Multilevel barriers to communication in pediatric oncology: Clinicians' perspectives

Abstract

BACKGROUND: Communication serves several functions in pediatric oncology, but communication deficiencies persist. Little is known about the broad spectrum of barriers contributing to these deficiencies. Identifying these barriers will support new strategies to improve communication. METHODS: The authors performed 10 focus groups on perceived communication barriers with nurses, nurse practitioners, physicians, and psychosocial professionals across 2 academic institutions. They analyzed transcripts by adapting a multilevel framework from organizational psychology. RESULTS: The authors identified 6 levels of barriers to communication from the clinicians' perspectives: individual, team, organization, collaborating hospital, community, and policy. Individual barriers were subdivided into clinician characteristics, family characteristics, or characteristics of the clinician-family interaction. Within each level and sublevel, several manifestations of barriers were identified. Some barriers, such as a lack of comfort with difficult topics (individual), cultural differences (individual), a lack of a shared team mental model (team), and time pressure (organization), manifested similarly across professions and institutions. Other barriers, such as a need for boundaries (individual), intimidation or embarrassment of family (individual), unclear roles and authority (team), and excessive logistical requirements (policy), manifested differently across professions. With the exception of collaborating hospitals, participants from all professions identified barriers from each level. Physicians did not discuss collaborating hospital barriers. CONCLUSIONS: Nurses, nurse practitioners, physicians, and psychosocial professionals experience communication barriers at multiple levels, which range from individual-to policy-level barriers. Yet their unique clinical roles and duties can lead to different manifestations of some barriers. This multilevel framework might help clinicians and researchers to identify targets for interventions to improve communication experiences for families in pediatric oncology.

Multilevel barriers and facilitators of communication in pediatric oncology: A systematic review

“…Team‐level factors were identified in 10 studies. Hierarchy within teams and perceived authority seemed to affect clinicians’ communication practices, especially related to prognostic discussions and introduction of palliative care 16,55,70 . Clear delineation and delegation of this authority seemed to facilitate communication 16,42,55,60,124 .…”

“…We further characterized the level of barrier or facilitator using a combined inductive and deductive coding approach. We used an evidence‐informed framework of multilevel barriers and facilitators of communication, including individual, team, organization/system, collaborating hospital, community, and policy‐level factors 16 . We utilized content analysis 29 to analyze these data, using the multilevel model of barriers as an a priori framework for coding, while also remaining open to novel categories of barriers that emerged from the collection of studies.…”

“…Understanding which factors facilitate or impede functions can help us to promote high‐quality communication in pediatric oncology and identify targets for communication interventions. In previous work, we developed a multilevel framework of factors that affect the fulfillment of communication functions, including individual, team, organization/system, collaborating hospital, community, and policy‐level factors 16 . This multilevel model was adapted from the field of organizational psychology 17 and tailored to pediatric communication based on key stakeholder input.…”

“Don't be afraid to speak up”: Communication advice from parents and clinicians of children with cancer

“…16 Communication efforts can fail, however, leading to negative consequences for parents and patients. 17 Past studies have explored barriers to communication of difficult news, identifying problems with timeliness of information, insufficient empowerment of parents, lack of parental preparation, lack of clarity about the future, and use of medical jargon. 17,18 These communication breakdowns can lead to unmet information needs, [19][20][21][22][23] inaccurate prognostic understanding, [24][25][26] decisional regret, 27 and distrust of clinicians.…”

“…17 Past studies have explored barriers to communication of difficult news, identifying problems with timeliness of information, insufficient empowerment of parents, lack of parental preparation, lack of clarity about the future, and use of medical jargon. 17,18 These communication breakdowns can lead to unmet information needs, [19][20][21][22][23] inaccurate prognostic understanding, [24][25][26] decisional regret, 27 and distrust of clinicians. 28 Several studies have explored parental communication experiences, 2,3,[29][30][31][32][33] and some studies have asked parents for communication advice to clinicians and researchers.…”