Interdisciplinary teams in palliative care: a critical reflection

Psychosocial intervention in palliative care: What do psychologists need to know

Emotional and existential suffering is prevalent in advanced diseases and psychologists have valuable skills to support people in this time of life. Yet, psychologists are rarely integrated in palliative care and relevant training is sparse. Being integrated in other areas of health, it is likely that we will be supporting these patients, whether integrated in a specialized team or not. This article is meant to serve psychologists, already skilled in the art and science of psychosocial intervention, who may find themselves supporting patients with advanced disease. Relevant history of palliative care is provided to elucidate palliative philosophy and approach. Evidence-based existential interventions will be reviewed. Integration of psychological models and both palliative theory and practice is provided to support palliative-appropriate case conceptualizations. Finally, case examples are provided throughout to help readers reconcile their existing practice in this domain of care.

Students' learning in theory-based simulation: A socio-material study

BACKGROUND

Simulation-based education (SBE) is crucial to prepare nursing students prior to their clinical learning experience. Theory-based simulation learning is increasingly important for analysing how students learn. This study describes and analyses how nursing students learn through simulation in the context of palliative care communication under a socio-material approach and explores the transfer of their knowledge and skills from simulation to clinical practice.

METHODS

Twenty-seven final-year nursing students in six groups participated in two simulated scenarios, followed by a debriefing and post-clinical focus groups to capture their reflections and learning. Fourteen of them joined the post-clinical focus groups after completing their clinical placements. Video recordings of the simulation, and the audio recordings from the debriefing, and post-clinical focus groups were transcribed and coded based on the human and non-human elements that were observed. These were triangulated with data collected through team participant observations, an analysis of the existing syllabi and curriculum, and a participant mapping exercise after the simulation. These various data sources illustrate how student learning and reflections took place.

RESULTS

The three themes of student learning derived from the results and analysis were (1) students' expanded learning of health care communication through a socio-material approach in the context of palliative care; 2) students' discovery of the diverse and complex relations and interactions between humans and materials and (3) students' new perspectives on health care communication and the transfer of knowledge and skills through a socio-material approach in clinical practice.

CONCLUSIONS

This study highlights how SBE can be further expanded using a socio-material approach to prepare students to learn beyond standardised and cognitively driven approaches and procedures. Student learning demonstrates that SBE may develop beyond high fidelity and standardisation to leave room for emergent learning and increased awareness in learning for students and teachers to optimise learning outcomes and competence.

A Qualitative Study of Stakeholders' Perspectives of Implementing Interprofessional Shared Decision-Making Education in Palliative Care

Introduction Shared decision-making (SDM) in palliative care is a highly complex process that requires an interdisciplinary team. Interprofessional team members need education on how to facilitate discussion of patient/family wishes at the end of life in hospital settings. So far, interprofessional shared decision-making (IP-SDM) education frameworks have been used to a limited extent in the area of education on palliative care. The aim of this study was to explore policymakers', health professionals', faculty members', and students' perspectives on implementing an IP-SDM educational framework in palliative care to identify aspects that should be prioritized to further develop interprofessional education for SDM in palliative care. Methods We used the qualitative method to capture the micro, meso, and macro factors using Oandasan and Reeves' model for the implementation of IP-SDM education regarding palliative care. Data collection tools included in-depth, face-to-face interviews with individual policymakers and focus group interviews with health professionals, faculty members, and undergraduate health professionals. The interview guide explores the teaching of SDM in palliative care, factors that could facilitate or hinder the implementation of IP-SDM education for health professions students in palliative care, and interventions to facilitate the implementation of this approach. This study was conducted at the Oncology and Palliative Care Department at King Abdulaziz Medical City in the Ministry of National Guard Health Affairs and at King Saud bin Abdulaziz University for Health Sciences in Jeddah, Saudi Arabia. Results The results indicated a high demand for IP-SDM in palliative care. The findings revealed factors that can facilitate or hinder the implementation of IP-SDM education in palliative care for undergraduate health professions students that is going to the local community. Factors include culture, religion, gender, power issues, team hierarchy, and respect among team members. Also, our findings have revealed potential solutions to the hindering factors. Conclusions IP-SDM education in palliative care is a highly relevant topic for improving patient outcomes. However, it might be a complex process to implement, especially given the challenges of palliative care settings. We recommend starting such a course in the early clinical phases of undergraduate health professional education.

