Cancer Care Team Functioning during COVID-19: A Narrative Literature Review and Synthesis

Amid pandemics, health care teams face unprecedented challenges, requiring significant efforts to sustain optimal functioning and navigate rapid practice changes. It is therefore crucial to identify factors affecting team functioning in these contexts. The present narrative review more specifically summarizes the literature on key elements of cancer teams’ functioning during COVID-19. The search strategy involved four main databases (i.e., Medline OVID, EMBASE, PsycINFO, and CINAHL), as well as Google Scholar, from January 2000 to September 2022. Twenty-three publications were found to be relevant. Each was read thoroughly, and its content summarized. Across publications, three key themes emerged: (1) swiftly adopting virtual technology for communication and interprofessional collaboration, (2) promoting team resilience, and (3) encouraging self-care and optimizing team support. Our findings underscore key team functioning elements to address in future pandemics. More research is needed to document the perspectives of broader-based team members (such as patients and lay carers) to inform more comprehensive evidence-based team functioning guidelines.


Introduction
Clinical guidelines and best practices recommend a well-integrated team-based approach to cancer care that brings together complementary disciplines to optimize team processes, care management, and patient outcomes [1,2].With the rapidly evolving and demanding nature of cancer care (e.g., higher caseloads, diverse treatment options, distinct needs and preferences of patients), teams often report feeling ill-equipped to meet these demands [3].Pandemics pose additional challenges on team functioning, including unexpected practice changes, delays in medical procedures, cancellations of treatments, and workforce shortages due to sickness [4].Pandemics are characterized by community-level outbreaks in at least two countries within a World Health Organization (WHO) region and at least one other country in a different WHO region [5].In the last two decades, pandemics have mainly involved respiratory viruses, including SARS (severe acute respiratory syndrome) in 2002-2003, H1N1 influenza (swine flu) in 2009-2010, the Ebola outbreak in West Africa in 2014-2016, the Zika Virus outbreak in 2015-2016, and the COVID-19 pandemic (2019-present), considered to be one of the most significant global health crises in recent history, caused by the novel coronavirus SARS-CoV-2.During these challenging times, healthcare professionals (HCPs) have often contended with rapid shifts in clinical practices while striving to provide high-quality and uninterrupted care [4,6].The incessant stress makes it significantly harder for teams to sustain performance and optimal functioning [7].

Publication Selection Criteria
Eligible publications focused on elements linked to cancer teams' functioning during the COVID-19 pandemic.Special publications, such as commentaries, perspectives, reports, and contributions without quantitative or qualitative data, were included if they provided an important forum for the cancer teams' experiences during the pandemic.Publications that were not directly relevant to cancer settings or to team functioning during the pandemic were excluded.Publications written in languages other than English or French also were excluded.

Data Synthesis
As per Green et al. (2006) [17], the first author (S.A.) read through each retained publications and took notes.A table was created with a synopsis of the contents and notes relevant to cancer care team functioning during the pandemic.The synopses were then reviewed, and publications with similar concepts were grouped, forming three tables.Some publications were included across tables if their content was relevant to more than one concept.Next, S.A. reviewed the synopses within each table and generated themes accordingly.

Results
A total of 3111 publications were retrieved from the databases, with the following breakdowns: Medline OVID (1161), Embase (998), PsycINFO (687), CINAHL (25), Google Scholar (241).Among these, 1257 duplicates were excluded, while 1856 were assessed for eligibility.After reading the abstracts, 1726 publications were excluded because they were not related to a pandemic.The remaining 128 were assessed by reading the full texts; 105 were not relevant to cancer care teams' functioning or experiences during the pandemic and were excluded.The process resulted in 23 publications deemed suitable for inclusion.The PRISMA flowchart [18] in Figure 1 describes the various steps taken for identifying relevant publications.
A total of 3111 publications were retrieved from the databases, with the following breakdowns: Medline OVID (1161), Embase (998), PsycINFO (687), CINAHL (25), Google Scholar (241).Among these, 1257 duplicates were excluded, while 1856 were assessed for eligibility.After reading the abstracts, 1726 publications were excluded because they were not related to a pandemic.The remaining 128 were assessed by reading the full texts; 105 were not relevant to cancer care teams' functioning or experiences during the pandemic and were excluded.The process resulted in 23 publications deemed suitable for inclusion.The PRISMA flowchart [18] in Figure 1 describes the various steps taken for identifying relevant publications.All 23 retained publications addressed the COVID-19 pandemic.Of these, seven publications with primary sources were identified (i.e., original research with quantitative, qualitative, or mixed designs), along with one literature review, thirteen special publications (i.e., commentaries, editorial pieces, reports), and two study protocols.The main characteristics of the retained publications are presented in Table 1.All 23 retained publications addressed the COVID-19 pandemic.Of these, seven publications with primary sources were identified (i.e., original research with quantitative, qualitative, or mixed designs), along with one literature review, thirteen special publications (i.e., commentaries, editorial pieces, reports), and two study protocols.The main characteristics of the retained publications are presented in Table 1.Three main themes were identified based on the in-depth review of the retained publications: (1) swiftly adopting virtual technology for communication and interprofessional collaboration, (2) promoting team resilience, and (3) encouraging self-care and optimizing team support.The publications' synopses and associated theme(s) are presented in Tables 2-4.• The pandemic created unique circumstances for team collaboration/made high-quality communication a necessity • The pandemic challenged typical interprofessional communication practices, with HCPs overwhelmed by electronic communication

