Hinal Patel and Oonagh McSorley The multidisciplinary team (MDT) as a concept is viewed as a best practice or gold standard in cancer healthcare services globally. It evolved initially when (i) patient outcomes were seen to improve when based on available evidence; (ii) treatments for cancer such as surgery, radiotherapy and chemotherapy were combined; and (iii) the medical experts in these fields were working together. With the growing awareness that this approach improved patient care, disciplines such as nursing and allied health professionals were acknowledged as members of the MDT. The objective of the MDT is to consider all relevant treatment options; from these, an individual treatment plan is developed collectively. However, effective teamworking can be challenging due to organisational structures and demands. The clinical nurse specialist is a vital member of the MDT and is best placed to advocate for the patient. More research is required to ensure that the MDT and MDT meetings are effective in delivering the best treatment plans for individuals with cancer. Globally, the delivery of healthcare is experiencing multiple challenges and increasing demands as a result of ageing populations, chronic illness, complexity of ill health, lack of funding and, more recently, the COVID‐19 global pandemic. Within this context, and driven by health policy, healthcare professionals are tasked with ensuring safe, quality health outcomes for individuals, which can be achieved through effective teamworking. In cancer care, the pathway to diagnosis and treatment can be complex; hence, consistency in care delivery is required to enhance patient outcomes. The multidisciplinary approach to care was designed to provide consistency in the quality of care delivered and improve survival rates (Hoinville et al. 2019). The crucial role of the clinical nurse specialist (CNS) in delivering effective healthcare through their contribution to the multidisciplinary team (MDT) will be emphasised. Hinal Patel is a Clinical Nurse Specialist at University College London Hospitals NHS Foundation Trust, she works under the lymphoma sub‐speciality in the CAR‐T and autologous stem cell transplant team. Oonagh Mc Sorley is a lecturer at the School of Nursing and Midwifery, Queen’s University Belfast and has a clinical background in cancer nursing. Many terms in healthcare literature and policies are used interchangeably to describe the concept of a team: interdisciplinary, multidisciplinary, multiprofessional and inter‐professional, among others. However, there is no consensus among healthcare professionals, policy‐makers and academics on the meaning of these terms, leaving them open for interpretation (Chamberlain‐Salaun et al. 2013; Martin et al. 2022). This debate warrants further discussion elsewhere; for the purposes of this chapter, the authors will use the description of the interdisciplinary team provided by Janssen et al. (2017), which describes it as co‐operation between a group of professionals for a shared purpose that is then facilitated in healthcare by MDTs. In cancer services, the MDT can be defined as specialised professionals working together in cancer care with the principal goal of improving patient care and treatment efficiency (Taberna et al. 2020). The MDT as a concept is viewed as a best practice or gold standard in cancer healthcare services globally, emerging initially in the United States of America (USA) in the 1980s and in the United Kingdom (UK), Europe and Australia from the late 1990s onwards (Patkar et al. 2011). As an example, the MDT developed in the UK following the publication of the Calman‐Hine report (Department of Health 1995) and the National Cancer Plan (Department of Health 2000); both reports drove for timely, quality care for people with cancer, with the aim of reducing inequalities in care. These reports recognised that an integrated team approach and collaborative working could help to achieve better outcomes for individuals with a cancer diagnosis. The MDT evolved initially when patient outcomes improved because treatments such as surgery, radiotherapy and chemotherapy were being combined based on the best available evidence; in addition, the medical experts in these fields were communicating and working together. With the growing awareness that multidisciplinary working improved patient care, disciplines such as nursing and allied health professionals involved in supportive care were invited to join the MDT (Taberna et al. 2020). Their addition to the team improved patients’ quality of care by preventing and managing side effects of treatment and subsequently empowering patients in the decision‐making processes before, during and after treatment (Punshon et al. 2017; Soukup et al. 2018). Cancer MDTs can comprise oncologists and/or haematologists, surgeons, radiologists, nurses such as the CNS, pathologists and allied healthcare professionals who meet on a regular basis, often weekly or monthly in multidisciplinary meetings (MDMs). The team objective is to consider all relevant treatment options; from these, an individual treatment plan is developed collectively. It is mandatory in the context of the UK that MDMs occur (Department of Health 2004, 2013) to ensure that all individuals with cancer receive consistent quality care. Interestingly, the MDT also have a governance role in overseeing and monitoring the impact of treatment decisions and ensuring the accountability of those decisions. However, for many years, this significant aspect of the MDM objective has been difficult to achieve due to a lack of time and resources (National Cancer Registration and