Moving Toward Improved Teamwork in Cancer Care: The Role of Psychological Safety in Team Communication.

Special Series: NCI-ASCO Teams

ORIGINAL CONTRIBUTION

Moving Toward Improved Teamwork in Cancer Care: The Role of Psychological Safety in Team Communication Anshu K. Jain, MD, Mary L. Fennell, PhD, Anees B. Chagpar, MD, Hannah K. Connolly, MA, and Ingrid M. Nembhard, PhD

Ashland Bellefonte Cancer Center, Ashland, KY; Yale University, New Haven, CT; Brown University, Providence, RI; and HK Communications, San Francisco, CA

ASSOCIATED CONTENT Appendix DOI: 10.1200/JOP.2016. 013300 DOI: 10.1200/JOP.2016.013300; published online ahead of print at jop.ascopubs.org on October 18, 2016.

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Abstract Effective communication is a requirement in the teamwork necessary for improved coordination to deliver patient-centered, value-based cancer care. Communication is particularly important when care providers are geographically distributed or work across organizations. We review organizational and teams research on communication to highlight psychological safety as a key determinant of high-quality communication within teams. We first present the concept of psychological safety, findings about its communication effects for teamwork, and factors that affect it. We focus on five factors applicable to cancer care delivery: familiarity, clinical hierarchy–related status differences, geographic dispersion, boundary spanning, and leader behavior. To illustrate how these factors facilitate or hinder psychologically safe communication and teamwork in cancer care, we review the case of a patient as she experiences the treatment-planning process for early-stage breast cancer in a community setting. Our analysis is summarized in a key principle: Teamwork in cancer care requires high-quality communication, which depends on psychological safety for all team members, clinicians and patients alike. We conclude with a discussion of the implications of psychological safety in clinical care and suggestions for future research.

INTRODUCTION Cancer care presents numerous challenges for delivery of team-based care. Patients with cancer typically receive care from multiple, diverse specialists as well as numerous ancillary care professionals. Additionally, a majority patients with cancer receive care in community settings, where providers are often geographically distributed.1 Each provider brings expertise that must be integrated not just among providers but also with the patient’s knowledge of self, circumstances, and preferences for coordinated, patient-centered care. In a recent

account, a patient with cancer and his primary care provider interacted with 11 other providers in the first 80 days after diagnosis; the primary care provider alone had 52 communications with other care providers and the patient during this time in efforts to coordinate care.2 The imperative for integrated and coordinated cancer care has become a national priority, given the number of patients living with cancer (14.5 million)3 and evidence indicating that coordinated care improves quality of care and minimizes costs (predicted to rise above $170 billion for cancer care by 2020).4

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Improving Communication in Cancer Care via Psychological Safety

Communication is a critical process for coordination among providers and patients.5 Effective communication is a function of several factors classified primarily into three categories: personal and interpersonal factors, team structure and process factors, and macroenvironmental factors (Table 1).7,33,35,36 When effective, communication exchanges are timely, clear, open, accurate, and relevant.37-42 Extensive research inside and outside of health care finds that effective communication is positively associated with better individual, team, and organizational performance.43 In health care, studies have linked communication to improved coordination, outcomes, patient and clinician satisfaction, learning, and performance improvement.44,45 In this article, we aim to advance understanding of effective communication in cancer care by examining a key personal/ interpersonal factor for communication: psychological safety. We focus on psychological safety because a growing body of research on organizations and teams suggests that it is a critical starting ingredient for effective communication and teamwork. We present the concept of psychological safety, findings about its communication effects for teamwork, and factors that affect it. Using a patient case, we demonstrate its effects on communication in the course of care. We conclude with implications of our analysis for clinical care and research. Our intent is to provide insights that promote understanding about communication in patient-centered oncology practice, efforts to improve it, and motivation for continued research. CASE SUMMARY The patient is a 37-year-old premenopausal woman with a history of miscarriages who recently noticed a left breast lump. She has one child with her husband and comes from a cultural background that values high fertility. She and her husband previously wished to have more children, but after multiple miscarriages over the preceding few years, they have mostly given up. She visits her primary care physician for assessment of the lump, undergoes a biopsy, and receives a diagnosis of early-stage breast cancer. She pursues care in her community. The patient and her husband see a nurse navigator at her local hospital. The navigator performs an intake assessment, reviews her medical history, and begins discussing options for fertility preservation. The patient, feeling anxious about her recent diagnosis, becomes uneasy and states that she does not wish to preserve fertility. However, she tells her husband privately that she is unsure about how she feels and is not