•
Opportunity to work in multidisciplinary teams and learn from colleagues (not normally interacted with pre-pandemic) • Mechanisms promoting team resilience, courses of action in difficult situations, mechanisms for problem resolution, and realistic solutions to professional workforce and team effectiveness challenges.

•
The BRIOT intervention: monitoring and preparing for situations of adversity (minimizing), coping with responses to adversity (managing), and recovering and learning from the experiences (mending) Cancer care team functioning underwent several transformations as the COVID-19 pandemic unfolded.Rapidly shifting to virtual communication and recommitting to interprofessional collaboration were evident in 13 of the publications reviewed (Table 2).
The integration of virtual technology in cancer teams' functioning showcased numerous advantages.Turner et al. (2022) [21] acknowledged the effectiveness of virtual technology in bringing together HCPs to coordinate care and collaborate with colleagues from within and outside institutions.Similarly, Standiford (2020) [24] emphasized the importance of high-quality virtual communication and reported that virtual technology made it possible for HCPs to collaborate with colleagues with whom they did not usually interact.Anderson et al. (2020) [29] and Soukup et al. (2021) [34] reported that switching to virtual team meetings was instrumental in improving collaborative decision-making and minimizing the impact of siloed team members on overall team performance [29,34].Paterson et al. [25] acknowledged virtual meetings as a pragmatic and timely approach to facilitate interprofessional communication and collaboration.Ueda et al. (2020) emphasized that the rapid implementation of virtual technology during the pandemic served to maintain interprofessional collaboration, shared goals, and clear and consistent communication among HCPs.
Farah et al. ( 2021) [31] reported that pre-pandemic attempts to implement virtual technology were challenging.However, during the pandemic, the urgent need for alternate methods of communication quickly became evident.Tumor boards and virtual rounds, for instance, were much easier to attend [31].Similarly, Shah et al. (2020) [32] also reported that weekly virtual staff meetings were successful in enhancing team cohesion while providing HCPs with a sense of control amid ongoing challenges.
Despite the benefits of implementing virtual technology, there were considerable challenges.Mohamedbhai et al. (2021) [20] and Boparai et al. (2021) [28] pointed out drawbacks such as HCPs' struggles to adapt to various communication modalities, deteriorated communication quality, training hurdles, and reduced interprofessional engagement.Turner et al. (2022) [21] stressed the necessity for more resources to ensure virtual meetings' quality.Moreover, Perlmutter et al. (2022) [23] highlighted the limitations of virtual meet-ings, particularly concerning networking with colleagues.They advocated for a hybrid model combining in-person and virtual means.Farah et al. (2020) [32] added that virtual technology can create additional clerical burden because of the lack of formalized protocols to follow.Likewise, Paterson et  Promoting cancer teams' resilience to adjust to changes, overcome obstacles, and bounce back from setbacks remained central in our review, with seven publications underscoring its importance (Table 3).Banerjee et al. (2021) [19], for instance, revealed that psychological resilience and changes in working hours during the pandemic significantly predicted HCPs' wellbeing, burnout, and job performance.In addition, 38% of HCPs (N = 1520) reported feeling burnout, and 66% were not performing their jobs effectively [19].Le Tallec et al. (2022) [37] reported that pandemic-related constraints hindered the smooth running of oncology radiation therapists' work, generating stress, demotivation, and loss of meaning.Similarly, Marshall et al. (2022) [22] revealed that pandemic challenges affected HCPs' work performance and their ability to reenergize for work.Marshall et al. (2022) [22] underscored the need for HCPs' adaptation and resilience amid significant shifts in workloads and workflows [22].Besson et al. (2020) [30] stated that pandemics may provide an opportunity to promote team resilience if HCPs are well supported.For instance, with enough supportive resources, HCPs can grow from the experienced trauma and difficult situations [30].
