Phase 1: Constructing CMO-configurations.

Key contexts (C), mechanisms (M), and outcomes (O) were identified in each article to construct individual CMO-configurations. ‘Contexts’ are the conditions necessary for a mechanism to be triggered. ‘Mechanisms’ are the processes occurring within individuals and driving change in order to generate outcomes of interest. Lastly, ‘outcomes’ encompass all relevant effects of IPC between PCTs and hospital ward staff, observed at the levels of patients, relatives, care workers, and hospitals [20].

High-rigour articles (n = 22) were analyzed first and individual CMO-configurations were extracted. Thereafter, individual CMO-configurations were clustered by grouping similar mechanisms. Ultimately, recurrent mechanisms were combined which led to an overarching CMO-model. Regarding the low-rigour articles (n = 26), only those with high (n = 1) or medium (n = 9) relevance were analyzed to strengthen the CMO-model. Articles with both low relevance and low rigor (n = 16) were excluded from the analysis as they were deemed not to provide any additional rigorous information to refine the CMO-model.

Phase 2: Grounding CMOs within third generation cultural historical activity theory (CHAT).

Identified recurrent mechanisms from phase 1, with their corresponding CMO-configurations, were analyzed using third-generation CHAT as an analytical framework. This way, the culture wherein the interprofessional collaborative process occurs is examined in order to identify appropriate strategies to optimize this process.

Third generation CHAT is a social theory suggesting that multiple activity systems can interact with one another [21–23]. Each activity system consists of 6 components interrelated with each other and the activity being carried out:

1. the goal of the activity (object).
2. an individual with its own perspectives and emotions (subject).
3. resources, protocols, or tools (mediating artifacts).
4. policies, norms, and expectations (rules).
5. social and relational dynamics (community).
6. division of tasks and roles (division of labor).

Using CHAT’s third generation enables us to focus on the interactions taking place between a PCT (activity system 1) and a hospital ward (activity system 2), how they may develop shared objectives, encounter moments of friction, and develop learning opportunities.

The analytical phase involved extensive round table discussions with experts in PC, ward staff, and researchers, in which every CMO-configuration was evaluated and grounded within CHAT third-generation by connecting the CMOs from phase 1 to the CHAT components (object, subject, mediating artifacts, rules, community, and division of labor). Additional discussion rounds were conducted with the entire research group to refine interpretations and ensure alignment. This enabled us to unpack contradictions as well as synergies within and between both activity systems. Overall, phase 2 contributes to the theory-building process within this review where the end-goal was to deliver a refined program theory providing insights into how interprofessional collaboration currently works, which important contradictions exist and where learning opportunities can be found.

Ward staff’s awareness for PC or PC services.

Ward nurses reported that (biweekly) case discussions enhanced their awareness of all dimensions of PC, thereby facilitating multidimensional symptom management for patients [34]. Additionally, PC training for ward staff positively influenced awareness of PC organization in the hospital [35]. Conversely, high staff turnover diminished ward staff’s awareness for the PCT [24]. The importance of the PCT’s presence and visibility was highlighted in two studies [24,33]. For instance, regular visits by the PCT to hospital wards or actions that enhanced its visibility were found to trigger ward staff’s awareness of PC and its services [24,33]. Over time, ward staff becomes aware of the added value of a PCT, fostering greater familiarity and positive experiences with its services [36]. Reported outcomes included improved clinical practice among ward staff [34], increased involvement of the PCT in patient care [35–37], and the requests of new consultations [33] once awareness for PC or the PCT was present.

Ward staff’s awareness for patients’ PC needs.

Four articles described PC interventions where PC specialists actively participated in morning rounds on hospital wards. This involvement triggered ward staff’s awareness of patients’ PC needs [38–41]. One study noted that this active involvement created opportunities for PC specialists to make informal recommendations to ward staff regarding PC, further triggering an increased awareness of patients PC needs [38]. Additional contextual factors were identified as triggering the awareness for patients’ PC needs, including a PCT being present through regular ward visits, screening for unmet PC needs in hospitalized patients, and PCTs facilitating goals-of-care discussions [24,40–43]. Eventually, receiving PC training was found to cause awareness for patients’ PC needs among ward staff [35]. One study reported that ward physicians, once aware for patient’s PC needs, became motivated to involve PC specialists. This collaboration allowed the specialists to provide advice and support, resulting in knowledge transfer, and gave ward physicians a sense of relief as they could delegate aspects of patient care to the PCT [44]. Awareness for patients’ PC needs led to several positive outcomes: reduced symptom burden for patients, improved coping with their disease, and relatives being included in the treatment approach enhancing their understanding of the situation [3]. At the PCT level, reported outcomes included increased utilization and timeliness of PC consultations, improved efficiency of PC, and increased involvement of the PCT in patient care [35,38,39].