comfortable discussing something so sensitive with the navigator whom she just met. One day later, the hospital tumor board convenes to review her case. A physician from a satellite location an hour away attends. He comes infrequently and has limited working relationships with other tumor board members. He does not hear the radiologist’s review of ultrasound findings. He refrains from asking to review the ultrasound again, not wanting to delay the group and reveal that he missed important information. The senior surgeon recommends that the patient undergo a lumpectomy. A rotating surgical resident remembers a recently published article describing lower reexcision rates using a refined lumpectomy technique. At a previous tumor board, he had made a recommendation that was rejected by the group and in a particularly dismissive fashion by the senior surgeon. Remembering his feeling of embarrassment, the resident does not mention the new technique to the group. The patient navigator, recalling a discussion she had had with the resident about the new technique, raises the topic with the group and asks the resident for his input. He describes the findings of the article, which are met with much enthusiasm and interest by group members. The patient undergoes a lumpectomy. The pathology shows negative margins but indicates a positive sentinel lymph node biopsy.Thepatientwishestoseeamedicaloncologistatadifferent hospital, who had treated the patient’s father previously. The patient’s navigator calls the oncologist to confirm the oncologist has all necessary records and discloses the patient’s uneasiness about discussing fertility. The oncologist recommends the patient receive adjuvant chemotherapy, given lymph node involvement. While describing the risks and benefits of adjuvant chemotherapy, the oncologist notices the patient’s changed expression when fertility risk is mentioned and tells the patient that she really wants to hear whether the patient has any concerns. After repeated invitations to discuss, the patient discloses her ambivalence and emotional distress about fertility preservation, compounded by feelings of failure brought about by cultural connotations. The oncologist refers her to a reproductive specialist and a psychologist before initiating chemotherapy. KEY PRINCIPLE: TEAMWORK IN CANCER CARE REQUIRES HIGH-QUALITY COMMUNICATION, WHICH DEPENDS ON PSYCHOLOGICAL SAFETY FOR ALL TEAM MEMBERS Psychological safety describes individuals’ perceptions of interpersonal threat and the consequences of taking

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Copyright © 2016 by American Society of Clinical Oncology

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1002 Terminology describes the choice of words used to communicate

Terminology and mental models

(continued on following page)

Mental model describes the framework for understanding variables and how they relate

Includes individual personality, knowledge, style of speech, skill level, disposition (eg, willingness to learn and share), biases, and emotions

Personal attributes

Personal or interpersonal Exists when a person feels comfortable speaking her or his thoughts (ideas, questions, concerns, or suggestions), without worry that doing so will have negative repercussions (eg, being excluded, embarrassed, belittled, dismissed)6

Description

Psychological safety

Factor

Table 1. Factors Affecting Communication Effectiveness

Differences in terminology and mental models, which often derive from different backgrounds and training, make effective communication challenging. Messages may not be clear, their relevance may be missed, and what is considered timely can differ because of differences in operational frameworks. As professionals become more specialized, effective communication with other specialists and with those they service can become more challenging.17-19 Success depends on performing the third step in the communication process: following up to confirm that the message was understood and interpreted appropriately. In the absence of this feedback, lack of understanding may be delayed or never identified.

When individuals are approachable and knowledgeable about a subject, limit the use of long or compound sentences, allow for turn taking, convey messages skillfully (mindful of nonverbal communication [eg, voice tone and eye gaze]), and are willing to share, communication is more likely to occur and be effective.14 Communication goes awry when intergroup biases (eg, belief that expertise of another group is of little value) prevail. Biases can limit interest in engaging in communication that might otherwise be valuable15,16 and lead to people hearing different messages in the same communication. An emotional individual may not be able to communicate well; emotions can prevent expression of messages and also hinder the ability to hear messages.7

Lack of or low psychological safety is associated with silence and distortion of information. Conversely, when feeling safe, people communicate openly.6 Note: Psychological safety tends to be lower for individuals interacting with others with whom they have little or no prior working or personal relationship7 because of an absence of familiarity and trust.8-10 Those in lower status or hierarchic positions (eg, primary care physician relative to surgeon or patient relative to physician) often feel that it is less safe to speak up as well.11-13 However, both those high and low in hierarchies may not feel psychologically safe in professional settings, because high-status individuals worry about the risk of ineffective communication to their reputation.