A Statement on the Role and Qualifications of Health Care Chaplains for Research and Quality

CONTEXT

This statement fills a significant gap in the efforts to demonstrate outcomes of the chaplaincy role in health care and to provide direction for quality measurement related to spiritual care as a key domain of serious illness care.

OBJECTIVES

The objective of this project was to develop the first major consensus statement on the role and qualifications of health care chaplains in the Unites States.

METHODS

The statement was developed by a diverse panel of highly regarded professional chaplains and nonchaplain stakeholders.

RESULTS

The document provides guidance to chaplains and other spiritual care stakeholders as they further integrate spiritual care in health care and conduct research and quality improvement efforts to strengthen the evidence base for practice. The consensus statement is in Fig. 1 and available at https://www.spiritualcareassociation.org/role-of-the-chaplain-guidance.html.

CONCLUSION

This statement can potentially drive the standardization and alignment of all phases of health care chaplaincy preparation and practice.

Occupational Therapy Practice in Palliative and End-of-Life Care in Québec

Background. There is an emerging evidence base about the scope of occupational therapy in palliative and end-of-life care, but little is known about this practice in Québec or barriers impeding it. Purpose. To describe Québec occupational therapists’ practice in palliative and end-of-life care and barriers they encounter. Method. Using the Québec regulatory board members list, we invited occupational therapists working in palliative and end-of-life care to answer an online survey comprising 24 closed- and 5 open-ended questions. We analyzed data using descriptive statistics and content analysis. Findings. The 67 survey participants mainly optimized comfort and safety in meaningful occupations such as mobility, transfers, and hygiene. Barriers to their practice included organizational obstacles and unfamiliarity with their role. Implications. Findings highlight the need to improve education and awareness among occupational therapists and other healthcare professionals about the scope of what occupational therapists can do in palliative and end-of-life care.

A National Survey of Palliative Care Team Compositions

Objective: It is unclear how well palliative care teams are staffed at US cancer centers. Our primary objective was to compare the composition of palliative care teams between National Cancer Institute (NCI)-designated cancer centers and non-NCI-designated cancer centers in 2018. We also assessed changes in team composition between 2009 and 2018. Methods: This national survey examined the team composition in palliative care programs at all 61 NCI-designated cancer centers and in a random sample of 60 of 1252 non-NCI-designated cancer centers in 2018. Responses were compared to those from our 2009 survey. The primary outcome was the presence of an interprofessional team defined as a palliative care physician, nurse, and psychosocial member. Secondary outcomes were the size and number of individual disciplines. Results: In 2018, 52/61 (85%) of NCI-designated and 27/38 (71%) non-NCI-designated cancer centers in the primary outcome comparison responded to the survey. NCI-designated cancer centers were more likely to have interprofessional teams than non-NCI-designated cancer centers (92% vs 67%; P = .009). Non-NCI-designated cancer centers were more likely to have nurse-led teams (14.8% vs 0.0%; P = .01). The median number of disciplines did not differ between groups (NCI, 6.0; non-NCI, 5.0; P = .08). Between 2009 and 2018, NCI-designated and non-NCI-designated cancer centers saw increased proportions of centers with interprofessional teams (NCI, 64.9% vs 92.0%, P < .001; non-NCI, 40.0% vs 66.7%; P = .047). Conclusion: NCI-designated cancer centers were more likely to report having an interprofessional palliative care team than non-NCI-designated cancer centers. Growth has been limited over the past decade, particularly at non-NCI-designated cancer centers.

Multidisciplinary Software Design for the Routine Monitoring and Assessment of Pain in Palliative Care Services: The Development of PainCheck

PURPOSE

The use of health information technology (HIT) to support patient and health professional communication is emerging as a core component of modern cancer care. Approaches to HIT development for cancer care are often underreported, despite their implementation in complex, multidisciplinary environments, typically supporting patients with multifaceted needs. We describe the development and evaluation of an e-health tool for pain management in patients with advanced cancer, arising from collaboration between health researchers and a commercial software development company.

METHODS

We adopted a research-led development process, involving patients with advanced cancer and their health professionals, focusing on use within real clinical settings. A software development approach (disciplined agile delivery) was combined with health science research methods (ie, diary studies, face-to-face interviews, questionnaires, prototyping, think aloud, process reviews, and pilots). Three software iterations were managed through three disciplined agile delivery phases to develop PainCheck and prepare it for use in a clinical trial.

