Oncologists' Palliative Care Referral Behaviour: Testing Utility of Social Exchange Theory as an Explanatory Framework

doi:10.21203/rs.3.rs-3105609/v1

Download PDF

Research Article

Oncologists' Palliative Care Referral Behaviour: Testing Utility of Social Exchange Theory as an Explanatory Framework

https://doi.org/10.21203/rs.3.rs-3105609/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 24 Jul, 2024

Read the published version in BMC Palliative Care →

You are reading this latest preprint version

Background

Adults and children with cancer are referred to palliative care infrequently or late. Oncologists often gatekeep these referrals. Social exchange theory is used to explain physician referral behaviour in various clinical settings. Its utility in a cancer palliative care setting is not known.

Methods

We used Karl Popper's hypothetico-deductive approach to test the hypothesis. The hypothesis was that social exchange theory is a helpful framework for explaining oncologists' palliative care referral behaviour in a cancer setting. The utility of the theoretical framework was tested against the empiric findings of a systematic review and original research.

Results

Most components of social exchange theory known to explain physician referral behaviour like beliefs about the provider or service, emotions triggered during the professional engagement, its symbolism and stigma, the complexity of the referral task, efforts needed to achieve it, its cost, benefit, and value were similar in a cancer setting. Empirical findings suggest that oncologists provided strategies and solutions to better palliative care integration instead of comparing their existing engagement with potential alternatives and choosing them.

Conclusion

Social exchange theory was found to be helpful in explaining oncologists' palliative care referral behaviour. To further develop the social exchange theory based on the data used to test it, it is recommended to include feedback and solutions as a component of the theoretical framework alongside a comparison level for alternatives.

Worldwide, adults and children with cancer are infrequently referred to palliative care and referred late (1–6). These trends are more pronounced in low-middle-income countries (7–12). Most referrals occur only in the last days of patients' lives (2, 4, 13, 14). A systematic review showed that, internationally, the median duration between specialist palliative care referral and death in adults and children was 19 days (15). Among many children with cancer needing palliative care, a small percentage have access to it (16, 17). Patients often receive cancer-directed therapies until the last days of their lives, hindering the benefit of symptom management and end-of-life care (4, 5, 14, 18). Late palliative care referrals often impede communication and shared decision-making processes (3, 19, 20) and may also lead to unnecessary invasive medical interventions at the end of life (5, 21) and increased in-hospital deaths (4, 5, 21, 22). A wide range of factors might influence healthcare professionals' behaviours, decision-making and clinical practice (23). Theory-driven approaches are often used to understand and predict clinicians' behaviour in healthcare (24). The social exchange theory has been used to explain physician referral behaviour in various healthcare settings (25–29). However, its usefulness in a cancer palliative care setting is not known. In this study, we explored the utility of social exchange theory as an explanatory framework to describe oncologists' palliative care referral behaviour in a cancer setting.

Our hypothesis was that social exchange theory is a helpful framework for explaining oncologists' palliative care referral behaviour in a cancer setting, and the hypothetico-deductive method was used to test this contention. (30). The hypothetico-deductive approach enables the exploration of how data contributes to testing a hypothesis and its role in confirming or undermining it (30). Furthermore, it formalises and demonstrates the relationship between the hypothesis and the data (30). In a hypothetico-deductive method, an established theoretical framework is tested against the data collected through observations (31). Using empirical evidence allows for testing, modifying, and rejecting a theoretical framework (32). The premise of Karl Popper's scientific philosophy is that all dogmas and theories should be tested and cautioned against their uncritical adoption (33). Furthermore, the researchers are confronted with data that needs explanation, testable hypotheses are deduced from existing theories, scientific data can be used to test a hypothesis and confirmed hypotheses are kept or modified, and falsified ones are rejected (34). Therefore, we chose Popper's hypothetico-deductive method for our scientific inquiry. Karl Popper's hypothetico-deductive approach has seven steps, detailed in the next section (35).

