Factors Affecting Communication Patterns between Oncology Staff and Family Members of Deceased Patients: A Cross-Sectional Study

Objective Perceptions of the role of oncology medical staff in supporting bereaved families have evolved with the transition to interdisciplinary cancer care. We investigated the interactions between oncology professionals and bereaved families. Methods This cross-sectional study involved all oncology medical staff at the Davidoff Center. Participants were given a questionnaire relating to bereavement follow-up. Responses were measured using a 5-point Likert scale. Results Of 155 staff members, 107 filled questionnaires with <20% missing data and were included in the analysis (α = 0.799; corrected, α = 0.821). Respondents included physicians (35%), nurses (46%), social workers (7%), psychologists (4%), or unspecified (8%); 85% were Jewish, and 60% had ≥10 years of oncology experience. Most respondents thought that contacting bereaved families was important (73%), and that it provided closure for staff (79%); 41% indicated that they contacted >50% of the families of their deceased patients. Contacting bereaved families was considered the responsibility of the physicians (90%), nurses (84%), or social workers (89%). The main barriers to contacting bereaved families were emotional overload (68%) and lack of time (63%); 60% indicated a need for additional communication tools for bereavement follow-up. In a multivariate analysis, profession (physician vs. nurse), primary workplace (outpatient setting vs. other), and self-defined religion were significant variables with respect to the perceived importance of contacting bereaved families and to actually contacting them. Other factors (e.g., age, gender) were non-significant. Conclusions Perspectives regarding bereavement actions differ significantly across medical professions, work settings, and self-defined religions. Additional guidance and education regarding bereavement actions is warranted.


Research tools
A questionnaire was prepared specifically for this study by the researchers (Factors Affecting Communication Patterns Questionnaire) (S1 File). It included a total of 39 statements (20 statements, of which 6 included sub-statements). The statements referred to: i) the caregiver's attitude towards communication patterns with bereaved families; ii) the type/frequency of interactions with the bereaved families; and iii) barriers and needs for additional tools. Responses were measured using a 5-point Likert scale (1, disagree; 5, agree), and participants could add free-text responses for each statement. A second questionnaire collected information on participants'-characteristics and work experience, including age, gender, country of birth, religion, marital status, number of children, discipline, position, years of oncology experience, work setting, and number of terminally-ill cancer patients treated each month.
In view of the contradicting findings among studies, and given Israel's multicultural society, we thought that additional factors such as socio-demographic, culture, age, marital status and country of birth may affect behavior.

Participants
Study participants consisted of the 155 staff members of the Davidoff Center for Oncology and Hemato-Oncology, including physicians (35 and 26, respectively), nurses (45 and 35, respectively), psychologists (4 in total) and social workers (10 in total).

Procedures
Researchers distributed the questionnaires to staff at the Davidoff Center, and collected the completed ones. All Davidoff health care providers were approached, and the study was presented at regular meetings. In order to ensure respondents' anonymity, they were instructed to put their responses in empty envelopes placed at each collection point. Questionnaire collection took approximately 6 weeks.

Statistics
Cronbach's alpha coefficient was used to evaluate the questionnaires' internal consistency. A Chi-squared test was used to assess differences between groups (p<0.05 was considered significant). Multivariate analysis was used to identify significant variables associated with bereavement follow-up (covariates were: age, gender, country of birth, marital status, number of children, years of oncology experience, number of dying patients treated by the oncology professional, and work setting).

Results
The questionnaires were handed to 155 Davidoff Center staff members, of whom 107 (69%) filled them out with <20% missing data. The reliability of the questionnaire was assessed using the Cronbach's alpha test (α = 0.789; corrected, α = 0.82).
Most respondents thought it was important to contact family members of deceased patients (73%), that such interaction was also important to staff members (66%), that it provided closure to the staff members (79%), and that it was professionally appropriate (84%). Forty-one percent of respondents indicated that they contact more than 50% of families. Contacting bereaved families was considered to be within the responsibility of the treating physician (90%), nurses (84%), or social workers (89%). The preferable means of communication was a phone call (88%), followed by a condolence letter (75%). The main barriers to contacting bereaved families included emotional overload (68%) and lack of time (63%). More than half of respondents (60%) indicated they would like to have additional communication tools with respect to contacting bereaved families. In a multivariate analysis, age, gender, country of birth, marital status, number of children, years of oncology experience, and number of dying patients treated by the oncology professional, were mostly non-significant variables, whereas the position (physician or nurse) and primary workplace (outpatient setting vs. other settings) were significant variables both to respondents' perspectives regarding the importance of contacting bereaved families, and to actually contacting them ( Table 2). Impact of oncology profession Physicians and nurses had significantly different perspectives with respect to their role in bereavement follow-up (Table 2), with more physicians than nurses agreeing that it was important to contact grieving families (89 vs. 52%, p = 0.0001), and that such contact was important to the grieving families (100 vs. 77%, p = 0.002), as well as to the caregiver (81 vs. 48%, p = 0.001). In addition, more physicians than nurses thought that all grieving families should be contacted (57 vs. 30%, p = 0.013), and that this contact should be made by the treating physician (100 vs. 83%, p = 0.011). Respondents indicated that the longer the relationship with the patient, the more important it was for them to contact the family after the patient's death (92 vs. 65%, p = 0.005). In contrast, more nurses than physicians indicated that lack of appropriate tools prevented them from contacting bereaved families (59 vs. 15%, p = 0.002).