Sample of Key Findings on Effect on Communication

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Relationship captures the state between two or more people or groups, the quality of which is exemplified in their regard and behavior toward each other Identification refers to the sense of commitment and belonging to a group and the significance that one attaches membership in that group20

Relationships and identification


Includes the composition, rules, norms, and arrangements of the workgroup, including how much time is allotted for the team’s activities and when and where they take place

Team design: team composition and work design

(continued on following page)

Captures the process in which one engages others to set and achieve a common goal22

Leadership

Team structure and processes

Description

Factor

Table 1. Factors Affecting Communication Effectiveness (continued)

When individuals know that they are members of a team, know who their team members are, and have a shared goal, they invest more in communication in service of the goal.26 Use of team charters—written plans that specify tasks, how they will be performed, by whom, and when—support communication in traditional teams and multiteam systems.27 Lack of time limits engagement in communication and communicating effectively. When time constrained, senders often do not carefully think through how best to communicate their message (who will receive, what to share, which channel to use, how to phrase), and receivers’ ability to decipher the message and determine its meaning is hindered.

If the person leading a group performs and/or encourages a behavior like effective communication, individuals are more likely to strive to communicate effectively.23,24 Communication is a function of not only the extent to which leaders invite it but also whether they acknowledge, appreciate, and follow up on the communication.11 When leaders withhold information, silence, dismiss, or embarrass individuals who communicate, or establish procedures that limit communication, individuals are more likely to conclude that communication is not worth the effort and thus avoid it,25 disrupting the feedback part of the communication process.

Team identification allows individuals to look past and embrace the diversity of others21 and therefore dedicate effort to working through communication challenges to perform well as a team. Formation of team identity can undermine the formation of multiteam identity, thwarting communication in multiteam systems. Likewise, identifying with the multiteam system can erode the local team identity and thus intrateam communication.21

Communication is more likely to occur between persons who have a relationship and when persons identify with each other and/or their team.20




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1004 Describes how physically far apart people are

Refers to the media by which people send messages and feedback (eg, e-mail, instant messaging, video conference)

Distance between people

Channels of communication

Describes the resources and infrastructure available to aid tasks; includes meeting space, technology, and administrative support Provide rewards or penalties for engaging in specific behaviors

Organizational support

Incentive systems

People are more likely to engage in communication if rewarded for it and less likely to engage if not rewarded or they suffer in any way as a result of engaging in it.34

When organizations provide support for communication, people are more likely to communicate and to do so by leveraging the provided support.33

People tend the adopt the communication norms of the culture or climate of the group to which they belong, even if they have belonged for only a short time.33

Effective communication occurs when the richness of a channel matches the complexity of the situation and message content.31 When then the wrong channel is used, time is wasted, and breakdown and misunderstanding occur. Even a seemingly reasonable channel may not facilitate communication because of technical issues.

Distance has an influence on the amount of interaction and communication with other people, even when they are members of the same team or organization.28 The greater the proximity between people, the more readily they communicate because it is easier to do so; access provides opportunity to do so, visibility reminds them to do so, and familiarity builds inclination to do so.29,30


NOTE. Communication refers to information exchange characterized by three steps: a sender initiates a message, sent to a receiver via some channel; the receiver acknowledges and decodes the message; and the sender confirms that it was appropriately interpreted.5 The listed factors demonstrate effects on the process of communication. Personal or interpersonal factors are those that arise from the people involved and their interactions with others. Team structure refers to the design, composition, rules, and arrangements of the workgroup, whereas team process refers to the activities and ways in which teamwork is performed. Macroenvironmental factors are characteristics of organizational and broader institutional settings (eg, social and policy contexts) in which the communicators are situated.