Ward staff’s awareness for relatives’ PC needs.

Two included articles reported on a mechanism related to relatives. The processes that enhance ward physicians’ awareness of patients’ PC needs also raise their awareness for relatives’ PC needs [44]. Furthermore, active involvement of a PCT during rounds or PC specialists screening for unmet PC needs in patients triggers ward staff’s awareness for relatives’ PC needs [40]. This contributes to earlier and more frequent family meetings and improved relatives’ satisfaction with care [40].

Ward staff feeling overwhelmed.

Two studies identified several contextual factors contributing to ward staff feeling overwhelmed, including lack of time, insufficient PC knowledge, the complexity of caring for patients with PC needs, and being confronted with worsening of the patient’s clinical status. These challenges often prompted ward staff to seek support from the PCT or make more referrals to them. Consequently, when ward staff feels overwhelmed, they are more inclined to involve the PCT [44,45].

Ward staff feeling supported.

Positive perceptions of PC specialists among ward staff played a significant role in fostering feelings of support. For instance, recognizing the extensive knowledge of PC specialists triggered ward staff to feel supported [24]. Similarly, education provided by a PC clinical nurse specialist, equipped ward staff with the tools and guidance to facilitate patients’ wishes [46]. Additionally, PC specialists maintaining a non-judgemental approach made ward staff feel supported, leading to burden relief when facing distressing situations [45].

Ward staff cultivating positive perspectives on PCT.

One study showed that weekly ward rounds with the PCT positively influenced ward staff’s perceptions of the PCT [47]. Additionally, physicians who attended a workshop about PC recognized their PCT as useful [48]. Furthermore, when physicians believe PC is part of their job they are able to identify the benefits of a PCT [30]. Moreover, PC specialists engaging in patient education or providing staff education and training triggers ward staff to cultivate positive attitudes and a good acceptance of the PC specialists’ role [46]. In one study, PC specialists reported exposure to PC as an important factor for cultivating positive views about the PCT enhancing collaboration [33]. However, this statement was not explicitly confirmed by the perspective of ward staff in this publication.

Ward staff developing expectations regarding PC and the role of PCT.

Ward staff that prioritizes active, discipline-specific treatment, experience a lack of time for PC, which results in the expectation that the PCT should provide direct guidance on decision-making related to PC [49]. Early PCT consultation (within 48 hours of admission) fostered regular interaction among the PCT, ward staff, and patients, which helped establish appropriate expectations and facilitated goals-of-care discussions. Eventually, this resulted in more Do-Not-Resuscitate (DNR) orders, increased hospice referrals, reduced Intensive Care Unit (ICU) and pharmacy costs, and lower medical resource utilization [50].

Cultivating feelings of partnership.

Awareness of PC organization within the hospital and a better comprehension of specific roles, was enhanced in ward staff that received a 4-hour PC training session. This process cultivated a sense of partnership which facilitated PCT involvement [35]. Accessibility of the PCT, their quick responsiveness, and their bedside engagement with patients, also triggered feelings of partnership between the PCT and ward staff [51]. This partnership led PC specialists to teach ward staff communication skills and assist with care transitions [51]. Furthermore, visible collaboration between the PCT and ward staff promoted early relationship-building between PC specialists and patients and their families, enabling them to address patient’s problems sooner [39]. Two studies found that PCT visibility in general or their presence during morning rounds cultivated feelings of partnership [33,51]. Enhanced communication between patients, PC specialists, and ward staff during PC consultations also contributed to cultivating feelings of an effective partnership which improved oncologists’ skills and comfort in communication, ultimately enhancing patients’ understanding of their illness [52].

Fostering trust.

Embedding a PCT within a hospital unit or conducting regular consultation rounds fosters feelings of trust among ward staff [37,53]. Trust was also fostered when ward social workers had positive perceptions of PC social workers’ abilities and when PC social workers adhered to principles of patient-centered care [25]. This study identified two other mechanisms interrelated with trust, namely information-sharing and role-negotiation. Contextual factors directly triggering these mechanisms were taking responsibility in communication and willingness to be flexible about tasks [25]. Trust, along with effective information-sharing and role-negotiation, was critical for successful interprofessional collaboration between ward and PC social workers, while the absence of any of these elements hindered it [25]. Additionally, an efficient, shared electronic health record system facilitated timely, relevant, and complete information exchange [54].

PCT feeling less motivated to collaborate.

Challenges to collaboration were reported when PC specialists perceived ward staff to have insufficient PC knowledge [27]. Furthermore, in this study, due to staffing problems within the PCT, hematologists reported that PC specialists used a less active approach towards them [27]. Additionally, when PC specialists felt unrecognized or believed their multidimensional approach was not appreciated, they found collaboration more challenging [28,34]. In the latter, this prevented the PCT to encourage ward staff in multidimensional symptom management [34].