RESULTS

Findings from development phases (inception, elaboration, and construction) informed the design and implementation of PainCheck. During the transition phase, where PainCheck was evaluated in a randomized clinical trial, there was variation in the extent of engagement by patients and health professionals. Prior personal experience and confidence with HIT led to a gatekeeping effect among health professionals, who were reluctant to introduce PainCheck to patients. Patients who did use PainCheck seemed to benefit, and no usability issues were reported.

CONCLUSION

Health science research methods seemed to help in the development of PainCheck, although a more rigorous application of implementation science methodologies might help to elucidate further the barriers and facilitators to adoption and inform an evidence-based plan for future implementation.

Stakeholder Perspectives on the Biopsychosocial and Spiritual Realities of Living With ALS: Implications for Palliative Care Teams

CONTEXT

Amyotrophic lateral sclerosis (ALS) is an all-encompassing, life-limiting disease, resulting in the eventual paralysis of all voluntary muscles and concurrent loss of independence. As the disease advances, both patients and their family caregivers develop complex biological, psychological, and social needs, leading to increasing calls for the involvement of palliative care teams in the management of ALS.

OBJECTIVE

The purpose of this study was to generate a rich description of the realities of living with ALS, equipping palliative care teams with an in-depth understanding of the experiences and needs of patients with ALS and their family caregivers.

METHODS

This study employed a mixed-methods design, with quantitative data supplementing a larger body of qualitative data. Semi-structured interviews with 42 key stakeholders, including patients, family caregivers, and health-care providers, were analyzed for themes essential for effective understanding of ALS.

RESULTS

Identified themes were organized into 2 broad categories: (1) biopsychosocial needs of patients with ALS and family caregivers and (2) the impact of ALS on spiritual and emotional well-being. Quantitative data supported the recognized themes, particularly with regard to challenges associated with preserving independence, securing sufficient social support, and managing the emotional complexities of the disease.

CONCLUSION

Study findings illustrate the intricacies of living with ALS and the importance of eliciting individualized values when caring for patients with ALS and their families. The complex biopsychosocial needs experienced by patients and family caregivers suggest numerous opportunities for meaningful palliative care involvement.

Insights and experiences of chaplain interns and social work interns on palliative care teams

Interdisciplinary palliative care teams provide critical, comprehensive end-of-life care, although the accumulated literature points toward barriers that impede their effectiveness. The current phenomenological qualitative study presents perceptions of chaplaincy interns (N = 24) and social work interns (N = 23) after a semester-long end-of-life clinical training experience with interdisciplinary palliative care teams. Analysis of the end of semester reflections resulted in seven themes, which are fairly consistent with the literature base. The described experiential learning and reflections in the current study are powerful and can inform how to prepare practitioners for teamwork and compassionate end-of-life care.

Interprofessional Silence at the End of Life: Do Swiss General Practitioners and Hospital Physicians Sufficiently Share Information About Their Patients?

BACKGROUND

Empirical research suggests that the quality of patient care at the end of life (EOL) is influenced by the effectiveness of the collaboration between the general practitioners (GPs) and hospital physicians (HPs).

AIM

To identify possible difficulties and barriers to effective collaboration at the EOL between GPs and HPs from the perspective of Swiss GPs.

DESIGN

Twenty-three qualitative semi-structured interviews with GPs were transcribed and analyzed using Mayring's content analysis. Interdisciplinary clinical-ethical analysis focused on the quality of GP and HP professional collaboration.

RESULTS

GPs described the quality of collaboration with HPs as poor, in particular the lack of communication. There were two main issues to emerge. First, infrequent communication with HPs could negatively affect the care of the patient. Second, GPs were concerned with the lack of information about hospital care and involvement in medical decision making given their longstanding relationships with their patients.

CONCLUSIONS

The research showed that Swiss GPs were concerned with the quality of their patients' EOL care and the current level of GP/HP collaboration. GPs appealed for greater involvement with EOL care decisions based on their relationship of care and knowledge of patient preferences. These findings require further critical evaluation to explore the potential advantages for patient care. Existing evidence suggests that there are measurable health benefits from successful GP/HP collaborations. A change in the way GPs maintain involvement with their patients during hospitalizations would be warranted if it resulted in a better use of resources, better patient experiences, and better health outcomes.