Refers to shared assumptions and ideology within a workgroup; it manifests in organizational choices (eg, providing infrastructure that aids communication or not) that are readily observed and facilitate desired actions32

Organizational culture

Macroenvironmental

Description

Factor

Table 1. Factors Affecting Communication Effectiveness (continued)

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interpersonal risk.46 Such risk exists when one exposes oneself by, for example, asking a question, providing input, seeking feedback, reporting a problem, or making a suggestion. Engaging in these behaviors makes individuals susceptible to the risk of appearing ignorant, incompetent, unable, disruptive, or negative and therefore being embarrassed, rejected, or punished in another way by others.6,47 Individuals tacitly assess the degree of risk.6 When an interaction or setting is perceived to have minimal interpersonal risk and thus feels psychologically safe, individuals share thoughts without worry of negative consequences. In contrast, when a setting is psychologically unsafe (ie, risky), individuals are less likely to share.6 Past work shows that psychologically safe teams, which communicate more openly, display a number of positive outcomes for teamwork. Safety contributes to the development of shared goals, transactive memory (ie, team-level memory system about formal roles within the team as well as team members’ unique skills and experiences),48 and shared understanding (ie, mental models) of situations, all of which improve team performance.49 Psychological safety facilitates teamwork by motivating a key type of communication termed speaking up or voice, which refers to upward communication that promotes improved processes (ie, promotive communication) or warns of existing practices that may harm the goals of teams or organizations (ie, prohibitive communication).50 Speaking up is particularly important for creating awareness of challenges and opportunities for potential improvement to achieve shared goals.6 Other studies across a variety of health care settings (eg, surgical, intensive care, primary care) have demonstrated additional ways in which psychological safety enables high-quality communication, thus facilitating team performance.11,12,51 Health care providers who are more psychologically safe have been shown to more successfully implement new clinical practices,52 learn new techniques more efficiently,51 make more medical error interceptions,53 and engage in greater quality improvement efforts.11,54 They also display higher commitment to their organizations.55 Organizations with more psychologically safe staff have greater patient safety.55 Organizational and teams researchers have identified several factors that affect psychological safety, summarized in reviews.6,46 We highlight five well-investigated factors: Hierarchy-Related Status Differences Status refers to the relative importance or influence of individuals as a result of some characteristic, such as education or

experience.56 Higher-status individuals perceive lower risk in self-expression and in general tacitly believe their input is valued. Conversely, lower-status individuals experience greater interpersonal risk, particularly in interactions with higher-status individuals. In medicine, status derives substantially from position in the professional hierarchy, with physicians ranked higher than nurses, attending physicians ranked higher than residents, and so on.57,58 Past work shows that psychological safety tends to mirror position in the medical status hierarchy, with professionals in lower-status specialties feeling less safe than those in higher-status specialties,11,12 leading them to stifle or alter their communications.59 A study involving analysis of medical malpractice cases showed that nurses, lower in status relative to physicians, withheld information regarding diagnosis and treatment from physicians because they felt unsafe.60 Despite having greater status, physicians also report not voicing their observations and concerns “even when a patient’s life might be threatened, preferring to swallow their discomfort.”61(p 304) Familiarity Familiarity with others in an interaction or setting has been shown to affect psychological safety. Psychological safety tends to be lower for individuals interacting with others with whom they have little or no prior working or personal relationship because of the absence of familiarity and trust.8-10 Research has shown that the relationship between team familiarity and team performance is mediated by psychological safety, with familiar teams learning at faster rates than unfamiliar teams as a result of greater knowledge sharing.62,63 Geographic Dispersion Geographically dispersed teams, in which members are not colocated, commonly exist to leverage the expertise of specialists wherever they work. In community oncology, we often see geographically dispersed care team members (eg, hospital based, private practice offices, radiation therapy). Such dispersion is associated with lower psychological safety and group performance, unless managed well.64 Distance within dispersed teams results in greater reliance on written or electronic communication (eg, e-mails, electronic health records) versus more direct communication, as well as less frequent communications, which limit formation of high-quality relationships,62,65 an antecedent to psychological safety.66-68 Although low psychological safety within these groups can erode the quality of information shared within them,