Analysis Service 2010). More recently, it has been reported that MDMs cannot cope with the demand: each patient is allocated only a few minutes for discussion, which means all information is not considered and, therefore, time for reflection and evaluation is restricted (Cancer Research UK 2017). With the increase in cancer incidence and advances in technology and treatments, in addition to the complexity of individual cases, meaningful discussion and effective decision‐making are vital within the MDT; therefore, it is important to reflect upon what makes a team effective and efficient. Prior to 2010, there was a lack of empirical evidence to demonstrate whether the MDT was effective (Soukup et al. 2018). The National Cancer Action Team (NCAT) developed an online survey that collected data from 2034 MDT members reporting on perceptions of the factors essential for an effective MDT (NCAT 2010). The results derived five main elements: the team, MDM organisational logistics, infrastructure for MDMs, person‐centred clinical decision‐making and team governance. Each of these elements could have its own chapter in this book; the next section summarises the pertinent points relating to the present National Health Service (NHS) culture in the context of the UK, which should be transferable to other contexts. In the context of the UK, each individual who develops cancer will navigate their journey from referral, often from their general practitioner (GP)/primary physician, to diagnosis and treatment – this is often referred to as the cancer pathway. The MDT has a significant role in this pathway. In England, UK, for example, rapid cancer diagnostic and assessment pathways for lung, prostate and colorectal cancer have been published (NHS England 2018). Embedded in these pathways is the MDT, who have a significant level of expertise and specialisation of professionals within the team to ensure that knowledge of the disease, evidence‐based treatments, and the patient’s preference are represented, leading to a timely diagnosis and treatment plan. However, for the team to function effectively, this expert knowledge needs to be combined with effective working relationships based on respect, open communication and leadership (Soukup et al. 2018). Furthermore, all members of the team must feel psychologically safe, which includes an opportunity to discuss their opinions and be comfortable reporting to their line manager when they have made an error without feeling insecure and embarrassed. This will lead to a supportive learning environment for development (Rosen et al. 2018). The NHS England and NHS Improvement (2019) highlight the importance of psychological safety in relation to delivering safe patient care. The NHS Health Education England (2021, p. 24) multidisciplinary toolkit summarises this issue as follows: ‘It is essential within healthcare.… Psychological safety is seen as a key ingredient for patient safety and is created by compassionate leadership encouraging team members to pay attention to each other; to develop mutual understanding; to empathise and support each other. Feeling part of a team protects individuals against the demands of the organisation they work for and if they have clarity about their role in the team, they are less likely to burn out and more likely to operate in a safe way’. Within the MDT, levels of hierarchy exist among different professions, and this can affect the individual member’s sense of psychological safety, degree of participation and appreciation of contributions. The CNS is present to advocate for the patient’s holistic needs. There is a paucity of research evaluating the contribution of the CNS in MDMs. The available research states that nurses and their knowledge are underrepresented in MDMs, and surgeons have a higher consideration for biomedical information (Atwal and Caldwell 2006; Lamb et al. 2013; Punshon et al. 2017). The CNS is faced with this underrepresentation alongside time constraints and increasing patient numbers that may restrict their ability to speak up and appropriately challenge in the context of the MDM (Punshon et al. 2017). This suggests that for some team members, psychological safety may be lacking within MDMs. Another consideration that improves the functioning of the team, by ensuring that effective decisions are made is regular attendance by the core members of MDTs, such as surgeons, radiologists, oncologists and pathologists; this was one of the conclusions in a recent systematic review by Walraven et al. (2022). In this review, attendance rates at MDMs varied from 45% to 90%, and studies that reported low attendance rates among these core members also reported less efficient decision‐making. Regular attendance may be difficult for many healthcare professionals to achieve due to staff shortages and competing demands on time. An effective chairperson for the MDM is also recognised as an essential element in the clinical decision‐making process (Lamb et al. 2011; Walraven et al. 2022). This role was traditionally held by the surgeon; however, it has been suggested that rotating the role of the chairperson among staff members and professions can increase team morale and reduce interprofessional conflict (Lamb et al. 2011). Furthermore, CNSs have demonstrated that patient outcomes are similar, if not better, when they chair the MDM instead of surgeons (McGlynn et al. 2017), demonstrating their value in the decision‐making process. However, it is interesting to note that the CNS was not viewed as a core member in the Walraven et al. (2022) paper, especially concerning decision‐making, suggesting that more evidence