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TITLE: INTERDISCIPLINARY COLLABORATION
FACTORS THAT INFLUENCE COLLABORATIVE EXPERIENCES AMONG
HOSPICE TEAM MEMBERS
By

Ric Kobayashi

A DISSERTATION
Submitted to
Michigan State University
in partial fulﬁllment of the requirements
for the degree of
DOCTOR OF PHILOSOPHY
Social Work

2009

ABSTRACT
INTERDISCIPLINARY COLLABORATION:
FACTORS THAT INFLUENCE COLLABORATIVE EXPERIENCES AMONG
HOSPICE TEAM MEMBERS
By
Ric Kobayashi
Today, an estimated 1.2 million Americans receive hospice or palliative care
annually (NHPO, 2006). This is one out of every three terminally ill individuals. As the
baby boomer generation approaches its senior years, a rapid increase in the aging
population will likely contribute to a greater use of hospice care in the next decades.
Although the interdisciplinary team represents a signiﬁcant part of hospice philosophy
and care delivery, there is a lack of research examining the effects of the use of hospice
interdisciplinary teams in general. Only a small number of published studies have
empirically investigated the processes, beneﬁts, or effectiveness of hospice
interdisciplinary teams (Amundson, 2005; Merriman, 1999; Parker-Oliver & Peck, 2006).
The purpose of this research study was to deepen an understanding of the

processes of interdisciplinary collaboration in hospice and inﬂuencing variables that aid
or hinder collaborative work. In this study, both quantitative and qualitative research
methodologies were employed. One hundred and twenty-six'hospice nurses, physicians,
spiritual care providers, and social workers completed a survey questionnaire. Twenty
hospice professionals from the disciplines of nursing, medicine, spiritual care, and social
work participated in the phone interview and shared their thoughts on the strengths of and
barriers to interdisciplinary collaboration, their professional contributions on a team, and

the practice of interdisciplinary team effectiveness evaluation.

Quantitative ﬁndings revealed that professional afﬁliation (commitment to one’s
profession), organizational characteristics (organizational support toward collaboration),
personal characteristics and relationships among collaborators (positive feelings toward
colleagues), quality of care (beneﬁts of team care), and job satisfaction all had
statistically signiﬁcant associations with the degree of perceived interdisciplinary
collaboration. In addition, a statistically signiﬁcant association was found between
professional diversity and variables of job satisfaction and personal characteristics and
relationships among collaborators. Hospice professionals were most likely to be satisﬁed
with their job and strong positive feelings toward colleagues from other disciplines.

Qualitatively, the majority of hospice professionals across disciplines identiﬁed
similar strengths of their hospice team, barriers their team faces, professional qualities,
and their hospice team effectiveness evaluation mechanisms. The responses to a question
about one’s professional quality highlighted their particular professional roles, values,
and skills on a team.

The quantitative and qualitative ﬁndings of the study convey that overall hospice
professionals, regardless of their professional diversity groups: (1) have a high level of
interdisciplinary collaboration; (2) share similar perceptions of strengths and challenges
of interdisciplinary collaboration; (3) enjoy, are satisﬁed with and proud of their work
and team; and (4) believe in holistic care as an effective way to serve those who are
terminally ill and their families.

The study results have implications for hospice professionals and the social work

profession as well as implications for future research.

Copy Right by
RIE KOBAYASHI
2009

DEDICATION
I dedicate this dissertation to:
My parents, Yoshinori and Kesako Kobayashi, for their support in pursing my
dreams,
Hospice professionals who share dedication and passion for maximizing the dignity
and integrity of those facing life-limiting conditions and their caregivers,
and
Hospice clients and their families who continue to teach me what matters the most in
life and what living life with dignity and integrity means.

You are my inspiration.

ACKNOWLEDGEMENTS

When I decided to return to school about six years ago, I had no idea what an
impact the decision would have on my life. As I look back on this journey, I cannot help
but notice how fortunate I have been to be surrounded by a large number of people who
have assisted me along the way. I am enormously grateful to the members of my
dissertation committee. Dr. Gary Anderson, my chairperson, has guided me through the
process with his gentle and patient spirit. Dr. Sally Rypkema has been an invaluable
mentor. Her generosity and creativity in helping me grow personally and professionally
cannot be described in words. My deep appreciation goes to Dr. Karen Ogle from the
College of Human Medicine and Professor Linda Keilman ﬁom the College of Nursing
who I have had an honor of sharing the passion and vision for improving end of life care
and interdisciplinary collaboration. Dr. Rena Harold has been instrumental in my
navigating the world of academia over the last six years. She has remained an unofﬁcial
committee member and mentor.

My family and friends have been the source of my Strengths. I would like to thank
my parents, Yoshinori and Kesako Kobayashi, for allowing me to move to this county to
pursue my dreams. They have quietly supported me from a distance. My brothers, Hiraku
and Hiroshi, have also been supportive and protective of me, even though I was not
always the best older sister they deserved. My American parents, Jarl and Pat Nischan
and their family have neVer failed to show me love and acceptance. My third parents,
Ken and Dianne McGuire, have always provided me a safe, nurturing place to rest up and

recharge. They have been the source of my serenity.

vi

The inspiration for my dissertation project came from working with a group of
hospice professionals on a hospice interdisciplinary team. I have been privileged to
practice as a social worker over the last 12 years for a same hospice. I would like to thank
my colleagues from Allegiance Hospice for their support and encouragement. Through
my hospice work, I have had the privilege of meeting and getting to know a countless
number of extraordinary individuals and families. Hospice clients and families have
allowed me to walk alongside in living life with courage, dignity and integrity. I carry
their life lessons, dreams, and hopes in my heart.

I have been truly fortunate in the friend department. My ﬁiends have remained the
source of much needed reality checks. In this ocean weather-like journey of ups and
downs, they were my emotional sanity. Friends who know me ﬁom my hospice work and
other non-academic settings have helped me remember who I am through the journey. I
would like to thank Carmen and Jill, in particular, for their understanding and acceptance
of me for who I am.

Lastly, but certainly not least, I would like to thank two of now my closest and
dearest friends, Kim Steed and Carolyn McCallister-Kobayashi, who married one of my
brothers and became my sister-in-law last year. Your friendship has made the last six
years of my life, full of joyful and challenging personal and professional experiences,
meaningful and unforgettable. I am most grateﬁrl for your authenticity and for never

saying, “We told you so” when I fell miserably. Thank you, and I love you.

vii

TABLE OF CONTENTS

LIST OF TABLES ................................................................................... xi
CHAPTER 1
INTRODUCTION ................................................................................... 1
Introduction and Problem Statement ...................................................... 1
Purpose of the Study ......................................................................... 4
Rationale for the Study .............................................................. . ....... 5
Research Questions .......................................................................... 8
Deﬁnition of Terms .......................................................................... 9
Theoretical Framework .................................................................... 10
Bronstein’s Model for Interdisciplinary Collaboration ....................... 10
Overview .................................................................................... 16
CHAPTER 2
REVIEW OF THE LITERATURE ............................................................... 17
Healthcare Teams: From Multidisciplinary to Interdisciplinary Teams ............ l7
Experiences of Interdisciplinary Collaboration ........................................ 21
Research on Healthcare and Hospice Interdisciplinary Teams ...................... 24
Team Processes and Beneﬁts .................................................... 24
Inﬂuences on Interdisciplinary Collaboration ................................. 26
Additional Inﬂuencing Variables on Interdisciplinary Collaboration. . ....31
Beneﬁts Associated with Interdisciplinary Collaboration ............................ 34
Overall Findings ............................................................................ 42
Limited Research on the Processes and Beneﬁts of the Hospice
Interdisciplinary Team ............................................................ 46
Summary .................................................................................... 47
CHAPTER 3
METHODOLOGY .................................................................................. 49
Research Questions ......................................................................... 49
Participation Recruitrnents and Procedures ............................................. 50
Sampling Design ............................................................................ 51
Participant Characteristics ................................................................ 51
Instrumentation and Variables ............................................................ 53
Quantitative Instruments and Variables ........................................ 53
Qualitative Design and Measures ............................................... 63
Data Analysis ............................................................................... 65
Quantitative Data ................................................................. 65
Qualitative Data ................................................................... 67
Summary .................................................................................... 67
CHAPTER 4
RESULTS ............................................................................................ 69
Overview .................................................................................... 69

viii

Characteristics of the Study Sample ...................................................... 70

Demographic Data ................................................................ 7O
Organizational Data ............................................................... 75
Survey Instruments and Reliability Statistics ........................................... 78
Modiﬁed Index for Interdisciplinary Collaboration (MIIC) ................. 78
Job Satisfaction and Quality of Care Subscales ............................... 78
General Findings ........................................................................... 79
Addressing of the Research Hypotheses and Results of Analyses .................. 80
Hypothesis 1 ....................................................................... 80
Hypothesis 2 ....................................................................... 81
Hypothesis 3 ........................................................................ 82
Hypothesis 4 ........................................................................ 83
Hypothesis 5 ........................................................................ 84
Phone Interviews ......................................................................... 88
Demographic and Organizational Data ......................................... 89
Open-ended Questions ............................................................ 91
Summary ................................................................................. 103
CHAPTER 5
DISCUSSION AND IMPLICATIONS ......................................................... 107
Review of Major Findings ............................................................... 108
Demographic and Organizational Characteristics ........................... 108
Review of Inﬂuencing Variables ....................................................... 110
Interdisciplinary Collaboration ................................................ 110
Personal Afﬁliation .............................................................. 1 10
Organizational/Structural Characteristics .................................... 111
Personal Characteristics and Relationships among Collaborators. . . . . ....1 12
History of Interdisciplinary Collaboration .................................... 113
Quahty of Care ................................................................... 115
Job Satisfaction .................................................................. 116
Professional Diversity ........................................................... 1 19
Study Limitations ......................................................................... 121
Implications for Hospice Professionals and Social Work Profession .............. 126
Implications for Hospice Professionals and Administrators. . . . . . . . . . . 126
Implications for Social Work Profession ..................................... 128
Recommendations for Future Research ................................................ 132
Conclusion ................................................................................. 134
APPRENDICES

Appendix A: Michigan State University Institutional Review Board (IRB)

Approval ................................................................. 138
Appendix B: Letter of Recruitment to the Hospice Executive

Director/Administrator ................................................ 139
Appendix C: Letter of Recruitment to the Hospice Colleague .................... 141
Appendix D: Consent Form and Telephone Interview Information Sheet ...... 142
Appendix E: Follow Up Email Messages ........................................... 146

ix

Appendix F: Survey Questionnaire ................................................... 149
Appendix G: Telephone Interview Script ............................................ 166

REFERENCES .................................................................................. 168

Table 1.

Table 2.

Table 3.

Table 4.

Table 5.

Table 6.

Table 7.

Table 8.

Table 9.

Table 10.

Table 11.

Table 12.

Table 13.

Table 14.

Table 15.

Table 16.

Table 17.

Table 18.1.

LIST OF TABLES

Chi-square Analysis of Gender by Professional Diversity .................. 71
Age Groups by Professional Diversity ........................................ 72
One-Way Analysis of Variance of Age by Professional Diversity. . . . . 73
Employment Status by Professional Diversity ............................... 73

Chi-square Analysis of Employment Status by Professional Discipline...74

Years of Hospice Operation ..................................................... 75
Hospice Interdisciplinary Team Core Members .............................. 76
Number of Hospice Teams in One’s Agency ................................. 76
Average Daily Census ........................................................... 77
Geographic Service Area ........................................................ 77
Internal Reliability Statistics of MHC and Subscales ........................ 78

Job Satisfaction and Quality of Care Subscales’ Internal Reliability
Statistics ........................................................................... 79

One-Way Analysis of Variance of Interdisciplinary Collaboration by
Professional Discipline .......................................................... 80

Means, Standard Deviations, and Intercorrelations for Interdisciplinary
Collaboration and Predictors Variables ....................................... 82

Summary of Multiple Regression Analysis for Three Variables Predicting
Interdisciplinary Collaboration ................................................. 82

Pearson Correlation Coefﬁcient between Quality of Care and
Interdisciplinary Collaboration ................................................. 83

Pearson Correlation Coefﬁcient between Job Satisfaction and
Interdisciplinary Collaboration ................................................. 83

Means and Standard Deviations Comparing Professional Diversity and
Variables of Professional Afﬁliation and Personal Characteristics. . . . . 85

xi

Table 18.2.

Table 18.3.

Table 19.1.

Table 19.2.

Table 19.3.

Table 19.4.

Table 19.5.

Table 20.

Table 21.

Means and Standard Deviations Comparing Professional Diversity and
Variables of History of Collaboration and Quality of Care ................. 85

Means and Standard Deviations Comparing Professional Diversity and
Variable of Job Satisfaction ..................................................... 86

One-Way Analysis of Variance Comparing Professional Diversity on
Professional Afﬁliation .......................................................... 87

One-Way Analysis of Variance Comparing Professional Diversity on
Personal Characteristics ......................................................... 87

One-Way Analysis of Variance Comparing Professional Diversity on

History of Collaboration ......................................................... 87
One-Way Analysis of Variance Comparing Professional Diversity on
Quality of Care .................................................................... 88
One-Way Analysis of Variance Comparing Professional Diversity on Job
Satisfaction ........................................................................ 90
Participant Information by Gender and Professional Diversity ............ 9O
Participant Demographic and Organizational Data by Professional
Diversity ........................................................................... 91
xii

CHAPTER 1
Introduction
Over two million people die each year in the United States, and most deaths are of
people over the age of 65 years (Kastenbaum, 2003). Prior to the advancement of medical
technology during the 20th century, deaths happened at any age, and most people died at
home (Bern-Klug, Gesset, & Forbes, 2001). Because there was no cure for many diseases
at that time, a great deal of attention was given to the emotional and spiritual comfort of
the sick and dying. Death was viewed simply as a natural part of life. Dramatic
improvement in medical and scientiﬁc technology in the beginning of the let century
transformed death into an event to interrupt, postpone, and prolong, evidenced by an
ilnprovement in life expectancy and a change in causes of deaths. Most deaths thus began
to take place in hospitals and other institutions, disappearing ﬁom the public view

(McDonnell, 1986), and death became stigmatized as fearful, shameful, and an event that

ought to be avoided at any cost.
While drastic medical and scientiﬁc advancements were shaping the way death

Was being treated in the early 21st century, a small group of people began to engage in a
grassroots movement to improve care for the dying. Inspired by the work of a nurse and
300i a1 worker turned physician, Dr. Cicely Saunders, and a physician, Dr. Elizabeth
I<ut>ler—Ross, in the mid—20th Century, the grassroots movement, known as the modern
hospice movement, came to challenge the traditional medical care model of solely
ﬁD‘T'I-lsing on treating one’s disease. Initially meant as a resting place for travelers on
pilgirnages to Jerusalem and operated by religious healers during the medieval period

: aradis, 1985), hospice emerged as a concept or philosophy of the care for the dying in

the 19603. Under the hospice philosophy, death is seen as a natural part and the last stage
of life, and hospice’s focus is on living and maximizing the experience of living until the

end rather than on death as an event (Kastenbaum, 2003; Paradis, 1985).

The modern hospice movement re-introduced the previously practiced whole
person or holistic care model for the dying by treating an individual as a whole, with bio-
psychosocial-spiritual components, in the context of illness in his/her environment
(Conner et al., 2002). Instead of looking at a person as an individual with a physical
deﬁciency to be managed, the hospice approach views an individual as a total person who
has vital connections to other people and is a unique part of a larger social system (Mor,
Greer, & Kastenbaum, 1988). The movement led to a paradigm shift in the care of the
dying from a curative care model to a palliative or comfort care model through the

comprehensive promotion of total comfort, which is a multi-layered, highly personal and

interrelated bio-psychosocial-spiritual aspect of the human experience (Saunders &

Bains, 1989).
The ﬁrst hospice in the United States, the New Haven Hospice opened its doors in

l 974 (Foster & Corless, 1999), and other hospices began to open their doors, following

the footsteps of the New Haven Hospice. By the late 1970, ﬁfty-nine hospice programs
were in operation as hospice in the United States with 73 programs in the planning or
0p enin g phase of a hospice program in the near future (United States General Accounting

OffiCe [GAO], 1979).
Hospice care became integrated into mainstream health care upon the inception of

title Medicare Hospice Beneﬁt (MHB) in 1983 under the Tax Equity and Fiscal

esponsrbrlrty Act (TEFRA) of 1982. Through the MHB, the federal government deﬁned

required components of and who is eligible to receive hospice care (Cassel & Demel,

2001). The MHB under TEF RA (1982) deﬁnes the term “terminally ill” as an individual
having a life expectancy of 6 months or less should the disease process follow its usual
course (Cassel & Demel, 2001; Kastenbaum, 2003). Hospice provides a comprehensive

program of care to individuals and families facing an advanced illness for which cure is
no longer an option. Central to the concept of hospice care are the recognition of patient
and family as the unit of care and the promotion of total comfort or holistic care through
the use of an interdisciplinary team (Bennahum, 2003; Sherman, 1999).

The MHB mandates the hospice interdisciplinary team provide and manage the
care of a terminally ill individual and his/her family. In order to promote client self-
determination and autonomy (Mor et al., 1988) as well as quality of life and death with
digtlity (Conner et al., 2002; Kastenbaum, 2003; Stoddard, 1978), individually tailored
care is developed and delivered by a group of professionals with expertise and skills in
multiple dimensions of human experiences. The interdisciplinary team in hospice consists
0f the core members of physicians, nurses, spiritual care providers, and social workers
(KaStenbaum, 2003) and other non-core members such as home health aides, volunteers,
phaJ‘Il’lacists, physical and occupational therapists, and bereavement care providers. The
team is used as a vehicle to providing holistic, comprehensive care to the patient and
fami 1y as a unit of care. It recognizes that adequately addressing and meeting multiple
311d Complex physical, social, psychological, and spiritual needs presented by the patient
md family requires collaborative work by a team of professionals ﬁ'om multiple
di Sc ip lines. Fineberg (2005) deﬁnes interdisciplinary collaboration as “. . ..not merely the

i - -
IICIIVICIual contributions of multiple professionals but rather a coordinated effort of

 

different disciplines toward a common goal grounded in patient-and-family focused care”

(p.858). The interdisciplinary team is responsible for developing, updating and evaluating
an individualized plan of care through on going assessments of the patient and family’s
needs (Center for Medicare and Medicaid Services [CMMS], 2008).

Today, an estimated 1.2 million Americans receive hospice or palliative care
annually (National Hospice and Palliative Care Organization, 2006). This is one out of
every three terminally ill individuals. The number of Medicare recipients receiving
hospice care in 2001 multiplied by nearly 10 times the number of recipients in 1989
(Hospice Association of America, 2003). As the baby boomer generation approaches its
senior years, a rapid increase in the aging population will likely contribute to a greater
use of hospice care in the next decades. Although the interdisciplinary team represents a
Significant part of hospice philosophy and care delivery, there is a lack of research
ex atnining the affects of the use of hospice interdisciplinary teams in general. Only a
Small number of published studies have empirically investigated the processes, beneﬁts,

or effectiveness of hospice interdisciplinary teams (Amundson, 2005; Merriman, 1999;

Parker-Oliver & Peck, 2006).

Purpose of the Research
The aim of this research study was to deepen an understanding of the processes of

interdisciplinary collaboration in hospice and the impact of variables that aid or hinder
Collaborative work. Interdisciplinary team members’ perceptions of their own
Participation and that of other team members in collaborative work as well as the
p Ere eived outcomes of collaboration were explored. In addition, the impact of variables

to interdisciplinary collaboration (professional role, structural/organizational

characteristics, personal characteristics, history of collaboration, quality of care, and job
satisfaction) on perceived level of interdisciplinary collaboration was examined.
Rationale for the Study
A large number of healthcare-related articles, examining and promoting concepts,
theories, practices, and beneﬁts of collaborative work, have been published over the last
20 years (Ansari et a1, 2001; Brown et a1, 2003; Faulkner-Schoﬁeld & Amodeo, 1999;
Grumbach & Bodenheirner, 2004; Hall & Weaver, 2001; Mickan, 2005; Mizrahi &
Abramson, 2000; San Martin-Rodriguez et a1, 2005). These have encouraged a push to
incorporate interdisciplinary collaboration in health care delivery, using the hospice

interdisciplinary team as the working model of such collaboration (Conner et a1. 2002;

Cowles, 2000).
In spite of the highly favored model of interdisciplinary collaboration in health

care delivery, particularly in end of life care, some practitioners and scholars have
recently begun to question the promotion as well as the practice of interdisciplinary
COllaboration, citing limited empirical evidence that actually validate the beneﬁts and
effectiveness of interdisciplinary collaboration (Ansari et a1, 2001; Brown et 31, 2003;
Fallllrtrner-Schoﬁeld & Amodeo, 1999; Mickan, 2005; Mizrahi & Abramson, 2000; San
Martin-Rodriguez et a1, 2005). As the current health care delivery system as a whole is
expected to show best practices and cost containment (Irvine et a1, 2002; Center for

Medicare and Medicaid Services, 2008) through evidence-based practice, the pressure to

PI‘oduCe empirical evidence is greater than ever.
Although the beneﬁts of hospice care, particularly the cost effectiveness, pain and

s
ynlptom management and bereavement family satisfaction, have been studied, this body

 

E5

[‘5

of research on hospice is insufﬁcient. The hospice interdisciplinary team, like

interdisciplinary teams in other settings, has been one of the least empirically studied
areas, as teams often have only been evaluated as a component of the study, rather than a
focus of the study. Although the hospice interdisciplinary team is a valued and required

feature of hospice care, little is known about hospice team collaboration processes and

factors that facilitate team collaboration.
The highly valued philosophy and concepts of the holistic approach to caring for

the dying through the interdisciplinary team are no longer sufﬁcient to support the
practice of interdisciplinary collaboration in end-of-life as well as in other health care
settings. Without substantial empirical evidence to validate the beneﬁts and effectiveness
of interdisciplinary collaboration, the credibility and even the existence of
interdisciplinary collaboration in health care, including hospice, may be threatened. The
assumed and rarely tested beneﬁts of collaborative practice thus bring to the surface an

undeniable need for systemic research and evaluation of the processes, beneﬁts and

effectiveness of interdisciplinary collaboration.
Clear evidence of a growing need for systemic research and evaluation of hospice

car e and interdisciplinary collaboration is reﬂected in the current changes taking place in
the Public policy arena. The Revised Hospice Condition of Participation (COP) under
Medicare Hospice Beneﬁt, 42 CFR 418, ﬁnalized in June 2008, became effective in
December, 2008. Compared to the original 1983 Hospice COP, the Revised Hospice CoP
lays a set of more detailed requirements for all hospices receiving Medicare
reir‘ntNJJsement to follow. Of particular importance to hospice interdisciplinary teams are

( ) Standards for developmg, implementing and updating 1nrt1al and comprehensrve

 

assessments by interdisciplinary team members; (2) standards for interdisciplinary teams,
care planning, and coordination of care; and (3) standards for developing, implementing,
and maintaining an effective, on-going, hospice-wide data driven quality assessment and
performance improvement program. Hospices are required to engage in quality
assessment and performance improvement projects, as of February 2, 2009.

This is a time of great opportunity to engage in empirical studies to systemically
explore and evaluate the work of the interdisciplinary team. Two major areas of focus are
the work of each individual discipline and the work of the interdisciplinary team as a
whole. Understanding factors that inﬂuence team collaboration can help team members
and team managers to identify ways to enhance team collaboration, leading to improved
patient/family and staff outcomes. In addition, gaining knowledge about interdisciplinary
tearn processes will assist hospice team members, managers, and administrators in

developing practices and policies that maximize the beneﬁts and effectiveness of

interdisciplinary collaboration.
Studies in this area are particularly important for social workers, considering the

Current trend and support in evidence-based practice associated with cost containment.
Und erutilization of hospice social workers for the purpose of cost containment by some
ho Spice agencies reported in recently published articles (Reese & Raymer, 2004; Reese &
Sontag, 2001) is alarming to the profession. As core members of the interdisciplinary
team, hospice social workers have played vital roles in the development and evolution of
end of life care (F onnan, Kitzes, Anderson, & Kopchak Sheehan, 2003). Their focus on
Self—determination (Luptak, 2004), person-in-environment, strength perspectives (Reese

8c
Raymer, 2004) on the micro level as well as their advocacy in addressing issues of

 

diversity, power and disparities (Kramer & Bem-Klug, 2004) on the macro level are
unique voices in the interdisciplinary team. The value of the role and contribution of the
socialworker as a member of the interdisciplinary team is an area of research worthy of
ﬁrrther study.
Research Questions
The overarching question for this study was: What variables are most highly
associated with interdisciplinary collaboration in hospice? Speciﬁc questions for the
study were as follows:
1. What is the relationship between perceived level of collaboration on hospice
teams and professional diversity (comparing physicians, nurses, spiritual care

providers, and social workers)?

H1: Social workers, compared to physicians, nurses, and spiritual care
providers, report a higher level of interdisciplinary collaboration.

2. What is the impact of professional afﬁliation, structural/organizational
characteristics, personal characteristics and relationships among collaborators,
and history of collaboration on interdisciplinary collaboration?

H2: Professional afﬁliation, structural/organizational characteristics, personal
characteristics and relationships among collaborators, and history of
collaboration have a positive direct effect on interdisciplinary collaboration.

3. What is the impact of interdisciplinary collaboration on perceived quality of
care the team provides?

H3: Degree of interdisciplinary collaboration has a positive direct effect on
perceived quality of care the team provides.

4. What is the relationship between interdisciplinary collaboration and job
satisfaction?

H4: Degree of interdisciplinary collaboration has a positive correlation with
job satisfaction.

5. Is professional diversity (physicians, nurses, spiritual care providers, and
social workers) an inﬂuencing factor in differences in professional afﬁliation,

personal characteristics and relationships among collaborators, history of
collaboration, perceived quality of care, and job satisfaction?

H5: Professional diversity is an inﬂuencing factor in differences in

professional afﬁliation, personal characteristics and relationships among
collaborators, a history of collaboration, perceived quality of care, and job

satisfaction.
Deﬁnition of Terms

It is essential to have a clear understanding of the following terms when

considering the research.

“Hospice,” for the purpose of the study, relates to an organization that utilizes an
interdisciplinary team to provide end-of-life care to terminally ill individuals as regulated
by Medicare. This can be done in both inpatient and outpatient settings.

“Interdisciplinary collaboration” is deﬁned as “. . ..a coordinated effort of different
disciplines toward a common goal grounded in patient-and-family focused care”
(Fineberg, 2005, p.858) and “. . ..an interpersonal process leading to attainment of speciﬁc

goals that are not achieved by one team member alone” (Bronstein, 2003, p. 299).
“Interdisciplinary team process” means “. . ..purposeful sequences of change-
oriented transactions between and among representatives of two or more professionals
who possess individual expertise, but who are functionally interdependent in their
COHaborative pursuit of commonly shared goals” (Billups, 1987, p.147).
“Job satisfaction” is deﬁned as one’s contentment with his/her work (Cammann,
Fichlhan, Jennings, & Klesh, 1983).
“Personal characteristics and relationships among collaborators” for the purpose

of the study refers to one’s attitude and behavior toward colleagues from other disciplines

o
n a te€:1.rn(Bronstein, 2003)-

“Professional diversity” relates to a professional discipline that “has a set of
knowledge, skills, practices, and values that causes it to contribute to healthcare
something distinct from those of other disciplines and whose theory, practice, and

tenninology is sufﬁciently different ﬁ'om other discipline so that serious effort is required

to communicate and collaborate within them” (Satin, 1994, p.6).

“Professional afﬁliation” for the purpose of the study is deﬁned as commitment to
one ’ s own profession (Bronstein, 2003).
“Quality of care” refers to one’s attitude about teamwork and the impact of

teamwork on quality of care provided to clients (Heinemann, Schmitt, Farrell, & Brallier,

l 999).
“Terminally ill” means an individual who has a life expectancy of 6 months or

less (P.L.97-248, 96STAT.361, 1982) should the disease process follow its usual course
(C assel & Demel, 2001; Kastenbaum, 2002).

Theoretical Framework

Bronstein’s Model for Interdisciplinary Collaboration

The hospice interdisciplinary team is the phenomenon of interest for this study.
BrOl‘lstein’s model for Interdisciplinary Collaboration provides the overarching
13' 3111 ework for this study. Originally developed as a guiding model of interdisciplinary
coll aboration for social workers working with other disciplines, Bronstein’s Model for
Interdi sciplinary Collaboration deﬁnes the processes of interdisciplinary collaboration

(2002 ; 2003) applicable to the study of hospice interdisciplinary teams. Four theoretical

ﬁ’anlevvorks, a multidisciplinary theory of collaboration, services integration, role theory,

10

and ecological systems theory (Bronstein, 2002; Bronstein, 2003), were used as the

foundation of the model.
Theoretical Frameworks of the Model for Interdisciplinary Collaboration

Bronstein (1999) utilized four theories as the foundation in developing the Model

for Interdisciplinary Collaboration (MIC), which includes the generic concept of
interdisciplinary collaboration, services integration, role theory, and ecological systems
tlleory. In exploring interdisciplinary collaboration through a literature review, Bronstein
( l 999) came to realize that a broader, generic concept of interdisciplinary collaboration

based on the multidisciplinary literature helps deﬁne collaboration as dimensions of both

processes and outcomes of individuals and agencies working together.