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psychologically safe climates can mitigate dispersion effects. In two studies, investigators examined the effects of a safe communication climate on team innovation and found that teams with limited psychological safety viewed geographic dispersion as a barrier, whereas teams that reported safe climates viewed dispersion neutrally or positively and had improved outcomes.69 In safe climates, members of dispersed teams demonstrated greater willingness to engage in knowledge sharing,70 an important observation because dispersed members often have decreased shared understanding of one another’s work context.71 Boundary Spanning How teams define themselves (to include or exclude certain actors) results in boundaries that are more or less difficult to cross, and the more difficult the boundaries, the more important the work of boundary spanners (ie, organizational actors whose task is to integrate the work of others around a project, process, customer, or—in our case—patient).72,73 For example, the communication of care plans must cross both internal and external boundaries to reach all stakeholders (eg, providers, patients, staff). Boundary spanning includes work to promote the goals of the team, build goodwill among stakeholders, and share context of team members’ work with others (both within and outside the team). When team members have a better understanding of others’ work, they are more likely to speak up, demonstrating the positive association between boundary spanning and team psychological safety.74 Research also shows that team members with boundary-spanning roles engage in greater communication,75 feeling greater safety.76 Leader Behavior Organizational research has found that psychological safety is greatly influenced by leader behavior.46 Leaders’ actions shape the climate and behavior within groups.32 A leader with a more authoritative and/or defensive approach erodes psychological safety, whereas a leader who invites input and opinions from all members tends to flatten hierarchic differences and create greater psychological safety for team members to communicate freely. Early work on psychological safety found that nursing managers who stressed the importance of speaking up as a tool for team learning and improvement had nurses who felt safe to do so and did.53 Subsequent research in health care and other industries further shows that leadership inclusiveness—the extent to which leaders explicitly invite 1006

and appreciate others’ input—and openness to new ideas are associated with psychological safety of group members.11,23 UNDERSTANDING THE EFFECT OF PSYCHOLOGICAL SAFETY ON COMMUNICATION THROUGH A CASE In the patients’s case, we observe situations involving high and low psychological safety and resulting examples of willingness and reluctance in patient–provider and provider–provider communications. For instance, despite the navigator discussing fertility preservation and inquiring whether the patient desired preservation, the patient does not communicate her ambivalence because of a lack of familiarity and comfort with the navigator. The resulting lack of psychological safety undermines communication for effective treatment planning by curtailing patient sharing of relevant information. In the tumor board, the satellite physician does not speak up about reviewing the ultrasound. Although seemingly harmless, he misses information that may consequently affect his ability to provide informed input. Distance is an important contributor to his lowered psychological safety in speaking up through its limiting effect on frequency of quality communications, resulting in weakened working relationships among tumor board members. The surgical resident initially does not share new research findings with the remaining group members. His previous experiences with board members had resulted in low psychological safety for him in this group. His perceived risk of being viewed as superfluous or as a showoff (thus, potential risk to his performance assessment) motivates his silence. Hierarchic status differences between himself and the more senior members of the tumor board exacerbate this risk, further eroding his sense of safety. Without knowledge sharing, the learning of the group would be adversely affected, which, in this case, has implications for patient care—a result that is clearly detrimental to the goals of the care team. This adverse outcome is avoided because the navigator speaks up and asks the resident to discuss the findings and possibilities further, creating a safer context for the resident to share. The navigator demonstrates boundary-spanning functions, which serve to improve psychological safety. She discusses surgical management with the resident. She promotes the work and goals of the team by actively discussing patient concerns and offering resources to the outside unfamiliar oncologist, who is not viewed as part of the local cancer care team, thus creating goodwill with external stakeholders. Combined with her inclusive behavior, the navigator’s actions result in a positive climate of safety and consequently team



Table 2. Management of Psychological Safety in Practice Strategies for Practice in Clinical Care

Factor Status differences

Perform early and ongoing assessment of patient’s views and attitudes as a part of the cancer care team Flatten status differences through team leader inclusiveness

Familiarity and comfort

Emphasize that patients are at the center of care teams Consider early use of briefing protocols or other communication tools to mitigate early lack of familiarity

