providing a record of events: “if something were to happen, I need to provide that evidence [in order] to say, ‘no hold on, this is the communication trail’” (KI3). However, electronic communication was viewed as cumbersome and unreliable at times, especially when information was needed immediately, as one staff member expressed: “I’d rather pick up the phone than e-mail” (KI5). Staff members did not always appear confident about whether the information was up to date, as indicated by staff double-checking the information verbally and cross-checking with colleagues whether this “sounded right” (Fieldnote p167).
Staff members were very aware of potential communication issues and took steps to mitigate the risk of possible pitfalls:
Following the deterioration of a patient, the oncology nurse involved in their care discussed their status with a senior nurse. The senior nurse asked the oncology nurse whether they might be available to switch shifts, so that they could be there when the consultant arrived, to handover and liaise the following day. (Fieldnote p72)
Points of transition in care appeared to be of particular concern, and this included transitions between services in the same district, as noted:
“it's okay to go, we'll treat the patient here and then treat them over there …but it's about continuity of care. And, again, I may know something and if, [that service] doesn't know [it, they] might potentially miss something.” (KI12)
Coherent with the patient-facing approach described earlier, staff were vigilant about the potential negative impacts that communication issues could have on patients, and attempted to carefully manage this:
“we've had to say, unless [it is clear the patient has been informed], we're not touching it […] I've said ‘hi my name is [name] I’m the [role] at [hospital]’ and it’s literally, ‘do I have cancer? Nobody told me. How come no one told me?’” (KI2)
Staff members invest time in attempting to untangle confusing and conflicting information from sources such as caregivers, interpreters, electronic systems and other staff members in order to clarify events and ensure continuity of care for the patient.
Theme 6. Negotiating patient-centred care
MDC occurred in many areas in the OPC, but nowhere was patient-centred care better exemplified, in the areas observed, than when the patient was in the chemotherapy suite:
The oncology nurse shows the patient in and prepares them for treatment, they conduct an assessment (e.g., weight), ask about any issues and follow up with ongoing concerns. Following discussion with a patient, the oncology nurse states: “yep, yep, still no good, let me just…”. The oncology nurse pages the dietician who arrives about 20 minutes later to speak to patient. (Fieldnote p287)
There was a “while you are here” (KI6) approach taken, as various professionals used this time for impromptu consultations. In some cases, it appeared opportune for several separate patient needs to be addressed when the patient attended the clinic. While there are alternative forums for engagement, this approach appeared to overcome barriers, including for patients for whom English language proficiency is a barrier:
“I must admit, if it is a post op patient that I haven't met, I often won't call them [beforehand]. I wait till they are on the ward, arrange an interpreter or see them in clinic when I know the interpreters are there because it's too difficult to have a three-way conversation.” (KI7)
Interaction between staff and patients was frequently typified by humour, empathy and familiarity, as illustrated in the interaction between an oncology nurse and a patient: “oh yes that’s right, and what was it, what is he called again, your fish?” [Discussion about a patient’s pet fish]. (Fieldnote p101).
Staff members negotiated a tension between the time taken to provide this care and competing demands on the clinic. As captured by one interviewee:
“It’s also the high patient load, it is really difficult. Sometimes you can see that a patient has been sitting in the waiting room for like 45 minutes. Then you bring them in and they wait another 30 minutes. Then you still can’t check the chemo [two oncology nurses need to review the information prior to chemotherapy administration] … and it sucks because you know they don’t want to be here, and they are having a [bad] day just from being here.” (KI10)
To this end, staff members within nursing teams sought to work together optimally, but were concerned about short-staffing, and worried about the implications if they took leave. In day-to-day practice staff members sought to shield patients from this tension and ensure the preservation of patient dignity:
Upon discovering that a patient had become confused and not taken a medication required in advance of chemotherapy treatment, the oncology nurse consulted the senior nurse, who organised it so that the patient could receive the drug intravenously (lengthening their time in the chair and impacting the schedule). While explaining the adaption to their care, the nursing staff minimised the issue and joked with the patient about being a “trouble-maker” who kept them on their toes, as after all, someone needed to. (Fieldnote p234)
Synthesis, barriers and facilitators
The four Cs—complexity, coordination, culture and capacity—were identified as key characteristics of MDC in ambulatory care settings, acting as threads that bind the themes. From this synthesis, factors which serve as barriers or facilitators were derived.
Staff variously navigate the complexity, or manoeuvre within it, in an attempt to make their way in organisational settings and coordinate their own and others’ activities. The delivery of MDC relies on coordinated and timely input from various professionals, each responsible for managing their workloads; misalignment of their respective priorities may present a barrier. Here, individual acumen is an asset, where team members make decisions about the ongoing allocation of their time, including assessing costs associated with participating in ad hoc collaboration and care. The self-organisation of staff, often across professional boundaries with shared superordinate goals, helps to tackle issues which require a multidisciplinary response. This was observed where administrative staff helped to coordinate between doctors, managers, pharmacists and chemotherapy nurses to secure appropriate approvals and obtain a newly-approved drug available via a compassionate access scheme. While cross-department collaboration was challenging at times, bridges linking these networks and the benefit of institutional knowledge helped staff to predict responses and informed forward planning.
The complexities of cancer care pose coordination challenges for staff, patients and their caregivers. OPC observations offer a glimpse into the plethora of services and professionals involved at a time point in the patient journey. While many aspects of care coordination are anticipated and planned, we noted the emergence of issues at the point of care. Descriptions of the themes provide examples of how staff members responsively adapt (e.g., paging the dietician to consult with a patient while they are receiving chemotherapy [Fieldnote p287]), sometimes aided by co-location, prioritisation and flexibility in staff members’ time and roles, as well as the fluidity of team membership. There was an awareness among staff about the potential pitfalls in coordination within and between services, and staff deployed institutional knowledge and flexibility in their roles to anticipate and address gaps (e.g., covering additional aspects of care where the relevant service did not have the capacity [KI5]). There was a concerted effort to preserve continuity of care for patients, with staff shielding patients from failures of communication or coordination.
MDC necessitates interdependent input from individuals each with their own respective professional identities and values. An appreciation of a colleague’s expertise, time constraints (e.g., “we don’t own their time” [K9]) and boundaries can enable collaboration. However, even where this appreciation was evident, misaligned priorities or pressure could potentially strain these relationships, forming barriers to MDC delivery. Social ties across disciplines provided channels for information flow, promoted cooperation and helped to dissipate tension. Often the social capital and institutional expertise of senior staff was called upon, offering an opportunity for junior colleagues to learn about the informal social conventions employed to sustain harmony and navigate difficulties. Striving for patient-centred care was core to professional identity, and connectedly the impetus to go “above and beyond” (K7) to achieve this appeared deeply ingrained within the culture.
A range of supports and resources are needed to facilitate practice in ambulatory settings. A key tool for staff is the electronic oncology information system, as this has capacity to centralise pertinent information, refer to colleagues (e.g., allied health) and to communicate changes. However, the doubts staff expressed about the recency of information suggest this system is not perceived as optimal, and potentially may be a barrier. Much of the ad hoc collaboration arising as a result of the identification of needs during clinic visits was made possible by the availability, proximity and workload adaptations of relevant staff members. Sufficient staffing was cited as an issue, with some professionals concerned about letting down colleagues, or in some cases resulting in limits on services offered (e.g., it was not possible to open assessment spaces in OPCs without a certain staffing profile).