Service Integration
Inﬂuenced by the structural, humanist and general systems perspectives, service

integration encourages a critical evaluation of organizational structure, individuals
working within the organization, and each professional discipline and organization as a
Part of a larger environment. The structural perspective on service integration sees

Organizational patterns and the role of hierarchy and bureaucracy as inﬂuencing factors in

interdisciplinary collaboration (Bronstein, 1999). The behaviors and characteristics of
111(iixriduals comprising a team and an organization and characteristics of interactions

between individuals in a team are central to interdisciplinary collaboration based on the

humanistic perspective of service integration (Bronstein, 1999).
General systems theory, focusing on the role of individuals as subunits of the

system as a whole, looks at interpersonal relationships that take place within the

rg anrzatron and external and internal mﬂuences on the rnterpersonal relatronshrps

11

(Bronstein, 1999). It also views the roles of motivation and effort as critical ingredients of
collaboration (Bronstein, 1999). The hospice interdisciplinary team can be applied to and
explained within the interrelated concept of systems theory. Using the interdisciplinary
team as a whole focal system, each professional discipline working interdependently can
be seen the subunits of the system. Suprasystems, a system external to the focal system,
may include hospice as an organization, healthcare system, policies, etc., and these

external factors guide the practice of the interdisciplinary team.

Role Theory

Role theory is a collection of concepts that predict an action of an individual in a
given role or types of expected behaviors based on certain circumstances. The concepts
of reference group and socialization, including professional socialization, are central to

role theory (Lum, 1998). Role theory views that professions have developed out of
soci ety’s needs for specialized services, and because the professions possess special
Competencies, society permits them to have a monopoly in their particular occupation
(Ll—1m, 1998). It means that the profession controls the body of knowledge being

di Sseminated and practiced, the number and kind of individuals being allowed to practice,

811d the education of the professionals (Lum, 1998).

The eight inﬂuencing variables of professional socialization, according to Lum,

C 1 99 8), include: (1) the level of formal and informal educational process; (2) the level of
expo sure to multiple agents such as clients, professional colleagues, and other

pro fessionals; (3) the impact of transition from adolescence to adulthood (developmental
Seci alization); (4) the level of heterogeneity of students and socializing agents; (5) the

l . . . . . .
eVel of hazrng, ntualrsm, and monopoly of students’ time; (6) learrung a professronal

12

language or jargon; (7) professions undergoing a transition in role deﬁnition develop a
less integrated professional self-image; and (8) student culture. Bronstein (1999) used
role theory as a way to understand the signiﬁcance of one’s professional role in
collaborating with others and the impact of individual attitudes and behaviors that shape
and are shaped through interactions with others. In a hospice team where interdependence
or blurring of professional roles are expected, role theory articulates an interesting
balance that team members engage in practicing commitment to professional role,

organization, and the hospice philosophy.

Ecological Systems Perspective
Ecological systems perspective, a framework known as the person-in-

environment approach, addresses the importance of human experiences within the
context of the individual’s relationship with the environment (Friedman, 1997) composed
of both living and non-living elements. Bronstein (1999) paid particular attention to four
maj or aspects of the perspective, including the dual emphasis on environmental change in
tarldem with individual initiatives, a focus on interactions, 3 lack of prescriptiveness
regarding methodology, and a focus on circular thinking. The concept of person-in-
e11‘fironment conveys continuous transactions or exchanges between individuals and their
enVironments that take place and that they shape each other over time (Germain &
Gi tterman, 1996). In her analysis, Bronstein (1999) argues that the focus on the
interrelated, reciprocal relationships of the environment and individuals fosters the
development and implementation of interdisciplinary collaboration. For instance,

Org aJ‘Lizational or structural factors such as administrative support toward collaborative

13

work and the availability of resources necessary for collaboration thus may affect the

level of team collaboration.
The hospice interdisciplinary team experiences constant changes and grth

when encountering a new client with a set of unique needs or welcoming a new team
member with his or her personal and professional experiences. The lack of a prescribed,
shared methodology, according to Bronstein (1999) encourages disciplines with diverse
skills and training to incorporate a various range of methods to meet needs unique to
particular client population. Each member of the hospice team as well as their clients

brings to the table their professional expertise, values, skills, and/or life experiences to

accomplish end-of-life goals.
Bronstein (1999) also linked the focus on circular thinking in ecological systems

Perspective as opposed to linear thinking as a way to diminish the role of blame from any

particular individual and to view the integral role of all parties involved in producing

Successful outcomes. For instance, in linear thinking, a client declining personal care
ﬁ‘orn a home health aide means the client causes an interruption in care that affects the
ai dc while the client remains unchanged. In contrast, in circular thinking, a client
(lee lining care from a home health aide affects the client, his/her caregivers, individual

team members, a team as a whole, and the system or environments surrounding the client

and team.
Model for Interdisciplinary Collaboration
Based on the four theoretical frameworks, Bronstein (1999; 2002; 2003)

deVeIOped the Model of Interdisciplinary Collaboration (MIC) and deﬁned what

QQnStitute interdisciplinary collaboration. Five core components that represent

14

f')
I“;

inter-professional processes are: (1) interdependence, (2) newly created professional
activity, (3) ﬂexibility, (4) collective ownership of goals, and (5) reﬂection on process.
Collaborative synergy is created through the interactions of the ﬁve core components.
Interdependence relates to “the occurrence of and reliance on interactions among

professionals whereby each is dependent on the other to accomplish his or her goals and

tasks” (Bronstein, 2003, p. 299).
Elements of interdependence include formal and informal time spent together,

oral and written communication among team members, respect for team members’
professional opinions and input, and a shared belief and attitude that group members’

abi lity to carry out their jobs is dependent on each other. In addition, a clear
mlderstanding of one’s own professional role as well as of others’ professional roles is
critical. Interdependence among team members leads to identifying and accomplishing
Shared goals. Newly created professional activities refer to “collaborative acts, programs,
arid structures that can achieve more than could be achieved by the same professionals
aCting independently” (Bronstein, 2003, p. 300). These professional activities maximize

the expertise of each team member (Bronstein, 2002) and accomplish goals and tasks that

would not be achieved without the collaborative effort of other team members.

Flexibility is crucial in the successful interdependence and professional activities

among team members. It extends beyond interdependence and accepts ﬂuidity in and

b lurl-ing of professional roles as part of interdisciplinary collaboration. Productive

compromises, adaptability to changes, and a decrease in hierarchical relationships among
tealil members are elements of ﬂexibility (Bronstein, 2002). Shared responsibility in the

etjltins: process of jointly designing, deﬁning, developing, and achieving goals leads to

15

collective ownership of goals (Bronstein, 2002). A commitment to client-centered care,
active and on-going partnership with clients in care planning and evaluation, and each
team member taking professional accountability for his or her contribution to the team
are also important elements leading to collective ownership of goals. Reﬂection on the
process of collaboration by team members symbolizes the interactions among team

members to discuss and evaluate their working relationships and to ﬁnd ways to

strengthen their collaborative effort.
Bronstein (1999; 2002; 2003) adapted elements of the multidisciplinary concepts

of collaboration, services integrity, role theory, and ecological systems theory in deﬁning
the processes of interdisciplinary collaboration and developing the MIC. While the four
theories articulate the work of hospice interdisciplinary teams and the overarching
ﬁ‘atnework for the study, the MIC describes the processes of interdisciplinary

co llaboration that take place in interdisciplinary collaboration in hospice.

Overview
Chapter 1 contains the introduction and problem statement, the purpose of the

Study, the rationale for the study, the research questions and hypotheses, the deﬁnition of
tel‘IIis, and theoretical framework for the study. A review of the relevant literature

pertaining to this study is provided in Chapter 2, followed by discussions of the research
methodology in Chapter 3 and the ﬁndings in Chapter 4. Chapter 5 provides a summary

0 f the study and examines the major ﬁndings and conclusions drawn from the ﬁndings.

Research implications and recommendations are also discussed.

l6

CHAPTER 2
Review of Literature

The following chapter provides a review of the literature related to
interdisciplinary collaboration and hospice care. First, the development and
transformation of interdisciplinary teams in health care will be discussed. Next,
experiences of interdisciplinary collaboration are described. This will be followed by a
discussion of current research on health care interdisciplinary teams and hospice care.
Bronstein’s Index of Interdisciplinary Collaboration model (1999; 2002; 2003),

particularly the inﬂuences of interdisciplinary collaboration, is used as the guiding

framework in discussing ﬁndings ﬁ'om the literature review and research variables for the

study.
H ealthcare Teams: From Multidisciplinary to Interdisciplinary Teams

The emergence of interdisciplinary work can be traced back to the work of
multidisciplinary teams in various health care settings during the early 20th Century
(Grumbach & Bodenheimer, 2004; Shoﬁeld & Amodeo, 1999). Inﬂuenced by an
Underlying recognition of the limitations of solely treating the medical needs of patients,
rnLlltidisciplinary teams began surfacing in acute and other settings as a way to maximize

the traditional medical model of care, which focuses on the treatment and cure of medical

illnesses. One of the ﬁrst forms of multidisciplinary teamwork was a physician-social
Worker partnership developed at Massachusetts General Hospital in 1905. Ida Cannon,
who is considered to be the ﬁrst medical social worker in the United States, began

Working alongside a physician named Dr. Richard Cabot to assist patients with

psychosocial needs (Dzielewski, 1998)-

17

Multidisciplinary teams refer to a group of professionals who are brought together
for their particular professional expertise to problem-solve issues presented by patients
(Hall & Weaver, 2001). In multidisciplinary collaboration, professional roles are clearly
deﬁned (Dziegielewski, 1998; Satin, 1994), meaning that each discipline works

independently from and parallel to each other and is only responsible for its particular
pro fessiOnal function. There is very little to no accountability as a member of the team,
and interaction among team members is minimally limited to coordination of care. In
addition, leadership in this setting is hierarchical, with physicians typically assuming the
leader role (Conner et al., 2002; Hall & Weaver, 2001). Frequently, the communication in
multidisciplinary teams takes place in an indirect form, using the medical records rather
that! direct verbal or face-to-face communication.

Prior to the late 18005, physicians commonly visited and served their patients in
their homes. As a result, they observed the patients in their own environment, including
the family and other social situations of the patient. The late 18003, however, saw a shift
in the center of medical practice from homes to institutions such as hospitals (Bern-Klug,
Gesset, & Forbes, 2001). As medical practice became more institutionalized,
specialization of work and division of labor became standard medical practice, and the
focus of patient care for physicians became solely the treatment of disease. The
establishment of medical social work, rising in popularity within hospital settings in the

early 1 900s as a way to provide non-medical care to patients, marked the beginning of
multidisciplinary health care teams (Grumbach & Bodenheimer, 2004; Schoﬁeld &

Amodeo, 1999). The partnership of medicine and social work signiﬁed the importance of

18

 

non-medical aspects of the patient in treatment, and the approach received support from
other hospitals and medical settings with increased interest in the continuum of care.

The development of multidisciplinary teams in other health care settings,
beginning in the mid-19505, was born out of an increased awareness and recognition of
the need for health care beyond traditional medical care. Some of these other health care
settings included in home care and public health care teams (Goode, 2000; Rehr,

B lumenﬁeld, & Rosenberg, 1998), rehabilitation medical teams for disabled veterans
(Germain, 1984), and community mental health teams (Leukefeld & Battj es, 1989).
Although several health care disciplines were working together to provide care to patients,
tearns had to rely on “trial-and-error methods of collaborating in a work group directed
by a physician” (Germain, 1984, p. 198), pointing out the continued adherence to the
traditional medical model of care. Non-medical disciplines were complementary services
to the medical care provided to patients in acute and other health care settings. The
function of non-medical disciplines focused on enhancing the medical care of the patient
through the use of their particular expertise, rather than being equal team members on a
health care team.

In the late 19608 and early 197 OS, the concept of the holistic, or the whole person,

approach entered the picture within acute hospital settings, greatly inﬂuenced by the
consumer movement (Luptak, 2004). An attempt to create a shift in the modern health
car e Practice from medical paternalism to that of autonomous decision-making process,
pr oITIOting patient self-determination and patient-centered care, was at the center of the

consumer movement (Conner et al., 2002; Luptak, 2004)-

19

 

The emergence of interdisciplinary practice appeared in its complete form in the
late 19608 and early 19708 with the introduction of hospice care. Hospice care revived
the concept of the holistic approach, or bio-psychosocial-spiritual, patient-centered care
for the terminally ill and their families, which for centuries had been the common way to
care for the sick and dying before an explosion in the advancement of medicine and

science. The holistic approach, a concept of treating and looking at an individual as a

whole in the context of illness and his/her environment (Conner et al., 2002), emerged as
a part of providing continuity of care to move a person from “the sick role to the well
role” (Parry, 2001, p.46). The concept of holistic care includes the notion that various
issues of a patient are often not speciﬁc to medical needs but rather are interrelated, and
need to be addressed in a coordinated manner (Leukefeld & Battjes, 1989).

The center of the hospice approach was an attempt to create a shift in the modern
healthcare practice from medical patemalism to that of an autonomous decision-making
process promoting patient self-determination and patient-centered care. This more
holistic approach, in theory and practice, quickly gained support from health care
providers and consumers (Conner et al., 2002; Luptak, 2004). This shift centered around
“consideration not only of rights to health care but also rights in health care, such as the
right to informed consent, the right to refuse treatment, and the right to participate in
n“edical decisions” (Bradley & Rizzo, 1999, p. 243).

A high functioning interdisciplinary team is assumed to possess: (1) a shared
und<31‘Standing of roles and values and the goals of the team among team members
(Conner et a1. 2002; D’Amour et a1. 2005; Rice, 2000); (2) an egalitarian, cooperative,

“Wasting and interdependent relationship in the team (Conner et al. 2002; D’Amour et a1.

20

2005; Rice, 2000); and (3) a shared decision-making process centering around the needs
of the patient and family (D’Amour et a1. 2005). The extent to which the interdisciplinary
team functions mirrors outcomes associated with the patient! family, team members and
organization (D’Amour & Oandasan, 2005).

What sets the hospice interdisciplinary team apart ﬁom other such teams is the
interdependent relationship that exists between the hospice team members as well as the
hospice philosophy of providing holistic care. Because the team is the vehicle in which
hospice delivers its philosophy and services, the team is an essential part of hospice.

Teams ﬁrst came to play a role in the health care ﬁeld in the early 19008 to
enhance medical interventions. Over the last 100 years, health care teams evolved ﬁom
multidisciplinary to interdisciplinary teams, reﬂecting historic changes and development.
The introduction of hospice care through the use of an interdisciplinary team in the 19608
brought in a new concept of holistic care to the heath care ﬁeld.

Experiences of Interdisciplinary Collaboration
This section describes experiences of interdisciplinary collaboration. In the
existing literature, extensive discussions on positive and negative experiences of
collaborative work is found, and more attention has been given, both conceptually and
empirically, to the challenges and problems with the interdisciplinary team model more
than advantages of the model (Abrahamson & Mizarahi, 1996; Faulcner Schoﬁeld &
Arnodeo, 1999; Hudson, 2007).

Abrahamson and Mizarahi (1996), in conducting a study of collaborative

relationships in acute care settings, found that positive experiences of collaboration

re13°11£ed by physicians and social workers included respect for collaborators, having

21

 

sinri lar perspectives, positive quality of communication, a well-understood role by
collaborators, capability of collaborators, and keeping well informed. In a study of the
experiences of nurse practitioners and family physicians working in collaboration at four
Caxradian rural primary care agencies (Bailey, Jones, & Way, 2006), the opportunity to
work together led to an increased perception of the competence of other disciplines. The
work of Haycock-Stuart and Houston (2005) revealed that those trained in
interdisciplinary collaboration reported improved quality in their own work (81%). All
practices reported beneﬁts from the involvement in a workshop series, but those who

already considered themselves to be working well with others and had clear leadership

were able to beneﬁt most from workshops.

Other positive experiences of teams found in the existing literature by Faukner

Schoﬁeld and Amedeo (1999) include heightened awareness and appreciation for one’s
own discipline, an improved understanding and enriched respect for other disciplines,
improved role satisfaction and facilitating work with difﬁcult patients. A literature review
on health care interdisciplinary team education, practice and research discovered that
interdisciplinary collaboration was found to have positive correlations with staff job

satisfaction and the promotion of professional identity (Rice, 2000).

A literature review conducted by Faulkner Schoﬁeld and Amedeo (1999)
identified drawbacks of teams as status differentiation, unequal team participation among
teal?! members, role confusion, varied personal commitment to team participation, jargon,

and I‘Ole blurring (Faulkner Schoﬁeld & Amodeo, 1999). A study by Abrahamson and
Mizarahi (1996) found that physicians and social workers working in collaboration

reported dissimilar perspectives as the most challenging part of collaboration while

22

 

Bailey, Jones, and Way (2006) observed the existence of an unclear understanding of the
role of other diSciplines hindering the collaborative relationship between nurse
practitioners and family physicians. Mizarahi and Abramson (2000) conclude, “The
beneﬁts of collaboration models are usually assumed, while barriers to the full
development of collaboration models are more frequently articulated” (p. 3).

Brewer (1999) describes six common obstacles of interdisciplinary work. They
are : (1) differences in cultures and ﬂames of reference; (2) differences in methods and
operations objects used within and between the disciplines; (3) differences in the use of
professional languages within and between the disciplines and the world at large; (4)
personal challenges of gaining trust and respect of others working in different disciplines
and ﬁelds; (5) organizational impediments such as incentives, ﬁmding, and priorities
given to disciplinary versus interdisciplinary work; and (6) professional impediments

such as hiring, promotion, status, and recognition.

Irvine et a1. (2002) took another approach by categorizing barriers to
interdisciplinary work into the two components of structural barriers and cultural barriers.
Structural barriers relate to the issues of authority, power and control that exist in teams.
Professional divisions, authority and division of labors, subverting medical dominance,
Professional organizations, different value systems, and legal effects are listed as
StruCtln‘al barriers (Irvine et al., 2002). Cultural barriers to interdisciplinary work result

from ﬁ'iclming and interpretation of a client’s situation/problem in terms of one’s own
professional frame of reference (intellectual baggage), terms used in one profession being
used With different meanings in another profession (language), diversity within a

P of esSlon (1ntraprofessronal vanatron), 1nter-group competition to marntanr rts own

23

 

 

professional status and distinctive social identity within a team setting (professional
identity), and training and education unique to a particular profession (training) (Irvine et
al., 2002).
Research on Healthcare and Hospice Interdisciplinary Teams
Team Processes and Benefits
Over the last twenty years, much has been written and published in the areas of
collaborative work within many ﬁelds, including the disciplines of sociology, education,
psychology, management studies, nursing, medicine, and social work (Graham & Barter,
l 999; Loxley, 1997). Though limited in numbers, empirical studies have been conducted
to explore various processes and outcomes associated with interdisciplinary teams.

Since hospice care became a part of the mainstream health care system in the
early 19808, studies on various aspects of hospice services and outcomes, particularly on
types of services, cost savings, and quality of services (Brita-Rossi et al., 1996; Sommers
et al., 20030 have been published. Many of the early studies on hospice care were

Conducted with grants from the Federal government and major foundations in the United
States, and generally very little attention was given to the impact of hospice
interdisciplinary teams on hospice outcomes.

Early studies on hospice services focused on exploring the existing hospice

pr Ograms and their characteristics, hospice service utilization, outcomes, and compliance
With the requirements of the Medicare Hospice Beneﬁt (Bencala, McIntosh, & Salzman,
l 982 ; United States General Accounting Ofﬁce [GAO], 1979). Very little to no attention

Was .given to the work of hospice interdisciplinary teams and the impact of teams on the

24

processes and outcomes of hospice services, and no study speciﬁcally focusing on the

tearnwork was found.
Several studies, though limited, speciﬁc to the work of hospice interdisciplinary

teams began surfacing in the late 19908. The vast majority of the literature currently
available on interdisciplinary collaboration in hospice has focused on exploring the
hospice team processes and their relational affects on organizational, team, and individual
variables (Clark et a1. 2007; Coopman, 2001; DeLoach, 2003; DiTullio & MacDonald,

1 999; Miceli & Mylod, 2003; Parker-Oliver, Bronstein, & Kurzejeski, 2005; Wittenberg-

Lyles, Parker-Oliver, Demiris, & Courtney, 2007).

The following contains a discussion of factors that are linked to hospice and other
interdisciplinary teams. Bronstein’s Model for Interdisciplinary Collaboration (MIC),
particularly four inﬂuences of interdisciplinary collaboration, was adapted to organize

and discuss variables associated with interdisciplinary collaboration in healthcare teams

as well as hospice teams based on a literature review.

Inﬂuences on Interdisciplinary Collaboration

Bronstein (1999; 2002; 2003) identiﬁed four inﬂuences on interdisciplinary
COIIaboration. Bronstein claims the presence of these factors support interdisciplinary

cOllaboration, and thus the absence of the inﬂuences refers as barriers to interdisciplinary

teen; work. First, professional afﬁliation, which she conceptualizes as a clear
mlderstanding and a strong sense of professional roles, values, and ethics of one’s

pro fession, respect for professional colleagues, a similar perspective shared with team

II‘lertribers, and balanced allegiances among one’s profession, team and organization

p r0Ilrote interdisciplinary collaboration. Second, structural inﬂuence, which refers to the

25

ways in which a manager or an organization “allocates resources and assigns work that
either supports or poses barriers to collaboration” (Bronstein, 1999, p. 40). Manageable
caseloads, professional autonomy, the time and resource available for collaboration, an
agency culture that supports collaboration and administrative support to collaboration are
elements of structural characteristics. Personal characteristics, the third inﬂuence, relate
to how team members view each other as people outside of their professional role.
Components such as the existence of trust, respect and understanding between team
members as well as positive attitudes towards team members and comfort with team
members’ personal behaviors enhance interdisciplinary collaboration (Bronstein, 2002;
2003). The fourth inﬂuence is a history of collaboration, and refers to the experiences and
existence of collaborative work (Bronstein, 2002; 2003).
Professional A jﬁliation
Professional afﬁliation is referred as commitment to one’s profession and
organization. Aube and Rousseau (2005), in a study of 74 teams working in 13
Organizations in Canada, found that team goal commitment was positively and
Signiﬁcantly (p<.05) related to team performance, the quality of group experience (the
tea—tn member’s perceptions about the common social climate within the work team and
Whether or not it is positive), and team viability (the team’s ability to adapt to internal
and external changes).
Professional discipline was identiﬁed as an inﬂuencing factor in a study of job
commitment and perceived team effectiveness by Freund and Drach-Zahavy (2007). Of
the four groups of professionals, administrators, physicians, nurses and paraprofessionals

Included in the study, the nurses expressed desire to work in a team the most. Physicians

26

saw job involvement as the main motive for team effectiveness while nurses saw both job
and organizational commitment as motivators of team effectiveness. Though different
professionals were motivated by different commitments, all professionals had
signiﬁcantly greater commitment to their jobs than to the organizations (F reund & Drach-
Zahavy, 2007).

Structural/Organizational Characteristics

Structural/organizational characteristics indicate organizational culture within an
agency. Organizational culture relates to combined conditions of the organizational work
environment, including its structure and philosophy, administrative support, coordination
and communication mechanisms (San Martin-Rodriguez et a1. 2005). It shapes
individuals’ assumptions, behavioral and thought patterns, group norms in subtle,
unconscious ways and in return shape the way organizations are run (Dershimer, 1991).

- The role of perceived team effectiveness in improving chronic illness care was

examined by Shortell et a1. (2004), using data obtained from 40 teams participating in the
national evaluation of the Improving Chronic Illness Care Program. The study found that

the existence of patient satisfaction focus and the presence of team leadership have a
Signiﬁcant positive association with overall perceived team effectiveness. Perceived team
eI‘I‘eetiveness was constantly associated with both a greater number and depth of changes

made to improve care to chronically ill patients (p<0.01). Working for an organization
that values teamwork and participation was positive and signiﬁcantly associated with the
number and depth of changes made to improve chronic care (Shortell et al., 2004).
A qualitative study further explored the role of organizational factors on

temnwork. DiTullio and MacDonald (1999) employed ﬁeld observations, individual

27

interviews, group discussions, and review of data by research participants to examine
occupational stress among 38 hospice workers. While teamwork and team support were
the most ﬁ'equently cited rewards of hospice work, hospice workers indicated
organizational changes as the major causes of occupational stress. In this study, 71% of
the participants expressed time “cramping” as a primary source of stress, followed by
55.3% of the respondents indicating lack of time for one’s emotional self-care and 52.6%
indicating restriction or demands imposed by policy changes as major factors in
occupational stress. Some other causational themes surfaced in the study. Over 55% of
study participants expressed inadequate communication was a major source of stress and
caused variety of organizational issues and cited the increased pace of work and
complexity of delivering care as the causes of faulty communication. In addition, over
5 5% of the team members expressed that those systemic problems of stafﬁng, scheduling

and role blun'ing were attributed to insufﬁcient response by organizational,

administrative culture (DiTullio & MacDonald, 1999).

In a qualitative study on factors that inﬂuence the perceived level of effective

Collaboration by Parker-Oliver and Peck (2006), hospice social workers saw

adlninistrative involvement as an important aspect of teamwork but felt distance from

u1313a management. Barriers to effective teamwork were related to organizational factors
Such as excessive overloads and overemphasis on medical issues as well as interpersonal

r e1 ationships of teams such as personality conﬂicts among team members (Parker-Oliver

& Peck, 2006).

28

Personal Characteristics and Relationships Among Collaborators

Personal characteristics and relationships among collaborators refer to how team
members view each other as people outside their professional role. In investigating the
role of group social and supportive norms and its impact on the perceived team
effectiveness, Amundson (2005) found that the individual members indicating positive

regard, support and respect toward other members was a signiﬁcant predictor of

perceived team effectiveness (p<.001).

Based on interviews with 23 social workers ﬁ'om 20 different hospices, Parker-
Oliver and Peck (2006) learned that the relationship between trust and communication

vvithin the team was a determining factor in the perceived level of effective

interdisciplinary collaboration.

History of Collaboration

History of collaboration relates to the experiences and existence of collaborative
Work. The experiences of training in collaborative work were found to be associated with
improved communication and improved decision-making among team members in an
evaluation study conducted by Haycock-Stuart and Houston (2005). In this study, a series
0 f nine educational and team building workshops were provided, andl40 clinical (nurses,
g eneral practitioners, and health visitors) and administrative (practice managers,
r 30 eptionists, secretaries, and other staff) staff members in the pre-workshop and 116
c l illical and administrative members in the post-workshop completed a questionnaire. In
th «2: same study, 84% of participants perceived that the interdisciplinary training

workshops had improved the quality of collaborative practice and 81% felt the workshops

had improved the quality of their own work.

29

Another study that found improved interdisciplinary communication as a beneﬁt
of interdisciplinary work examined interdisciplinary team performance in a long-term
care setting, using surveys completed by health care providers who work for one of the
26 Program of All-Inclusive Care for the Elderly (PACE) sites. Temkin-Greener et al.
(2004)’s work found a positive correlation between level of communication and team
cohesion, and level of communication and team performance. Communication had the
greatest impact on both perceived team cohesion and effectiveness, followed by conﬂict
management, coordination and leadership. Perceived team effectiveness signiﬁcantly
increased with age of the respondents, longer length of the team’s professional work
experience, more ethically diverse composition of the team, greater ethnic concordance
between team members and the participants, and greater perceived resource availability
(Temkin-Greener et al., 2004).

Another study examined the impact of mastery of teamwork knowledge on team
performance. Hirschfeld et a1. (2006) examined team members’ mastery of teamwork
lcnowledge as a potential predictor of team task proﬁciency and observed teamwork
effectiveness, using a large group of United States Air Force ofﬁcers in a 5-week

teamwork development program. Their hypothesis, that the greater individual mastery of

teaanork knowledge within a team, the greater team task proﬁciency and observed

teEllnwork effectiveness, was supported (Hirschfeld et al., 2006).

The work of Award et a1. (2005) showed the impact of medical team training on

ltl'llaroving communication based on professional diversity. They found a statistically
Si gmiﬁcant increase in the self-reported communication scores by the surgeons and

allesthesiologists, but no signiﬁcant change in communication among nurses. The results

30

 

of the pre-brieﬁng communication survey indicate that there was a real disconnect in the
perception in level of communication among the operating room staff. Surgeons
perceived communication in the operating room as good (average of 5.2 on the 1-7 Likert
scale). Nurses perceived interprofessional communication as adequate (average of 4.3 on
the 1—7 Likert scale). For anesthesiologists, their perception of interprofessional
communication was very poor (average of 2.0 on the 1-7 Likert scale). A post—brieﬁng
training communication survey was completed at 4 months after the training. Surgeons
reported an increase in communication among the surgical team by an average of 0.6
points (6.6 on the 1-7 Likert scale). The perceived increase in communication was most
signiﬁcant among anesthesiologists. Their average post-briefmg communication training
grew to 4.5 ﬁ'om 2.0 on the 1-7 Likert scale. Nurses, on the other hand, reported no
improvement in communication scores after the training. Their post-training score was
4.2, 0.1 lower than the pro-training test (Award et al., 2005).