Geographic dispersion

Encourage more frequent highquality communication Invite input from dispersed members to facilitate working relationships Assess attitudes of dispersed members toward team communication and safety

Leadership roles

Establish norms within teams and organizations to invite input from team members (including patients) as part of care process Model behaviors that reinforce positive norms among team members, especially inclusiveness (eg, inviting and appreciating questions, suggestions, and other contributions from team members) Legitimize boundary-spanning roles within teams Routinely re-evaluate effectiveness in team settings

NOTE. Strategies may address multiple factors. The table is intended to provide potential strategies for the most commonly encountered and relevant factors.

learning (ie, all members learning about new surgical technique) and team performance (ie, better patient-centered care). Despite not being a clinician (which often translates into less status in medical settings), the navigator feels safe; her boundary-spanning role creates individual safety. The case also shows that boundary spanners like our navigator are not the only persons who can create psychological safety for better communication. The oncologist creates a climate of psychological safety for the patient by spending more time with her and inviting her to share her feelings regarding fertility. This display of leader inclusiveness

contributes to an environment in which the patient feels comfortable discussing a sensitive topic. IMPLICATIONS FOR CLINICAL CARE Past research and experiences such as the patients’s indicate that psychological safety, which enables effective communication, is a necessity for patient-centered teamwork in cancer care. The major implication for those involved in cancer care delivery (eg, clinicians, patients, administrators or service-line managers) is that the creation of a psychologically safe climate is critical to minimize perceived risks of communication necessary to achieve care team goals. To foster safety and effective communication, cancer care providers must consider the various factors that affect psychological safety and use strategies for cultivating safety in both provider–provider and provider–patient interactions (Table 2). Status differences should be minimized when possible. Status differences can be felt not only among providers but also between patients and providers and can negatively affect patients’ perception of being a part of the team or having a valued contribution to the care plan. Additionally, patients’ lack of familiarity and comfort with team members can make interactions with providers seem risky. Patients worry about seeming bothersome to providers by raising issues and about the risk that their physicians might become upset or disinterested. Early and ongoing assessment of patients’ attitudes and concerns as regards their role and/or status within the care team may reveal important insights into optimal strategies to augment their sense of safety and participation during the crafting and subsequent execution of a care plan. A validated scale for measuring psychological safety exists,13 as do abbreviated scales that have been used in health care settings.11,52,54,77 These may be a useful starting point for care providers to assess the psychological safety of their patients in interactions with them. Leadership serves a vital role in establishing psychological safety for effective communication. Physician leaders and administrative leaders have the ability to establish organizational and cross-team cultural norms that support psychological safety within cancer care teams. The process of establishing cross-organizational team norms is daunting; a conscientious leader plays an indispensable role in propagating best practices through role modeling and cultivating psychological safety.6,11 At the team level, leadership is essential to minimizing the negative effects of status and hierarchy differences among team members, including patients.



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Table 3. Psychological Safety Sample Tool: Are You Psychologically Safe in Your Team? Question

Response Scale

1. In this team, it is easy to speak up about what is on your mind.

1, highly inaccurate; 2, moderately inaccurate; 3, slightly inaccurate; 4, neither accurate nor inaccurate; 5, slightly accurate; 6, moderately accurate; 7, highly accurate.

2. If you make a mistake in this team, it tends to be held against you (reverse score). 3. People on this team are usually comfortable talking about problems and disagreements. 4. People on this team are eager to share information about what does and does not work. 5. Keeping your cards close to your vest is the best way to get ahead on this team. 6. People on this team sometimes reject others for being different. 7. It is safe to take a risk on this team. 8. It is difficult to ask other members of this team for help. 9. Working with members of this team, my unique skills and talents are valued and used. 10. No one on this team would deliberately act in a way that undermines my efforts. NOTE. Questions from validated survey instruments.13,78 Questions 1 through 5 may be used as an abridged instrument; questions 6 through 10 are from a longer and additional instrument. Ideally, individuals feel highly psychologically safe, which accords with an average score of 6.5. An average score less than 5.5 would thus indicate less than moderate psychological safety, which should be addressed. Past work that validated and used the abridged scale (questions 1 to 5) to survey across many organizations suggested a similar threshold. The abridged scale developers suggest that an average score less than 5.3 implies that efforts to improve psychological safety should be taken or psychological safety should be investigated further; 5.3 equates to the median scaled score across the sampled organizations, which was calculated by multiplying the average score (range, 1 to 7) by 100 and dividing by 7 to get a scaled score. Therefore, an average score of 5.3 equates to a scaled score of 76 [(5.3 3 100)/7].