Impact of the primary workplace
Forty-seven respondents (44%) indicated that the outpatient clinic was their primary workplace. These respondents differed significantly from the other respondents (Table 2) in that more of them stated that it was important to contact grieving families (93 vs. 57%, p<0.0001), and that such contact is important to the grieving families (100 vs. 79%, p = 0.001) as well as to the caregiver (86 vs. 50%, p = 0.0001), to whom it provides closure (88 vs. 68%, p = 0.035). In addition, more respondents working in the outpatient clinic indicated that they contacted all grieving families of patients they treat (57 vs. 15%, p = 0.0001) and that the longer the relationship with the patients the more important it was to them to contact the family after the patient's death (90 vs. 73%, p = 0.029). Statistically significant was the finding that more respondents working in settings outside the outpatient clinic indicated that a lack of appropriate tools and emotional overload prevented them from contacting bereaved families (58 vs. 11%, p = 0.0001, 83 vs. 50%, p = 0.004 respectively). These observed differences prompted us to explore the differences between nurses working in the outpatient clinic and those working in other settings (Table 3). We found that the perspectives of nurses working in the outpatient clinic differed significantly from those working in other settings, and were similar to those of physicians working in the outpatient setting. Thus, more nurses working in the outpatient clinic than in other settings agreed that contacting grieving families is important to the caregiver (83 vs. 38%, p = 0.039), and more of them indicated that they contacted all grieving families (60 vs. 8%, p = 0.002). Furthermore, nurses working in other settings than the outpatient clinic were more likely to agree that emotional overload prevented them from contacting grieving families (83 vs. 40%, p = 0.037).

The impact of self-defined religion
Respondents identified as Muslim agreed less than others that contacting grieving families is important to the family (56 vs. 92%, p = 0.001), and to the caregiver (22 vs. 70%, p = 0.003), that such contact provides an opportunity to say goodbye to the grieving family (40 vs. 87%, p = 0.004), and that the preferable way for such contact is by phone (57 vs. 90%, p = 0.011).

Discussion
This study is unique, since it investigated interactions of an interdisciplinary cancer care team with families of deceased patients. Differences were found between the various oncology professionals (physicians vs. nurses), between those working in an outpatient setting vs. other work settings, and between professionals of different self-defined religions. The study also showed that most staff members consider contacting bereaved families to be important, and that most of them thought they lacked proper tools to deal with such interaction. Variables such as age, gender, or a high number of deceased patients did not affect the willingness of staff members to contact bereaved families, unlike previously-reported findings [8][9][10]. Our study showed that contacting bereaved families was more important to physicians than to nurses (except for nurses working in the outpatient clinic). This difference probably stems from physicians' perception of themselves as the main, constant caregivers, making them feel obligated to the patient's family, as well as from the fact that some of the nurses only interact with the patients for short periods of time, and may not even be aware of their death [9]. Notably, this finding contradicts findings from a 2010 Israeli study, in which 42% of surveyed physicians (medical/radiation oncologists) said that contacting bereaved families was beyond their professional duty [11]. Regarding nurses working in outpatient clinics, our findings are consistent with reports demonstrating differences between nurses working in the outpatient vs. the inpatient setting, and suggesting that devotion of nurses to patients and their families may increase by strengthening the relationships between physicians and nurses, addressing nurses' workloads, and implementing communication-strengthening strategies [12,13]. Cancer care approaches have evolved to be patient-centered, with an interdisciplinary health-care team (physicians, nurses, social workers, and psychologists) attending to the patients and/or their families and providing continuity of care (in the outpatient setting) [14][15][16][17][18][19]; this might explain the observed differences in perspectives regarding bereavement followup between staff members working in the outpatient setting and other settings. As revealed herein, the differences between physicians and nurses seem to stem from the workplace and the nature of the interaction with patients rather than from their role per se, as the perspectives of nurses in the outpatient clinic were similar to those of physicians.
Staff at the out patients' setting, agreed less than others that emotional overload prevents them from contacting bereaved families. Although the literature does address the issue of emotional overload among oncology health care providers and its consequence regarding behaviors [20,21], the contribution of differences in primary workplace has not been highlighted until now.
To the best of our knowledge, our study is the first to demonstrate the impact of cultural differences on perspectives surrounding bereavement follow-up, although the differences in positions (the majority of Muslims were oncology nurses) may account for some of the observed difference. In addition, the small number of Muslim participants in our study limits our ability to draw conclusions. Published reports addressing cultural differences focused on patients' cultural differences and how they affect the interactions with the medical staff, but not on cultural variability among staff, possibly due to the assumption that medical staff members adopt the expected professional code without letting their cultural background get in the way. Our findings regarding cultural or religious differences raise the question of staff members' cultural or religious variability and its effects on professional decision making. However, Campinha-Baccot and Granot & Pollak suggested that when caregivers acknowledge, understand and reflect on their own values and cultures, they better understand and address patients' cultural variability and needs [22,23].
In addition, our study also revealed oncology staff members' need for tools to support them in contacting bereaved families and gaining closure on their patients' death. This could be achieved through professional development programs (e.g., education, mentoring). Regarding the fact that only half of the participants agreed with the claim: 'Writing letters is important due to institutional guidelines', in this matter, there is no reinforcement to health care providers. This remains as an educational process to be continued.
The study is limited by its descriptive cross-sectional design and a relatively small sample of workers in a single tertiary center, limiting our ability to draw definite conclusions regarding certain subgroups (e.g., nurses working in the outpatient setting or cultural/religious differences).
In conclusion, this study investigating the interactions between oncology staff members and bereaved families in Israel demonstrated differences in perspectives between physicians and nurses, between staff members working in the outpatient and other settings, and between oncology staff of different self-defined religions.