Additional Inﬂuencing Variables on Interdisciplinary Collaboration

Additional inﬂuencing variables on interdisciplinary collaboration surfaced in the
process of a literature review. They are quality of care and job satisfaction.

Quality of Care

Quality of care indicates the interdisciplinary team members’ perception of team
function and quality of care the team provides. One of the early studies on hospice care
conveyed a link between the hospice interdisciplinary team work and quality of care. A
comparison study of two types of home health-based hospice programs involved a
hOSpice composed of nurses and trained volunteers and the other composed of nurses,

social workers, aides, chaplain, a volunteer coordinator and trained volunteers. Quality of

31

care was measured based on satisfaction survey questionnaires completed by families and
referring physicians. Families and physicians in general reported both hospices studied to
be very helpful and of high quality. Hospice of Seattle, a hospice using an
interdisciplinary team, was rated slightly higher on their effectiveness in providing pain
and symptom management. In addition, Hospice of Seattle, overall, received a higher
rating in its effectiveness of helping with coping both by families and physicians
(Bencala, McIntosh, & Salzman, 1982).

Abrahm, Callahan, Rosetti, and Pierre (1996) conducted a prospective study to
evaluate the effectiveness of a hospice consultation team with hospitalized advanced
cancer patients at the Philadelphia Veterans’ Affairs Medical Center. The hospice
consultation team in this study consisted of an oncologist with palliative care training, a
nurse coordinator, an oncology social worker, and a hospital chaplain. All members of
the team completed initial assessments and completed data, including demographic and
medical information and assessments of medical, nursing, psychosocial, and spiritual
needs of the patients and their families. Weekly team meetings were held, and the team
met more ﬁequently, if needed, as 75 patients participated in the study were seen daily
(Abrahm et al., 1996).

The study found that the hospice consultation team identiﬁed a large number of
medical, nursing, psychosocial, and spiritual care needs not previously identiﬁed or
adequately treated by the hospital multidisciplinary team. For instance, 90% of the
patients who initially reported unacceptable pain achieved acceptable pain relief, and
96% of the patients achieved acceptable management of other symptoms. Documentation

of the patient’s wishes regarding life-sustaining treatments was obtained in 66% of the

32

patients initially lacking documentation. The hospice consultation team identiﬁed 152
psychosocial and spiritual needs in the 75 patients, including psychological/mental health
issues such as unappreciated anxiety, depression, and/or anger. The study found that the
consultation team was less successful in resolving psychosocial problems identiﬁed,
citing that only 40% of issues of anxiety, depression, and anger were resolved with
counseling from the team social worker or chaplain (Abrahm et al., 1996).

Job Satisfaction

Job satisfaction relates to team members’ satisfaction with their jobs. Clark et a].
(2007) argues that job satisfaction by team members is essential not only for job retention
but also maximizing the quality of care provided to patients.

Coopman (2001) examined the perceptions of hospice team decision-making
processes and their relationships to assessments of team performance, individual
outcomes and job satisfaction. Hospice team decision-making processes were positively
and signiﬁcantly associated with team productiveness and cohesiveness, though not all
dimensions were associated with both outcomes. The level of involvement in the
decision-making process by all team members was moderately related to perceived team
cohesiveness (r=.52, p<.001) and perceived team productivity (r=.56, p<.001).

Additionally, involvement in the decision-making process by all team members
was moderately related to overall satisfaction with the team (r=.62, p<.001), satisfaction
with team communication (F64, p<.001), and desire to stay with the team (r=.48,
p<.001). Involvement in the decision-making process, the independent variable, was a
Signiﬁcant but not strong predictor of job satisfaction, the dependent variable. In this

StUdy, satisfaction with job communication was not related to job satisfaction (r=.19,

33

p.18). Job satisfaction was moderately related to evaluation of team productiveness (r=.55,
p<.001) and weakly related to team cohesiveness (r=.36, p<.01). The ﬁndings suggest
that team productiveness serves as a mediating variable between involvement in team
decision making and job satisfaction (Coopman, 2001).

Another study investigated factors that affect job satisfaction among hospice
interdisciplinary team members. Inﬂuencing factors of job satisfaction examined by
DeLoach (2003) related to team processes such as supervisory support, autonomy, work
motivation, and the role of professional diversity. Supervisory support, positive
affectivity, role ambiguity, autonomy, and routinization predicted 62% of the explained
variance in job satisfaction among hospice members. The most signiﬁcant predictor
variable was supervisory support (DeLoach, 2003).

Beneﬁts Associated with Interdisciplinary Collaboration

The majority of published studies on interdisciplinary collaboration relates to
beneﬁts of interdisciplinary collaboration. This section discusses beneﬁts associated with
interdisciplinary collaboration.

Improved services and cost containment associated with interdisciplinary
collaboration are often based on the results of comparison studies between
interdisciplinary team services and no-team services. Various patient beneﬁts from
interdisciplinary collaboration have been drawn in empirical studies while no
improvements were observed in some aspects of patient lives.

Brita-Rossi et a1. (1996) created a 25 member multidisciplinary orthopedic work
group and measured its effectiveness based on overall costs, length of hospital stay,

Patient satisfaction. A decreased length of hospital stay (from 5.9 to 4.6 days pre-work

34

team) is reported, and is hypothesized to be related to early involvement of social work
services, timely arrangements of rehabilitation beds, and improved delivery of pre-
operation information to patients/families. In addition, a decrease in operating room
delays accomplished by teamwork contributed to a reduction of overall cost of orthopedic
service (Brita-Rossi et al., 1996).

The study conducted by Wagner et al. (2003) had similar ﬁndings in regards to
the impact of interdisciplinary practice on shorter length of hospital stay. In this study,
correlations between the use of physical medicine and rehabilitation consultation and
variables such as acute functional outcome, length of hospital stay, and discharge
planning after a traumatic brain injury were studied. Data were obtained from 1,866 adult
hospitalized patients with non-fatal traumatic brain injury. Of the 1,866 patients, 510
received a consult from a physical medicine and rehabilitation team and the 1,346
remaining did not. The study results indicated that earlier (less than 48 hours after
admission) physical medicine and rehabilitation consultation resulted in a signiﬁcantly
shorter acute length of hospital stay (p=0.001) (Wagner et al., 2003).

Sommers et al. (2000) also supports that interdisciplinary teams decrease
readmission and ofﬁce visits and increase team impact sustainability over time. This
experimental study focused on the effectiveness of collaboration in primary care
involving 543 seniors. The intervention group received care from an interdisciplinary
team consisting of a physician, nurse, and social worker during the middle 18 months of
the 3 year study, while the control group continued to only receive services as usual from
their primary care physician. The data regarding hospital admissions and readrnissions,

emergency room visits, ofﬁce visits, home care service visits, and nursing home

35

placements as well as patient-reported health status were collected for the 3 study years.
Their ﬁndings indicate a decrease in hospital readmission and ofﬁce visits for those in the
intervention group while these incidents increased for the control group. The rate of
hospitalization increased for the control group (from 0.39 in the baseline year to 0.34 in
the year 1 and 0.52 in the year 2) while it stayed stable for the intervention group (0.38 in
the baseline year and 0.36 in the year 2 of the interdisciplinary services). The readmission
rate within 60 days of the initial hospitalization showed a 4% to 6% decrease for the
intervention group (4.8 in the baseline year to 3.6 in the intervention year 2) compared to
an increase in hospital readmission for the control group (6.1 in the baseline year to 9.4 in
the year 2). During the follow up period, six months after the ending of the experimental
study, group differences in hospitalization rate changes were found no longer signiﬁcant,
but the rate of ofﬁce visits remained law for the intervention group. No signiﬁcant
differences in emergency room visits, nursing home placements, and home care visits
between the two groups were found (Sommers et al., 2000).

The sustainability of the effect of interdisciplinary practice on the length of
hospital and nursing home stay was also supported by Nikolaus et al. (1999). The
effectiveness of geriatric evaluation and management for hospitalized seniors with post
discharge home interventions using an interdisciplinary team (nurses, a physiotherapist,
an occupational therapist, a social worker, a secretary and primary physicians) was
studied with a total of $45 seniors that were randomly assigned to (1) a home
interdisciplinary intervention group (comprehensive geriatric assessment and additional
ill-hospital and post-discharge follow-up interventions by an interdisciplinary team), (2) a

geriatric assessment group (comprehensive geriatric assessment with recommendations

36

followed by traditional care), or (3) a control group (Assessment of activities of daily
living and cognitive functioning followed by traditional care in hospital and at home).
The main outcome variables studied included survival rate, functional status, hospital
readmission, nursing home placement, and direct care costs over 12 months (Nikolaus et
aL,l999)

The participants in the intervention group had a shorter length of nursing home
stays (114.7 days compared to 161.6 and 170.0 days of assessment group and control
group). Although the rate of readmission to hospitals did not differ between the groups,
the length of stay was signiﬁcantly shorter in the intervention group (22.2 days compared
to 34.2 and 35.7 days of assessment group and control group). Unlike the ﬁndings of
Sommers at al. (2000), the authors found no difference in the mean number of visits to
primary care physicians between the three groups at one year in this study (Nikolaus et al.,
1999). The reduced costs of care in an intervention group that received services from an
interdisciplinary team along with a geriatric assessment were reported by Nikolaus et al.
(1999). The intervention group cost was $ 1,922,400 compared to $2,276,600 in the
assessment group that received a geriatric assessment along with traditional care and
32,36,300 in the control group that received traditional care only.

A year-long investigational study on the effectiveness of palliative medicine
consultation teams in serving outpatient patients who continue to pursue aggressive,
curative treatments for their underlying disease conducted by Rabow et a1. (2004) shows
mixed results. The study involved 40 control patients and 50 intervention patients. The
participants in the intervention group, along with their physicians received multiple

palliative care consultations to address physiological, social, psychological, and spiritual

37

needs of the patients. The palliative consultation team consisted of three physicians, a
social worker, nurse, chaplain, pharmacist, psychologist, art therapist, and volunteer
coordinator. Patients in the intervention group were found to make fewer primary care
and urgent care visits while no statistically signiﬁcant group differences were found in
regards to emergency room visits, specialty clinic visits, or hospitalizations (Rabow et al.,
2000).

Finally, one study showed no impact of interdisciplinary collaboration on
organizational beneﬁts. In evaluating the impact of integrated, collaborative health and
social care teams versus traditional, multidisciplinary teams on the services provided to
older people in the UK, Brown et al. (2003) found no difference between the two groups
concerning a number of contacts made with social services and visits made by a visiting
nurse. A total of 393 people (195 in the integrated group and 198 in the traditional group)
participated in the study and were evaluated at three time periods (at the initial referral
time, at 6 months, and 18 months of the services). More people in the traditional group
died compared to the integrated group (49 versus 36) and more people in the traditional
group were placed in nursing homes (20 versus 13). These results, however, were not
statistically signiﬁcant (Brown et al., 2003).

The reduced costs of care in the intervention group were associated with fewer
days spent in hospital and nursing homes. Sommers et a1. (2000) found that an
interdisciplinary team intervention for chronically ill seniors, compared to a traditional
care, resulted in an average of $90 saving per patient. Service cost savings associated
With the use of teams were not supported, however, in a study of the impact of an

outpatient palliative medicine consultation team (Rabow et a1. 2004). A comparison of

38

costs between an intervention group of patients who received services from an
interdisciplinary team as well as primary care, and a control group of patients who only
received primary care service, found no statistically signiﬁcant differences in urgent care,
emergency room or hospitalization charges per patient (Rabow et al. 2004).

The study by Wagner et al. (2003) indicated that earlier (less than 48 hours after
admission) physical medicine and rehabilitation consultation resulted in signiﬁcantly
better acute functional scores with transfers and locomotion. The study by Mukamel et a1.
(2006) involving 3,401 chronically ill seniors who participated in the Program of All-
Inclusive Care for the Elderly (PACE) and 1,860 direct care, full-and part-time PACE
care team members, revealed that the measure of overall team performance was
signiﬁcantly associated with activities of daily living scores of the seniors at 3 months

= -0.71) and at 12 months (F= -1.77). Also, the overall team performance was
signiﬁcantly associated with the status of urinary incontinence of the seniors at 12
months (F=0.23) (Mukamel et al., 2006).

In the investigation of individuals continuing to receive aggressive medical
treatment, (Rabow et al. 2004) the use of an interdisciplinary team resulted in
improvements in the physical (dyspnea and sleep), psychological (anxiety), end of life
planning, and spiritual well-being aspects. However, no change in levels of pain,
depression, satisfaction with care, or quality of life was found. Contrary to this ﬁnding in
regards to quality of life, the work of Brown et al. (2003) found an increase in quality of
life scores in the integrated group, compared to the control group, by a mean score of
0.65. A comparative study of integrated team service and traditional care service for

older adults living in a rural area showed that those receiving care from the integrated

39

team had higher quality of life scores over time than those in the traditional care group
(paired t=2.389, d%184; p=0.018) (Brown, Tucker, & Domokos, 2003).

In terms of patient self-reported health status measured by Sommers et al. (2000),
the participants in the intervention group who received services ﬁ'om an interdisciplinary
team on the average reported an increase in social activities (8.3 in the baseline year to
8 .8 in the intervention year 2) and a decrease for the control group (8.8 in the baseline
year to 8.6 in the year 2). Those in the intervention group, compared with the control
group, reported fewer symptoms (17.7 to 17.2 vs. 17.9 to 18.9) and slightly improved
overall health (3.2 to 3.3). There was no difference in changes of health status reports in

terms of physical, emotional, nutrition, or number of medications based on the group
status.

Another experimental study shows similar ﬁndings. Nikolaus et al., (1999)
studied the effectiveness of geriatric assessment and management of a group of seniors in
Germany who had been hospitalized and discharged. Those in the intervention group who
received comprehensive geriatric assessment and follow-up by an interdisciplinary team
reported a higher score of self-perceived health (3.7 compared to 3.0 in the assessment
group and control group). The intervention group also scored higher on life satisfaction
(3 .9 compared to 3.2 in the assessment and control groups) and use of community
resources (Case management, shopping help, meal services, household help, and

c0mmunity centers for seniors). The authors analyze that being better informed about
coxnmunity resources and resource allocation led to greater life satisfaction and higher

perceived health status in the intervention group. The participants in the intervention

40

group showed better functional capacities (5.6 compared to 4.1 and 4.3 of assessment
group and control group).

Reese & Raymer (2004) measured the effectiveness of hospice social worker
involvement on hospice outcomes, and included an assessment of team functioning.
Based on a literature review on hospice social workers, Reese and Ramyer (2004) assert
that some hospice agencies were trying to minimize social work services to contain
hospice expenditures. Other authors also have suggested that the trend to undermine
social work or spiritual care services might be related to the pressure from third insurance
companies. For instance, Herbst (2004) makes an observation on this trend stating,
“Although regulatory surveyors and third-party payers who monitor the delivery of
palliative are ﬁnd it relatively easy to understand the need for pain control, to stop
patients’ vomiting, and to provide information for decision making, it is often harder for
them to understand the need for other interventions. Insurance companies often try to

negotiate payment packages with hospices that exclude social work and chaplain
services. Problems in any domain may adversely affect a person’s well-being, however”
(p.756).

The National Hospice Social Worker Survey (Reese & Raymer, 2004) was
undertaken to study the signiﬁcance of having a social worker as a core member of the
interdisciplinary team. The study used 330 patient cases from 66 hospices based on a
Stratiﬁed random sample of the 350 hospices listed with the NHPCO. In terms of social
Work involvement and hospice processes, having a sole assignment as a hospice social

Worker rather than having multiple roles was signiﬁcantly associated with addressing

1'hore concerns on the interdisciplinary team. Furthermore, higher educational

41

background, more experiences in hospice work, full-time status, and no additional duties
outside of hospice social work position were all associated with better team functioning
(Reese & Raymer, 2006).

In reviewing the effectiveness of the hospice interdisciplinary team, the study
found that better team functioning was signiﬁcantly associated with lower average
number of hospitalizations per patient as well as lower overall hospice costs, including
lower costs in home health aide, nursing and labor costs. In addition, the study found that
the more issues addressed by social workers on the team, the fewer visits by other
members of the team required. Social work participation in the initial admission process
was associated with lower average costs of pain medications per patient, lower home
health aide, nursing and labor costs, and more social work contacts, Master’s degree
social worker, more experience in hospice were associated with lower pain medication
costs (Reese & Raymer, 2004).

Overall Findings

The ﬁndings in this literature review support the common themes found by earlier
literature reviews on the beneﬁts of interdisciplinary collaboration. The themes include:
(1) inefﬁcient empirical studies evaluating the outcomes and beneﬁts of interdisciplinary
practice (Faulkner Schoﬁeld & Amodeo, 1999; San Martin-Rodriguz et a1, 2005; Saultz
& Lochner, 2005), (2) persistent limitations in deﬁnition, model, and measurement
methodologies employed in studies (Faulkner Schoﬁeld & Amodeo, 1999; Mickan, 2005;
San Martin-Rodriguez et a1, 2005; Saultz & Lochner, 2005), (3) difﬁculties of capturing
and measuring the processes and beneﬁts of interdisciplinary collaboration due to the

multifaceted nature of interdisciplinary practice (Mickan, 2005; San Martin-Rodriguez et

42

a1, 2005; Saultz & Lochner, 2005), and (4) limited evidence suggesting that
interdisciplinary practice is beneﬁcial on organizational, team, and individual levels
(Faulkner Schoﬁeld & Amodeo, 1999; Mickan, 2005; San Martin-Rodriguez et a1, 2005;
Saultz & Lochner, 2005).

The lack of empirical studies evaluating the outcomes and beneﬁts of
interdisciplinary practice became evident for those conducting a literature review on the
topic. Of over 2,200 abstracts of the articles (published between 1974 and 1996) read and
224 articles analyzed by Faulkner Schoﬁeld and Amodeo (1999), only 32 articles were
considered empirical studies. The vast majority of the articles reviewed by Faulkner
Schoﬁeld and Amodeo (1999) focused on describing the education, training, or job
satisfaction with interdisciplinary team members, “with little critical analysis” (p.217).
San Martin-Rodriguez, et al. (2005) searched several databases for the period of 1980 and
2003 and found only 10 empirical studies that focused on determinants of
interprofessional collaboration. They concluded that the majority of published work on
interdisciplinary collaboration is based on a conceptual approach rather than empirical
data.

Of particular concerns raised by San Martin-Rodriguez et al. (2005) relate to
absence of attention given to the inﬂuence of organizational and systemic factors on
interdisciplinary collaboration. Organizational factors are conditions of the organizational
work environment such as its structure, philosophy, administrative support, and
coordination and communication mechanisms. Systemic factors are elements outside the
organization, including power differences between professionals in a team, speciﬁc

cultural values unique to a team, discipline speciﬁc values, philosophy, and theoretical

43

values, and professional speciﬁc training and education. Only forty studies reviewed by
Saultz and Lochner (2005) were found to be empirically based studies on the beneﬁts of
interdisciplinary work on care outcomes, despite the fact that they had reviewed 2,424
citations of articles published between 1966 and April 2002.

The persistent limitation in terminology, model and methodologies used in studies
is another theme highlighted by previous and this literature review on the processes and
beneﬁts of interdisciplinary collaboration. There is considerable diversity in how
interdisciplinary collaboration is deﬁned and measured (Faulkner Schoﬁeld & Amodeo,
1999; Mickan, 2005; San Martin-Rodriguez et a1, 2005; Saultz & Lochner, 2005).

Faulkner Schoﬁeld and Amodeo (1999) found in their literature review that the
terms “multidisciplinary” and “interdisciplinary” rarely were deﬁned and often were used
interchangeably. They state, “A prerequisite to a rigorous evaluation of any model is a
clear and consistently used deﬁnition of terms; however, we found no such clarity or
consistency in our searches. Obviously, the literature suffers from a failure to use the
terms consistently in articles” (F aulkner Schoﬁeld & Amodeo, 1999, p. 211). The present
literature review supports persistent inconsistency in deﬁnition of interdisciplinary
collaboration. Other terms such as teamwork (Haycock-Stuart & Houston, 2005),
multidisciplinary team (Y un, Faraj, & Sims Jr., 2005), and integrated team (Brown etal.,
2003) were used, along the term “interdisciplinary team,” interchangeably.

The literature review completed by Saultz and Lochner (2005) reveals that only
fourteen of 40 empirical studies possessed a clear deﬁnition and measurement of

interpersonal continuity. Six of 40 studies did not deﬁne or measure interpersonal

continuity. In addition, less than half of 40 empirical studies employed study
methodologies that truly measured what they were intended to measure.

Absence of a shared and clear deﬁnition and measurement methodology might be
a reﬂection of the very nature of interdisciplinary practice. Multifaceted aspects of
interdisciplinary collaboration and practice are intended to attend to bio-psychosocial-
spiritual issues of human experiences at both micro and macro levels (Conner et al. 2002).
The difficulty of conceptualizing the deﬁnition of interdisciplinary collaboration,
according to Graham and Barter (1999), comes ﬁom the verb-based, action-driven nature
of collaboration. Parker-Oliver, Bronstein, and Kurzejeski (2005) point out that the
delivery system and philosophy of a particular health care team or organization affects
how that team provides services to a speciﬁc, targeted population. This can explain
diversity in the deﬁnition and scope of interdisciplinary practice, and ultimately in
methodologies used in studies addressing interdisciplinary collaboration.

Lastly, the available empirical studies suggest that interdisciplinary practice is
associated with signiﬁcant improvement in some care outcomes‘on all organizational,
team, and individual levels. Faulkner Schoﬁeld and Amodeo (1999) identiﬁed 11
outcome-based articles that covered some improvement in outcomes. The ﬁndings ﬁ'om
the literature review conducted by Saultz and Lochner (2005) counted a total of 81
separate care outcomes in the 40 empirical studies reviewed. Of the 81 care outcomes, 51
were signiﬁcantly improved (Saultz & Lochner, 2005).

The ﬁndings from these literature reviews validate the promotion of the use and

beneﬁts of interdisciplinary teams without sufﬁcient scientiﬁc proof and thus highlight an

45

alarming need for empirical studies on the processes, outcomes, and effectiveness of
interdisciplinary collaboration.

Limited Research on the Processes and Beneﬁts of the Hospice

Interdisciplinary Team

One explanation for the lack of studies done on the beneﬁts of hospice teams may
be related to the essential role of the interdisciplinary team played in hospice. Because
the holistic care model has always been practiced as the halhnark of hospice care,
challenging the beneﬁts of the team might have been taken as a denial of the whole
concept of hospice care. In addition, as discussed earlier, the concept of the
interdisciplinary team is logically sound and considered to be the best teamwork model
presently available compared to unidisciplinary (no team at all) or multidisciplinary team
models (Conner et. al., 2002). In general, therefore, the beneﬁts of the interdisciplinary
team have been rarely questioned (Ansari et al., 2001; Brown et al., 2003; Faulkner-
Schoﬁeld & Amodeo, 1999; Mickan, 2005; Mizrahi & Abramson, 2000; San Martin-
Rodriguez et. al., 2005).

A second explanation related to the lack of research on the interdisciplinary team
in hospice may be that the use of the interdisciplinary team is one of the requirements
under MHB. Therefore, regardless of the actual beneﬁts of the team, hospice services
must be provided through the interdisciplinary team. Because many hospices have not
been highly involved in research in general (Tolley & Payne, 2006), the hospice industry
is still in its beginning stage of practicing data collection on their patient demographics,
practices, and outcomes (Conner, Tecca, LundPerson, & Teno, 2004). In fact, it was not

until 1999 that the NHPCO began developing a national data set to keep track of key

46

information on hospice services and outcomes (Conner et al., 2004). While the hospice
industry tries to prove its beneﬁts compared to other settings for the dying, studies on the
processes and beneﬁts of the interdisciplinary team in hospice may continue to receive
the least priority.

Merriman (1999) argues that hospice care is effective and has had made an impact
on individual patients and their families, health industry, communities, and society, but
the lack of documented beneﬁts of hospice has resulted in no comprehensive body of
evidence to support the claim. Some challenges to documenting the impact of hospice
care, identiﬁed by Merriman (1999) are: (1) the difﬁculty of deﬁning quantiﬁable
measures of impact, of collecting quantiﬁable data from highly individualized plans of
care tailored for each patient and his/her family, and of objectively measuring a care
experience that is inherently subjective; (2) the limited number of well-validated
measurement tools; (3) the ethical questions that rise when studying already vulnerable
dying patients and their families; (4) the methodological issues, including a non-random
nature of the sample (hospice care chosen by the dying voluntarily), the validity of
comparing hospice patients with non-hospice patients, and the difﬁculty of measuring
lasting effects of hospice care on the health care industry and society; and (5) the costs
and time commitment required to conduct studies.

Summary

This chapter provided background information on the development and

experiences of interdisciplinary teams, followed by a discussion of currently available

literature on the processes, inﬂuencing factors, and beneﬁts of interdisciplinary

47

collaboration. The next chapter will outline the study of interdisciplinary collaboration

and factors that affect collaborative work in hospice teams.

48

CHAPTER 3
Methodology
Following a discussion of the research questions, this chapter presents the
methodology of this study, including procedures, sampling design, instrumentation, and
data analysis. The chapter then concludes with a summary. In this study, both quantitative
and qualitative research methodologies were employed to understand interdisciplinary
collaboration among hospice interdisciplinary team members and to explore what may
help or hinder their collaborative work. The study was conducted upon approval from the
Social Science/ Behavioral/ Education Institutional Review Board (SIRB) at Michigan
State University (Appendix A).
Research Questions
The purpose of the study was to evaluate factors that affect interdisciplinary
collaboration among hospice interdisciplinary team members. The proposed study was
guided by the ﬁve research questions listed below:
1. What is the relationship between perceived level of collaboration on hospice
teams and professional diversity (physicians, nurses, spiritual care providers,

and social workers)?

H1: Social workers, compared to physicians, nurses and spiritual care
providers, report a higher level of interdisciplinary collaboration.

2. What is the impact of professional afﬁliation, structural/organizational
characteristics, personal characteristics and relationships among collaborators,
and history of collaboration on interdisciplinary collaboration?

H2: Professional afﬁliation, structural/organizational characteristics, personal

characteristics and relationships among collaborators, and history of
collaboration have a positive direct effect on interdisciplinary collaboration.

49

3. What is the impact of interdisciplinary collaboration on perceived quality of
care team provides?
H3: Degree of interdisciplinary collaboration has a positive direct effect on
perceived quality of care team provides.

4. What is the relationship between interdisciplinary collaboration and job
satisfaction?

H4: Degree of interdisciplinary collaboration has a positive correlation with
job satisfaction.

5. Is professional diversity (physicians, nurses, spiritual care providers, and
social workers) an inﬂuencing factor in differences in professional afﬁliation,
personal characteristics and relationships among collaborators, history of
collaboration, perceived quality of care, and job satisfaction?

H5: Professional diversity is an inﬂuencing factor in differences in

professional afﬁliation, personal characteristics and relationships among

collaborators, a history of collaboration, perceived quality of care and job

satisfaction.
Participation Recruitment and Procedures

The procedure for this study involved the administration of the questionnaire

described below to medical directors (physicians), nurses, spiritual care
providers/counselors, and social workers working in a hospice agency within the state of
Michigan. Using the 2008 Michigan Hospice and Palliative Care Organization
membership directory (Michigan Hospice & Palliative Care Organization, 2008), a
packet of information was mailed to all the member hospices’ executive directors or
administrators with a letter explaining the purpose of the study and requesting their
participation. In 2008, a total of 117 hospice agencies held membership status with
Michigan Hospice and Palliative Care Organization. Along with the letter to the
executive director or administrator, the packet of information enclosed four copies of the

self-administered questionnaire to be disseminated to a medical director, nurse, spiritual

care provider/counselor, and social worker of the agency.

50

Each survey questionnaire was accompanied with a cover letter explaining the
purpose of the study, an estimated time of survey, conﬁdentiality, consent for
participation, and ways to contact the researcher. In the cover letter, each individual
choosing to participate in the survey study was asked to complete an informed consent
form prior to participating in the study. A letter requesting participation in a future phone
interview was also enclosed. For those individuals who chose to participate in a ﬁrture
phone interview was asked to complete a consent to voluntary participate in the interview
and a contact information sheet. Self-addressed and stamped return envelopes were
provided to all participants. Three follow-up e-mail messages were send to hospice
administrators in approximately two weeks, four weeks, and six weeks after the survey
questionnaires were ﬁrst mailed. Rubin and Babbie (1993) state that two or three weeks
is “a reasonable space between mailings” (p.339) as the timing of follow-up mailing.
Sampling Design

The sampling of this study involved four core professional disciplines of hospice
interdisciplinary team, which are medical directors, nurses, social workers, and spiritual
care -providers/counselors. Participants working for a hospice agency in the state of
Michigan that is a member of the Michigan Hospice and Palliative Care Organization in
2008 were recruited for the study. Study participants worked either full-time or part-time
for hospice.