Step 1: Identifying a Broad Problem Area

Timely palliative care referral in a cancer setting was the problem area identified. In adults and children, timely palliative care referral is associated with improved quality of life, symptom control, communication, treatment decision-making, advance care planning, end-of-life care, and reduced costs (36-41). However, oncologists in a cancer care setting may act as gatekeepers, and their gatekeeping behaviour might facilitate or hinder referral to palliative care (42, 43). Studies have shown gatekeeping behaviours include waiting till the end of a potentially curative treatment to make a palliative care referral or making a referral when there is an explicit request from the family (44-46). Furthermore, studies also showed that oncologists preferred to gatekeep the referral process and liked to control and coordinate the care process of their patients at all stages of their illness trajectories (47-52). Therefore, understanding their palliative referral behaviour in a cancer setting could facilitate better engagement and early integration of services.

Step 2: Defining a Problem Statement

The problem statement: Referral behaviour of oncologists underpins timely palliative care referrals. The study aimed to explore this phenomenon. Socio-cultural context and the perspectives of involved social actors influence referrals in healthcare (43). Knowing their views on what helps or hinders referral can influence policies and practices that could have a transformative impact and might overcome health inequity (53). Social exchange theory has been previously used to explain physician referral behaviours in a few healthcare settings (25-29). In all these studies, the exchange behaviour during referral correlated well with aspects of social exchange theory described later. However, none of these studies was conducted in a cancer care setting. In this study, we tested the utility of social exchange theory as a framework for explaining oncologists' referral behaviour in a cancer palliative care setting using a systematic review (54) and original research (55) conducted by the authors of this paper.

Step 3: Develop a Hypothesis

Hypothesis: Social exchange theory is useful for explaining oncologists' palliative care referral behaviour in a cancer setting.

In a healthcare setting, the referral is a social event. It can be perceived as a social exchange behaviour (28), where there is a temporary or permanent sharing of responsibility for patient care between the referrer and the referee (29). Social exchange theory theorises the social behaviour of exchange where people are motivated to engage in an exchange where they may gain or forfeit something of value (56). It is often viewed in terms of social actors interacting to meet their needs, in which the interaction aims to seek reward and avoid the cost (56). The components included in the social exchange process are detailed in Table 1.

Steps 4,5, and 6: Determining measures for Hypothesis Testing, Data Collection and Analysis

In this step, the hypothesis was tested using a systematic review (54) and original research (55) conducted by the authors of this paper. The data collection and analysis of these two measures are described below.

A systematic review (54) was conducted with a review question: "What are the views of oncologists and haematologists on palliative care referral"? Studies published in English involving human subjects from 01/01/1990 to 31/12/2019 were accessed. Studies exploring the views of the oncologists, haematologists, and cancer specialists about palliative care referral in a cancer care setting were included. All studies were scored for methodological rigour using Hawker's tool (65). Studies with Hawker's methodological quality score of 19 or above were included. Screening, quality appraisal and data extraction were conducted independently by two reviewers. The typology of evidence informing this review was a heterogeneous mixture of surveys, qualitative studies, and mixed-method studies. Popay's narrative synthesis method was chosen as the review approach as it is appropriate for synthesising textual data from surveys and qualitative studies into themes (66). Furthermore, it facilitated using a theoretical framework for interpreting study findings (66). Out of 9336 initial database citations, 23 studies were included for synthesis. Five themes were developed during synthesis. They were a) presuppositions of oncologists and haematologists, b) power relationships and trust issues, c) Making a palliative care referral: A daunting task, d) cost-benefit of a palliative care referral, and e) strategies to facilitate a palliative care referral (54).

The subsequent qualitative study (55) was conducted with a research question: What are the views of oncologists and haematologists on what facilitates or hinders the referral of a child with advanced cancer to palliative care? Twenty-two eligible oncologists and haematologists managing children with cancer were purposively recruited from 13 tertiary cancer centres. The cancer centres were selected based on three essential criteria: a. sites where paediatric oncology and haematology services were offered, b. the availability of oncologists and haematologists managing children with cancer, and c. the availability of palliative care services. Research data were collected through individual, face-to-face, semi-structured qualitative interviews. Research data were analysed using Braun and Clarke's Reflexive Thematic Analysis method (67). Four themes and their subthemes were generated during the thematic analysis of the data. The four themes developed were: 1) presuppositions about palliative care and palliative care referral, 2) the task of making a palliative care referral, 3) cost-benefits of making a palliative care referral, and 4) strategies for developing an integrated palliative care model in paediatric oncology (55).