As noted earlier, leadership inclusiveness to invite and appreciate contributions from all team members has a significant impact on establishing and propagating psychological safety. Because clinicians are often seen as the de facto leaders of care teams, their role in promoting inclusiveness of team 1008

members (including patients) is of paramount importance. Cancer care team leaders should evaluate opportunities to practice inclusiveness in an ongoing manner, and to monitor psychological safety. Using existing scales can be helpful in this regard (Table 3 provides scale13,78 to assess psychological safety). Multidisciplinary teams often have limited shared meeting time, such as tumor boards or carecoordination conferences. These present important opportunities to establish inclusiveness as a team priority for psychologically safe communication as a part of patientcentered care. A study of multidisciplinary cancer conferences found that leader behavior was a critical factor in fostering discussion in which all attendees actively communicated and patient-centered information was included.79 Leaders can also play an important role in formalizing boundary spanning. Although not clearly defined within cancer care teams, boundary-spanning roles can be empowering and foster individual psychological safety through spanning work. As demonstrated in our case, these role players can create psychological safety for others. Creating psychologically safe climates in clinical practice may take time. In the short term, briefing protocols (eg, SBAR80 and STICC81,82; Appendix Table A1, online only) may promote effective communication in settings with limited psychological safety. Studies inside and outside of health care have shown that they facilitate delivery of clear, concise, and relevant communication.83 Such tools are especially helpful in communicating across disciplinary and organizational boundaries with others with whom one is unfamiliar, making them particularly relevant for cancer care in community settings. Implementing them can minimize perceived risk, because the protocol—not the person—structures the communication. Institutionalizing their use can make traditionally risky behavior (eg, making a suggestion) a norm. IMPLICATIONS FOR RESEARCH Past research and clinical experience have provided important insights into psychological safety as an antecedent for effective communication and teamwork and strategies for increasing psychological safety in practice. These insights beget a series of questions requiring greater research to answer and improve cancer care. For example: What other strategies exist to promote psychological safety, particularly in geographically dispersed (cancer care) teams? It may be that leaders should use behaviors beyond inclusiveness and openness or perform these in varying ways in different



stages of interaction to cultivate and preserve psychological safety. Combining learning and performance goals may create a level of accountability needed for participants to feel safe communicating risky information. Other structural strategies may be more effective facilitators in cancer care teams. Are there ways to promote effective communication in the absence of or with limited psychological safety? Because of the nature of cancer care teams (eg, large, with fluid membership, where members may never interact in person), it is possible that psychological safety may be not be achievable in all situations. However, effective communication remains a necessity. Therefore, it would be useful for future research to examine whether other factors may substitute for psychological safety in eliciting high-quality communication or be applied to complement or strengthen the effect of psychological safety on communication. Which communication templates are most helpful for promoting psychological safety in cancer care teams? SBAR and STICC have been shown to improve communication in other settings; comparative-effectiveness studies in cancer care are lacking. Moreover, most tools focus on provider– provider communication. Research is needed about how to structure communications with patients to foster psychological safety so they can participate in their care as desired. How do we reliably and validly assess psychological safety from patients’ perspectives? Understanding current performance is a necessity for developing and selecting interventions. Researchers are developing Cancer Care CAHPS, a survey to assess care experience, including provider–patient communication and coordination from the patient perspective.84 A helpful complement would be a measure for patient–customer psychological safety. Measurement lays the foundation for improvement. In conclusion, psychological safety for all care team members, including patients, is an integral component of effective communication in patient-centered cancer care teamwork. Several factors influence whether psychological safety exists. Strategies such as leader inclusiveness are critical to fostering an environment of psychological safety for communication. By evaluating and managing mitigating factors, cancer care teams can move toward improved patient care experiences for providers and patients alike. Additional research is needed to identify other ways to improve psychological safety in cancer care.