Participant Characteristics

The study focused on gaining an understanding of interdisciplinary collaboration

among core members ofihospice interdisciplinary teams and of inﬂuences of

interdisciplinary collaboration. The researcher chose to recruit hospice workers from four

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speciﬁc professional diversities, including medicine, nursing, spiritual care/counseling,
and social work. A literature review revealed that the majority of past studies on
interdisciplinary collaboration focused on evaluating teams as a whole (Aube &
Rousseau, 2005; Brital-Rossi et al.,, 1996; Clark et al.,, 2007; Coopman, 2001; DeLoach,
2003; Rawbow et al., 2004). Despite much discussion about the obstacles of teamwork
based on the diversity in individual professional disciplines (Bailey, Jones, & Way, 2006;
Brewer, 1999; Coopman, 2001; Irvine et al., 2002), only a few published studies were
found to evaluate the impact of individual professional diversity on interdisciplinary
collaboration (Abrahamson & Mizarahi, 1996; Bailey, Jones, & Way, 2006; Freund &
Drach-Zahavy, 2007; Parker-Oliver, Wittenberg-Lyles, & Day, 2006). This ﬁnding led to
the decision to include an evaluation of individual professional diversity and its
relationship to interdisciplinary collaboration in this study.

The professional diversities represent the four core members of hospice
interdisciplinary teams required and deﬁned by MHB (Kastenbaum, 2003). Inclusion
criteria for the study are individuals who: (1) work either full-Me (at least 36 hours a
week of work) or part-time (work less than 36 hours a week but are expected to work a
certain number of hours each week and are not an “per diem” employee) as a medical
director, nurse, spiritual care provider/counselor, or social worker; (2) work as a core
member of an interdisciplinary team in a hospice agency; and (3) volunteer to participate
in the study. Exclusion criteria for the study include individuals who: (1) do not meet the

three criteria above and (2) are not willing to sign a consent form.

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Instrumentation and Variables

Quantitative Instruments and Variables

The review of the literature on interdisciplinary collaboration and hospice was the
driving force of the development of the questionnaire for this study. The literature
suggested the utilization of a combination of existing scales that assess interdisciplinary
collaboration and various inﬂuencing factors of interdisciplinary collaboration (F reund &
Drach-Zahavy, 2007 ; Lichtenstein et al., 1997; Rawbow et al., 2004; Shortell et al., 2004).

The level of interdisciplinary collaboration was measured using the Modiﬁed
Index for Interdisciplinary Collaboration (MIIC) (Parker-Oliver, Bronstein, & Kurzej eski,
2005). This instrument has been used to test interdisciplinary collaboration in a hospice
setting (Parker-Oliver, Bronstein, & Kurzej eski, 2005; Parker-Oliver, Wittenbeg-Lyles,
& Day, 2006). Factors that inﬂuence interdisciplinary collaboration was measured using
a combination of: (1) modiﬁed questions of the inﬂuences of interdisciplinary
collaboration originally theorized and tested by Bronstein (2002) within the original
version of the MHC; (2) the Quality of Care subscale, a part of the Attitudes Toward
Health Care Teams (ATHCT) instrument developed by Heinemann, Schmit, & Farrell
(1991); and (3) items on job satisfaction and turnover intention subscales from the core
questionnaire of the Michigan Organizational Assessment Questionnaire (MOAQ)
developed by Carnmann, Fichman, J enkings, and Klesh (1983).

Descriptive and Demographic Variables

The questionnaire contained a section designated to obtain demographic data from
the study participants about themselves as well as the agencies for which they work.

Items included in the demographic variables relating to individual participants were: age,

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gender, race/ethnicity, professional discipline, full-time (at least 36 hours a week of
work) versus part-time (those who work less than 36 hours a week, are expected to work
a certain number of hours each week and are not an “per diem” employee) employment
status, years of professional discipline experience, years of hospice experience, and years
of collaborative work experience including hospice and other work settings. Age was
determined with one multiple question with ﬁve options (under 30 years, 31-40 years, 41 -
50 years, 51-60 years, and over 60 years). Five options with one option labeled as “other”
are listed to determine race/ethnicity.

Professional discipline was determined with one question speciﬁc to each
discipline with multiple responses to indicate a speciﬁc educational background for the
particular discipline. For instance, social workers were asked to choose from three
choices of BSW, MSW or other. In this question, participants were asked to respond to
whether or not they are certiﬁed in palliative care/hospice. Nominal questions were used
to indicate sex, male or female, and full time versus part-time employment status. Years
of professional discipline experience, hospice experience, and collaborative work
experience are each determined with multiple choice questions. Ten answer options
included: Less than 2 years, 2-5 years, 6-10 years, 11-15 years, 16-20 years, 21-25 years,
26-30 years, 31-35 years, 36-40 years, and over 40 years.

Information relating to the team and organization in which the participants work
included: Agency status, the age of the hospice program, daily census, a number of teams
in the organization, a number of core members, geographic service areas of the
organization (rural, urban/suburban, or combination), location within Michigan. A three

scale of non-proﬁt, for-proﬁt, or govemment-run hospice agency indicated the agency’s

54

organizational status. The age of the hospice program was determined with a multiple
choice question with six options of less than 2 years, 2-5 years, 6-10 years, 11-15 years,
16—20 years, and over 20 years.

Average daily census was indicated with a multiple choice question with six
options of less than 30, 31-50, 51-70, 71-90, 91-110, and over 100 patients. The range of
responses for the question was created based on the information published by National
Hospice and Palliative Care Organization on Hospice Facts and Figures (2007) that the
median hospice daily census in 2006 was 45.6 patients with 41.6% of hospice programs
serving fewer than 25 patients daily on average. Only 16% of hospice programs had a
daily census of 100 and greater (NI-[PCO, 2007). A multiple choice question of less than
5, 6-10, 11-15, 16-20, 21-25, 26-30, and greater than 31 core members indicated the
number of core hospice team members. The number of teams within the organization
was determined by a multiple choice question of 1, 2-3, 4-5, and greater than 6 teams
within in the organization. Three options of rural, suburban/urban, or combination of
rural and suburban/urban areas were given to determine geographic service areas of the
organization.

Dependent Variables

Interdisciplinary Collaboration: Modiﬁed Index for Interdisciplinary
Collaboration (MIIC)

Hospice interdisciplinary collaboration processes was measured using the
Modiﬁed Index for Interdisciplinary Collaboration (MIIC), a 42-item instrument that
assesses the perceptions of hospice team members of interdisciplinary collaboration
within their team (Appendix B). The original instrument, the Index for Interdisciplinary

Collaboration (HC) developed by Bronstein (2002; 2003), measured social workers’

55

perceptions of collaborative work on a team and had ﬁve components regarding
interdisciplinary collaboration processes including interdependence, newly developed
professional activities, ﬂexibility, collective ownership of goals, and reﬂection on process.

The HC was initially developed as a 49-item scale and then was narrowed to a 42
item self-report questionnaire (Parker-Oliver, Bronstein, & Kurzej eski, 2005), using a 5-
point Likert scale with one indicating “Strongly Agree” and ﬁve indicating “Strongly
Disagree”. The documented reliability on the 42-item scale was Cronbach a of 0.92
(Bronstein, 2002; Parker-Oliver, Bronstein, & Kurzej eski, 2005). The reliability rates of
ﬁve subscales were between 0.62 and 0.82. The interdependent and ﬂexibility
components were later combined and showed Cronbach a of 0.80 (Parker-Oliver,
Bronstein, & Kurzejeski, 2005). The four subscales’ Cronbach a ranged from 0.75 and
0.82 (Parker-Oliver, Bronstein, & Kurzej eski, 2005).

Parker-Oliver, Wittenberg-Lyles, and Day (2007) modiﬁed the IIC, changing
some wording in the questionnaire, to target and measure perceptions of interdisciplinary
collaboration by all hospice team members. The MIIC, a 42-item self-report
questionnaire, includes the same four subscales as the IIC, including interdependence and
ﬂexibility (18 items), newly created activities (6 items), ownership of goals (8 items), and
reﬂection on process (10 items). Like the original HC, a 5-point Likert scale with one
indicating “Strongly Agree” and ﬁve indicating “Strongly Disagree” was used as the
range of responses.

The MHC was tested with 95 hospice team members from ﬁve hospice programs
in the United States. Within this sample, a total of eleven individual disciplines, including

nurse, physician, chaplain, bereavement, home health aide, dietary, volunteer, therapist,

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team leader, secretary, and social worker, responded to the questionnaire (Parker-Oliver,
Wittenberg-Lyles, & Day, 2007 ). Both positively and negatively phrased questions were
used in the MHC, and a paired sample t-test was completed to compare the two sets of
questions. The mean of thirty positively phrasing questions was 1.98, and the mean for
twelve inversely worded and recorded phrasing questions was 2.77, with no statistically
signiﬁcant difference between the two sets of questions (Parker-Oliver, Wittenberg-Lyles,
& Day, 2007). The internal consistency of the MIIC, measured by Cronbach a, had a
score of 0.935, reﬂecting very high reliability (Rubin & Babbie, 1993).

The interdependence and ﬂexibility component measured the degree to which
individual team members rely on other members and deliberately cross professional roles
to accomplish goals. Cronbach’s alpha reliability score of 0.867 was found for the
interdependent and ﬂexibility subscale (M=2.l9, SD=0.70). The newly created activities
component assessed the degree to which organizational and structural mechanisms are in
place to support collaborative work. This subscale had Cronbach’s alpha of 0.767

=2.07, SD=0.7 5). Measuring the degree to which individual team members share
responsibility in the process of assessing, developing, and evaluating client-centered care
planning related to the collective ownership of goals. The collective ownership of goals
subscale had a Cronbach’s alpha reliability score of 0.795 (M=2.22, SD=0.77).

The reﬂection on process component examined the degree to which individual
team members engage with each other to evaluate and improve their collaborative work.
Cronbach’s alpha for the reﬂection on process subscale was 0.791 (M=2.31, SD=O.66).
The internal consistency of the four subscales demonstrated moderate to good reliability

rates (Garson, 2008) between 0.767 and 0.867. Test-retest reliability, a measurement of

57

stability of an instrument over time, examined in the original version of MIIC had a
reported correlation of 0.824 (p<.01), which indicates good stability of the instrument
over time (Rubin & Babbie, 1993).

Independent Variables

Four Inﬂuences of Interdisciplinary Collaboration: Professional Aﬂiliation,

Structural/Organizational Characteristics, Personal Characteristics and

Relationships Among Collaborators, and History of Collaboration.

Independent variables for this study included the four inﬂuences of
interdisciplinary collaboration theorized and tested by Bronstein (2002; 2003). The four
inﬂuences were: Professional afﬁliation, structural/organizational characteristics,
personal characteristics and relationships among collaborators, and history of
collaboration (Appendix B). Some modiﬁcations to the original statements relating to
each inﬂuence were made to include various professional disciplines and to further
explore information regarding each inﬂuence.

Professional afﬁliation was determined by three statements with ﬁve Likert scale
responses of one indicating “strongly agree” to ﬁve indicating “strongly disagree.” Three
professional afﬁliation statements were: (1) I am strongly committed to the professional
role at my agency; (2) I am strongly committed to the values of my profession; and (3) I
strongly identify with my profession. Five statements with ﬁve Likert scale responses of
one being “strongly agree” to ﬁve being “strongly disagree” indicated
structural/organizational characteristics. Five structural/organizational characteristics
statements were: (1) My organization provides physical space needed for

interdisciplinary collaboration; (2) My organization provides communication resources

such as a phone, pager, and computer needed for interdisciplinary collaboration; (3) My

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workday allows me time for interdisciplinary collaboration with other team members; (4)
The administration at my organization supports interdisciplinary collaboration; and (5)
The administration at my organization expects interdisciplinary collaboration.

Four statements with Likert scale responses with one indicating strongly agree
and ﬁve indicating strongly disagree indicated personal characteristics and relationships
among collaborators. The four statements about personal characteristics and relationships
among collaborators include: (1) I like the colleagues from other disciplines whom I
work with on a team; (2) My colleagues from other disciplines and I socialize outside of
work; (3) My colleagues from other disciplines and I trust each other; (4) My colleagues
from other disciplines understand my personal values and perspective.

History of collaboration inﬂuence involved a question about a prior collaborative
experience of “Have you ever had experience with interdisciplinary collaboration?” with
yes or no response. Those who respond “yes” to the question will respond to this
statement: “My past experience with interdisciplinary collaboration has prepared me well
for my current collaboration with other disciplines,” with ﬁve Likert scale responses of
strongly agree to strongly disagree. Another question included under the history of
collaboration inﬂuence relates to a prior training in collaborative work, “Have you ever
had training in interdisciplinary collaboration?” For those who respond “yes” to the
participant will respond to a statement,” My past training in interdisciplinary
collaboration helps me in my current collaborative wor ” with ﬁve Likert scale responses

of strongly agree to strongly disagree.

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Quality of Care: The Quality of Care Subscale

“Quality of care” was another independent variable measured in this study. The
Quality of Care Subscale (Appendix B) ﬁom the Attitudes toward Health Care Teams
instrument (AHCT) developed by Heinemann, Schmitt, and Farrell (1991) was used to
measure the level of quality of care perceived by individual team members. Developed as
one of the earlier version of the three subscales (quality of care, process, and physician
centrality) of the Attitudes toward Health Care Teams, the Quality of Care Subscale
involves an ll-item self-administered questionnaire with six Likert scale responses of
zero indicating strongly disagree and ﬁve indicating strongly agree. Heinemann et al.,
(1999) used three study phases to develop, test, and ﬁne tune the AHCT. The last study
phase involved surveying 973 individuals from 111 interdisciplinary, geriatric health care
teams in 34 Veterans Affairs medical centers across the United States. The internal
consistency reliability for the Quality of Care Subscale measured by a Cronbach’s alpha
was 0.82, indicating good reliability (Rubin & Babbie, 1993). The test-retest reliability
computed using Person’s correlations showed that the Quality of Care Subscale had a
correlation of 0.71 (p<.001). This indicates acceptable stability of the subscale instrument
over time (Rubin & Babbie, 1993).

In terms of validity of the Quality of Care Subscale, the subscale showed a
correlation of 0.60 (p<.001) with other scale measuring semantic differential measures of
attitudes toward health care teams indicating concurrent validity of the subscale
(Heinemann et al., 1999). In addition, Heinemann et al., (1999) measured construct
validity by correlating nurses’ scores on the subscale with their scores on another scale

measuring the collaborative behavior of nurses with physicians. The subscale showed a

60

statistically signiﬁcant, moderate association, and the magnitude and direction of the
correlation (F21, p<.05) support construct validity of the scale (Rubin & Babbie, 1993).

For the current study, the decision was made to remove one item ﬁ'om the
Subscale questionnaire as this particular item, “Hospital patients who receive team care
are better prepared for discharge than other patients,” does not apply to a hospice setting.
Thus, a total of ten statements will measure individual team members’ perceived quality
of care provided by team. In order to maintain consistency and cohesiveness with other
questions and responses in the entire questionnaire, ﬁve responses of strongly agree to
strongly disagree were adapted for the Quality of Care Subscale in this study.

Job Satisfaction

Another independent variable tested in the study is job satisfaction. The Job
Satisfaction Subscale, a part of the Michigan Organizational Assessment Questionnaire
(MOAQ) developed by Cammann, Fichman, Jennings, and Klesh (1983) was used to
measure the level of job satisfaction perceived by hospice interdisciplinary team
members (Appendix B). The MOAQ is a self-administered instrument that assesses the
attitudes and perceptions of organizational members on six factors associated with work,
including job facets, tasks and job role characteristics, work group functioning,
supervision, and pay. The Job Satisfaction Subscale (MOAQ-J SS) consists of three item
statements with a 7-point Likert scale (1=strongly disagree, 2=disagree, 3=slightly
disagree, 4=neither agree nor disagree, 5=slightly agree, 6=Agree, 7=Strongly Agree)
(Cammann et al., 1983). The three statements in the subscale are: (1) All in all, I am
satisﬁed with my job; (2) In general, I don’t like my job (reversed scoring); and (3) In

general, I like working here (Cammann et al., 1983).

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The entire MOQA instruments were tested using a total of 3,381 individuals from
11 diverse organizations located in major regions of the United States, including a tool
and a die company, a metropolitan bank, a pharmaceutical plant, and an urban solid-
waste disposal department (Cammann et al., 1983). A Cronbach’s alpha used to measure
internal consistency reliability for the Job Satisfaction Subscale was 0.77 (Cammann et
al., 1983), indicating a moderate to good scale reliability (Rubin & Babbie, 1993).

Bowling and Hammond (2008) measured the construct validity of the J ob
Satisfaction Subscale using meta-analysis of a total of 80 sample studies. The overall
result of the study showed strong evidence of the construct validity of the MOAQ-JSS,
both with directions and magnitudes of the correlations between the MOAQ-J SS and
variables associated with job satisfaction. For instance, autonomy (average weighed
correlation p=.35, number of samples k=l3, total sample size N=2984), co-worker social
support (average weighed correlation p=.33, number of samples k=4, total sample size
N=703), and perceived organizational support (average weighed correlation p=.46,
number of samples k=4, total sample size N=1084) were positively related to and role
conﬂict (average weighed correlation p=—.32, number of samples k=12, total sample size
N=3164) and interpersonal conﬂict (average weighed correlation p=-.29, number of
samples k=18, total sample size N=7634) were negatively associated with the MOAQ-
J SS.

Turnover intention (average weighed correlation p=-.65, number of samples k=3 1 ,
total sample size N=12,618), satisfaction with work itself (average weighed correlation
p=.74, number of samples k=2, total sample size N=316), and organizational commitment

(average weighed correlation p=.69, number of samples k=9, total sample size N=3161)

62

were among the strongest relationships found in the study. In order to maintain
consistency and cohesiveness with other questions and responses in the entire
questionnaire, ﬁve responses of strongly agree to strongly disagree were adapted for the
Job Satisfaction subscale in this study.

Qualitative Design and Measures

A telephone interview was used to gather in-depth information about hospice
interdisciplinary team collaboration, and as a follow up to the questionnaire. Individuals
indicated an interest to voluntarily participate in a future telephone interview by
completing a telephone interview information sheet and informed consent for the
interview when responding to the survey questionnaire. Those individuals were contacted
on later date by phone to respond to six standardized, open-ended questions about their
experiences and thoughts on interdisciplinary collaboration.

The standardized open-ended interview involves a set of carefully worded and
arranged questions that each participant will be asked to respond (Patton, 1987). In terms
of strengths of this approach, the standardized open-ended interview: (1) increases
comparability of responses; (2) minimizes interviewer effects and bias when more than
one interviewer is used, (3) permits the researcher to review the instrumentation used in
the evaluation; and (4) facilitates organization and analysis of the data (Patton, 1987). On
the other hand, this approach: (1) allows little ﬂexibility in relating the interview to
particular participants; (2) constrains the exploration of topics that were not anticipated
when the interview questions were written; and (3) reduces the extent to which individual
differences can be taken into account (Patton, 1987). A telephone interview information

sheet asked the willing participants to provide a telephone number of choice and

63

preferred time of contact. Informed consent for the telephone interview containing
permission to record the interview was completed by the participants prior to the
interview.

The researcher contacted each participant for the standardized open-ended
interview. Prior to the start of an interview, the researcher informed each participant
about the estimated duration of the interview and reminded each participant that the
interview would be recorded. Informed consent was requested for a second time, but for
this occasion verbally, before the interview began. The interview began with four
demographic and organizational questions about a participant. They were: (1)
professional diversity (physician, nurse, social worker, or spiritual care
provider/counselor); (2) how long have you been a physician/nurse/social
worker/spiritual care provider/counselor?; (3) how long have you worked for your current
hospice agency?; and (4) does your hospice agency serve mainly rural, metropolitan, or
urban area of the state? The six open-ended questions then followed and are described as
follows.

1. Who do you consider to be members of your interdisciplinary team?

2. What is the biggest strength of your hospice team?

3. What poses as the biggest barrier in your hospice teamwork?

4. What professional qualities do you bring to your team in assisting your
clients?

5. In what ways does your agency evaluate team effectiveness?

6. Is there anything about hospice teamwork we did not cover that you would
like to share?

64

Data Analysis

The following section discusses data analysis for the quantitative and qualitative
methodologies employed in this study.

Quantitative Data

The informed consent forms and questionnaires for individual participants of the
study were ﬁled separately in locked ﬁles in the researcher’s ofﬁce. Data from the
questionnaire including demographic information and responses to the MHC, inﬂuences
of interdisciplinary collaboration, Quality of Care Subscale, and MOAQ-J SS were
entered on and computed by Statistical Package for the Social Sciences 17.0 (SPSS,
2005) software, with secured access ﬁelds. Unique conﬁdential numbers were assigned to
each participant.

Descriptive statistics were used to examine individual, team, and organizational
level demographic questions. Frequencies and percentages of the demographic
characteristics were reported. The following discusses speciﬁc statistical tests that
addressed each of the ﬁve research hypotheses.

Hypothesis I: Social workers, compared to physicians, nurses and spiritual care
providers, report a higher level of interdisciplinary collaboration.

Hypothesis one was tested employing one—way analysis of variance (AN OVA) to
examine signiﬁcance of the relationship between interdisciplinary collaboration
(dependent variable) and professional diversity (independent variable). One-tailed tests
for signiﬁcance were used for this hypothesis as the nature of differences and association
is speciﬁed.

Hypothesis 2: Professional afﬁliation, structural/organizational characteristics,

personal characteristics and relationships among collaborators, and history of
collaboration have a positive direct effect on interdisciplinary collaboration.

65

Hypothesis two was tested using multiple regression analysis. Multiple regression
shows “the overall correlation between each of a set of independent variables and an
interval-or-ratio-level dependent variable” (Rubin & Babbie, 1993, p.507). It tests how
much portion of the variance in a dependent variable at a signiﬁcant level can be
explained by a set of independent variables (through a signiﬁcance test of 1'2) and
establishes the relative predictive importance of the independent variables (by comparing
beta weights) (Garson, 2008). Backwards regression evaluated the strength of the
relationship between perceived interdisciplinary collaboration and four inﬂuences of
interdisciplinary collaboration.

Hypothesis 3: Level of interdisciplinary collaboration has a positive direct eﬂect
on perceived quality of care team provides.

Pearson’s product-moment correlations were employed to test hypothesis three.
Pearson’s correlation allowed testing of statistical signiﬁcance as well as measuring of
the strength of association (Rubin & Babbie, 1993) between interdisciplinary
collaboration (dependent variable) and the level of quality of care perceived by team
members (independent variable).

Hypothesis 4: Level of interdisciplinary collaboration has a positive correlation
with job satisfaction.

Hypothesis four was tested using Pearson’s correlation as the test allowed
measurement of the strength of association between interdisciplinary collaboration and
job satisfaction.

Hypothesis 5: Professional diversity is an inﬂuencing factor in dijferences in

professional aﬂiliation, personal characteristics and relationships among collaborators,
a history of collaboration, perceived quality of care and job satisfaction.

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ANOVAs were be used to test hypothesis ﬁve. ANOVAs examined signiﬁcance
of the relationship between a dependent variable of professional diversity (physicians,
nurses, spiritual care providers, or social workers) and independent variables of
professional afﬁliation, personal characteristics, a history of collaboration, quality of care,
and job satisfaction. One-tailed tests for signiﬁcance were used for this hypothesis.

For all statistical tests, a Type I error level of .05 was employed as statistically
signiﬁcant probability level (Keppel & Wickens, 2004).

Qualitative Data

Each recorded interview was transcribed verbatim and given a unique code. The
transcribed data were ﬁled in locked ﬁles in the researcher’s ofﬁce. Content analysis was
employed to identify and categorize themes and patterns in the collected, transcribed data.
The purpose of content analysis is “organizing and simplifying the complexity of data
into some meaningful and manageable themes and categories” (Patton, 1987, p. 150).
Manifest content, the visible, surface content (Rubin & Babbie, 1993), was measured
thorough computing the frequencies of certain words, phrases and patterns. Using the
result of manifest content, latent content, coding underlying meaning of the data (Rubin
& Babbie, 1993), were employed to further interpret the data. Underlying themes and
concepts surfaced from the phone interview are reported.

Summary

Chapter 3 contains a discussion of the methodology that will be utilized in

addressing the research questions and collecting the data The next chapter presents the

results of the data analysis that include a detailed description of study participant

67

characteristics, general ﬁndings, and results of inferential statistical tests of the research

questions. It will also include a discussion of themes surfaced in the qualitative study.

68

CHAPTER 4
Results
Overview

This chapter discusses and analyzes Michigan hospice interdisciplinary team
members’ perceptions of their own participation and that of other team members in
collaborative work, as well as the perceived outcomes of collaboration. The targeted
hospice clinicians for this study included physicians, nurses, spiritual care providers, and
social workers. The primary purpose of this study was to deepen an understanding of the
processes of interdisciplinary collaboration in hospice, and the impact of variables that
aid or hinder collaborative work. The study involved a mixed method of survey and
phone interview. The survey instrument measured perceived degree of interdisciplinary
collaboration and the impact of demographic and other variables such as professional role,
structural/organizational characteristics, personal characteristics, history of collaboration,
quality of care, and job satisfaction, on perceived degree of interdisciplinary
collaboration. Of 468 self-administered survey questionnaires mailed in January, 2009
and three follow-up email requests, 129 hospice clinicians returned the questionnaires.
This leads to a return rate of 27.5%.

Sixty three hospice interdisciplinary team members volunteered to participate in
phone interviews. Of 63 volunteers, twenty hospice interdisciplinary team members, ﬁve
each from the professional disciplines of medicine, nursing, spiritual care, and social
work, were randomly chosen for the qualitative component of the study. Six open-ended
questions about their thoughts on their contribution to their team, strengths of their team,

challenges their team faces, and practice of team effectiveness evaluation were addressed.

69

This chapter will ﬁrst address characteristics of the study sample using descriptive
data, including personal demographic variables of age, gender, race/ethnicity,
professional discipline, and years of hospice work experience. In addition, organizational
variables about study participants’ hospice agencies such as the geographic service area,
the number of hospice teams within one’s agency, and the number of core hospice team
members within one’s agency will be discussed. Second, with a focus on signiﬁcant
relationships, trends, and group differences, the results of the data analysis, addressing
each research question, will be discussed. The chapter concludes with a summary of the
ﬁndings.

Characteristics of the Study Sample

Demographic Data

Of the 129 survey questionnaires returned, 126 surveys were analyzed by the
researcher. Three questionnaires were omitted from the data analysis because one
returned questionnaire was missing the majority of responses on the survey instrument,
and two were completed by hospice bereavement service coordinators who were not from
the four targeted hospice professional disciplines for this study.

With regards to the professional discipline, the survey participants included 39
nurses (31%), 25 physicians (19.8%), 29 spiritual care providers (23%), and 33 social
workers (26.2%). Of 39 nurses, 26, 65%, were registered nurses (RNs), 11, 27.5%, had a
Bachelor’s degree in Nursing (BSN), and two, 5%, had a Master’s degree in Nursing
(MSN). Of the 38 nurses (one data was missing), 11 (28.9%) were certiﬁed in palliative
care while 27 (71.1%) were not certiﬁed. The majority of physician participants (18

physicians, 72%) were Medical Doctors (MD). There were seven (28%) Doctors of

70

Osteopathy (DO). Of the physician participants, 52% were certiﬁed in palliative care
and/or hospice while the other 44% were not.

The spiritual care provider group had the most diversity in credentials.
Approximately 38% of the spiritual care provider participants were Master of Divinity
(MDiv), and the other 62% of them identiﬁed themselves as having other credentials.
Other credentials reported include chaplain, sister, ordained minister, Bachelor’s degree
in Theology, Master’s degree in Religious Education, Master’s degree in Counseling,
Doctor of Ministry, etc. Of 27 spiritual care providers (two were missing data), only three
were certiﬁed in palliative care. The majority of social workers (81.8%) were Master’s
educated social workers while the other 18.2% were Bachelor’s educated. Only two
social workers were palliative care certiﬁed.

The survey participants included 94 females (73%) and 32 males (27%). A Chi-
square test of association showed that gender was a statistically signiﬁcant variable in the
study sample (x2 = 36.771, df= 3, N = 126 , p < .0005) in terms of the professional
discipline (Table 1). Nurse and social worker survey participants were more likely to be

female, while physicians and spiritual care providers were more likely to be male.

Table l: Chi-square Analysis of Gender by Professional Diversity

 

 

 

 

 

 

 

 

 

 

 

 

 

N Nurse Physician Spiritual Social 96 p
Care Work
Male 34 3 16 13 2 36.771 .0005
Female 92 36 9 16 32
Total 126 39 25 29 33

 

In terms of race/ethnicity, of the 126 survey participants, 118 individuals (93.7%)

identiﬁed as Caucasian American, 3 individuals identiﬁed as Aﬁican American (2.4%), 2

71

identiﬁed as Asian or Paciﬁc Islander (1.6%), 1 identiﬁed as Native American (0.8%),
and two identiﬁed as other ethnicity (1.6%) which included Pakistani and a mixed
heritage of Native American, French, and Norwegian. There was no relationship between
race/ethnicity identiﬁed and professional diversity.

In terms of age, the participants were composed of a wide range of age groups
ﬁ'om under 30 years old to over 60 years old. The 51 to 60 years old group was the
largest age group in this sample with 43 participants (34.1%), followed by 34 participants
(27%) in the 41 to 50 years old group. Only three individuals were in the 30 years and
younger group (2.4%). Table 2 provides information on age by professional diversity.