Step 7.1: Data Interpretation and Theory Evaluation

The findings of the systematic review (54) and the original research (55), used to test the hypothesis, were interpreted using the tenets of social exchange theory.

Human Cognition and Emotions

Human cognition is an essential motivation for social exchange that goes beyond the process or outcome of the exchange (68). The social actors are emotive and cognising, and the emotions experienced by the social actors act as an internal reinforcement for the exchange behaviour (57). However, sentiments go beyond emotions, representing an affective state or feeling where emotions are linked to a social object or social unit (69). It is a social construct that leads to an affective response, which is the psychological state of the social actor (70). The presupposition is an implicit assumption or belief about a phenomenon (71). Presuppositions trigger cognitive responses that impact decision-making and social behaviour (72).

In both the review (54) and research (55) findings, oncologists expressed presuppositions about the trustworthiness of palliative care providers. Trust is a cognitive process in which one social actor expects another to be trustworthy (73). Trustworthiness refers to the belief in another person's ability, reliability, integrity, resourcefulness and benevolence (74). In both review and research findings, oncologists highlighted the role of competence-based trust while making a referral to expect another person or team to perform a task effectively (75).

The study (55) brought out benevolence as a facet of trustworthiness. Benevolence corresponds to doing good and being kind (76). In the study (55), oncologists felt that some palliative care providers were less benevolent due to a perceived lack of empathy and a lacklustre approach. The study (55) also highlighted the role of the social identities of social actors on trustworthiness, cognition and exchange behaviour (69).

In the review (54), oncologists expressed self-efficacy in catering to palliative care needs. However, the study (55) found that oncologists had mixed feelings about their ability to respond appropriately to these needs. Perceived self-efficacy is a person's belief about their capabilities to produce a level of performance to accomplish a task that meets the expectation of the self and others (77). The perception of self-efficacy influences cognitive and affective processes and impacts social behaviour and action (77). In the study (55), only a small number of oncologists perceived self-efficacy in providing palliative care. Most oncologists valued the benefit of palliative care referral and acknowledged their constraints regarding the limits to their skills and knowledge needed to provide palliative care. The equipoised appraisal of perceptions of their limitations and self-efficacy formed the presuppositions that impacted the referral behaviour.

Emotions triggered by task activities are central to social exchange behaviour (57). The exchange process can trigger a host of emotions. Some are general feelings like pleasure or dissatisfaction, while others are specific feelings like anger, shame, trust, confidence, gratitude or pride (78). The exchange outcomes also produce emotions that influence the social actor's commitment to the exchange process (78). A positive emotion triggered will encourage the social actor to repeat the experience, whereas a negative emotion may deter future participation in the exchange process (78). The review found that (54), referral to palliative care caused some oncologists to experience therapeutic failure, abandonment, and a break in the therapeutic alliance. Moreover, these felt emotional and experienced a loss of hope. Emotions triggered by the task of referral could hinder future engagement. Conversely, the study (55) found oncologists believed that family feedback provided an opinion about the quality of palliative care services and that positive family feedback was a reinforcement for future referrals.

Power, Status and Expectations

In social exchange, the social actor making the referral retains the reward power, whereas another social actor is rewarded with the referral if they meet the expectations of the referrer (62). In the study (55), oncologists made a referral to palliative care if those services met referrer expectations and agreed with the line of management advised by referring oncologists. This one-sided dependency leads to asymmetrical relationships where the person receiving the referral must comply with the person's wishes for making the referral (62). and can lead to coercive power, in which a social actor obtains compliance from another (62). This phenomenon was observed in our review (54) and research (55) findings. Oncologists preferred to control and coordinate the care at all stages of the illness trajectory. They wished to retain control over the patient even when the palliative care providers managed them. In an exchange relationship, a social actor's status or superior attributes allow them to command others' compliance (59).

Expert power is where the social actor believes they have expert skills and knowledge in a domain not possessed by another social actor, and legitimate power is derived from the virtue of their position (79). In the study (55), the qualifications and experience of the palliative care provider influenced referral. Oncologists thought they had higher qualifications because of their training and were more experienced than palliative care providers. Furthermore, the oncologists felt they had expert and legitimate power or authority to control and coordinate all referral activities (62). These observations were supported by the review findings (54) where oncologists could gatekeep the referral process and perceived palliative care referral as a loss of control and interference in the care process.