Besson et al. (2020) [30] and Marshall et al. ( 2022) [22] reported that HCPs showed resilience during the pandemic, were committed to work, strived to remain unified, and did their best to cope with occupational challenges [22,30].Besson et al. (2020) [30] added that initiatives implemented to maintain team resilience during the pandemic (e.g., weekly educational newsletters, mindfulness and resilience resources, and quizzes) enhanced team cohesion [30].Farah et al. (2022) [31] explored strategies to build and enhance team resilience and prepare for future threats.They proposed investing in enhanced training of HCPs, hiring a robust supply of staff, enhancing virtual technologies to prevent future interruptions, and addressing burnout through tailored wellness programs and work-life balance strategies [31].
Our review also identified two study protocols on promising interventions to build and sustain team resilience in cancer settings.The first, by Tremblay et al. (2022) [26], aimed to identify contextual factors promoting cancer teams' resilience and strategies to manage challenges post-COVID-19.The proposed intervention includes three main components aiming to monitor and prepare teams for adversity, managing their responses to challenging situations, and learning from these experiences and recovering [26].The second protocol, developed by Chenevert et al. (2022) [27], aimed to evaluate a participatory approach that fosters team resilience, optimizes team effectiveness, and identifies critical factors linked to better organizational outcomes among cancer care teams [27].Theme 3. Encouraging self-care and optimizing team support.
During COVID-19, cancer teams faced significant stressors impacting their wellbeing and job performance.HCPs' self-care and support for team members were critical, as outlined by ten publications (Table 4).Marshall et al. (2022) [22] reported that pandemic challenges significantly impacted HCPs' wellbeing, causing higher anxiety and feelings of isolation.Banerjee et al. (2022) [28] linked HCPs' wellbeing to their job performance and stressed the significance of supporting them to maintain high-quality cancer care.Similarly, Anderson et al. (2020) [29] highlighted the importance of supporting HCPs' safety and wellbeing to ensure the continuity of clinical operations [22].Davies et al. (2020) [33] reported that staff shortages and lack of resources challenge teamwork and lead to higher risk of distress among HCPs.Boparai et al. [28] revealed that pandemic-related work disruptions placed significant personal and professional demands on HCPs.Moreover, they were not able to seek informal support or engage in traditional self-care activities (such as meeting their family and friends) due to public health restrictions.In response to these challenges, Hlubocky et al. (2021) [6] underscored the responsibility of cancer organizations to support their team members.They highlighted how allocating organizational resources to tackle COVID-19-related stressors empowers HCPs for better long-term coping [6].Hlubocky et al. (2021) [6] suggested several supportive initiatives such as ongoing needs assessment, peer or grief support groups, wellbeing support groups, mental health hotlines, and timely access to mental health specialists.Davies et al. (2020) [33] and Ngoi et al. (2020) [35] suggested boosting HCPs' morale by establishing wellbeing hubs, mindfulness meditation videos, and weekly newsletters of available supportive resources [25,33,35].
Rosa et al. ( 2022) [39] argued that evidence-based interventions such as meaningcentered psychotherapy (MCP) can be adapted to promote HCPs' wellbeing and address pandemic-related distress.MCP can facilitate team connectedness through HCPs' openness and shared experiences [39].Farah et al. (2021) [31] suggested several interventions for team support (e.g., wellness programs, vacations during outbreaks, reducing the stigma associated with mental health, etc.) and the creation of a chief wellness officer position to oversee supportive strategies and allocate funds [31].Marshall et al. (2022) [22] emphasized how organizations may tend to prioritize financial aspects of the pandemic over staff safety and wellbeing.Self-care activities are therefore essential to reduce personal and professional stressors [22].Marshall et al. added that HCPs should be watchful for the symptoms of distress among colleagues and prioritize self-care by taking breaks to reenergize and refocus [22].