Table 2: Age Groups by Professional Diversity

 

NS BB .89 .5117. _.Total

 

Age N % % % N % N %

 

 

 

N

Under 30 l 0.79 O O O 2 1.59 3 2.35
O
5

4lto 50 12 9.52 6.35 3.97 9 7.14 34 26.98

 

51to60 14 11.11 6.35 12 9.52 9 7.14 43 34.12

 

N
0
31 to 40 9 7.14 2 1.59 0 10 7.94 21 16.67
8
8
7

Over 60 3 2.38 5.56 12 9.52 3 2.38 25 19.84

 

Total 39 31 25 19.8 29 23 33 26 126 100

 

 

 

 

 

 

 

 

 

 

 

 

 

NS (nurses), PH (physicians), SC (spiritual care providers), and SW (social workers)
A One-way AN OVA test was performed to examine whether or not age
difference by professional discipline was statistically signiﬁcant. The test revealed (Table
3) that there was a statistically signiﬁcant difference among the participants’ age based
on professional diversity, F (3, 122) = 10.14, p < .0005. Social workers as a group were

the youngest group while spiritual care providers represented the oldest age group.

72

Table 3: One-Way Analysis of Variance of Age by Professional Diversity

 

 

 

 

Source df SS MS F p
Between groups 3 28.22 9.40 10.14 .000
Within groups 122 1 13.20 .92

Total 125 141.42

 

 

 

 

 

 

 

 

In regard to employment status, of the 126 participants, 78 professionals (61.9%)
reported their employment status to be full-time (greater than 36 hours a week) and 46
(36.5%) part—time (less than 36 hours weekly but not as needed status) (Table 4). A
Pearson Chi-square test was performed to investigate whether employment status differed
based on professional diversity. A statistically signiﬁcant difference in employment
status was found based on professional diversity ()6 = 11.03, df= 3, N = 124, p = .012).
The test revealed that nurses and social workers were more likely to be employed full-
time while physicians and spiritual care providers were likely to be employed both full-

time and part-time (Table 5).

Table 4: Employment Status by Professional Diversit

 

 

Nurses Physicians Spiritual Social
_C_ar_e Worke
_rs
Employment N % N % N % N %

Status
Full-time 31 82.1 11 47.8 14 48.3 21 63.6
Part-time 7 17.9 12 52.2 15 51.7 12 36.4
Total 39 100 23 100 29 100 33 100

 

 

 

 

 

 

 

 

 

 

 

 

 

 

73

Table 5: Chi-square Analysis of Emplo

ent Status by Professional Discipline

 

N

Nurse

 

 

 

Physician Spiritual Social x2 p
Care Work
Full-time 78 31 11 14 21 11.03 .012
Part-time 46 7 12 l 5 12
Total 124 39 23 29 33

 

 

 

 

 

 

 

 

 

 

Reported years of practice in one’s current discipline varied ﬁ'om less than two
years to over 40 years. For nurses, the majority have been practicing for two to 10 years,
making up 46% of all the nurse participants, followed by 13% practicing 11 to 15 years.
Physician participants’ years of experience were diverse. Seven physicians (30%) had
practiced medicine for six to ten years, and this was the largest group among physicians,
followed by 16% of them with 16 to 20 years of experience. Two had 36 to 40 years and
one had over 40 years of practice. Nearly 50% of the spiritual care providers have been
practicing between two to 10 years. Though they represent the oldest age groups, only
four had experiences of practicing clergy work or spiritual care over 21 years. For social
workers, their years of practice experience were diverse, ranging from two to 25 years of
experience, with 15 to 18% or ﬁve to six individuals in each of the experience groups.
Three social workers had less than two years of practice experience. There was no
statistical difference between years of experience in one’s discipline based on
professional discipline.

Years of working for current hospice also varied from less than two years to 36 to
40 years. Of the 125 responding to the question (one person did not respond to this
question), 45 (35.7%) of them have been with their current hospice between two and ﬁve

years, 29 (23%) with six to 10 years, 28 (22.2%) with less than two years working for

74

their current hospice agency, and 15 (11.9%) with 11 to 15 years. Years of hospice
experience varied from less than two years to 31 to 35 years. There was no statistical
difference in years with current hospice based on professional discipline.

Organizational Data

Six questions were asked to explore organizational characteristics about hospice
agencies for which the survey participants’ work. One hundred and one (80%) of the 124
participants who responded to the question about organizational status reported to work
for a non-proﬁt hospice agency. Nineteen (15.1%) work for a for-proﬁt hospice agency,
and four (3.2%) work for govemment-run hospice. Of the 126 participants, 116
responded to the question about their organization’s years of operation (Table 6). Sixty-
ﬁve (56 %) individuals reported to work for an agency with over 20 years in business,
followed by 20 individuals (17.2 %) working for a hospice agency with 11 to 15 years in
business. Over 84 % of the respondents work for a hospice with over 11 years of history,

while ﬁve participants work for hospice with less than two years of operation.

Table 6: Years of Hospice Operation

 

 

 

 

 

 

 

 

Years of Operation N Percentage
Less than 2 5 4.3

2 to 5 7 6.0

6 to 10 6 5.2

11 tolS 20 17 .2

16 to 20 13 11.2
Over 20 65 56.0
Total 116 100

 

 

 

 

 

The fourth organizational question was about the number of core hospice

interdisciplinary team members. Table 7 provides the results. The responses ranged from

75

less than ﬁve members to over 30 core members. Close to 40% of the participants
reported to have more than 30 core members in their agency, which was the most
frequent response by the study sample, followed by 21.1% reported to have 16 to 20 core
members. Two individuals reported to have less than ﬁve core members.

Table 7: Hospice Interdisciplinary Team Core Members

 

 

 

 

 

 

 

 

 

Core Members N Percentage
Less than 5 2 1.6

6 to 10 9 7.3

11 to 15 16 13.0

16 to 20 26 21.1

21 to 25 12 9.8

26 to 30 9 7.3
Greater than 30 49 39.8
Total 123 100.0

 

 

 

 

 

In terms of a number of interdisciplinary teams, 124 participants responded to the
question. Over 70% of the participants reported to work for hospice with one team (23%)
or two to three (21.4%) teams. Twenty participants (15.9%) reported to work for hospice

with more than 6 interdisciplinary teams (Table 8).

Table 8: Number of Hospice Teams in One’s Agency

 

 

 

 

 

 

 

 

 

 

Teams N Percentage
1 team 46 37.1
2 to 3 teams 44 35.5
4 to 5 teams 14 11.3
Greater than 6 20 16.1
Total 124 100

 

Responses to the question regarding one’s hospice agency’s average daily census

ranged greatly ﬁom less than 30 cases to over 110 cases (Table 9). The most frequent

76

response was the over 110 average daily census group with 38 participants (30.2%),
followed by 29 (23%) reporting less than 30 daily cases, showing great diversity in

average daily census among participating hospices.

Table 9: Average Daily Census

 

 

 

 

 

 

 

 

 

Averag: Daily Census N Percentage
Less than 30 29 23.0

30 to 50 27 21.4

51 to 70 12 9.5

71 to 90 15 11.9

91 to 110 5 4.0
Over 110 38 30.2
Total 126 100.0

 

 

 

 

The last organizational characteristic question related to geographic service area.
Of the 125 survey participants who responded to the question, 44% reported to serving
mainly rural areas, 36.8% serve a combination of rural and urban areas, and 19.2%
reported to mainly serve urban and suburban area (Table 10). This shows that the

participants work for hospice with a variety of service areas.

Table 10: Geographic Service Area

 

 

 

 

 

Geographic service area N Percentage
Rural 55 44.0
Urban and suburban 24 19.2
Both 46 36.8
Total 125 100.0

 

 

 

 

 

77

Survey Instruments and Reliability Statistics

Modified Index for Interdisciplinary Collaboration (MIIC)

MHC is a 42-item self-administered survey questionnaire utilized to measure the
perceived level of interdisciplinary team collaboration among the four hospice core
members (nurses, physicians, spiritual care providers, and social workers). SPSS was
used to test for scale reliability with Cronbach’s coefﬁcient for internal reliability on four
subscales as well as the entire questionnaire. As seen in Table 11, the subscale alphas
ranged from .76 to .86 which indicate moderate to good reliability (Garson, 2008). The
interdependence and ﬂexibility subscale’s internal reliability had an alpha of .81, the
newly created activities subscale .76, the collective ownership of goals subscale .85, and
the reﬂection of process .86. The internal consistency of the entire MHC, measured by

Cronbach’s alpha, had a score of .94, showing very high reliability (Garson, 2008).

Table 11: Internal Reliability Statistics of MIIC and Subscales

 

 

 

 

 

 

MIIC subscales # of Items Cronbach’s alpha
Interdependence and ﬂexibility 18 ' .814
Newly created activities 6 .760
Collective ownership of goals 8 .846
Reﬂection of process 10 .858
MIIC 42 .935

 

 

 

 

 

Job Satisfaction and Quality of Care Subscales
Internal reliability of the Job Satisfaction and Quality of Care instruments was

also tested with Cronbach’s coefﬁcient (Table 12). The Job Satisfaction subscale had an

78

alpha of .95, and the Quality of Care subscale had an alpha of .91. Both scales showed

very high internal reliability (Garson, 2008).

Table 12: Job Satisfaction and Quality of Care Subscales’ Internal Reliability Statistics

 

 

 

 

 

 

 

 

Scales # of Items Crobach’s alpa

Job Satisfaction 3 .948

Quality of Care 10 .911
General Findings

The following section addresses the results of analyses performed to test each of

the ﬁve hypotheses about factors that may aid or hinder collaborative work among

hospice interdisciplinary team members. The ﬁve research questions and hypotheses that

guided the study are listed below. For analyses of data, the conﬁdence level of .05 was

employed for rejecting the hypotheses.

1.

What is the relationship between perceived level of collaboration on hospice
teams and professional diversity (physicians, nurses, spiritual care providers,
and social workers)?

H1: Social workers, compared to physicians, nurses and spiritual care
providers, report a higher degree of interdisciplinary collaboration.

What is the impact of professional afﬁliation, structural/organizational
characteristics, personal characteristics and relationships among collaborators,
and history of collaboration on interdisciplinary collaboration?

H2: Professional afﬁliation, structural/organizational characteristics, personal
characteristics and relationships among collaborators, and history of
collaboration have a positive direct effect on interdisciplinary collaboration.

What is the impact of interdisciplinary collaboration on perceived quality of
care team provides?

H3: Degree of interdisciplinary collaboration has a positive direct effect on
perceived quality of care team provides.

What is the relationship between interdisciplinary collaboration and job
satisfaction?

79

H4: Degree of interdisciplinary collaboration has a positive correlation with
job satisfaction.

5. Is professional diversity (physicians, nurses, spiritual care providers, and
social workers) an inﬂuencing factor in differences in professional afﬁliation,
personal characteristics and relationships among collaborators, history of
collaboration, perceived quality of care, and job satisfaction?

H5: Professional diversity is an inﬂuencing factor in differences in
professional afﬁliation, personal characteristics and relationships among
collaborators, a history of collaboration, perceived quality of care and job
satisfaction.

Addressing of the Research Hypotheses and Results of Analyses

Hypothesis 1: Social workers, compared to physicians, nurses and spiritual
care providers, report a higher level of interdisciplinary collaboration.

Hypothesis one was tested with one-way analysis of variance (AN OVA). It
examined signiﬁcance of the relationship between interdisciplinary collaboration
(dependent variable) and professional diversity (independent variable). One-tailed tests
for signiﬁcance were used for this hypothesis as the nature of differences and association
was speciﬁed. The result of the test shows that there was no statistically signiﬁcant
difference in the perceived degree of interdisciplinary collaboration based on professional
discipline, F (3, 111) = 1.42, p = .24 (Table 13).

Table 13: One-Way Analysis of Variance of Interdisciplinary Collaboration
by Professional Discipline

 

 

 

 

Interdisciplinary df SS MS F P
Collaboration

Between 3 1 185.63 395.21 1.42 .24
Groups

Within Groups 1 1 1 30816.49 27763

Total 1 14 32002.12

 

 

 

 

 

 

 

 

8O

Hypothesis 2: Professional affiliation, structural/organizational
characteristics, personal characteristics and relationships among
collaborators, and history of collaboration have a positive direct effect on
interdisciplinary collaboration.

Multiple regression analysis was employed to test hypothesis two. It tested how
much portion of the variance in perceived interdisciplinary collaboration (dependent
variable) at a signiﬁcant level can be explained by professional afﬁliation,
structural/organizational characteristics, personal characteristics and relationships among
and history of collaboration variables. Backwards regression was used to evaluate the
strength of the relationship between perceived interdisciplinary collaboration and four
inﬂuences of interdisciplinary collaboration. Based on the number of data missing for the
history of collaboration variable (71 participants did not respond to the questions
corresponding with this variable), a decision was made to remove the variable ﬁ'om the
data analysis. Thus, backwards regression test examined how much of the variance in
perceived interdisciplinary collaboration was explained by the three remaining
inﬂuencing variables of interdisciplinary collaboration.

As seen in Tables 14 and 15, the result of multiple regression tests shows that the
combination of variables to predict interdisciplinary collaboration from the three
inﬂuencing variables of professional afﬁliation, organizational characteristics, and
personal characteristics and relationships was statistically signiﬁcant and had a positive
effect on perceived interdisciplinary collaboration, F (3, 109) = 37.07, p<.001. The beta
coefﬁcients are presented in Table 15. The adjusted R2 value of .51 indicates that 51% of
the variance in perceived interdisciplinary collaboration was explained by the three
inﬂuencing variables. This result, according to Morgan, Leech, Gloeckner, and Barrett

(2007), is a large effect.

81

Table 14: Means, Standard Deviations, and Intercorrelations for
Interdisci linary Collaboration and Predictors Variables (N=113)

 

 

 

 

 

 

 

Variables M SD Professional Organizational Personal
Afﬁliation Characteristics Characteristics

Interdisciplinary 79. 16.84 .49 .52 .65

Collaboration 42

Predictor

Variables

1. Professional 3.5 .99 .34 .47

Afﬁliation 0

2. Organizational 7.3 2.68 .52

Characteristics 7

3. Personal 7.7 1.96

Characteristics 8

 

 

 

 

 

 

Table 15: Summary of Multiple Regression Analysis for Three Variables Predicting
Interdisciplinary Collaboration (N=113)

 

 

 

 

 

 

Variables B SEB [3 t Sig. 1p)
Professional

Afﬁliation 3.52 1.30 .21 2.70 .003
O'gm‘zatlmlal 1.38 .50 .22 2.76 .007 '
Characterrstrcs

Personal

Characteristics 3'80 '73 '44 5-21 .000
““5““ 27.33 5.16

 

 

 

 

 

 

 

Note. R2 = .51; F (3, 109) = 37.07,p<.001

Hypothesis 3: Degree of interdisciplinary collaboration has a positive direct

effect on perceived quality of care team provides.

To investigate if there was a statistically signiﬁcant association between

82

interdisciplinary collaboration and the degree of quality of care perceived by team
members, Pearson’s product-moment correlation was computed. The Pearson correlation
statistics was calculated, r (110) = .68, p = .0005 (Table 16). The direction of the
correlation was positive, which means that those who have higher degree of perceived
interdisciplinary collaboration tend to have higher level of perceived quality of care

provided by team and vice versa. The correlation statistics of .68, according to Cohen

 

(1988), is a large effect and indicates that approximately 38% of the variance in
perceived interdisciplinary collaboration can be predicted ﬁom the level of quality of care

perceived by the team member.

Table 16: Pearson Correlation Coefﬁcient between Quality of Care
and Interdisciplinary Collaboration

 

 

 

Mean Std. N Pearson Sig. (2-
- Deviation Correlation tailed)
Quality of Care 15.38 4.77 112 .68 .000
Interdisciplinary
Collaboration 79.45 16.92 1 12

 

 

 

 

 

 

 

 

Hypothesis 4: Degree of interdisciplinary collaboration has a positive
correlation with job satisfaction.

Hypothesis four was tested using Pearson’s correlation to measure the strength of
association between interdisciplinary collaboration and job satisfaction. The Pearson
correlation statistics was calculated, r (111) = .52, p = .0005, and the direction of the
correlation was positive. The result indicates (Table 14) that those who have higher
degree of perceived interdisciplinary collaboration tend to have higher level of Job
Satisfaction and vice versa. The correlation statistics of .52, according to Cohen (1988),
is a large effect and indicates that approximately 33% of the variance in perceived
interdisciplinary collaboration can be predicted from the level of j ob satisfaction
perceived by the team member.

Table 17: Pearson Correlation Coefﬁcient between Job Satisfaction
and Interdisciplinary Collaboration

 

 

 

Mean Std. Deviation N Pearson Sig. (2-
Correlation tailed)
Job Satisfaction 4.47 1.97 113 .52 .000
Interdisciplinary
collaboration 79.56 16.90 1 13

 

 

 

 

 

 

 

 

83

H5: Professional diversity is an influencing factor in differences in
professional affiliation, personal characteristics and relationships among
collaborators, a history of collaboration, perceived quality of care and job
satisfaction.

ANOVAs were used to test hypothesis ﬁve. AN OVAs examined signiﬁcance of
their relationship between a dependent variable of professional diversity (physicians,
nurses, spiritual care providers, or social workers) and independent variables of
professional afﬁliation, personal characteristics, a history of collaboration, quality of care,
and job satisfaction. One-tailed tests for signiﬁcance were employed for this hypothesis.
Post-hoe tests were performed to determine the independent subsets between professional
diversity groups in the event of a signiﬁcant ANOVA test. Table 18.1, 18.2, and 18.3
provide means and standard deviations comparing professional diversity and variables of
Professional Afﬁliations, Personal Characteristics, History of Collaboration, Quality of
Care, and Job Satisfaction.

The mean scores (with standard deviations in parentheses) of Professional
Afﬁliation for nurses was 3.39 (.82), physicians 3.56 (1.08), spiritual care providers 3.59
(1.05), and social workers 3.58 (1.06). The mean scores (with standard deviations in
parentheses) of Personal Characteristics and Relationships among Collaborators for
nurses, physicians, spiritual care providers, and social workers were 7.47 (1.97), 6.62
(1.38), 8.00 (2.13), and 8.93 (1.84), respectively.

The History of Collaboration variable had mean scores (with standard deviations
in parentheses) of 11.27 (27.70) for nurses, 4.00 (1.00) for physicians, 4.07 (.99) for
spiritual care providers, and 4.26 (1.76) for social workers. It is important to note that the

majority of the participants did not respond to the questions relating to the history of

collaboration variable. Of 126 surveys used for data analysis, only 55 individuals

84

responded to the history of collaboration related questions. Thus, the results may not be
representative of the study sample as a whole.

Means of Quality of Care (with standard deviations in parentheses) for nurses was
15.05 (4.86), physicians 15.17 (4.43), spiritual care providers 16.00 (5.21), and social
workers 15.76 (4.70). In order, means of Job Satisfaction for nurses, physicians, spiritual
care providers, and social workers were 4.29, 3.68, 4.69, and 5.06 (SDs = 1.70, 1.14, 2.01,
and 2.41, respectively).

Table 18.1: Means and Standard Deviations Comparing Professional Diversity and
Variables of Professional Afﬁliation and Personal Characteristics

 

 

 

 

 

 

 

Professional Personal
Afﬁliation Characteristics
Professional N M SD N M SD
Diversity

Nurse 38 3.39 .82 38 7.47 1.97

Physician 25 3.56 1.08 25 6.92 1.38

Spiritual 29 3.59 1.05 28 8.00 2.13
Care

Social 33 3.58 1.06 33 8.93 1.84
Work

Total 125 3.52 .99 124 7.78 1.99

 

 

 

 

 

 

 

 

 

Table 18.2: Means and Standard Deviations Comparing Professional Diversity and
Variables of History of Collaboration and Quality of Care

 

 

 

 

 

 

 

History of Quality of
Collaboration Care
Professional N M SD N M SD
Diversity

Nurse 15 11.27 27.70 39 15.05 ‘ 4.86

Physicians 7 4.00 1.00 24 15.17 4.43

Spiritual 14 4.07 .99 26 16.00 5.21
Care

Social 19 4.26 1.76 33 15.76 4.70
Work

Total 55 6.09 13.53 122 15.47 4.77

 

 

 

 

 

 

 

 

 

85

Table 18.3: Means and Standard Deviations Comparing Professional Diversity
and Variable of Job Satisfaction

 

 

 

 

 

 

 

Job Satisfaction

Professional N M SD
Diversity

Nurse 38 4.29 1 .70

Physician 25 3.68 1.14

Spiritual Care 26 4.69 2.01

Social Work 33 5.06 2.41

Total 122 4.46 1.94

 

 

 

 

 

 

The results of AN OVA tests show (Table 191-4) that there were no statistically
signiﬁcant differences in the level of perceived professional afﬁliation, F (3, 121) = .29, p
= .832 (Table 19.1), history of collaboration, F (3, 51) = 1.008, p = .397 (Table 19.3), or
Quality of Care, F (3, 121) = .28, p = .84 (Table 19.4) based on professional diversity.
Professional diversity, in this sample, is not an inﬂuencing factor in individual
differences in the level of professional commitment, history of collaboration, or
perceived quality of care provided. On the other hand, a statistically signiﬁcant difference
in the level of Personal Characteristics based on professional diversity, F (3, 120) = 6.37,
p < .0005, was found (Table 19.2). Compared to the other three disciplines, physicians
rated personal characteristics and relationships among other collaborators the lowest. The
survey instrument used a 5-point Likert scale with one indicating “strongly agree” and
ﬁve indicating “strongly disagree. It means that lower the score, the higher level of
personal characteristics one has. Therefore, physicians were most likely to have positive
feelings and trust toward other disciplines and felt understood by other disciplines. Social

workers as a group had the least positive attitudes toward other disciplines.

86

There was also a statistically signiﬁcant difference in Job Satisfaction based on
professional diversity, F (3, 118) = 2.73, p = .047 (Table 19.5). Again, the survey
instrument with a 5-point Likert scale with one indicating “strongly agree” and ﬁve
indicating “strongly disagree” was used. The data suggests that physicians as a group
were most satisﬁed with their job while social workers were the least satisﬁed group.

Table 19.1: One-Way Analysis of Variance Comparing Professional Diversity
on Professional Afﬁliation

 

 

 

 

 

Source df SS MS F P
Professional Afﬁliation
Between Groups 3 .87 .29 .29 .832
Within Groups 121 120.33 .99
Total 124 121.20

 

 

 

 

 

 

 

 

Table 19.2: One-Way Analysis of Variance Comparing Professional Diversity
on Personal Characteristics
Source df SS MS F P

Personal Characteristics

 

 

 

 

 

Between Groups 3 66.74 22.25 6.37 .000
Within Groups 120 419.19 3.49
Total 123 485.3

 

 

 

 

 

 

 

 

Table 19.3: One-Way Analysis of Variance Comparing Professional Diversity
on History of Collaboration
Source df SS MS F P

History of Collaboration

 

 

 

 

 

Between Groups 3 553.00 184.33 1.008 .397
Within Groups 51 9327.55 182.89
Total 54 9880.55

 

 

 

 

 

 

 

 

87

Table 19.4: One-Way Analysis of Variance Comparing Professional

 

 

 

 

 

Diversity on Quality of Care
Source df SS MS F P
Quality of Care
Between Groups 3 19.08 6.36 .28 .84
Within Groups 121 2733.29 23.16
Total 124 2752.37

 

 

 

 

 

 

 

 

Table 19.5: One—Way Analysis of Variance Comparing Professional
Diversity on Job Satisfaction

 

 

 

 

 

Source df SS MS F P
Job Satisfaction
Between Groups 3 29.62 9.87 2.73 .047
Within Groups 1 18 426.67 3.61
Total 121 456.30

 

 

 

 

 

 

 

 

Phone Interviews

The purpose of phone interview was to gain in-depth information about hospice
team members’ attitudes toward interdisciplinary collaboration beyond what the survey
questionnaire allowed gathering. A total of twenty hospice nurses, physicians, spiritual
care providers, and social workers, with ﬁve individuals from each professional
discipline, participated in the phone interview. The participants were randomly selected
from a pool of professionals who completed survey questionnaires and volunteered to
take a part in the phone interview in later date. Each participant completed the telephone
interview information sheet (Appendix C), providing contact information and consenting
to an audio-taped interview. The researcher contacted and interviewed each participant

between February and March, 2009.

88

Upon receiving verbal consent to participate in the taped phone interview, the
participants were asked four demographic and organizational character questions about
themselves and their hospice agency. The four questions were: (1) what is your
professional discipline (nurse, physician, spiritual care provider, or social worker)?; (2)
how long have you been a nurse/physician/spiritual care provider/social worker?; (3) how
long have worked for current hospice agency?; and (4) does your hospice agency serve
mainly a rural, urban/suburban area, or combination of the two? The participants were
then asked to respond to the following six open-ended questions.

1. Who do you consider to be members of your interdisciplinary team?

2. What is the biggest strength of your hospice team?

3. What poses as the biggest barrier in your hospice teamwork?

4. What professional qualities do you bring to your team in assisting your clients?
5. In what ways does your hospice agency evaluate team effectiveness?

6. Is there anything about hospice teamwork we did not cover that you would like to
share?

Demographic and Organizational Data
A total of 63 professionals volunteered for the interview, including 19 nurses, 13

physicians, 15 spiritual care providers, and 16 social workers (Table 20). As seen in
Table 20, of the 63 professionals, there were 20 males and 43 females. For the disciplines
of nursing (2 males and 17 females) and social work (0 male and 16 females), more
females than males volunteered to participate in the interview. The ten randomly selected
nurse and social work participants, ﬁve from each discipline, were female. Of the 13
physicians, ten were male. Four male and one female physicians were randomly selected

for the interview. Spiritual care providers as discipline had about an equal number of

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male and female volunteer participants, with 8 males and 7 females. The ﬁve randomly
selected spiritual care participants included three males and two females.

Table 20: Participant Information by Gender and Professional Diversity

 

 

 

 

 

 

 

 

 

 

 

 

Volunteered Interviewed
Professional Diversity Male Female Male Female
Nurse 2 17 0 5
Physician 10 3 4 1
Spiritual Care 8 7 3 2
Social Worker 0 16 0 5
Total 20 43 7 l 3

 

 

Table 21 is a summary of three demographic questions about years of experience
in one’s discipline, years of working for current hospice agency, and geographic service
area. Years of experience in one’s discipline among the interview participants ranged
from eight to 44 years. Social workers as professional diversity had the least years of
experience in its discipline, which was also reﬂected in the survey questionnaire. The
participants who identiﬁed as nurse or physician had the greatest range in years of
experience in one’s discipline, ten to over 42 years for nurse and 12 to over 44 years for
physicians. Spiritual care providers’ years of experience were between 13 to over 30
years. Overall, the participants were more likely to be representative of experienced
professionals regardless of one’s professional diversity.

As seen in Table 21, years of working for current hospice agency ranged from
seven months to over 20 years. Three of the ﬁve nurses reported between four to seven
years with current hospice, and two had around one year experience. The physician as
group reported the most range as three had nine to over 20 years of experience, one with
3 to 4 years and the other with less than one year with current hospice. All spiritual care

providers had at least two years and less than eight years of working for current agency.

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Except for one social worker with over a year with its hospice, social workers as group
have been with current hospice for at least over six years.

In terms of geographic service area, 13 (65%) reported to work for hospice which
services a combination of rural and urban/suburban areas, followed by 6 (30%) serving

rural area, and 1 (5%) urban/suburban area.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 21: Participant Demographic and Or 7arrizational Data by Professional Diversity
Years of experience Years with current Service area
in discipline hospice
Nurses

NS 1 Over 10 Over 1 Combination

Ns 2 Over 42 5 Combination

Ns 3 36 Less than 1 Combination

Ns 4 28 7 Rural

Ns 5 10 4-5 Rural

Physicians

Ph 1 20 3-4 Combination

Ph 2 25 12 Combination

Ph 3 18 Less than 1 Combination

Ph 4 l2 9 Combination

Ph 5 44 Over 20 Rural

Spiritual Care

Sp 1 Over 25 7-8 Urban

Sp 2 13 4 Combination

Sp 3 24 2 Combination

Sp 4 Over 30 4 Combination

Sp 5 18 Over 2 Combination

Social Worker

Sw 1 1 1 11 Rural

Sw 2 18 6 Combination

Sw 3 10 8 Rural

Sw 4 8 Over 1 Combination

Sw 5 15 15 Rural

 

 

 

 

 

Open-ended Questions
The following section reports the results of six open-ended questions asked to 20
hospice nurses, physicians, spiritual care providers, and social workers. The results are

organized based on each of the questions.

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Question 1: Whom do you consider to be members of your hospice team?