Professional identity at stake: a phenomenological analysis of spiritual counselors' experiences working with a structured model to provide care to palliative cancer patients

Background

Good palliative care requires excellent interprofessional collaboration; however, working in interprofessional teams may be challenging and difficult.

Aim

The aim of the study is to understand the lived experience of spiritual counselors working with a new structured method in offering spiritual care to palliative patients in relation to a multidisciplinary health care team.

Design

Interpretive phenomenological analysis of in-depth interviews, was done using template analysis to structure the data. We included nine spiritual counselors who are trained in using the new structured method to provide spiritual care for advanced cancer patients.

Results

Although the spiritual counselors were experiencing struggles with structure and iPad, they were immediately willing to work with the new structured method as they expected the visibility and professionalization of their profession to improve. In this process, they experienced a need to adapt to a certain role while working with the new method and described how the identities of the profession were challenged.

Conclusions

There is a need to concretize, professionalize, and substantiate the work of spiritual counselors in a health care setting, to enhance visibility for patients and improve interprofessional collaboration with other health care workers. However, introducing new methods to spiritual counselors is not easy, as this may challenge or jeopardize their current professional identities. Therefore, we recommend to engage spiritual counselors early in processes of change to ensure that the core of who they are as professionals remains reflected in their work.

Negotiating the equivocality of palliative care: a grounded theory of team communicative processes in inpatient medicine

In the majority of U.S. hospitals, inpatient medicine teams make palliative care decisions in the absence of a formalized palliative system. Using a grounded theory approach, interviews with inpatient team members were systematically analyzed to uncover how participants conceptualize palliative care and how they regard the communicative structures that underlie its delivery. During analysis, Weick's model of organizing emerged as a framework that fit the data. The 39 participant inpatient team members discussed palliative care as primarily a communicative process. Themes describing the meaning of palliative care emerged around the concepts of receiver of care, timeline of care, and location of care. The emerging model included four stages in the communicative processes of inpatient palliative care: (a) interpret the need, (b) initiate the conversation, (c) integrate the processes, and (d) identify what works. In contrast to stable, focused palliative care teams or hospice care teams, which have prescribed patient populations and processes, the inpatient medicine team faces the equivocality of providing palliative care within a broader practice. This research offers a four-phase model to show how these inpatient teams communicate within this context. Implications for the provision of palliative care are discussed.

"Oh, yeah, I'm getting closer to god": spirituality and religiousness of family caregivers of cancer patients undergoing palliative care

PURPOSE

Within the cancer palliative care setting, where both patients and family caregivers (FCs) undergo a transition from the end of curative treatment to palliative therapy, spirituality and religiousness (S/R) may be a strategy to help the patients and FCs better cope with the disease, in addition to exerting a positive impact on symptoms, particularly emotional symptoms. The present study aimed to understand how S/R influence FCs of cancer patients undergoing palliative care.

METHODS

This study was an exploratory and descriptive qualitative study. The qualitative approach to the data was based on Bardin's content analysis technique. The consolidated criteria for reporting qualitative research (COREQ-32) was used in the description of the results. Thirty FCs of individuals with advanced cancer undergoing palliative care were included.

RESULTS

Analysis of the FCs' narratives indicated that the FCs considered that religiousness and faith in God or a Supreme Being provide them with the strength to cope with the suffering associated with the care of relatives with advanced cancer. Many FCs emphasized that talking about God was somehow comforting and made them feel at peace with themselves. Four categories were identified in the FCs' narratives: (1) increase in faith and closeness to God becomes stronger, (2) rethink life issues, (3) negative interference in the extrinsic religiosity, and (4) quest for religiousness to gain strength or support. A conceptual framework was developed.

CONCLUSIONS

The results of the present study indicated that S/R are a coping strategy frequently used by FCs of individuals with advanced cancer. The perceptions of the FCs interviewed in the present study corresponded to the four distinct categories related to spirituality and religiousness.