Discussion
To the best of our knowledge, this narrative review is the first to provide a summary of the current literature on cancer care teams' functioning during the COVID-19 pandemic.The publications' findings converged toward three main themes, related to (1) swiftly adopting virtual technology for communication and interprofessional collaboration, (2) promoting team resilience, and (3) encouraging self-care and optimizing team support.
For more than two decades, a growing body of evidence has demonstrated that the care provided through interprofessional collaboration-defined as "active and ongoing partnership between professionals from diverse backgrounds working together to provide services for the benefit of healthcare users"-results in better patient outcomes [42][43][44][45].During the COVID-19 pandemic, the complexity of sustaining in-person interprofessional collaboration fast-tracked the implementation of innovative virtual communication tools [46].Our review revealed that virtual technology facilitated a resurgence of interprofessional collaborations among HCPs, granting them the opportunity also to engage with colleagues with whom they typically would not interact, whether within or outside their institution.Virtual team meetings have now become an integral part of cancer care, significantly changing the ways teams function and HCPs interact with one another.Virtual team communication is also documented in the broader healthcare literature.Marlow et al. (2017) [47] argued that virtual communication offers a chance for team members to learn how to use different team processes, such as coordination, to include others' ideas and boost overall team performance [47].They also highlighted the significant link between team performance and the timeliness and quality of virtual communication-both crucial factors during pandemics, as seen in the works of Standiford (2020) and Paterson et al. (2020) [24,25,47].
Our observations herein reveal that strong IT infrastructures and effective meeting coordination are two key strategies to enhance cancer teams' quality of virtual meetings.This aligns with the findings of Rajasekaran et al. (2021) [48], who compared virtual meetings during the pandemic to in-person interactions.They found that, with a robust infrastructure, virtual team meetings facilitated interprofessional collaboration, both within and outside the same institution [48].Paul et al. (2016) [49] also indicated that effective coordination of virtual teams can create positive feedback loops with trust and cohesion, improving overall team performance.
This narrative review's findings also indicate that further training of HCPs regarding virtual technology is needed.Particularly in the context of busy cancer care settings, the IT learning curve might be perceived as overwhelming.Being IT proficient can contribute to more effective management of work demands, as this is becoming an inherent component of healthcare practices in most settings [50].As seen in our review, the integration of new training programs within HCPs' curricula can help address gaps in virtual proficiencies.Kanavos et al. (2022) [51] highlighted the challenge of potential reluctance among HCPs to learn and adopt IT tools, due to a resistant mindset.Offering incentives could effectively address these issues [51].
In addition, this narrative review's findings underscore the importance of promoting team resilience during a pandemic.Resilience, defined as "the capacity to withstand and overcome stressors that can endanger team cohesiveness and performance", can manifest at the individual, team, and organizational levels [52][53][54].In the context of pandemics, cancer teams need to respond collectively and adjust to work challenges in unity.Understanding the factors that underlie effective collective responses to adversity can help reveal key elements for sustained team functioning during pandemics [54].Existing evidence, for instance, links team resilience to self-care and team support [55].This corresponds closely to our third theme, emphasizing the importance of self-care and team support during the pandemic.Indeed, interventions to support HCPs are therefore critical to optimize team functioning when cancer teams face disruptions in routine work and higher rates of burnout [56][57][58].Creating a supportive work environment, where team members can openly express challenges and access support, fosters team resilience [30,31,59].A survey conducted at the onset of the pandemic and three months later indicated a significant increase in the percentages of HCPs reporting distress and burnout at 3 months [19].These findings suggest that although HCPs may be adapting effectively to change, they continue to be at increasing risk for distress [56].Long-term supportive strategies are therefore crucial so that HCPs cope more effectively as the pandemic evolves.
Supportive strategies summarized in this review focus primarily on HCPs, with no mention of auxiliary staff.Gasper et al.(2020) posited that such strategies should be inclusive of all cancer care team members, clinical and non-clinical (e.g., clerical and volunteers) alike [60].As such, preparing healthcare systems to meet pandemic-related demands means addressing the entire team's needs.However, there is a lack of evidence on the experiences of all team members [60].According to Hlubocky (2022) [61], burnout tends to be contagious within teams [61].When one team member experiences occupational stress, significant demands are placed on others, who, in turn, are at greater risk of developing burnout in the future [61].Consequently, we must promptly identify and implement supportive strategies for all involved.
This review also points to gaps in our understanding of the cognitive processes affecting team functioning amid pandemics.Team members, however, have the capacity to construct mental models pertaining to their work and cultivate a collective comprehension of operational processes [14].This is both significant and complex.Exploring team members' mental models of team functioning can add to our shared understanding of what constitutes optimal team performance.Consequently, this can lead to the co-creation of targeted interventions and the fostering of environments that are conducive to team performance.
Despite meaningful contributions of this review, findings should be interpreted with some caution, considering the heterogeneity of publications and the sole focus on cancer care teams.The exclusion of publications addressing specific units (e.g., emergency, COVID-19 units) may have narrowed our understanding of team functioning during the pandemic.In addition, the paucity of robust studies on the topic means that we do not have much evidence on significant predictors of team functioning (positive and negative) during a public health crisis.Last, whereas our search ended in October 2022, COVID-19 continued to evolve, with relevant data still being published.