In response to question one, three main responses were identiﬁed from the
participants’ responses. One main response among the participants was that their
deﬁnition of hospice interdisciplinary team included strictly the hospice interdisciplinary
core and non-core members as are outlined by the Medicare Hospice Beneﬁt. The
hospice interdisciplinary care members deﬁned by Medicare include nurses, medical
directors (physicians), spiritual care providers/counselors, social workers, volunteers,
pharmacists, physical and other therapists, home health aides, and bereavement
services(Center for Medicare and Medicaid Services [CMMS] , 2008). Some others, in
addition to the hospice interdisciplinary team members deﬁned by Medicare, included
other hospice staff such as administrators, clinical managers, quality assurance personnel,
and ofﬁce support staff. A few individuals focused on their patients and families as the
center of their interdisciplinary team, supported by hospice staff. One spiritual care
provider responded to the question by saying:

Patients and families, ﬁrst. Beyond that, nurses, social workers, chaplain, hospice

physicians, patient’s own physicians, volunteers, volunteer coordinator, and

bereavement team (Sp 5)

Question 2: What is the biggest strength of your hospice team ?

The hospice professionals provided a variety of comments in response to question
two, which can be categorized to three main areas. One relates to the skills that their
hospice team members possess such as expertise and experience in one’s profession and

hospice work and good communication. One physician stated, “. . .we have a lot of

experience in our team (Ph 3),” and one spiritual care provider

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reported, “Each member brings their expertise to the team (Sc 5).” One social worker

stated:

That would be our experience. Many of the people that are here at our hospice are
very experienced, and they have a great deal of knowledge (Sw 3).

In regards to good communication as strength of one’s hospice team, one social
worker reported:

I think we communicate well with each other, keeping each other informed with
one another on the patients (Sw 4).

This comment was echoed by a physician who stated:

I think the biggest strength of ours is the communication between each other and
respect for each other as we have pretty open discussions (Ph 1).

A nurse also noted:

The biggest strength I think is the communication between each other, you know.
Everybody is willing to share, so I think that is the most important. . .(Ns 3)

The second theme found from the responses of the interview participants connect
to hospice philosophy of providing a holistic, patient-centered care. One nurse stated:

Biggest strength. . .I think is that everyone is motivated to support and encourage

patients and families to the best of their abilities. I think that we are a very

patient-centered care (N s 1).

One social worker, in response to the biggest strength of her hospice team,
discussed hospice’s emphasis on treating their client as a whole and including patient and
family or caregivers as a unit of care:

I think it is our ability to identify the client and family needs that go beyond their

diagnosis. . .We don’t just work with their physical needs, but their emotional

mental, and spiritual (needs). We have a very holistic approach, and it’s not just

the person we are serving. It is also the other people involved that are going to be
impacted by the loss of the individual (Sw 2).

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The third theme has to do with characteristics considered to be essential to
successful interdisciplinary collaboration. They include: ﬂexibility among team members,
trust and respect for one another, equal contributions made by all members, closeness,
and passion and compassion for one’s work and assisting clients (Conner et al. 2002;
D’Amour et al. 2005; Rice, 2000). One spiritual care provider discussed ﬂexibility that
exists in her hospice team:

I think our ﬂexibility. . .Our ability to handle a number of patients that come to us,
to provide excellent care. We are a very dedicated group (Sc 3).

Another spiritual care provider also talked about attitudes of his team and ﬂexibility and
ﬂuidity in roles that exit in his team:
Well, I would say that we work so well together, and it’s kind of like we are in
this together. . .We are very, very interactive with each other. We are not people to
have a ‘turf’ if you know what I mean, and so I think that kind of respect for each
and other and working together I think is probably our greatest strength (Sc 4).
In regards to equal contribution made by all members, one physician stated,“. . .all the
people are considered equally important parts of the team (Ph 4).
For one physician, it was about the distribution of power among team members.
He compared a hospice team with a traditional medical team and discussed two very

different distributions of power in healthcare teams (Ph 5):

Not like a traditional medical setting where physicians are on the top, our hospice
team members make equal contributions, like a round table.

Strong support that hospice team members provide to each other was also highlighted.
One nurse described her hospice team as:
We are like a family. . .If one person is down, you know we help each other, no

questions or anything. We need help, we just ask. You know somebody is there to
always catch your back (N s 5).

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Many interview participants talked about trust and respect for one another that
exist in their hospice team as strength. One nurse asserted, “. . .every single person’s
opinion counts and is listened to (N s 2)” while a physician said, “. . .respect for each
other’s opinions (Ph 2).”

One social worker discussed high level of trust that her team has for each other by
stating:

We have a really great team. We are all very comfortable with each other, saying

what we think. We feel comfortable giving each other information, advice,

input. . .even if it is not our discipline. And, we are comfortable asking each other

question. . .it is a wonderful strength we have (Sw 5).

Compassion and passion for one’s work and assisting clients were discussed by a
few hospice professionals. One spiritual care provider responded to the question by
simply stating, “Our compassion for our work and patients (Sc 2)” while a nurse
explained her team’s strength as “. . .the real passion or the real heart that they have for
what they are doing for the patients and the families (N s 4).”

Question 3: What poses as the biggest barrier in your hospice teamwork?

Interview participants’ responses to question three can be categorized into six
major themes of time constraints, communication difﬁculties, agency and government
regulations on paperwork and team practices, adjustments to new technology, staff
shortage, and the existence of superiority based on professional diversity. In the course of
interviews, it became very clear that all six major themes were connected to each other
and created difﬁculties for the team as well as patient care. Of the twenty hospice
interdisciplinary members interviewed, eleven professionals, 55%, indicated lack of time

as the major barrier in their teamwork. One nurse stated, “One of the biggest barriers is

time constraints (N s 4).” Lack of communication, often due to lack of time, was another

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major barrier to collaborative work shared by the interview participants, regardless of
professional diversity.

Not having enough time to communicate, particularly face-to-face, was
mentioned by many. One physician stated, “. . .the biggest barrier I think is probably that
all members are out in the ﬁeld a lot of the time, and it makes it difﬁcult to get together
physically (Ph 1),” and one spiritual care provider asserts, “. . .we don’t see each other
enough (So 4).”

Some hospice professionals shared their opinions on the importance of
communication and impact of lack of time. One spiritual care provider shared his thought
on communication and stated:

(The biggest barrier is) Lack of communication, mainly due to lack of
time. . .Communication happens best face-to-face, followed by phone calls (Sc 5).

A physician reported the impact of lack of time on communication as it leads to
some team members being left out of being updated on patient information:

Time to collaborate and communicate. Time to have meetings to discuss cases or
update each other. And, sometimes some members get left out (Ph 5).

One social worker further explained the negative impact of lack of communication due to
time constraints as:

...At times there is a lack of communication where you are not informed of
something that would be necessary for you to better serve the client (Sw 2).

Large amounts of paperwork required by the agency and government, leading to
lack of time for patient care, was another barrier discussed by hospice professionals. One
spiritual care provider explained the relationship between lack of time and large amount

of required paperwork and how they impact patient care:

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(The biggest barrier in hospice teamwork is) I am thinking mainly of time,
although the ﬂip side of that. . .the tangent of time is the paperwork. Sometimes
the paperwork required by the government can actually get in the way sometimes

in taking care of the patients (Sc 2).

An impact of changes in hospice interdisciplinary team meeting practice required
by new Condition of Participation in Medicare on a hospice agency was discussed by one
social worker:

...there are some new hospice Medicare guidelines about how to run an

interdisciplinary team meeting, and they are very restrictive. We were much more

informal before and shared anecdotal information as well as other information,
but now they don’t. . .now they are giving us a hard time, saying “stick to the

script,” and “don’t do the anecdotal stuff” and that is a challenge (Sw 5).

Staff shortage as barrier was also discussed, particularly by nurses. One nurse
reported, “Well. Probably our real problem is not enough staff...Not everyone is beating
down the door to work for hospice (N s 2).” Another nurse discussed the difﬁculty of
dealing with nursing shortage and the impact of it on her client care:

..Our load of patients is sometimes strained so that the quality is maybe

sometimes a little hindered. . .sometimes you just. . .you are torn between. You

would like to see a patient more often than you actually can (Ns 3).

Another barrier in hospice teamwork was difﬁculty caused by a transition to new
technology, such as a new phone system and computerized assessments ﬁ‘om paper-based
assessments. One social worker stated, “(The biggest barrier) Right now it is our phone
system. It is very hard to get messages to each other (Sw 5).”

Frustration of adjusting to new technology and seeking understanding ﬁom
administrators about practical difﬁculties with new technology was expressed by one

nurse:

We are out in the rural areas, and we are trying to get everything computerized.
We tell our superiors, the higher ups that stuff (computer) is not working, so it is
slowing us down. It is not allowing us to hook it to the computer. And, it is

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getting them (superiors) to understand what we are facing out there when we are
trying to pull up the information and can’t. That is the biggest headache right now

(Ns 5).

Finally, one person, a nurse reported the existence of superiority among team
members based on professional diversity:

...it is a signiﬁcant barrier when there is superiority among whatever profession,

there is that a person believes that their scope of practice is more important than

another’s scope of practice (Ns 1).

Question 4: What professional qualities do you bring to your team in assisting
your clients?

Two major themes surfaced from hospice professionals’ responses to question
four. First, many discussed their experience, knowledge, and expertise in their profession
and hospice work to meet patient needs as their professional quality. Their responses
were reﬂected by the focus and values of their particular expertise. For instance,
physician participants discussed their ability to manage physical pain and other
symptoms as their professional quality, while spiritual care providers discussed
facilitating spiritual and religious matters in end of life with patients and families as their
quality. Additionally, three out of ﬁve physicians (Phs 2, 3, and 4) discussed providing
in-service or educational sessions to their hospice teams, indicating their role as educator
to the team, and one physician (Ph 5) spoke of his responsibility as making ﬁnancially
sound decisions about medications and other treatments for clients. The most frequently
used terms by spiritual care providers to describe their professional quality were values,
understanding, and compassion. One spiritual care provider stated:

...everyone is a sacred being. Everyone has spirituality and that end of life issues

need to be addressed in a kind and gentle way, and people need to be afﬁrmed for
their life (Sc 3).

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Being a patient advocate and having practice wisdom that come with many years
of practice experiences were reported as professional quality by nurse participants. For
instance, three out of ﬁve nurses reported that their professional quality relate to being
patient advocate in dealing with physicians (N s 3) and families (Ns 4 and Ns 5). One
nurse stated, “My ability to be assertive with physicians to get what the patient wants (N s
3) while another nurse stated:

I am I am very much a patient advocate. And, I try to tell what the patient wants
even though the family might want something else. If the patient wants something
else, then I ﬁght for the patient, and I explain and try to make the family
understand what the patient wants (N s 5).

One nurse articulated how her practice wisdom beneﬁts her clients as well as co-
workers:

(My professional quality is) Many years of experience. I have the ability to be
very good at being independent, thinking and decision making. And, I have the
experience to bring forward. We have a team that recently went through just a
huge change over nursing staff and new social workers. You know a lot of the
core members are fairly new to the program, so I see myself also as being a
resource, a mentor, probably more to the nurses but a resource both in terms of,
you know, kind of knowing the history of the way we operated or why we have
operated the way we have, bringing that to the table. And, just you know,
experience in various settings that we get into with families and patients. And,
having had enough of a background to go well in the past, you know, this is how
we handle this, when we have had the patients say, ‘don’t tell my children the
truth.’ You know, kind of bringing the wisdom ﬁ'om the past

(Ns 4).

For social workers, their professional qualities related to their values on self-
determination, non-judgmental attitude, advocacy as well as their focus on an ecological
perspective and approach with their clients. One social worker discussed “advocacy for
the clients and families (Sw 5)” while another talked about “the ability to be non-

judgmental (Sw 1).”

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One social worker explained how her past experience in other areas of social
work prepared her to pay attention to different difﬁculties clients may face besides their
terminal illness:

I have worked with people who suffered traumatic events in their lifetime, people

with substance abuse, mental health issues, so I have a wide range of experience.

So, when you are serving someone who in terminally ill, you are serving anyone,

and you might encounter anyone of these additional difﬁculties, so having the

professional experience in those areas can help to maybe identify what may be

barriers to them or in the family system (Sw 2).

Another social worker summarized her professional quality of taking an
ecological approach with her clients:

I think I have a good concept of ‘the big picture’ . . .Sometimes I think social

workers are comfortable with ambiguity and the ‘grey areas’ and can see that

families manage. They manage very, very well without being. . .meeting
traditional expectations, and there are a lot of different ways of doing things that

are okay (Sw 4).

A second theme surfaced from the participants’ contributions related to one’s
personal characters. They included positive and calming attitude, good communication
skills, being a good team player, and being comfortable with the nature of
interdisciplinary collaboration. One nurse indicated bringing a calming effect to the ofﬁce
(Ns 2) as her professional quality. Good communication skills as professional quality
were reported by many participants across all professional diversity groups. Another
nurse discussed her belief in collaboration as her professional quality. She stated:

I have a spirit of collaboration. I do wanna get along with everybody, to be the
best I can be. I feel I am not doing the job on my own, and I need other people

(Ns 1).
One physician (Ph I) discussed being a team player as his quality by reporting:
I enjoy working with our team as a team member, not much as a traditional role of

physician that I have to be the person making all the decisions. . .and, I think I do a
pretty good job of creating a setting in which we can talk openly.

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Another physician discussed ﬂexibility and ﬂuidity of roles in hospice team as the
nature of interdisciplinary collaboration:

We all have qualities we bring to the table, and sometimes my role extends to

doing some of other team members’ jobs. . .I, for example, may provide spiritual

care to our patients and families because that is what happens with hospice. Our
roles involve ﬂexibility and ﬂuidity in that we share roles and responsibilities

over our patients (Ph 5).

Question 5: In what ways does your agency evaluate team effectiveness?

A variety of responses were received in response to question four. While a few
reported to have no evaluation mechanisms in place, with their agencies being in the
process of creating a tool for team effectiveness evaluation, most fell in the following
four responses. One was formal or informal peer and/or supervisor performance reviews.
Six of the 20 study participants reported peer and/or supervisory review as their agency’s
established team effectiveness evaluation. Two involved a review of plans of care, mainly
at interdisciplinary meetings, mentioned by ﬁve clinicians. Three, the participants
reported the role of on-going quality assurance projects such as chart audits to check
frequency of visits or update medication lists. Seven clinicians discussed quality
assurance projects, often conducted by their quality assurance managers, as a way that
their hospice evaluated team effectiveness. Finally, the use of patient/family satisfaction

surveys was reported by four study participants as a tool to evaluate team effectiveness.

Question 6: Is there anything about hospice teamwork we did not cover that you
would like to share?

The last open-ended question was created to provide some freedom in the
participants’ thoughts on interdisciplinary collaboration. Overall, the participants shared

deep pride and passion for the work they perform as team in hospice. One physician

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simply stated, “We have a great team (Ph 3)” while a spiritual care provider said, “We all
get along very, very well. And, I think that really helps to have a close team. We don’t
have personality conﬂicts. We work very well together (Sp 2).”

How well team members work together and the beneﬁts of healthy teamwork
were expressed by a few study participants. For instance, one nurse stated:

...We all help each other, you know. Everyone has each other’s back. All you

have to do is call someone and say I need help. It is all about the key members

working together (N s 5).

The following statement was made by a spiritual care provider as he discussed his
team and the impact of good communication on team:

We always keep each other in touch with concerns and issues about patient care.

It works very well. I have gotten and given calls to (other members). That kind of

communication is important because more than just the information but the

content of the message, the fact that there is a telephone call or message, I think,

indicates to the person on the other end of the line that they are a valued part of

the team (Sp 1).

One social worker shared how her team members deal with overlapping of
professional roles as the nature of hospice work by stating:

What is interesting is that each of us can, when we are going to see someone, may

encounter something that blends into another discipline’s and I think that although

the nurses may not feel comfortable dealing with psychosocial issues, they

address it as best they can, and then they contact the appropriate discipline (Sw 1).

One nurse expressed how hospice work differs from other nursing jobs she had
had and stated, “In the 28 years of nursing, I have never worked in an arena before where
there truly was interdisciplinary communication and teamwork (N s 4).”

Another nurse shared a similar experience:

Well, probably it is the ﬁrst time that I have had a job where I really felt that my

opinion counted as much from the very lowest person to the very highest person.
It is just so wonderful to be appreciated and listened to so much (N s 2).

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Another nurse connected pride in her work and the impact of supportive team
environment to job satisfaction:

I think how the team cares for one another, I think, affects how your job
satisfaction is, because you are not tense, you are enjoying the company. There is
trust, you know. You want the best for the people you work with. You want to
make them feel you are supporting them. . .the whole team rally around your
patient. . .It is all about customer service, and you know we give customer service
to one another, social workers to the nurses to the aides to the physicians. . .It just
makes the whole place better, and the company has a better reputation, and you
are going to feel more better about your job and the company you work for and
feel a sense of pride (Ns 1).

One physician discussed matters of job satisfaction and turnover in terms of how
professionals choose hospice work and the unique feature of hospice interdisciplinary
team in the healthcare industry:

We have virtually zero turnovers in personnel, and there is a waiting list for

nurses who want to work on our hospice team. . .I think that everybody loves this

work. Frankly, my experience generally has been that most people who do this
work generally love it. You can make a major difference in people’s lives. And,
another piece is that we are not afraid to sit down and go nose to nose and toes to
toes with people and listen to them, which is a unique thing in

healthcare. . .unfortunately (Ph 2).

Some shared unique challenges in their hospice work as a rapid growth in their
patient caseload and large service areas as well as the impact of rules and regulations.
One spiritual care provider reported the impact of rules and regulations on hospice work:

Most of us who are working in hospice, regardless of disciplines, have hearts in it.

It is hard at times to separate ourselves from serving real people and worry about

the rules and regulations (Sp 5).

Summary

The following is a summary of the ﬁve research hypotheses and their test results.

H1: Social workers, compared to physicians, nurses and spiritual care providers, report
a higher degree of interdisciplinary collaboration.

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The hypothesis was rejected. There is no statistically signiﬁcant difference in the degree
of perceived interdisciplinary collaboration based on professional diversity.

H2: Professional aﬂiliation, structural/organizational characteristics, personal
characteristics and relationships among collaborators, and history of collaboration have
a positive direct effect on interdisciplinary collaboration.

The hypothesis was partially retained. Professional afﬁliation, structural/organizational
characteristics, and personal characteristics and relationships among collaborators have a

statistically signiﬁcant, positive direct effect on interdisciplinary collaboration.

H3: Degree of interdisciplinary collaboration has a positive direct eﬂect on perceived
quality of care team provides.

The hypothesis was retained, and the null hypothesis was rejected. Degree of
interdisciplinary collaboration has a statistically, positive direct effect on perceived
quality of care team provides.

H4: Degree of interdisciplinary collaboration has a positive correlation with job
satisfaction.

The hypothesis was retained, and the null hypothesis was rejected. Degree of
interdisciplinary collaboration has a statistically, positive correlation with job satisfaction.

H5: There is a diﬂ'erence in the level of professional aﬂiliation, personal characteristics
and relationships among collaborators, a history of collaboration, perceived quality of
care and job satisfaction based on professional diversity.

The hypothesis was partially retained. Reported levels of personal characteristics and
relationships among collaborators as well as job satisfaction showed statistically
signiﬁcant difference based on professional diversity.

Qualitatively, the study participants, regardless of professional diversity for the
most part, identiﬁed and shared similar strengths of their hospice team, barriers their
team faces, professional qualities, and their hospice team effectiveness evaluation
mechanisms. The most signiﬁcant strengths of hospice team included: (1) possessing
skills, experiences, and expertise in one’s professional discipline; (2) providing a holistic,

patient-centered care; and (3) demonstrating characteristics considered essential to

successful interdisciplinary collaboration. The most critical barriers to teamwork were

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time constraints, communication difﬁculties, agency and government regulations on
paperwork and team practices, adjustments to new technology, staff shortage, and the
existence of superiority based on professional diversity.

Two major themes surfaced in response to the question regarding to one’s
professional qualities. One is participants’ experience, knowledge, and expertise in their
profession and hospice work to meet patient needs. Their responses were reﬂected by the

focus and values of their particular expertise. Two relates to one’s personal

characteristics such as positive and cahning attitude, good communication skills, being a
good team player, and being comfortable with the nature of interdisciplinary
collaboration. Diverse responses were found in terms of team practice evaluation
mechanism. Tools utilized as team practice evaluation mechanisms included: (1) formal
/informal peer and supervisor performance reviews; (2) a review of plans of care; (3) the
use of quality assurance projects; and (4) the use of patient/family satisfaction surveys.

Throughout the phone interviews, the participants, regardless of professional
diversity groups, echoed pride and passion for their hospice work. They endorsed the use
of interdisciplinary collaboration and viewed an interdisciplinary team as essential in
delivering a holistic, patient-centered care. They also reported the crucial role that their
interdisciplinary team members play to each other in providing support, fostering pride,
and leading to job satisfaction.

This chapter addressed a comprehensive discussion of the quantitative and
qualitative study results. The quantitative study ﬁndings included descriptive data on the
study sample and testing of six research questions. Demographic information and trends

about the study sample as well as responses to the six open-ended phone interview

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questions were reported in the qualitative study ﬁndings section. The following chapter,
Chapter 5, discusses the ﬁndings ﬁ'om the surveys and phone interviews, the implications
of the study for social work profession as well as hospice interdisciplinary team, and the
limitations of the study. Lastly, recommendation for future research in the area of

interdisciplinary collaboration is offered.

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CHAPTER 5
Discussions and Implications
Overview
This exploratory dissertation study was designed to investigate variables that aid
or hinder collaborative work among core hospice interdisciplinary team members. Both
the quantitative methods of the survey questionnaires and qualitative methods of the

phone interview were utilized to address the overarching question of what variables are as

.._.~u

most highly associated with interdisciplinary collaboration in hospice. Speciﬁcally, the

E. --

study examined the relationship between a dependent variable of a perceived level of
interdisciplinary collaboration and seven independent variables: professional diversity,
professional afﬁliation, history of collaboration, organizational/structural characteristics,
personal characteristics and relationships among collaborators, job satisfaction, and
quality of care provided by team. These constructs have been found to be linked to the
level of interdisciplinary collaboration in other studies (Abrahm et al., 1996; Bronstein,
2002; Coopman, 2001; Freund & Drach-Zahavy, 2007; Parker-Oliver, Bronstein, &
Kurzejeski, 2005; San Martin-Rodriguez et al. 2005).

Additionally, the study reviewed the inﬂuences of the demographic variables such
as age, gender, employment status, and years of practice in one’s discipline and the
organizational variables of organizational status, the number of hospice teams within the

agency, and the geographic service area. One hundred and twenty-nine hospice nurse,

 

physicians, spiritual care providers, and social workers participated in the survey study.
Twenty telephone interviews were conducted to complement the ﬁndings from the survey

and to aid in understanding the quantitative data.

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This ﬁnal chapter will highlight major research ﬁndings from the survey and
phone interviews. Variables, hypothesized to be associated with the degree of
interdisciplinary collaboration in the study, including personal afﬁliation,
organizational/structural characteristics, personal characteristics and relationships among
collaborators, history of collaboration, quality of care, job satisfaction, and professional
diversity, will be reviewed individually. Next, the chapter will address the study’s
strengths and limitations, followed by a discussion of implications for social work
practice, policy and evaluation. The chapter concludes with recommendations for future
research.

Review of Major Findings

Demographic and Organizational Characteristics

Three existing survey instruments were used for the quantitative study to address
the ﬁve research questions. The survey results highlighted common trends among the
study participants. Between 25 and 39 professionals ﬁom the disciplines of nursing,
medicine, spiritual care, and social work participated in the study. The majority of the
survey participants were female (73% female versus 27% male), which was particularly
true for nurses and social workers. Almost all of the participants were Caucasian (93.7%),

and the majority of them reported to be between 41 and 60 years old (61.1%). Over 60%

of the participants indicated full-time (36 hours or more hours a week) employment status.

Nurses and social workers were most likely to work ﬁrll-time while physicians and
spiritual care providers were more likely work either full-time or part-time. A wide range
of responses in years of experience in one’s discipline, years of working for current

hospice agency, and years of hospice experience were reported across all the disciplines.

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The study sample also reported some shared information about their hospice
agencies. Eighty percent of the participants reported working for a non-proﬁt hospice
organization, and 84% worked for hospice with at least 11 years in business experience.
In terms of a number of core hospice team members, hospice teams within agency, and
average daily caseload, responses among the study sample varied. The majority of the
participants reported to have one to three teams with close to 40% of them having over 30
core team members. Over 30% had greater than 110 patient cases a day on average while

over 20% had less than 30 average daily patient cases. Compared to the national data

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(NHPCO, 2007) of median hospice daily census of 45.6 clients with over 40% serving
fewer than 25 clients and 16% serving over 100 clients, the study sample had larger daily
client cases. The survey study participants worked for various geographical service areas
in the state of Michigan.

Survey study participants were asked to volunteer for audio-taped phone
interviews. Of the 63 hospice clinicians that volunteered to participate in the interview,
ﬁve each within the professions of nursing, physicians, spiritual care coordinators, and
social workers were randomly chosen for the qualitative study. Similar demographic and
organizational data observed in the survey study, in terms of volunteered study
participants, years of working for one’s current hospice, and geographic service area,
were also found in the qualitative study sample. As a group, the qualitative study

participants were more experienced in their professional discipline compared to the

 

survey participants as a whole. This may be related to the level of comfort in one’s ability
to discuss interdisciplinary collaboration in that more experienced clinicians felt

comfortable participating in the phone interview. It would be of future interest to ﬁnd out

109

if the described demographic and organizational data about the study sample would be
reﬂected by hospice professionals in other states.
Review of the Influencing Variables

Interdisciplinary Collaboration

The degree of interdisciplinary collaboration was measured, using the MHC, a 42-
item survey questionnaire (Parker-Oliver, Bronstein & Kurzejeski, 2005). The
questionnaire was designed to measure the experiences, attitudes, and perceptions of
individual team members about interdisciplinary collaboration within their team. The
instrument had been tested in a hospice setting by others (Parker-Oliver, Bronstein, &
Kurzejeski, 2005; Parke-Oliver, Wittenberg-Lyles, & Day, 2006) and had high reliability
rates of .92 to .93. Similar to the reports from other studies, the MIIC with this study
sample had a very high reliability rate of .935.

Professional Afﬁliation

In this study, the level of perceived interdisciplinary collaboration was found to
be positively associated with the degree of professional afﬁliation. The higher the
perceived interdisciplinary collaboration, the higher personal afﬁliation, and vice versa.
This ﬁnding supports various other studies in the literature (Aube & Rousseau 2005;
Bronstein 1999:2002z2003; Freund & Drach-Zahavy, 2007) and suggests that strong
professional afﬁliation, measured by commitment to one’s profession, professional
values, and professional identity, results in positive impact on one’s perception of
interdisciplinary collaboration. Hospice professionals who have strong connection to their
particular professional diversity are also likely to have positive experiences, attitude

towards, and perceptions of interdisciplinary collaboration. The qualitative component of

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the study reveals that professionals see their particular expertise as a strength and
professional quality that they bring to the team. It may be of a beneﬁt to hospice
managers and administrators, when hiring hospice personnel, to seek professionals who
have strong commitment to their profession, professional values, and professional
identity, as those individuals in turn may have a higher degree of collaboration.
Organizational/Structural Characteristics
Organizational/structural characteristics, symbolized by administrative support in

interdisciplinary collaboration and the availability of time, space, and resources needed

577—73“? .a 3.1!

for collaboration, are predicting factors in hospice team members’ perceived degree of
interdisciplinary collaboration. Those professionals who report having strong
administrative support and the availability of collaboration time, space, and resources
also report positive experiences, attitudes, and perceptions about interdisciplinary
collaboration. The impact of administrative support on interdisciplinary collaboration was
also found in the study by Shortell et al. (2004) as the researchers reported a positive
association between administrative support on teamwork and changes made to improve
care to chronically ill patients.

The qualitative component of the study adds depth to the quantitative ﬁnding.
While the phone interview participants conveyed the existence of excellent
communication among their team members, the majority of them voiced lack of time,
leading to communication difﬁculties among team members, as the main contributing

factor of barriers to interdisciplinary collaboration. One past qualitative study involving

 

hospice social workers (DiTullio & MacDonald, 1999) reported similar ﬁndings and

111

suggested that lack of time and inadequate communication were the major sources of
stress.

Additionally, the conditions of shortage of staff in one’s agency and large volume
of paperwork required by one’s agency and the government were reported by the phone
interview participants as negative elements of organizational/structural characteristics,
affecting interdisciplinary collaboration. Past qualitative studies of hospice social

workers’ perceptions of interdisciplinary collaboration and the impact of organizational

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characteristics also indicated insufﬁcient responses by organizational administrative
culture attributing to excess overload of scheduling and lack of stafﬁng (DiTullio &
MacDonald, 1999; Parker-Oliver & Peck, 2006).

Organizational/structural characteristics are crucial elements in enhancing
individual team members’ positive experiences, attitudes, and perceptions about
collaborative work. It is thus invaluable for hospice managers and administrators to
create a work environment where: (1) collaborative work is expected and supported, (2)
time, space, and resources necessary for collaboration is provided, (3) sufﬁcient stafﬁng
is guaranteed, and (4) reasonable amount of paperwork is required. Promoting and
providing a supportive, collaboration-enhancing work environment may lead to not only
improved interdisciplinary collaboration but also improved client care.