needs to be collected on the role and influence of the CNS in the MDM. NHS Trusts and other health organisations should support staff, including the CNS, by ensuring that they have protected time to attend and prepare for the MDT. Some evidence suggests that oncologists, pathologists and radiologists are more likely to attend and be better prepared for the MDM than other professionals (Soukup et al. 2016). For those who are not able to attain the relevant information and investigation results before the meeting or prepare sufficiently, this may be a barrier to attendance (Soukup et al. 2018). Lack of preparation time and unavailability of investigation results can also result in the development of a non‐definitive care plan, rushed decision‐making and poor morale, ultimately impacting the patient’s care (Hoinville et al. 2019). The increase in cancer caseloads, without a similar increase in resources and capacity, has resulted in a lack of time for each case to be discussed at the MDM, which again can lead to decisions not being made and treatment plans being delayed (Hoinville et al. 2019). Streamlining patient discussions by spending more time on complex cases has been suggested as a method to improve effectiveness; however, further evidence is required, as varying opinions among different professionals highlighted concerns around patient safety: i.e. those patients who are not discussed fully may receive sub‐optimal care (Hoinville et al. 2019; Winters et al. 2021). The COVID‐19 pandemic has advanced technological changes in how healthcare professionals communicate with each other in the workplace. Virtual conference calling is now an alternative to the traditional face‐to‐face clinic meeting (Walraven et al. 2022) for all healthcare professionals including the CNS. It has been suggested that this could help with the attendance issue as previously outlined and allow specialists from across the world to attend MDMs, which could help in reaching decisions on complex cases (Rajasekaran et al. 2021). Due to this shift towards online meetings, the physical environment – finding a suitably sized room to accommodate all attending the MDM, with the technology required to show scans and other investigations – has become less of an issue. The information provided at MDMs must be person‐centred. Content should include the patient’s co‐morbidities, disease progression, frailty, preference regarding treatments and psycho‐social needs. This information will facilitate the team to make clinical decisions that are acceptable to the patient (Soukup et al. 2018). Including timely and accurate person‐centred information can be challenging, as patients’ preferences may change according to circumstances, personal values and beliefs and the type of disease. The CNS plays a valuable role in this aspect of care. A recent integrative literature review (Kerr et al. 2021) demonstrated that the CNS had a positive outcome on patients’ psychological needs and clinical outcomes, by managing pain and fatigue, in addition to general satisfaction with healthcare. This highlights that the CNS is well placed to be the patient’s advocate within the MDT, as they will have developed a relationship with the individual and have a sense that they ‘know’ and can represent the patient holistically. Team governance involves organisational support, which includes funding and resources; both issues are challenging in the current climate (Winters et al. 2021) but essential for MDTs and MDMs to function effectively (Soukup et al. 2018). Learning and development within the team should derive from the results of audits of the outcomes for patients arising from the decisions made at the MDM and data collected during team meetings (Soukup et al. 2018). It has been reported that there is a lack of regular and rigorous audits performed on MDMs, which could affect patient safety (Winters et al. 2021). Clinical governance is adhered to by using agreed policies and guidelines about the structure and processes within the meeting, e.g. adhering to time schedules, using the correct forms to document data and evaluating the function of the meeting by using validated evaluation tools (Soukup et al. 2018; Walraven et al. 2022). However, from the literature, it remains unclear if any of these tools have demonstrated to optimise MDMs (Walraven et al. 2022). Future developments to help with the functioning and effectiveness of the MDMs include computerised clinical decision‐support systems (CDSSs). These systems consider the patient’s data at a genomic and molecular level as well as information on novel treatments and clinical trials. Some may also contain electronic care records. These systems can aid in the decision‐making process in MDMs (Winters et al. 2021). The NCAT (2010) emphasises that leadership within the MDT and wider cancer team is one of the key contributions a CNS makes. The National Cancer Patient Experience Survey has highlighted that individuals with cancer who have access to a CNS generally report an enhanced experience during their care and a better understanding of their disease (Department of Health 2019). This highlights the importance of the CNS role and incorporates the ‘no decision about me without me’ approach. Macmillan Impact Briefs (2015) outlines the CNS role as a key worker who manages the health concerns of individuals with cancer during and after their treatment. (The key worker role is the focus of Chapter 5 in this book). A CNS works as part of a MDT that supports other healthcare professionals in delivering effective, efficient services and improves the quality of care for those with cancer. The CNS