Acknowledgment The production of this manuscript was funded by the Conquer Cancer Foundation Mission Endowment. Presented in part at the National Cancer Institute–American Society of Clinical Oncology Teams in Cancer Care Delivery Workshop, Phoenix, AZ, February 25, 2016. We thank Tessa Chu for research assistance, and patient advocate, Temaya Thompkins, for her helpful perspective on the case. Authors’ Disclosures of Potential Conflicts of Interest Disclosures provided by the authors are available with this article at jop.ascopubs.org. Author Contributions Conception and design: All authors Collection and assembly of data: Anshu K. Jain, Ingrid M. Nembhard Manuscript writing: All authors Final approval of manuscript: All authors Accountable for all aspects of the work: All authors Corresponding author: Anshu K. Jain, MD, Ashland Bellefonte Cancer Center, 122 St Christopher Drive, Ashland, KY 41101; e-mail: [email protected].

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AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Moving Toward Improved Teamwork in Cancer Care: The Role of Psychological Safety in Team Communication The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jop.ascopubs.org/site/misc/ifc.xhtml. Anshu K. Jain No relationship to disclose Mary L. Fennell No relationship to disclose Anees B. Chagpar No relationship to disclose

Hannah K. Connolly Stock or Other Ownership: Halozyme Therapeutics, ARIAD Pharmaceuticals, Sarepta Therapeutics Consulting or Advisory Role: Genentech Patents, Royalties, Other Intellectual Property: Medical identification band with digital capability Ingrid M. Nembhard No relationship to disclose

Copyright © 2016 by American Society of Clinical Oncology Volume 12 / Issue 11 / November 2016 n Journal of Oncology Practice Downloaded from ascopubs.org by University of California, San Diego on January 24, 2017 from 132.239.001.231 Copyright © 2017 American Society of Clinical Oncology. All rights reserved.


Appendix Table A1. SBAR and STICC Item to Communicate SBAR80 Situation Background Assessment Recommendation STICC81,82 Situation (this is what I think we face) Task (this is what I think we should do) Intent (this is why) Concern (this is what we should keep our eye on) Calibrate (now talk to me; tell me if you do not understand, cannot do it, or see something I do not)



Effective teamwork and communication mitigate task saturation in simulated critical care air transport team missions.

Palliative Care in Iran: Moving Toward the Development of Palliative Care for Cancer.

Team-based learning in the gross anatomy laboratory improves academic performance and students' attitudes toward teamwork.

Do safety checklists improve teamwork and communication in the operating room? A systematic review.

Moving toward evidence-based complementary care.

The impact of brief team communication, leadership and team behavior training on ad hoc team performance in trauma care settings.

Making Teamwork Work: Team Knowledge for Team Effectiveness.

Exploring the importance of team psychological safety in the development of two interprofessional teams.

Psychologists' views of inter-disciplinary psychosocial communication within the cancer care team.

The Role of Teamwork in IR Research.

Cancer care team.

Moving toward the light.

Finding Antecedents of Psychological Safety: A Step Toward Quality Improvement.

Moving toward appropriateness of breast cancer care: a balanced act to redefine the scope of standard of care.

A systematic review of teamwork in the intensive care unit: what do we know about teamwork, team tasks, and improvement strategies?

Evaluation of the Dawson College Shooting Psychological Intervention: Moving Toward a Multimodal Extensive Plan.

Prioritization of psychological well-being in the care of diabetes: moving beyond excuses, bringing solutions.

Reviewing cancer care team effectiveness.

Communication, teamwork, and trust in an office-based practice.

Structured nursing communication on interdisciplinary acute care teams improves perceptions of safety, efficiency, understanding of care plan and teamwork as well as job satisfaction.

Sustained Improvement in Neonatal Intensive Care Unit Safety Attitudes After Teamwork Training.

Patient-reported quality of life, unmet needs and care coordination outcomes: Moving toward targeted breast cancer survivorship care planning.

Communication elements supporting patient safety in psychiatric inpatient care.

Interprofessional education in team communication: working together to improve patient safety.