Personal Characteristics and Relationships among Collaborators

Statements that reﬂect the personal characteristics and relationships among
collaborators variable in the quantitative study connect to: (l) one’s feeling toward

colleagues from other disciplines on a team, (2) level of socialization outside of work

 

with colleagues from other disciplines, (3) the existence of trust toward colleagues ﬁom

112

other disciplines, and (4) being understood by colleagues from other disciplines of
personal values. The quantitative study results suggest that those who have positive
feelings toward colleagues from other disciplines, socialize with colleagues from other
disciplines outside work, trust colleagues from other disciplines, and feel their personal
values are understood by colleagues from other disciplines report high interdisciplinary
collaboration.

Matters of trust toward, respect for, and genuine liking of other team members

were frequently echoed by the qualitative study participants as strengths of their hospice

team. The effect of personal characteristics of positive regard and support toward
colleagues and of trust among colleagues on interdisciplinary collaboration and team
effectiveness were also reported in other studies (Amundson, 2005; Parker-Oliver & Peck,
2006). In the hiring process, it would be of a beneﬁt to hospice team members, managers,
and administrators to pay attention to personal characteristics, besides job qualiﬁcations,
of new applicants and consider how well a potential new member ﬁts with other team
members. Asking questions about one’s past experiences with and attitudes toward

his/her then co-workers or giving a personal attitude test on teamwork, for instance, may

 

give important information about his/her attitude toward teamwork.

History of Interdisciplinary Collaboration

Several studies reported that a history of or training in interdisciplinary
collaboration was associated with improved interdisciplinary collaboration, team
effectiveness, and communication among team members (Award et al., 2005; Haycock-
Stuart and Houston, 2005; Hirschfeld et al., 2006). Contrary to these past study ﬁndings,

the quantitative component of the study rejects a positive association between the degree

113

 

of interdisciplinary collaboration and history of collaboration. It is also important to note
that this ﬁnding is based on a limited number of respondents. Less than a half of the
survey participants, 55 out of the 126 participants, responded. In this study, history of
collaboration was measured using a set of two statements and question about the impact
of past collaboration experience and past training experience in interdisciplinary
collaboration. These statements and question were adopted from the original MIIC
developed by Bronstein (1999).

In order to understand the low response rate on the variable, the researcher

H ”F‘T—ﬁi

reviewed data on each of the two statements and one question. The ﬁrst statement about
history of collaboration was “My past experience with interdisciplinary collaboration has
prepared me well for my current collaboration with other disciplines.” Of the 126 survey
participants, 123 responded to this statement. The ﬁrst statement was followed by a
question of “Have you ever had training in interdisciplinary collaboration?” by answering
either yes or no. One hundred and twenty four hospice professional responded to this
question, with 55 of them (43.7%) indicating past training in interdisciplinary
collaboration and 69 (54.8%) reporting no past training in interdisciplinary collaboration.
It directed those who answered “no” on the question to skip to the next section of the
survey. As a result of the question, only 55 individuals responded to the second statement

about history of collaboration, “My past training in interdisciplinary collaboration helps

 

me in my current collaborative work.” Because most of the survey study participants had
no prior training in interdisciplinary collaboration and were asked to skip the second
statement about history of collaboration, it signiﬁcantly reduced the response rate on this

variable as a whole.

114

The difﬁculty with the MHC survey instrument which included a set of history of
collaboration-related statements, however, was not reported by others who previously
used the instrument in their studies (Bronstein 1999: 2002; Parker-Oliver et al. 2007).

Quality of Care

The quality of care subscale (Heinmann, Schmitt, & Farrell, 1991) was used to
measure the quality of care variable. Ten statements relating to quality of team care
included statements about the beneﬁts of teamwork on the team and patient care levels.
On the team level, avoiding errors in delivering care, fostering communication,
understanding the work of other disciplines, maintaining enthusiastic attitude, and
making better patient care decisions represented beneﬁts of teamwork. On the patient
care level, the beneﬁts related to teams better meeting patient and family caregiver needs,
being more responsible to the emotional and ﬁnancial needs of patients, patient being
treated as a whole person, and improved quality of care. The beneﬁts of teamwork on the
patient-care level, including improved services and cost containment have been reported
by multiple studies (Abrahm et al., 1996; Bencala et al., 1982; Brita-Rossi et al., 1996;
Nikolaus et al., 1999; Sommers et al., 2000). The internal consistency reliability for the
Quality of Care Subscale from the study was higher (Cronbach’s alpha = .911) than the
score previously reported by Heinmann, Schmit, & Farrell (1991) which was .82.

The quantitative study ﬁnding reveals that those who see the beneﬁts of teamwork
both on the team and patient-care levels also have positive experiences with, attitudes
toward, and perceptions about interdisciplinary collaboration, and vice versa.
Qualitatively, the hospice professionals were very vocal about the positive impact of

teamwork on the team members as well as clients. Many discussed experiences of being

115

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valued and treated as an equal partner by other team members for the ﬁrst time in their
professional careers.

One possible explanation for this ﬁnding may be related to the function as well as
philosophy of hospice care. Interdisciplinary collaboration is not only a required function
of hospice care deﬁned by the MHB, but also an integral part of delivering holistic care

driven by hospice philosophy. Hospice professionals are expected to work collaboratively

for legislative as well as philosophical reasons. Hospice’s emphasis on seeing physical, r a! ,1
psychosocial, and spiritual needs of individuals as equally signiﬁcant parts of human
experience may work to diminish the traditional medical model of hierarchy among 'l‘

health care providers and reinforce equal contributions of all disciplines involved.
Another possible explanation for this ﬁnding is that professionals who work for

hospice might have chosen hospice work because they identify strongly with hospice

 

philosophy and believe the best way to deliver holistic care is through the use of

 

interdisciplinary teams. As a result, hospice professionals may view interdisciplinary
collaboration as an effective tool to deliver holistic care to their clients and families, and
the team approach is beneﬁcial for meeting the needs of their clients and team members.
Hospice professionals serve those who live with life-limiting conditions and their
families/caregivers. The qualitative study ﬁndings convey that hospice professionals see
working on a team crucial to providing and receiving emotional support in their work.

Job Satisfaction

Job satisfaction was measured using the Job Satisfaction subscale (Cammann et a1.
1983), which included three statements indicating one’s attitude toward his/her job. The

quantitative study ﬁnding suggests that hospice professionals who are satisﬁed with their

116

 

jobs are more likely to have a high level of interdisciplinary collaboration. Those who
have positive experiences, attitudes, and perceptions about collaborative work are also
satisﬁed with their jobs. Past studies (Coopman, 2001; DeLoach, 2003) also support this
ﬁnding. The connection between a well-functioning team, customer satisfaction, and
team member job satisfaction was also articulated in the qualitative component of the
study. The correlating relationship between job satisfaction and perceived degree of
interdisciplinary collaboration should be of interest to hospice team members, managers,
and administrators in improving job satisfaction and thus interdisciplinary collaboration
and vice versa.

Furthermore, for most hospice professionals, their feelings toward their job
extended beyond liking and being satisﬁed with what they were hired to do. They
consistently expressed genuine passion and pride for doing hospice work and seeing
hospice work almost as their life’s calling, not simply “a job.”

Professional Diversity

“Professional diversity” refers to a professional discipline with a set of special
knowledge, values, and skills. The primary focus of the professional diversity groups for
the study included nurses, physicians, spiritual care providers, and social workers. The
quantitative and qualitative data provide some interesting ﬁndings relating to the impact
of professional diversity on the degree of interdisciplinary collaboration as well as other
aspects of the study. First, the ﬁnding from the survey study rejects an assumption that
hospice social workers, compared to hospice professionals ﬁom other three disciplines,
have better experiences of, attitudes toward, and perceptions of interdisciplinary

collaboration. The researcher hypothesized that social work training and values on

117

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collaboration with other professionals may contribute to social workers’ perceived
interdisciplinary collaboration. In reality, professional diversity had no association with
the degree of interdisciplinary collaboration reported by hospice team members.

Second, professional diversity may be a contributing factor in one’s level of
personal characteristics and relationships with collaborators and job satisfaction.
Although all professional diversity groups reported high to very high positive feelings
and trust toward other disciplines and being happy with their jobs, differences on these
outcomes based on professional diversity were statistically signiﬁcant. The quantitative
data of the study suggests that physicians, followed by nurses, reported the most positive
feelings and trust toward other disciplines and felt understood by other disciplines. Social
workers, on the other hand, expressed the least positive attitude and trust toward other
disciplines and feel least understood by other disciplines. Also, as a professional
discipline, physicians were most happy with their jobs, followed by nurses. On the other
hand, social workers were least satisﬁed with their jobs.

One possible reason for these outcomes may be related to professional and
structural barriers to interdisciplinary collaboration (Brewer, 1999; Irvine et al. 2002)
discussed earlier in the literature review section. Professional and structural barriers of
inequality in professional incentives, status, recognition, authority, division of labors, and
legal effects (Brewer, 1999; Irvine et al. 2002) may explain differences in attitudes
toward colleagues from other disciplines and job satisfaction based on professional
diversity. Though hospice has been perceived as unique in promoting holistic care over
the traditional medical care and valuing interdisciplinary collaboration of various

professionals as equally important in delivering services, it is still very much a part of the

118

 

 

mainstream healthcare system. Healthcare professionals, whether or not working for
hospice, learn a set of discipline-speciﬁed knowledge and skills as well as their
professional status within the healthcare system and society.

The issue of professional status may be best understood in terms of differences in
compensation, and professional recognition and ranking that exist among hospice
professionals. For instance, social workers, despite their advanced degree, those with

master’s degree, are compensated signiﬁcantly less than registered nurses. In fact, in

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2007, hospice registered nurses (RNs) made an average of $26.82 per hour, $4 more per

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hour than hospice social workers who were master’s degree educated (Hospice
Association of America, 2008). Hospice physicians are compensated signiﬁcantly more
than hospice nurses and social workers. One resource reports that the median salary for a
hospice medical director working for non-proﬁt hospice was $93,000 and $101,530 for
for-proﬁt hospice annually (PayScale, 2009). Information on salary for hospice spiritual
care providers was not available.

Differences in compensation among hospice professionals are very much

reﬂective of the mainstream healthcare system. Findings ﬁ'om a study by Acker (2004)

 

support the impact of compensation on job satisfaction. In her study of the effect of
organizational conditions on job satisfaction among social workers, satisfaction with
worker’s salary had statistically signiﬁcant positive correlation with job satisfaction
(Acker, 2004). The level of ﬁnancial incentives may explain the level of contentment
toward one’s job and other disciplines.

Additionally, the existence of professional recognition and ranking among

healthcare professionals is not foreign to hospice. Physicians, by the nature of their

119

 

professional practice and well-established political, ﬁnancial, and societal status, are one
of the most highly regarded professions in society (Irvine et al. 2002). In hospice, each
core discipline of medicine, nursing, spiritual care, and social work, is expected to work
together to deliver individually tailored holistic care to clients. Yet, hospice physicians,
much like physicians in other settings, have the highest inherited power, recognition, and
ranking among hospice professionals. The law supports and reinforces the professional
distinction. By Medicare Hospice Beneﬁt, hospice physicians are required to dictate and _____,
approve plans of care before they are turned to action by other hospice professionals. For
instance, hospice physicians are ultimately responsible for re-certifying clients for ’”
continued hospice service on an ongoing basis, although other team members may share
inputs toward the decision making process.

Social workers face the matter of professional status as well in hospice. In order
to deal with economic issues, many hospices are trying to cut down social worker jobs
(Reese & Raymond, 2002). One study found that hospice social workers identiﬁed over-
emphasis placed on physical aspects over psychosocial aspects of clients needs as one of
the challenges of interdisciplinary work (Parker-Oliver & Peck, 2006). The limited focus

on psychosocial aspect of clients needs was also observed by a study of interdisciplinary

 

team meeting communication processes (Wittenberg-Lyles et al. 2005). In addition, one
study revealed a statistically signiﬁcant, positive relationship between recognition of
personal and professional identities by others on a team and job satisfaction (Thatcher &
Greer, 2008). They found that those individuals who felt their personal and professional
identities were well recognized by colleagues on their team were more likely to be

content with their jobs.

120

 

These study outcomes may explain a reason for social workers’ feeling their
values and perceptions less understood by other disciplines. Hospice social workers, as a
result, may feel under-compensated and under-appreciated for the contribution they make
in hospice while physicians may be satisﬁed with their compensation and inherited
professional recognition and ranking within the team, leading to the difference in job
satisfaction and personal characteristics and relationships among collaborators based on
professional diversity.

Study Limitations

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This section discusses limitations of the study, relating to sampling, research
design, and procedures. First, the study’s sampling method was problematic as it was not
possible to do random sampling. Because there is no known published list of hospice
core members’ information (names, a number of professionals in each discipline, for
example) currently working in the state of Michigan, the researcher chose to recruit study
participants through contacting hospice agencies and requesting they distribute the study
materials.

The initial recruitment process involved the researcher contacting administrators
of Michigan Hospice and Palliative Care Organization’s 2008 member hospice agencies.
Each hospice agency received a packet of information which included the initial
recruitment letter addressed to the administrator and four copies of the survey
questionnaire. In the initial recruitment letter, hospice administrators were asked to

disseminate four copies of the questionnaire, one each to the disciplines of nursing,

 

medicine, spiritual care, and social work. Dissemination of the survey questionnaire as

well as the selection of four professionals within each particular hospice organization, as

121

a result, was left to the discretion of hospice administrators and managers. Although
hospice professionals were made aware of their right not to participate in the study, they
may have felt obliged to take a part in the study because of who was facilitating the
dissemination.

In addition, the study relied on the voluntary participation of the then selected
hospice professionals. The researcher had to rely on the administrators to encourage their
hospice professionals to return the survey as follow-up e-mail messages were sent to the
administrators. Even with three follow up e-mail messages to the administrators of
MHPCO member hospices, the return rate for the survey study was 27.5%. These steps
may have resulted in sampling selection biases (e. g. those whom hospice administrators
felt had a strong team sprit were chosen for the study), history (e. g. a participant
completed the questionnaire after receiving positive appraisal for his/her work), mortality
(e. g. individuals who were less committed to interdisciplinary collaboration did not
complete the questionnaire) as potential threats to internal validity (Rubin & Babbie,
1993)

One possible explanation for the low return rate may be that some hospice
administrators were not interested in their hospice team members participating in the
study and thus did not disseminate the surveys. Another possible explanation may be that
some hospice professionals were simply not interested in participating in this study. For
instance, some individuals might have felt that they did not relate to the importance of
research or felt completing the questionnaire appeared to be too time consuming, thus
declining to participate in the study. Although the study guaranteed conﬁdentiality and

provided self-addressed and stamped individual return envelopes for the surveys, many

122

 

did not take a part in the study. As one study (Edwards et al. 2002) reported, offering a
monetary incentive and using a colored ink might have improved the return rate.

The qualitative study participants were randomly chosen from volunteer hospice
professionals who had participated in the survey study. This method, much like the
quantitative study participants recruitment method, restricted the recruitment of hospice
core members to those who work for MHPCO member hospices. The study sample
therefore may not be representative of core hospice team members in general and thus .,
limit generalization and representativeness of study ﬁndings, potential threats to external
validity (Rubin & Babbie, 1993). Again, a potential threat to internal validity in terms of ‘ j
mortality (e.g. individuals who were enthusiastic about teamwork volunteered to
participate in the interview) was also identiﬁed (Rubin and Babbie, 1993). ‘

Second, this study brought attention to an instrument issue previously not reported
by studies that had utilized the MHC (Bronstein, 2002; Parker-Oliver, Wittenberg-Lyles,
& Day, 2008). A question, aimed to examine history of training in interdisciplinary
collaboration as part of the MIIC, led to a signiﬁcant reduction in the response rate on the
history of interdisciplinary collaboration. As a result, there was a reduction in the overall
response rate on the variable. Revision of the question may be necessary to avoid a
response rate issue in ﬁrture research.

Another issue with the survey instrument is that the survey questionnaire
examined perceptions of individual hospice professionals, not individual interdisciplinary

teams. Matching and being able to compare individual professionals’ perceptions with

 

other individual professionals on the same team and also with their team as a whole

123

would provide an opportunity to investigate gaps in perceptions that may exist among
members of the same hospice team.

Because this study relied on the perceptions of hospice professionals about their
own teams and team experiences, the information was only limited to professional
perceptions and did not reﬂect perceptions of administrators or clients/families. Inclusion
of the perceptions of administrators and clients/families may aid in understanding the
impact of interdisciplinary collaboration on administrators as well as clients/families.

Third, the study sample was limited by the homogeneity. Of 126 participants,
73% of them were female and 118 (93.7%) identiﬁed as Caucasian. Thus, the study
ﬁndings have limited generalizability as a potential threat to extemal validity (Rubin &
Babbie, 1993). Because no state-wide or national data on personal demographic
information (e.g. gender, race/ethnicity, and age groups) about hospice professionals are
available, whether or not the study sample is representative of hospice professionals in
general is not known. The availability and accessibility of state-wide and national level
data on hospice professionals would strengthen future study sarnpling methods.

Fourth, this study was limited to four core hospice disciplines of nursing,
medicine, spiritual care, and social work. Inclusion of other hospice team members, such
as home health aides, bereavement services, and volunteers would be of beneﬁt to further
understand interdisciplinary collaboration.

Lastly, because the qualitative study was conducted before the completion of the
quantitative data analysis, interview questions did not include questions reﬂective of

ﬁndings ﬁom the survey study. A follow up interview with hospice professionals that

124

include questions relating to job satisfaction and quality of care, for instance, would
allow gathering of in-depth information.

Despite these limitations, the study also has strengths. One is that this study
utilized established instruments with a good level of reliability and validity. Additionally,
because this study utilized the MIIC already tested in other studies to measure
interdisciplinary collaboration, the ﬁndings of the study can be compared to results from
previous studies to validate and further strengthen the instrument. At the same time, the
study tested new inﬂuencing variables on interdisciplinary collaboration, thus adding to
the knowledge base of what factors aid or hinder collaborative work.

Another strength is that this study included four core hospice disciplines, with
between 25 and 38 individuals from each discipline represented. Other published studies
of interdisciplinary team members in hospice and other health care ﬁeld often focused on
a few speciﬁc disciplines or included various professionals but some of participating
professionals did not have a large enough number representing their disciplines for data
analysis based on professional diversity (Abrahamson & Mizarahi, 1996; DeLoach, 2003;
Parker-Oliver, Witttenberg-Lyles, & Day, 2008).

The mixed method used to address the overarching research question of this study
is another strength. Mixed method research design increase quality of data and give a
comprehensive understanding of analyzed data (Creswell, 2003). Information ﬁ'om the
telephone interview in this study provided an opportunity for the survey study data to be

veriﬁed, enhanced, and interpreted.

125

Implications for Hospice Professionals and Social Work Profession

The ﬁndings of this study have implications for hospice interdisciplinary team
members as well as administrators in terms of practice and policy. A discussion on social
work practice implications follows.

Implications for Hospice Professionals and Administrators

The study ﬁndings examined factors that aid or hinder collaborative work among
hospice interdisciplinary team members. Professional afﬁliation (commitment to one’s
profession), organizational characteristics (organizational support toward collaboration),
personal characteristics and relationships among collaborators (positive feelings toward
colleagues), quality of care (beneﬁts of team care), and job satisfaction were all found to
be associated with the degree of perceived interdisciplinary collaboration.

Information about the association between interdisciplinary collaboration and
professional affiliation and personal characteristics should aid hospice administrators,
managers, and team members in the hiring process. Those professionals who have strong
commitment to their profession and have positive personal feeling toward colleagues
ﬁ'om other disciplines have a higher level of interdisciplinary collaboration. Hiring
individuals with a strong commitment to one’s profession and positive feelings toward
other professionals may beneﬁt overall quality and function of one’s team. Hospice
professionals should take an active role in the hiring process of new team members,
regardless of professional diversity, as a new team member affects the entire team climate
and may affect their team performance.

Hospice administrators and managers can work to enhance interdisciplinary

collaboration of their hospice teams by improving organizational and structural support.

126

They may include: (1) providing time, space, and resources necessary for collaboration;
(2) encouraging and supporting collaboration; (3) maintaining enough staff; and (4)
requiring reasonable, not excessive, amounts of paperwork.

Being overwhelmed by an excessive amount of paperwork and a large number of
cases was a barrier to collaborative work repeatedly mentioned by the interview
participants. There is a crucial need for hospice administrators to alter their practice
regulations to streamline paperwork to allow team members to have more focus on

clients and building interdisciplinary collaboration with other team members.

Additionally, assessments of hospice team members’ needs for speciﬁc organizational
support should be practiced on an on-going base. For instance, an annual survey on
organizational support completed by hospice team members may provide practical
information for hospice managers and administrators in reviewing and revising
organizations regulations and practices.

Policy changes in the use of interdisciplinary collaboration may also be helpful.
As found in this study and other studies (Abrahm et al., 1996; Coopman, 2001), the
degree of interdisciplinary collaboration affects the level of quality of team care. If
hospice administrators and policy makers are looking for ways to improve quality of care
provided to clients, then organizational regulations as well as government policies need
to reﬂect and outline detailed, substantial use of interdisciplinary collaboration. Once in
place, these regulatory and policy changes, aimed to maximize the use and function of
interdisciplinary collaboration, can be evaluated on an on-going basis. Evaluation should
include examining the work of team in terms of level of collaboration and quality of care

the team provides to clients.

127

 

The matters of team practice and regulations should not be solely left to hospice
managers, administrators, and policy makers. Hospice professionals, regardless of
professional diversity, need to actively participate in reviewing and revising
organizational regulations that directly affect their interdisciplinary collaboration
practices and services provided to their clients. As identiﬁed in the qualitative study
ﬁndings and other studies (DiTullio & MacDonald, 1999; Parker-Oliver & Peck, 2006),
hospice professionals have ﬁrst-hand knowledge of how certain practice regulations such

as excessive paperwork and shortage of staff may affect client services. Assisting

O
‘5

administrators with creating ways to streamline required paperwork without "'1
compromising service quality, for instance, would permit more time for direct client care
and team collaboration.

Furthermore, if hospice professionals want to improve public policies that directly
affect client service, interdisciplinary collaboration, and hospice practice, it is essential
for them to be aware of current policy issues ﬁrst. Educating each other and themselves
about current policy issues allows hospice professionals to make informed decisions
about how to lobby for the improvement of public policies relating to hospice and
interdisciplinary collaboration practice.

Implications for the Social Work Profession

The study ﬁndings provide insight to implications for the social work profession.
The qualitative ﬁndings of the study bring the contributions of social workers on the
interdisciplinary team to the forefront. As discussed before, professionals who have
strong commitment to and value their profession have a high level of perceived

interdisciplinary collaboration. The social work profession’s focus on ecological,

128

 

 

strengths perspectives and comrrritrnent to promoting self-determination/autonomy in
assessing and addressing client needs was very evident among the study participants. The
qualitative data reﬂected a unique professional perspective in social work consisting of:
(1) translating the environmental impact of terminal illness on clients and their families;
(2) understanding the affect of history on current issues and problem solving mechanism
among clients and families; and (3) deﬁning client and systems strengths in creative ways.

Social workers’ perspective and skills in understanding human behavior and
environmental impacts allow them to advocate for the importance of addressing not only
psychosocial needs but also of reviewing all aspects of human experiences as inter-
connected. In addition to fostering a strong commitment to the mission and values of
social work in classrooms and ﬁeld practicum, social work education should also assist
students in articulating their professional contributions in a team setting. Use of case
studies involving various professionals in class rooms, for instance, may aid social work
students in understanding how differences in professional values and training may affect
attitudes toward and relationships with other professionals in an actual practice setting.
This is also true for other hospice professionals, including physicians, nurses, and
spiritual care providers. Their professional education should involve fostering strong
professional values and comrrritment unique to their professional discipline while
educating students on the role of their profession in a team setting.

In addition, social work education should assist students in gaining an
understanding of other professionals that they may be working with on a team. For
instance, offering a course on social work practice in healthcare that includes a lesson on

medical language and common jargon may help in understanding professionals who use

129

them and also in enhancing professional conﬁdence in working with other professionals.
Having knowledge of other professionals’ practices and values should aid social
workers/social work students in understanding the roles that other professionals play,
based on their particular set of knowledge, skills, and values.

Social work educators may also join in force with educators from other disciplines
in creating opportunities for social work students and students from other disciplines to
learn about the art of interdisciplinary collaboration. Although this study’s ﬁndings did
not support the positive impact of past teamwork experience on the perceived level of
interdisciplinary collaboration, other studies found a history of collaboration training and
experiences correlating with signs of high levels of interdisciplinary collaboration such as
improved communication and collaborative practice (Haycock-Stuart & Houston, 2005;
Temkin—Greere et al. 2004). Jointly offering a course on interdisciplinary collaboration
using educators ﬁ'om multiple disciplines as co-instructors may provide students ﬁ'om
various disciplines a unique classroom experience to not only learn about
interdisciplinary collaboration but also interact with and learn from each other. For
instance, a course on interdisciplinary collaboration in healthcare instructed by educators
from the disciplines of nursing, medicine, theology, and social work will provide students
a great opportunity to have ﬁrst-hand experiences working with professionals with
different values and trainings.

In regard to education and training, social work schools may play a major role in
promoting social work practitioners in their life long learning. Making continuing

education courses on various topics of social work practice, policy, and research

130

accessible and available to social work practitioners is one way that social work schools
can assist practitioners in their continued professional development.

In terms of social work research, quantifying the impact of social work
interventions on client, team, and organizational outcomes should be of a high priority.
As evidenced by the new Condition of Participation, demands to provide means—tested
interventions in hospice practice, like in other healthcare settings, will continue to grow.
The development of tools that quantitatively measure social work interventions will
provide a baseline for continuous evaluation and contribute to creating means-tested
interventions. The study by Reese and Raymor (2004) on the effectiveness of hospice
social work interventions is a good example of how researchers may evaluate and
demonstrate social work contributions on an interdisciplinary team. Being able to
quantify contributions in improving client care and teamwork may also lead to improved
professional recognition in hospice as well as other healthcare settings for social workers.
Positive changes in professional recognition in return may result in improved
compensation and job satisfaction.

The need to quantify the impact of one’s professional intervention applies to other
hospice professionals as well. Hospice care is provided through the use of an
interdisciplinary team, and as noted in the qualitative study ﬁndings, hospice
professionals take strong belief and support in its philosophical and actual beneﬁts of
collaboration in delivering care to their clients. If the use of an interdisciplinary team is to
survive a greater scrutiny posed by consumers, researchers, and public policy makers,
then all hospice professionals need to seek a part in producing evidence that empirically

validate the practice. Social workers need to take a leading role in collaborative research

131

 

 

 

opportunities with other hospice professionals to evaluate the beneﬁts of interdisciplinary
collaboration on individual team members, teams, organizations, and clients. This may
include forming a partnership with researchers ﬁom acaderrrics settings and engaging in
evaluations of hospice team interventions.

The study revealed an interesting ﬁnding about social workers as compared to
other professionals. Despite the unique contributions that social workers make on the
team, hospice social workers as a discipline had the least positive feelings toward other r- :1
professionals and were the least happy with their jobs. These ﬁndings may be deeply =
rooted in the issues of professional status that exist in hospice, the healthcare system as a .; _
whole, and society. Social workers have always worked and continue to work on
improving the lives of their clients. Promoting professional and public acceptance and
recognition in all areas of social work may bring positive changes in the issues of

professional status thus improve job satisfaction and personal feelings toward other

 

disciplines among social workers. As discussed earlier, one way to accomplish this may
be through the use of research and quantifying the effectiveness of social work
intervention in improving client care. It is essential for social work educators to make a
tireless effort to help their students understand the interrelatedness of education, practice,
policy, and evaluation/research.
Recommendations for Future Research

This study investigated factors that aid or hinder collaborative work among
hospice interdisciplinary team members. While the ﬁndings add to an understanding of

interdisciplinary collaboration, they also inspire ideas for future research.

132

 

First, continued research on inﬂuencing variables of interdisciplinary
collaboration is crucial in gaining an understanding of the processes and functions of
interdisciplinary collaboration. Future research should include further exploration on the
roles of personal demographic variables of age, gender, employment status, educational
credentials, and certiﬁcation in palliative care on the degree of interdisciplinary
collaboration. In terms of organizational characteristics, the impact of organizational
status (non-proﬁt, for-proﬁt, and govemment-run) on the degree of interdisciplinary
collaboration, job satisfaction, and quality of care, for instance, may reveal additional
information about what factors inﬂuence collaborative work. Information on team
leadership, spiritual afﬁliation, and feelings toward death and their relationships to the
degree of interdisciplinary collaboration may also lead to interesting ﬁndings about what
factors may aid or hider collaborative work.

Second, future research should include studies of not only individual team
members but also individual teams. Examining differences in perceptions and
experiences of interdisciplinary collaboration between members and within teams would
provide further information on how to improve collaborative work on individual and
team levels. Inclusion of other disciplines such as home health aides and bereavement
services would allow an opportunity to further investigate the impact of professional
diversity on interdisciplinary collaboration and inﬂuencing variables.