Conclusions
This narrative review provides a comprehensive account of the literature on key elements of cancer teams' functioning during the COVID-19 pandemic including virtual collaboration and communication, team resilience, self-care, and team support.More research is needed to document the perspectives of broader-based team members (such as patients and lay carers).The findings summarized herein can serve to inform priority domains during a pandemic so that timely strategies can be co-created among all team members involved.
To evaluate the effects of virtual head-and-neck multidisciplinary team meetings on the functioning of the team N = 97 head-and-neck cancer team members (i.e., oncologists, nurses, pathologists, radiologists, dieticians, speech and language therapists)

Swiftly Adopting Virtual Technology for Communication and Interprofessional Collaboration
Mohamedbhai et al., 2021 [20] • 58.8% believed that HCPs' communication during virtual meetings was worse than in person • 69.1% believed that interpersonal relationships and teamwork had deteriorated since moving to virtual meetings • 43.9% felt that interprofessional engagement had decreased • 47.7% reported that virtual training was worse than in person • 70% (junior trainees) felt that their training had deteriorated since transitioning to virtual training • Solutions needed to address the deficiencies in engagement, training, teamwork, and communication Turner et al., 2022 [21] • Easier to coordinate care with other HCPs virtually • Virtual technology: collaboration within the same institution and beyond institutions • More resources needed to ensure the consistency and professional conduct of meetings Perlmutter et al., 2022 [23] • Virtual board meetings: lack of opportunity to network with colleagues; connectivity issues • Hybrid model to address the challenges of virtual meetings (i.e., combining virtual meetings with an in-person component) • Meetings' leadership reinforces engaged interprofessional participation Standiford, 2020 [41]

Swiftly Adopting Virtual Technology for Communication and Interprofessional Collaboration
•Pre-pandemic attempts to implement virtual technology were challenging • During the pandemic, HCPs committed to rapid changes in communication, work, and collaboration when faced with urgency • Rapid transition to virtual care • Benefits of virtual technologies: relieve some space/time constraints; tumor boards easier to attend • Challenges of virtual technologies: clerical burden; less interaction with colleagues Shah et al., 2020 [32]
•Lower ability of HCPs to rejuvenate and reenergize for work • Limited resources; concerns for the mental health of HCPs; need for adaptation • Resilience amid shifting workloads, workflow, and new restrictions Tremblay et al., 2022 [26]

Encouraging Self-Care and Optimizing Team Support
•Minimizing the risk of exposure to COVID-19, for the health and wellbeing of the HCPs and the continuity of clinical operations •The Compassion and Resilience Education (CARE) program/peer support •Wellbeing initiatives/mindfulness meditation videos /tips on home isolation • Integration of department-supported "socially distanced" morning teas for siloed staff and virtual "after work drinks" in an attempt to boost staff morale • Encouraging leave to continue to be taken (where possible), to ensure a mental break • Regular "check-ins" with staff to ensure that their needs are being met, that they are well and safe, and that any barriers to their work are being addressed

Table 4 .
Cont.HCPs at risk of moral strain, in the form of moral distress and moral injury • Strategies for institutional wellbeing programs (i.e., assessment of oncologists' needs, proactive engagement of leadership and mental health in collaborative action planning, establishment of oncology wellbeing programs, execution of empirical-based wellbeing interventions, reassessment of needs, and modification of interventions as needs change).
Theme 1. Swiftly adopting virtual technology for communication and interprofessional collaboration.