manages their own caseload of patients, coordinates their care and ensures that the patient’s needs are met and heard by the wider team. The CNS is often the patient’s first point of contact, putting them in a valued position, as they are relied upon for healthcare advice and other matters concerning the patient. Punshon et al. (2017) state that patient advocacy is a key component of the role of the CNS, something that is highly valued in practice. The CNS has a role in supporting the patient to understand their disease and treatment options and ensure that their concerns are listened to and wishes adhered to (Giesler et al. 2005). It has been suggested that a patient advocate should always be present during MDT meetings so the patient’s point of view is always considered (Campagna 2013). However, findings from Lavender (2017) suggested that although CNSs are present during MDT discussions, they are often only observant and do not have much input. Theories such as person‐centred care support the role of the CNS and the value of their role. However, as previously stated in this chapter, it has also been well‐documented that although nurses try to act as patient advocates, in some instances they are unfortunately dismissed by more senior members of the MDT (Devitt et al. 2010; Lamb et al. 2011). Although multidisciplinary teamworking offers many benefits, such as sharing knowledge, enhancing skills, effective management and integrated care, there are also challenges. Four main themes can contribute to barriers experienced in relation to CNS contributions: authority over the treatment agenda, power dynamics, issues of understanding and implementing the role of the CNS and issues within the team (Amir et al. 2004; Willard and Luker 2007; Lanceley et al. 2008; Lamb et al. 2013; Rowlands and Callen 2013). Evidence suggests that in some areas, CNSs do not feel valued as part of the wider team and are often left unheard (Taylor et al. 2014; Punshon et al. 2017). In group settings such as MDT meetings with other healthcare professionals, nurses may occasionally struggle to voice their thoughts and opinions due to traditional hierarchical structures. Some may assume that others with higher professional status may not value them or their input. Often, the CNS may have to be more assertive and find the confidence to advocate for the patient and for their voice to be heard. This theory is supported by Taylor et al. (2010), who outline that hierarchical boundaries and hostility between different professionals is the main cause of dysfunctional teams. Willard and Luker (2007) have reported that one of the most important strategies CNSs use to gain acceptance and contribute is building effective relationships with key members of the MDT, mainly the senior clinicians, such as consultants leading the patient’s care. Wallace et al. (2019) discuss the barriers to nurse participation in MDT meetings; these are well‐identified and discussed earlier. However, they also provide insight into pathways that can be used by CNSs to strengthen their impact on the decision‐making process, allowing the wider team to benefit from their knowledge and expertise. These processes include sharing person‐centred information that only the CNS may be able to contribute because they are the patient’s first point of contact and often the member of staff at the MDM who spends the most time with the patient. The CNS uses holistic assessment and care to identify any psycho‐social needs and can confidently act as a patient advocate in this setting. Asking relevant questions is another approach to address challenges for the CNS in the MDM, as this can prompt further discussion and influence the outcome. It may also facilitate other healthcare professionals in the meeting to contribute with their knowledge and expertise. These approaches enable the CNS to be the patient’s advocate by asking questions the patient may wish to be addressed. Another strategy is to provide practical suggestions that may influence the treatment and frame contributions to plan or change the course of action. Some examples of practical suggestions made by a CNS are accommodating the patients’ needs without causing them too much disturbance, e.g. ad hoc clinic appointments, safety measures and raising awareness of specific issues that the patient is experiencing, considering social situations if patients need additional support and discussions on how they will cope with day‐to‐day activities. An additional strategy is using appropriate humour within the MDT to build rapport and de‐escalate tense discussions. For example, if two colleagues disagree, humour can be used appropriately to diffuse a disagreement in an MDT meeting. Overall, these strategies can influence discussions, contribute to decisions about treatment plans and promote teamwork. This demonstrates that being part of the MDT provides the CNS with the opportunity for discussion, questions and influence. Following is a personal reflection on the CNS role, written using Jasper’s (2013) experience, reflection and action (ERA) model.
9
Multidisciplinary Teamworking
Abstract
9.1 Introduction
9.2 The Multidisciplinary Team
9.2.1 Characteristics of an Effective Multidisciplinary Team
9.2.1.1 The Team
9.2.1.2 Multidisciplinary Meeting Organisational Logistics
9.2.1.3 Infrastructure for the Multidisciplinary Meeting
9.2.1.4 Person‐Centred Clinical Decision‐Making
9.2.1.5 Team Governance
9.3 The Role of the Clinical Nurse Specialist in Relation to the Multidisciplinary Team
9.3.1 Challenges of the Clinical Nurse Specialist Working in a Team
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