A Prospective Study of the Clinical Content of Palliative Medicine Interdisciplinary Team Meetings

Structured interprofessional communication should improve the structure and clarity of the plan of care. The interdisciplinary team meeting (IDTM) is an opportunity for shared information on patients’ and family care needs. We report a prospective observations study of palliative medicine IDTM, which recorded the clinical issues discussed. One hundred and forty-five disparate clinical items were identified for 59 patients and were discussed by the IDTM in about 240 minutes. By content analysis and research meeting consensus, they were grouped into 9 agreed interdisciplinary themes. The 9 themes were then subjected to biostatistical analysis and 3 communication clusters identified. Themes consisted of 3 major communication clusters: (1) clinical services, (2) psychosocial, and (3) care plan. Two themes (information exchange and clinical transitions) did not cluster. The IDTM identified patient care need, reported concerns, and supported collaboration in proactive patient care plans. Future research projects with more patients and a large number of meetings can confirm our findings. This should also examine specific contributions by professional discipline.

The entry-level physical therapist: a case for COMFORT communication training

Entry-level physical therapists provide clinical care for patients with functional mobility limitations. Their care spans the continuum of settings, disease processes, and diagnoses. Although effective communication skills are required to conduct physical therapy work, there is limited instruction provided in physical therapy education and students receive little exposure to seriously or chronically ill patients. The goal of this study was to assess the effects of communication training for the entry-level physical therapist facing palliative and end-of-life communication with patients/families. A pre-post survey design and narrative writing were used to assess the effect of the COMFORT communication training curriculum provided to doctorally trained, graduating physical therapists. The study demonstrated decreased student apprehension about communicating with dying patients and their families, and a comparison of mean scores reflecting the students' communication knowledge, confidence, and behaviors increased in a positive direction. As students became more willing to communicate, they were also more adept at integrating task and relational messages, as well as assimilating emotional support messages for patients and families. This study shows promise for the feasibility and utilization of the COMFORT curriculum for entry-level physical therapists. Further research should address the integration of COMFORT earlier into physical therapy education, as well as assess evidence of COMFORT communication skills in the clinical context.

Till death do us part: getting married at the end of life

At the end of life, patients often reflect on the meaning of their lives and decide how to best take advantage of the remaining time to accomplish their life goals. We report the case of a patient with advanced cancer who got married in our acute palliative care unit weeks before her death. Our interdisciplinary team was able to support her physically and emotionally, thereby assisting her in achieving her life goals. The wedding gave her the opportunity to acquire further meaning in life, deepen her connection with her loved ones, and enhance her sense of dignity, self-worth, and pride. It also was associated with a significant improvement in her symptoms and had a positive effect on the health care team. This example illustrates the effectiveness of a palliative care team in helping patients to achieve their life goals and supporting their families during a time when two major life events, marriage and end of life, occur concurrently.

Tolstoy, stories, and facilitating insight in end of life care: exploring ethics through vicarious experience

Facilitating moral insight in end of life care can be challenging, and the purpose of this paper is to illustrate how this can be nurtured by means of creative literature. Tolstoy's Death of Ivan Ilych is presented as an example of such literature. Aristotle's Nichomean Ethics provides the philosophical underpinning for the method used. Sources also include the nursing literature, and students' evaluations of the impact of Tolstoy's novella on their ability to perceive the ethical issues arising in end of life care. Comments from evaluations were analysed and significant themes emerged. Students' comments clearly support the suggestion that use of this novella has facilitated insight into ethical issues at the end of life. Evaluations also indicate that vicarious experience gained through reading this novella has helped to nurture sensitivity and professional insight into the importance of compassion and offering 'comfort' to the dying person.

The palliative care interdisciplinary team: where is the community pharmacist?

Palliative care emphasizes an interdisciplinary approach to care to improve quality of life and relieve symptoms. Palliative care is provided in many ways; in hospices, hospital units, and the community. However, the greatest proportion of palliative care is in the community. In hospice and palliative care units in hospitals, clinical pharmacists are part of the interdisciplinary team and work closely with other health care professionals. Their expertise in the therapeutic use of medications is highly regarded, particularly as many palliative care patients have complex medication regimens, involving off-label or off-license prescribing that increases their risk for drug-related problems. However, this active involvement in the palliative care team is not reflected in the community setting, despite the community pharmacist being one of the most accessible professionals in the community, and visiting a community pharmacist is convenient for most people, even those who have limited access to private or public transport. This may be due to a general lack of understanding of skills and knowledge that particular health professionals bring to the interdisciplinary team, a lack of rigorous research supporting the necessity for the community pharmacist's involvement in the team, or it could be due to professional tensions. If these barriers can be overcome, community pharmacists are well positioned to become active members of the community palliative care interdisciplinary team and respond to the palliative care needs of patients with whom they often have a primary relationship.