Furthermore, the study ﬁndings suggest that hospice team members associate: (l)
administrative support to the level of interdisciplinary collaboration and (2) team-based
care to quality of care provided to clients. Inclusion of hospice administrators and clients

in future studies would examine perceptions from the perspectives of hospice

133

 

 

 

administrators and service recipients. Differences found among those who manage teams,
deliver services, and receive services reveal information on how to improve
interdisciplinary collaboration from diverse perspectives.

Third, qualitative research, focusing on understanding the roles of inﬂuencing
variables such as job satisfaction and quality of team care, would strengthen quantitative
knowledge. Focus groups and individual team member interviews regarding individual

members’ and teams’ perceptions about interdisciplinary collaboration, job satisfaction

and quality of team care, may be used to gather information on team and individual levels.

Fourth, ﬁrture studies should explore the relationship between the degree of
interdisciplinary collaboration and speciﬁc outcomes for clients. The development of
instruments that address bio-psychosocial-spiritual aspects of hospice care interventions,
particularly quantifying psychosocial and spiritual interventions, would be highly
beneﬁcial.

Fifth, comparing the study ﬁndings about interdisciplinary collaboration in a
hospice setting to teams in other settings would test whether on not hospice teams indeed
have a higher degree of interdisciplinary collaboration than teams in other settings.
Conclusion

The hospice interdisciplinary team has been described as the ideal model for
interdisciplinary collaboration and delivering holistic care to clients. The literature review
revealed that support for interdisciplinary collaboration, particularly hospice
interdisciplinary teams, is often assumed and rarely tested. Since the inception of hospice
care in the late 19603 to early 1970s, only a handful of studies have focused on and

examined the processes, beneﬁts, and effectiveness of hospice interdisciplinary teams.

134

El

 

 

With the current condition of the economy, a growing pressure to produce
erupirical evidence for healthcare services in general has recently reached the hospice
industry. The new Condition of Participation (CoP) under the Medicare Hospice Beneﬁt,
requiring hospices receiving Medicare reimbursement to engage in on-going quality
assessment and performance improvement projects, is now in effect. Before the
implementation of the new CoP, the evaluation of interdisciplinary work was left to the
discretion of each hospice. Hospices are now expected to evaluate their services in a
more systemic way than before. As hospice provides services utilizing an
interdisciplinary team, gaining an understanding of hospice team collaboration processes
is invaluable to evaluating and improving collaborative work.

This study aimed to examine the processes of interdisciplinary collaboration and
variables that affect interdisciplinary collaboration among hospice team members. The
quantitative and qualitative ﬁndings of the study convey that overall hospice
professionals, regardless of their professional diversity groups: (1) have a high level of
interdisciplinary collaboration; (2) share similar perceptions of strengths and challenges
of interdisciplinary collaboration; (3) enjoy, are satisﬁed with and proud of their work
and team; and (4) believe in holistic care as an effective way to serve those who are
terminally ill and their families. Findings reported in this study make a contribution to the
existing body of knowledge on interdisciplinary collaboration, particularly in interpreting
the impact of variables on interdisciplinary collaboration in a hospice setting and
encourage further studies in this area.

As the baby boomer generation approaches its older age, demand for hospice

services is expected to grow even greater. This is evidenced in a growing number of

135

 

 

 

hospice organizations and clients over the years. Between 1984 and 2007, the number of
Medicare-certiﬁed hospices grew ﬁom 31 to 3,257 (Hospice Association of America,
2008). In addition, the number of individuals receiving hospice care in 2006 was 964,614,
a large increase from 60,802 in 1989 (Hospice Association of America, 2008). With the
increased utilization of hospice care as an option for end of life care and growth in
hospice agencies, the hospice industry is expected to receive greater attention.

The development of systemic evaluation of hospice interdisciplinary teams and
their interventions will aid in improving care to those who face life-limiting illnesses and
their families. Also, an on-going systemic evaluation of interdisciplinary work may
provide empirical evidence to support and promote the use of interdisciplinary teams in

delivering holistic, bio-psychosocial-spiritual care to clients in all aspects of healthcare.

136

 

APPENDICIES

137

Appendix A:

Michigan State University Institutional Review Board (IRB) Approval

Michigan State University
December 12, 2008

To: Gary Anderson
254 Baker Hall

Re: IRB # X08—1 142
Approval Date: December 12, 2008

Title: Interdisciplinary collaboration: Factors that inﬂuence collaborative experiences
among hospice team members

The IRB has found that your research project meets the criteria for exempt status and the criteria for the
protection of human subjects in exempt research. Under our exempt policy the Principal Investigator
assumes the responsibility for the protection of human subjects in this project as outlined in the
assurance letter and exempt educational material. The IRB ofﬁce has received your signed assurance for
exempt research. A copy of this signed agreement is appended for your information and records.

Renewals: Exempt protocols do n_ot need to be renewed. If the project is completed, please submit for an
Application for Permanent Closure.

Revisions: Exempt protocols do nit require revisions. However, if changes are made to a protocol that may
no longer meet the exempt criteria, a new initial application will be required.

Problems: If issues should arise during the conduct of the research, such as unanticipated problems,
adverse events or any problem that may increase the risk to the human subjects and change the category of
review, notify the IRB ofﬁce promptly. Any complaints from participants regarding the risk and beneﬁts of
the project must be reported to the IRB.

Follow-up: If you exempt project is not completed and closed after three years, the IRB ofﬁce will contact
you regarding the status of the project and to verify that no changes have occurred that may affect exerrrpt
status.

Please use the IRB number listed above on any forms submitted which relate to this project, or on any
correspondence with the IRB ofﬁce.

Good luck in your research. If we can be of further assistance, please contact us at 517-355-2180 or via
email at IRBfa'zrrguedu. Thank you for your cooperation.

Sincerely,

Dan Ilgen, Ph. D.

SIRB Chair
c: Rie Kobayashi
10 Baker Hall
School of Social Work

138

Appendix B:
Letter to the Hospice Executive Director/Administrator

Interdisciplinary Collaboration: Factors that Inﬂuence Collaborative Experiences among
Hospice Team Members

Gary Anderson, Ph.D.

Rie Kobayashi, LMSW

Michigan State University School of Social Work
254 Baker Hall

East Lansing, MI 48824

Dear Hospice Executive Director/Administrator:

My name is Rie Kobayashi, and I am a Ph.D student at Michigan State University. I have
also been a social worker in a hospice organization for the past 11 years. In partnership
with the Michigan Hospice and Palliative Care Organization, I am conducting a research
study on hospice interdisciplinary teams and would like your assistance in disseminating
the survey questionnaire enclosed. This study is supported by my committee members,
Gary Anderson, Ph.D., LMSW, Sally Rypkema, Ph.D., LMSW, Linda Keilman, MSN,
APRN, BC., and Karen Ogle, MD.

The survey aims to deepen our understanding of the processes and experiences of hospice
interdisciplinary team collaboration and learn about factors that aid or hinder
collaborative work. This study is designed to target full-time and part-time (not PRN)
hospice medical directors, nurses, spiritual care providers/counselors, and social workers
as study participants. In the entire study, approximately 117 hospice organizations and
488 hospice medical directors, nurses, spiritual care providers/counselors and social
workers in the state of Michigan are being asked to participate.

Enclosed in this packet are four copies of the survey questionnaire and informed
consent/telephone interview information sheet. I ask that you disseminate a copy of the
questionnaire to one medical director, one nurse, one spiritual care provider/counselor,
and one social worker in your organization. After collecting data, we plan to share our
ﬁndings with you through the Michigan Hospice and Palliative Care Organization
website. The data ﬁ'om this study will not be connected to individual hospice agencies,
and participants will not be asked to name their hospice on the survey document. It is our
hope that the ﬁndings from the study will help your organization in strengthening your
interdisciplinary team collaboration.

If you have any concerns or questions regarding this study, please contact me at (517)
862-6015 or e-mail l_<obavas6@msu.edu.

139

 

Thank you in advance for your time and attention to this matter. Your assistance and
support in disseminating the survey are essential to the success of the study.

Rie Kobayashi, LMSW
254 Baker Hall

East Lansing, MI 48824
kobaLas6@msu.edu

140

Appendix C:
Letter to the Hospice Colleague

Interdisciplinary Collaboration: Factors that Inﬂuence Collaborative Work among
Hospice Team Members

Gary Anderson, Ph.D.

Rie Kobayashi, LMSW

Michigan State University School of Social Work
254 Baker Hall

East Lansing, MI 48824

Dear Hospice Colleague:

My name is Rie Kobayashi, and I am a Ph.D student at Michigan State University. I have
also been a social worker in a hospice organization for the past 11 years. In partnership
with the Michigan Hospice and Palliative Care Organization, I am conducting a research
study on hospice interdisciplinary teams and would like your assistance. This survey aims
to deepen our understanding of the processes and experiences of hospice interdisciplinary
team collaboration and learn factors that aid or hinder collaborative work. As a practicing
hospice social worker myself, I am often reminded of the importance of teamwork and
the impact that teamwork has on our clients. This study is designed to target ﬁrll-time and
part-time (not PRN) hospice medical directors, nurses, spiritual care providers/counselors,
and social workers as study participants. In the entire study, approximately 480 hospice
medical directors, nurses, spiritual care providers/counselors and social workers in the
state of Michigan are being asked to participate.

Enclosed please ﬁnd the survey questionnaire and informed consent/telephone interview
information sheet. Your response on the survey will be used to ﬁnding ways to improve
hospice interdisciplinary collaboration. After collecting data, we plan to share our
ﬁndings with you through the Michigan Hospice and Palliative Care Organization
website. The data from this study will not be connected to individual hospice agencies,
and participants will not be asked to name their hospice on the survey document. It is our
hope that the ﬁndings ﬁom the study will help your team and organization in
strengthening interdisciplinary collaboration.

If you have any concerns or questions regarding this study, please contact me at (517)
862-6015 or e-mail kobavas6@msu.edu.

Thank you in advance for your time and attention to this matter. Your assistance and
support in completing the survey are essential to the success of the study.

Rie Kobayashi, LMSW
254 Baker Hall
East Lansing, MI 48824 kobayas6@msu.edu

 

141

Appendix D:

Consent Form and Telephone Interview Information Sheet

Michigan State University

Interdisciplinary Collaboration: Factors that influence Collaborative Experiences
among Hospice Team Members

Consent Form
Dear Hospice Colleague:

You are being asked to participate in a research study of interdisciplinary collaboration in
a hospice setting. This study is being conducted in partnership with Michigan Hospice
and Palliative Care Organization. You have been selected as a possible participant in this
study to represent your hospice organization and profession of medicine, nursing,
spiritual care provider/counselor or social work in helping us deepen our understanding
of the processes and experiences of hospice interdisciplinary team collaboration. From
this study, we hope to learn factors that aid or hinder collaborative work. In the entire
study, approximately 480 hospice medical directors, nurses, spiritual care
providers/counselors and social workers in the state of Michigan are being asked to
participate. Your participation in the following survey questionnaire will take
approximately 18 minutes.

Enclosed is a survey questionnaire and an information sheet. If you choose to participate
in the study, please sign the consent form and begin the survey. We ask that you respond
to each question by choosing only one response. Once you complete the survey, place the
survey and the consent form in a self-addressed, stamped envelope enclosed and mail it
back to us. The information sheet needs to be completed only if you choose to participate
in a phone interview at a later date to answer ﬁve open-ended questions on your thoughts
and experiences about collaborative work in hospice. If you complete the information
sheet for a phone interview, you will be contacted to schedule an appointment. In order to
ensure the accuracy of the information, your phone interview will be recorded and later
transcribed verbatim. You indicate your voluntary agreement to participate by beginning
the phone interview. The phone interview will take about 15 minutes. After collecting
survey and phone interview data, we hope to share our ﬁndings with you through
Michigan Hospice and Palliative Care Organization website.

The potential beneﬁts to you for taking part in this study are an increased understanding
of interdisciplinary collaboration and an opportunity to compare your current
collaborative practice to the practice of other hospice team members and organizations in
Michigan. The potential risks of participating in this study may include distress or
discomfort from responding to sensitive questions.

142

The data for this project will be kept conﬁdential. The informed consent forms and
questionnaires for individual participants of the study will be ﬁled separately in locked
ﬁles in the researcher’s ofﬁce. The information sheet, recorded and transcribed phone
interviews will be ﬂied separately in locked ﬁles. The audio-taped phone interviews will
be destroyed upon the completion of transcription. Also, unique conﬁdential numbers
will be assigned to each returned questionnaire, and recorded and transcribed phone
interviews. Information about you will be kept conﬁdential to the maximum extent
allowable by law unless there is a danger to yourself or others. The researchers and
research staff and Institution Review Board at Michigan State University will have access
to the collected data. The Michigan Hospice and Palliative Care Organization will have
access to the ﬁndings of the data. The results of this study may be published or presented
at professional meetings, but the identity of all research participants will remain
anonymous.

Participation in this study is completely voluntary. You may choose not to answer
speciﬁc questions or to stop participating at any time. Choosing not to participate or
withdrawing ﬁom this study will not make any difference in beneﬁts to which you are
otherwise entitled. You will be told of any signiﬁcant ﬁndings that develop during the
course of the study that may inﬂuence your willingness to continue to participate in the
research. You will not receive money or any other form of compensation for participating
in this study.

If you have concerns or questions about this study such as how to do any part of it, please
contact Rie Kobayashi, LMSW at (517) 862-6015, e-mail kobavas6@msu.edu or regular
mail at 254 Baker Hall, East Lansing, MI 48824. You may also contact Gary Anderson,
Ph.D., Primary Investigator at gary.anderson@ssc.msu.edu.

If you have any questions or concerns about your role and rights as a research participant,
would like to obtain information or offer input, or would like to register a complaint
about this study, you may contact anonymously if you wish, the Michigan State
University’s Human Research Protection Program at (517) 355-2180, Fax (517) 432-
4503, or e-mail irb@msu.edu or regular mail at 202 Olds Hall, MSU, East Lansing, MI
48824.

143

Thank you for your participation in this study. If you choose to participate in a phone
interview in a later date, please complete the Telephone Interview Information Sheet
attached below. If you choose not to participate in the phone interview, you do not have
to complete the information sheet and please proceed with the questionnaire. Please feel
ﬂee to make a copy of this form for your record.

You indicate your voluntary agreement to participate in this study by returning the
attached survey.

Rie Kobayashi, LMSW, ABD
Michigan State University School of Social Work
254 Baker Hall, E. Lansing, MI 48823
lgobayas6@msu.edu
Telephone Interview Information Sheet
If you choose to participate in a phone interview, please provide contact information
below. A total of 20 professionals, ﬁve each from the disciplines of medicine, nursing,
spiritual care provider/counselor, and social work, will be randomly selected to
participate in the phone interviews.
Your name:
Occupation (circle one):
Medical Director
Nurse

Spiritual Care Provider/Counselor

Social Worker

Phone number: ( ) -

Preferred time of contact (circle one):

Day time (8am-5pm)

Evening (after 5pm)

In order to ensure the accuracy of the information you provide to us, your phone

interview will be audio-taped and then transcribed verbatim. Please respond to the
following statement and place your initial where indicated.

144

I agree to allow audio-taping of the phone interview.

Yes No Initials

 

Your signature below means that you voluntarily agree to participate in this phone
interview.

 

 

Signature Date
Thank you for choosing to participate in a phone interview. You will be contacted at a

later date to schedule an appointment. Please feel free to make a copy of this form for
your records.

145

Appendix E:
Follow Up E-mail Messages
Follow up E-mail Message 1

January 20, 2009

Dear Hospice Executive Director/Administrator:

Approximately three weeks ago I sent you a packet of information, containing four copies
of a survey questionnaire, informed consent/telephone interview information sheets, and
self—addressed, stamped envelopes. I asked that you disseminate a copy of these items to
one medical director, one nurse, one spiritual care provider/counselor, and one social
worker in your organization. I am e-mailing you today as follow up to ensure that you
have been able to disseminate these materials to your staff.

As stated in the initial letter, your support in disseminating the survey is essential to the
success of the study. I will be more than happy to send you additional copies of the
survey, and I am available to answer any questions or concerns relating to the study.

Thank you again for your time and assistance.

Rie Kobayashi, LMSW

Michigan State University School of Social Work
254 Baker Hall

E. Lansing, MI 48824

Kobayas6@msu.edu

146

Follow Up E-mail Message 2
February 9, 2009

Approximately ﬁve weeks ago I sent you a packet of information, containing four copies
of a survey questionnaire, informed consent and telephone interview information sheets,
and self-addressed, stamped envelopes. I asked that you disseminate a copy of these
items to one medical director, one nurse, one spiritual care provider/counselor, and one
social worker in your organization. If you have already disseminated the materials to your
staff, I thank you very much. I have been receiving returned surveys and entering data to
a statistical program. '

I am e-mailing you today to ask your help in encouraging your hospice staff to complete
and return the survey. Your staffs participation in the survey is essential to the success of
the study. I am attaching the survey today for your staff’s convenience. Instead of mailing
in a completed survey, they may fax it back to (517) 353-3038, attrr: Rie Kobayashi.
Please feel free to contact me for any questions or concerns.

Thank you again for your time and assistance with this survey.

Rie Kobayashi, LMSW

Michigan State University School of Social Work
254 Baker Hall

E. Lansing, MI 48823

kobayas6@msu.edu

147

Follow Up E-mail Message 3
February 28, 2009

Approximately eight weeks ago, I sent you a packet of information, containing four
copies of a survey questionnaire, informed consent and telephone interview information
sheets, and self-addressed, stamped envelopes. I asked that you disseminate a copy of
these items to one medical director, one nurse, one spiritual care provider/counselor, and
one social worker in your organization. If you have already disseminated the materials to
your staff and encouraged them to return the surveys, I thank you very much. I have been
receiving returned surveys and entering data to a statistical program.

I am e-mailing you today to ask your help again in encouraging your staff to complete
and return/fax the survey. Your staff’s participation in the survey is essential to the
success of the study. In the last e-mail, I attached the survey and provided a fax number
for submitting the survey. Again, I am more than happy to provide additional copies of
the survey or e-mail you the survey with a fax number.

Thank you very much for your time and attention to this matter.

Rie Kobayashi, LMSW

Michigan State University School of Social Work
254 Baker Hall

E. Lansing, MI 48823

kobayas6@gmsu.edu

148

Appendix F:
Survey Questionnaire

Hospice Interdisciplinary Team Survey

 

 

Directions: Please share some information about yourself and about the
hospice agency/organization where you currently work that might help us
better understand interdisciplinary collaboration. For each question, please
check the correct answer or fill in the blank where applicable.

 

Personal Demographics

1. What is your gender?
_Male
_Female

2. What is your age?
Under 30 years
31-40 years
41-50 years
51-60 years
Over 61 years.

3. What is your race/ethnicity? (Please check only one)
_Native American (American Indian/Alaska Native)
_African American/Black (Non-Hispanic)

_Asian or Paciﬁc Islander
_Hispanic/Latino
White Caucasian (Non-Hispanic)

_Other (Please specify)
4. What is your professional discipline?

If you a nurse, please check one:

 

_LPN _RN _BSN _MSN
_Other (Please specify)

Are you certiﬁed in palliative care/hospice? _Yes _No
If you are a physician, please check one:

_MD _DO

Are you certiﬁed in palliative care/hospice? _Yes _No

149

 

If you are a social worker, please check one:
_BSW MSW _Other (Please specify)

Are you certiﬁed in palliative care/hospice? _Yes _No

If you are a Spiritual care provider, please check one:

_MDiv _Other (please specify)

Are you certiﬁed in palliative care/hospice? _Yes _No
5. What is your employment status?

_Full-time (at least 36 hours per week)

_Part-time (less than 36 hours per week)

6. How may years have you been practicing in your current discipline?

_Less than 2 years _21-25 years
__2-5 years _26-30 years
_ -10 years _31-35 years
_11-15 years _36-40 years
_16-20 years _Over 40 years

7. How many years have you been practicing in your current agency?
_Less than 2 years _21-25 years
_2-5 years _26-30 years
__ -10 years _31-35 years
_11-15 years _36-40 years
_16-20 years _Over 40 years

8. How many years of hospice work experience do you have?
_Less than 2 years _21-25 years
_2-5 years _26-30 years
_ -10 years _31-35 years
_11-15 years _36-40 years
_16-20 years _Over 40 years

Agency/Organizational Characteristics

1. What is your hospice’s organizational status?
_Non-proﬁt
_For proﬁt
_Govemment-run

2. How long has your hospice organization been operating for?
_Less than 2 years
2-5 years
~10 years
1 1-15 years

150

_16-20 years
_Over 20 years

3. How many core members (physicians, nurses, social workers, spiritual
care providers/other counselors) does your hospice have?
_Less than 5 members
6-10 members
11-15 members
16-20 members
_21-25 members
_26-30 members
_Greater than 31 members

4. How many interdisciplinary teams does your hospice have?
_1 team 2-3 teams _4-5 teams _greater than 6

5. What is your hospice’s average daily census/patient loads?

_Less than 30 _71-90
_31-50 _91-110
_51-70 _Over 1 11
6. What is your hospice’s major geographic service area (Check all that
applies)?
_Rural _Urban _Suburb

Rural: Less than 2,500 people
Urban: At least 2,500 but less than 50,000 people
Suburb: Greater than 50,000 people

Professional Afﬁliation: (Please choose only one response for each
statement.)

1. I am strongly committed to the professional role at my agency.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

2. I am strongly committed to the values of my profession.
_Strongly Agree
_Agree

_Neither Agree nor Disagree
_Disagree

151

_Strongly Disagree
3. I strongly identify with my profession.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

Structural/Organizational Characteristics: (Please choose only one
response for each statement.)

1.

My organization provides physical space needed for interdisciplinary
collaboration.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

My organization provides communication resources such as a phone,
pager, and computer needed for interdisciplinary collaboration.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

My workday allows me time for interdisciplinary collaboration with other
team members.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

The administration at my organization supports interdisciplinary
collaboration.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

152

_Strongly Disagree

5. The administration at my organization expects interdisciplinary
collaboration.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

Personal Characteristics and Relationships with Others: (Please choose
only one response for each statement.)

1. I like the colleagues from other disciplines whom I work with on a team.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree '
_Strongly Disagree

2. My colleagues from other disciplines and I socialize outside of work.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

3. My colleagues from other disciplines and I trust each other.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

4. My colleagues from other disciplines understand my personal values and
perspective.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

153

History of Interdisciplinary Collaboration: (Please choose only one
response for each question/statement.)

1. My past experience with interdisciplinary collaboration has prepared me
well for my current collaboration with other disciplines.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

2. Have you ever had training in interdisciplinary collaboration?
_Yes _No (If you answer “No” to this question, skip to the next section).

3. My past training in interdisciplinary collaboration helps me in my current
collaborative work.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

Job Satisfaction: (Please choose only one response for each statement)
1. All in all, I am satisﬁed with my job.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

2. In general, I don’t like my job.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

154

3. In general, I like working here.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

Quality of Care Subscale (Please choose only one response for each
statement).

1. Having to report observations to the team helps team members better
understand the work of other health professionals.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

2. The team approach permits health professionals to meet the needs of
family caregivers as well as patients.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

3. Working on a team keeps most health professionals enthusiastic and
interested in their jobs.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

4. Health professionals working on teams are more responsive than others to
the emotional and ﬁnancial needs of patients.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

155

_Strongly Disagree

. Patients receiving team care are more likely than other patients to be
treated as whole persons.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

. Team meetings foster communication among team members from
different disciplines.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

. The team approach makes the delivery of care more efﬁcient.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

. Developing a patient care plan with other members avoids errors in
delivering care.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

. The give and take among team members helps them make better patient
care decisions.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

156

10.The team approach improves the quality of care to patients.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

Modiﬁed Index of Interdisciplinary Collaboration (Please choose only one
response for each statement).

1. l utilize other professionals in different disciplines for their particular
expertise.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

2. I consistently give feedback to other professionals in my setting.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

3. Professionals in different disciplines in my setting utilize me for a range of
tasks.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

4. Teamwork with professionals from other disciplines is not important in my
ability to help clients.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

157

. The colleagues from other professional disciplines and I rarely
communicate.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

. The colleagues from other disciplines with whom I work have a good
understanding of the distinction between my role and their role(s).

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

. My colleagues from other disciplines make inappropriate referrals to me.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

. I can deﬁne those areas that distinct in professional role from that of
professionals from other disciplines with whom I work.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

. | view part of my professional role as supporting the role of others with
whom I work.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

158

10. My colleagues from other disciplines refer to me often.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

11.Cooperative work with colleagues from other disciplines is not a part of my
job description.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

12. My colleagues from other professional disciplines do not treat me as an
equal

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

13. My colleagues from other disciplines believe that they could not do their
jobs as well without my professional discipline.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

14. Distinct new programs emerge from the collective work of colleagues from
different disciplines.

_Strongly Agree

_Agree

__Neither Agree nor Disagree
_Disagree

_Strongly Disagree

159

15. Organizational protocols reﬂect the existence of cooperation between
professionals from different disciplines.

_Strongly Agree

_Agree

__Neither Agree nor Disagree
_Disagree

_Strongly Disagree

16. Formal procedures/mechanisms exist for facilitating dialogue between
professionals from different disciplines (ie, at stafﬁngs, inservice, rounds,
etc).

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

17.l am not aware of situations in my agency in which a coalition, task force,
or committee has developed out of interdisciplinary effort.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

18.Work with colleagues form other disciplines leads to outcomes that we
could not achieve alone.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

19. Creative outcomes emerge from my work with colleagues from other
professions that I could not have predicted.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

160

20.l am willing to take on tasks outside of my job description when that
seems important.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

21 .I am not willing to sacriﬁce a degree of autonomy to support cooperative
problem solving.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

22.l utilize formal and informal procedures for problem-solving with my
colleagues form other disciplines.

_Strongly Agree

_Agree '
_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

23.The professional colleagues from other disciplines with whom I work stick
rigidly to their job descriptions.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

24. Colleagues from other disciplines and I work together in many different
ways.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

161

25. Professionals from other disciplines with whom I work encourage family
members’ participation in the treatment process.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

26. My colleagues from other disciplines are not committed to working
together.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

27. My colleagues from other disciplines work through conﬂicts with me in
efforts to resolve them.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

28.When colleagues from other disciplines make decisions together they go
through a process of examining alternatives.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

__Strongly Disagree

29. My interactions with colleagues from other disciplines occur in a climate
where there is freedom to be different and to disagree.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

162

30. Clients/patients/students participate in interdisciplinary planning that
concerns them.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

31 . Colleagues from all professional disciplines take responsibility for
developing treatment plans.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

32. Colleagues from all professional disciplines do not participate in
implementing treatment plans.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

33. Professionals from different disciplines are straightforward when sharing
information with clients/patients/students.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

34. My colleagues from other disciplines and I often discuss different
strategies to improve our working relationships.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

163

35. My colleagues from other professions and I talk about ways to involve
other professionals in our work together.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

36. Colleagues from other disciplines do not attempt to create a positive
climate in our organization.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

37.l am optimistic about the ability of my colleagues from other disciplines
to work with me to resolve problems.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

38.| help my colleagues to address conﬂict with other professionals directly.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

39. Colleagues from other disciplines are as likely as I am to address
obstacles to our successful collaboration.

_Strongly Agree

_Agree

__Neither Agree nor Disagree
_Disagree

_Strongly Disagree

164

40. My colleagues from other disciplines and I talk together about our
professional similarities and differences including role, competencies,
and stereotypes.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

41 . My colleagues from other professionals and I do not evaluate our work
together.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

42.l discuss with professionals from other disciplines the degree to which
each of us should be involved in a particular case.

_Strongly Agree

_Agree

_Neither Agree nor Disagree
_Disagree

_Strongly Disagree

165

Appendix G:

Telephone Interview Script
Telephone Interview Script
1. Introduction
My name is Rie Kobayashi. I am a Ph.D student at Michigan State University.
I am calling you today to conduct a phone interview. What I will be asking you involve 4
demographic and your hospice organizational questions, followed by 6 open-ended
questions about your thoughts on hospice interdisciplinary team, teamwork, and your
contribution to the team. The interview will take about 15 minutes.
I know that you have given written informed consent to participate in a phone interview
when you completed the survey. As indicated in the consent form, our interview will be
audio-taped in order to assure the accuracy of data analysis later on. Your identity will be
protected.

Do you have any questions or concerns at this point?

I want to make sure that you are still comfortable with participating in a phone interview
and you are giving me verbal consent to proceed with the questions.

2. Interview

I have four demographic and your hospice organizational questions.
First, what is your professional discipline?

How long have you been a “ .......... ”?

How long have you worked for your current hospice agency?

Does your hospice agency serve a mainly rural or urban area?

Now, I would like to start asking you following 6 open-ended questions.

Who do you consider to be members of your hospice interdisciplinary team?
What is the biggest strength of your hospice team?

What poses as the biggest barrier in your hospice interdisciplinary team work?
What professional qualities do you bring to your team in assisting your clients?
In what ways does your agency evaluate team effectiveness, if there is any?

Is there anything about your hospice teamwork we did not cover that you would
like to share?

99??!"2"

166

3. Ending the interview

I have asked all the questions that I needed to ask for the interview. Thank you for taking
the time to participate in the interview. If you have any questions about the interview or
my study, please feel free to contact me at 24 Baker Hall, E.Lansing, MI 48823. My
phone number is 517-862-6015. Thank you again for your assistance with this study.

167

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168

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