Remaining individual CMO-configurations.

Not all CMO-configurations derived from individual articles could be integrated in the overarching CMO-model. Some contextual factors are similar, but they trigger different mechanism and outcomes and are therefore described separately.

A cross-sectional study with registered nurses found that those working at oncology or hematological wards exhibited more favorable attitudes toward their PCT and demonstrated a greater understanding of the consultation process. This enhanced understanding was also observed among nurses who had frequent interactions with the PCT or had received prior education in PC. In addition, they showed improved abilities regarding collaboration with their PCT (e.g., better proactive communication with PCT) [55].

The presence of a PCT, whether through consultation or integration within the care team, facilitated shared decision-making, which in turn contributed to holistic patient care, improved pain management, an increase in DNR orders, as well as more hospice transfers [37,43]. Additionally, having a PC specialist integrated within the hospital wards’ care team provided access of expertise, through which management of broader patient problems is facilitated [39]. Furthermore, PCT presence by regularly visiting the hospital wards influenced ward staff’s need for more PC knowledge [24]. Moreover, when ward staff is aware of deficits in their PC knowledge, they are more receptive to learning during interaction with the PCT [51].

Lastly, using a co-rounding model fostered more direct communication, contributing to greater clarity, mutual understanding, and respect between teams. Ultimately, leading to greater efficiency in delivering PC [39]. However, disagreements between teams were perceived as inhibiting efficient care delivery [39]. Additional challenges, such as busy schedules, failure to act on PCT’s suggestions as well as differing views on PC and how good PC is achieved, contributed to misunderstandings, frustrations and suboptimal communication [27,49].

Object.

In the PCT activity system, the primary object is to ensure that every in-hospital patient with PC needs receives appropriate PC (Object 1). If interaction with the hospital ward activity system occurs, the objective of the PCT is to enable ward staff to provide PC independently (Object 2). PCT involvement contributes to Object 2 by providing the necessary support, advice, and expertise to ward staff, thereby strengthening their ability to deliver optimal PC. Additionally, the sense of partnership between ward staff and PCT members fosters opportunities for interpersonal learning, enabling PCTs to teach and assist ward staff in developing their PC skills. This too contributes to ward staff being able to deliver PC independently. However, a lack of motivation among PC specialists to collaborate creates friction, as it inhibits the application of a multidimensional approach to patient care. This, in turn, prevents the PCT from achieving its second object of enabling ward staff to provide PC, impeding both effective interprofessional collaboration and the provision of optimal care.

Within the hospital ward activity system, Object 1 focuses on delivering discipline-specific high-quality care for every patient. If interaction with the PCT activity system occurs, Object 2 is to ensure that all patients on the ward receive optimal PC. When ward staff feels supported by the PCT, this reduces ward staff’s burden and distress, leading to outcomes in line with the ward’s objectives, such as reduced patients’ symptom burden, improved patient coping, and better inclusion of relatives in treatment plan. Furthermore, when appropriate expectations are set through goals-of-care discussions, ward staff is more likely to refer patients to the PCT, resulting in improved patient outcomes, such as more hospice referrals, and reduced ICU and pharmacy costs. These actions directly contribute to the hospital ward’s objectives one and two of providing holistic care and optimal PC.

Subject.

Within the hospital ward activity system, ward staff are central subjects whose internal states, such as their perceptions, beliefs, knowledge, and professional attitude significantly influence their engagement with the PCT. For example, when ward staff perceive the PC specialists as highly knowledgeable, they feel supported, which may enhance their motivation to collaborate. In addition, a lack of PC knowledge among ward staff triggers feelings of being overwhelmed, creating a need for support from the PCT. Ward staff’s beliefs about the scope of their role, for instance considering PC as their responsibility, enables them to develop positive perspectives towards the PCT. In contrast, ward staff prioritizing a treatment-focused culture can lead to the expectation for the PCT to direct their actions. This dynamic inhibits the PCT’s objective of enabling ward staff to provide PC independently, creating friction between the two activity systems.

From the perspective of PC specialists, one study highlighted that when PC social workers adopted a patient-centered care approach, ward social workers perceived them more positively. This positive perception fostered trust, making collaborative relationships more likely to develop. On the other hand, if PC specialists feel their way of working is not recognized or valued by ward staff, it can demotivate them and reduce their willingness to collaborate. Thus, the internal states and motivations of subjects in both activity systems – shaped by their perceptions, knowledge, and beliefs – are central in determining the quality of interprofessional collaboration and in achieving the second objectives of both the hospital ward and the PCT.

Mediating artifacts.