Palliative care curriculum for speech-language pathology students

This paper reports on the experience of undergraduate speech-language pathology students at one university chosen for the implementation stage of the Palliative Care Curriculum for Undergraduates (PCC4U) Project. Funded by a government department for health and ageing through a national palliative care programme, the project was managed by a team of researchers from the discipline of nursing. The PCC4U project championed the inclusion of palliative care education as an integral part of medical, nursing, and allied healthcare undergraduate training. Of the pilot sites chosen for the PCC4U project, only one site, reported here, included both speech-language pathology and social work disciplines, providing an important opportunity for interdisciplinary collaboration on novel curriculum development in an area of mutual interest. This synergy served as an excellent foundation for ongoing opportunities for interdisciplinary teaching and learning in the university. Speech-language pathology students reported that the project was an invaluable addition to their education and preparation for clinical practice.

Community nurses' perceptions of a good death: a qualitative exploratory study

AIMS

This study sought to gain an insight into perceptions of a 'good death' among community nurses, and to identify its central components. By understanding these factors, it was hoped that common difficulties could be identified, enabling recommendations to be made to enhance patient care and reduce the pressures to which nurses are exposed.

METHOD AND SAMPLE

This qualitative exploratory study relied on semi-structured interviews, incorporating the critical incident technique to elicit retrospective accounts of experiences of palliative care and a good death. Data was obtained from a purposive sample of 17 community nurses, working in a single primary care trust in south-east England.

RESULTS

The participants identified eight key themes in supporting a good death: symptom control, patient choice, honesty, spirituality, interprofessional relationships, effective preparation and organization and provision of seamless care. When these are in place, a good death is possible. Factors such as lack of necessary medication/resources, unsuccessful interprofessional relationships and lack of teamwork were significant determinants of less successful care. The provision of seamless care was an important criterion for success.

CONCLUSIONS

In identifying the contributory factors, this study has shown that a good death can be provided in the community, although it has also revealed many challenges associated with such care. While it could be argued that due to the unpredictability of death, such challenges may always be a threat to effective care anticipatory planning and a recognition that patients need and are entitled to specialist care many of these difficulties could be overcome.

Interdisciplinary geriatric and palliative care team narratives: collaboration practices and barriers

Despite the development and implementation of team training models in geriatrics and palliative care, little attention has been paid to the nature and process of teamwork. Geriatrics and palliative care in the clinical setting offer an interdisciplinary approach structured to meet the comprehensive needs of a patient and his or her family. Fellowship members of an interdisciplinary geriatric and palliative care team participated in semistructured interviews. Team members represented social work, chaplaincy, psychology, nursing, and medicine. A functional narrative analysis revealed four themes: voice of the lifeworld, caregiver teamwork, alone on a team, and storying disciplinary communication. The content-ordering function of narratives revealed a divergence in team members' conceptualization of teamwork and team effectiveness, and group ordering of narratives documented the collaborative nature of teams. The study findings demonstrate the potential for narratives as a pedagogical tool in team training, highlighting the benefits of reflective practice for improving teamwork and sustainability.

An interdisciplinary team communication framework and its application to healthcare 'e-teams' systems design

BACKGROUND

There are few studies that examine the processes that interdisciplinary teams engage in and how we can design health information systems (HIS) to support those team processes. This was an exploratory study with two purposes: (1) To develop a framework for interdisciplinary team communication based on structures, processes and outcomes that were identified as having occurred during weekly team meetings. (2) To use the framework to guide 'e-teams' HIS design to support interdisciplinary team meeting communication.

METHODS

An ethnographic approach was used to collect data on two interdisciplinary teams. Qualitative content analysis was used to analyze the data according to structures, processes and outcomes.

RESULTS

We present details for team meta-concepts of structures, processes and outcomes and the concepts and sub concepts within each meta-concept. We also provide an exploratory framework for interdisciplinary team communication and describe how the framework can guide HIS design to support 'e-teams'.

CONCLUSION

The structures, processes and outcomes that describe interdisciplinary teams are complex and often occur in a non-linear fashion. Electronic data support, process facilitation and team video conferencing are three HIS tools that can enhance team function.