Mediating artifacts play a crucial role within and between the activity systems of a hospital ward and a PCT, influencing how subjects behave, think, and collaborate. One such artifact is PC training, serving as both a catalyst and inhibitor for collaboration. Several studies report on the profound impact of PC training on ward staff’s awareness of PC services and patients’ PC needs. PC training can foster positive perceptions of the PCT, creates a sense of synergy between both activity systems, and enhances ward staff’s motivation to involve the PCT in patient care. The latter of which creates a positive feedback loop, as greater involvement of the PCT generates more interaction and opportunities for learning, further reinforcing collaboration. However, the impact of PC training is not uniform, with several studies reporting conflicting results related to PC training and the level of PC skills among ward staff. For instance, both ward staff feeling confident in their own PC skills (e.g., taking pride in their symptom management skills) and those that lack PC knowledge (e.g., limited understanding of the role of PC) may be less inclined to involve their PCT. Conversely, in other studies, ward staff with limited PC skills may actually be more motivated to seek PCT involvement. Another mediating artifact, lack of time, triggers similarly mixed responses: some staff, feeling overwhelmed by the lack of time do seek PCT involvement, while others are less motivated to initiate collaboration. These dual effects, highlight the complexity of mediating artifacts in shaping interactions between PCTs and hospital wards.

Mediating artifacts such as communication tools like shared electronic health records facilitate information sharing between ward staff and PC specialists, possibly fostering trust and a sense of partnership. Meanwhile, a lack of human resources within the PCT limits the team’s ability to actively approach and engage with ward staff, further complicating collaboration efforts.

Rules.

The presence of certain norms, such as PCT involvement through regular consultation rounds or presence of the PCT during ward rounds, play a critical role in fostering trust and a sense of partnership between PCTs and ward staff. Regular PCT involvement enhances ward staff’s awareness of PC needs and services through which knowledge transfer between the systems is facilitated. This creates a positive feedback loop, because ward staff’s awareness reinforces engagement with the PCT. This aligns with the PCT’s goal of enabling ward staff to provide PC independently and the hospital ward’s aim of delivering optimal PC. Furthermore, when ward staff hold negative expectations about the care and treatment provided by the PCT, their motivation to engage decreases. Similarly, when ward staff expect to be involved in decision-making but perceive exclusion by the PCT, their willingness to consult the PCT diminishes. These misalignments in expectations create friction between the systems, undermining effective collaboration.

Community.

In the hospital ward activity system, the community includes PCTs, patients, and their relatives, all of whom are vital to the mechanisms that drive interprofessional collaboration. For example, ward staff engaging in goals-of-care discussions with patients increases their awareness of patients’ PC needs, often resulting in greater PCT involvement. In some instances, being confronted with the worsening of a patient’s clinical status or the complexity of a patient’s care caused ward staff to feel overwhelmed, triggering more referrals to the PCT. This process does not necessarily reflect collaborative interaction between the two systems, as it is primarily reactive rather than collaborative. Interactions with the community were often influenced by other components of the hospital ward’s activity system, such as the beforementioned rules on PCT involvement. Conversely, other factors within the community demotivate ward staff from engaging the PCT, such as limited involvement of relatives in patient care, ward staff feeling resentment towards PC among patients and relatives, or patients hoping for a cure. On the other hand, sensing a lack of understanding about the disease trajectory among patients or sensing intra-family disagreements are moderating factors positively influencing the initiation of PCT involvement.

Within the PCT activity system, the community factor of ward staff’s PC knowledge plays a significant role. A lack of PC knowledge among ward staff can reduce PC specialists’ motivation to collaborate. Furthermore, when PCTs are perceived as having in-depth PC expertise, ward staff feel supported, which strengthens the partnership between the two systems.

Division of labor.

Our review demonstrates the importance of having well-defined tasks for interprofessional collaboration to occur. For example, when a PCT has the task to provide PC education to ward staff, it shifts the dynamics within the hospital ward, making the ward staff feel more supported. This educational task also triggers ward staff to cultivate positive perspectives on the PCT, recognizing the team as beneficial and accepting the specialist’s role. In addition, the division of labor underscores the need for flexibility in task assignments to enable role negotiation.

Furthermore, our CHAT analysis demonstrates the need for clear role definitions. For example, screening for unmet PC needs was a PCT-role which directly influenced ward staff’s awareness of patients’ and families’ PC needs. However, when roles are unclear this reduces ward staff’s motivation to involve the PCT. The lack of role clarity may lead to misunderstandings about responsibilities, resulting in ward staff feeling unsure of when and how to consult the PCT. The perception that it is not ward staff’s place to suggest a PC consultation further reduces engagement and collaboration. Therefore, a clear delineation of tasks and roles is essential to ensure trust and meaningful partnership between ward staff and PCTs.