Symbolism and Stigma

Exchange behaviour also has a symbolic perspective where social actors interact and communicate about a phenomenon using symbolic inferences (70). In the review (54), oncologists felt that palliative care referral symbolised the loss of hope, a break in therapeutic relationships and abandonment. In the study (55), oncologists thought that the relationship between oncologists and patients is akin to a family relationship where palliative care referral was equated to handing over the family member to another person symbolising therapeutic failure and failing the child. Oncologists felt that families equated palliative care referral as a change in the child's condition, the intent of treatment or that the child would not survive.

Stigma is a complex phenomenon characterised by social structures like stereotypes, prejudices and discrimination (80). In the study (55) and review (54) findings, oncologists expressed stigma associated with palliative care due to the negative stereotyped association of palliative care with death. Public stigma refers to stereotyped thoughts based on general opinion (81). Due to the public stigma associated with palliative care, families were disinclined to engage with palliative care. According to the study (55), both families and oncologists had negative views about palliative care. Label avoidance stigma refers to not pursuing a line of management due to the stigma associated with its name (82). In the review (54), oncologists avoided the term palliative care as it induced fear. They felt families were alarmed by mentioning palliative care, requiring oncologists to explain what palliative care is and is not. In the study (55), oncologists avoided the term palliative care, symbolising the loss of hope and negative attributes. The perception of public stigma and label avoidance stigma among some oncologists conferred the social power to exclude palliative care providers from the care process (83).

Task and Efforts

The effort needed to complete the task affects future exchange (69). The social actor's contribution to the task depends on the perceived fairness of the effort-to-reward ratio (61). If the effort-reward balance is inequitable, the social actor may have diminished interest in the exchange relationship (84). Therefore, social exchange behaviour is moderated by the social actor's perception of the effort-to-reward ratio (85). In both review (54) and the study (55), oncologists felt that efforts needed to make a palliative care referral were significant. Oncologists found it challenging to navigate a complex set of illness-related factors like the course of illness, complications, stage of the disease, presence of symptoms, cure potential, the intent of treatment, prognosis and performance status of the patient underpinning the palliative care referral decision (54, 55).

Reward, Cost, Profit and Value

Anything that leads to a selective repetition of a previous behaviour is a reinforcer (56). Reinforcement is a central concept in a social exchange relationship, and reinforcement behaviour is strongly linked to rewards, cost, profit and value (58). Socially significant behaviour will not be repeated unless it is reinforced (58). From a social exchange perspective, several rewards are described (60). Moreover, rewards are not restricted to physiological or materialistic benefits but can extend to higher self-actualisation needs (60).

Behavioural rewards are linked to immediate outcomes of activity that determine future exchange (60). Social actors notice these rewards first as they are outcomes of the short-term association (60). In both the review (54) and the study (55), most oncologists appreciated behavioural rewards in the form of pain and symptom management, improvement in the quality of life, better family coping, enabling prognostic discussion, decision-making support, and advance care planning. The study (55) found that they also appreciated the support children received at home from palliative care services during the terminal phase of the illness.

Relational rewards are the long-term benefits of continuous and extended association (60). Social actors may notice these rewards late due to a longer-term relationship (60). Some oncologists participating in the study (55) felt that a collaborative relationship between the oncology and palliative care teams could enhance the productivity of the oncologists by reducing stress, saving time, improving treatment outcomes and sharing the responsibility of care. Saving the oncologists' time was the only relational reward noted in the review (54). Self-actualisation rewards can transform the social actor and bring about personal growth (60). Self-actualisation rewards were only seen in the study findings (55). A few oncologists felt that their association with palliative care had improved their symptom management and prognostication skills and made them more empathetic and compassionate.

In social exchange, the cost is the loss incurred while pursuing rewards (63) and is considered the withdrawal of a positive reinforcer or the application of a negative reinforcer (58). It may cause the social actor to forego the exchange process or choose an alternative (58). The more costly the activity, the less often it is undertaken. Profit is reward minus costs, and the social exchange process may continue when the social actor stands to profit from the exchange (60). In the review (54) and the study (55), oncologists experienced a disadvantage of palliative care referral when the palliative care team provided conflicting information about the patient's clinical condition, prognosis and outcomes causing families to receive mixed messages from the oncology and palliative care teams.

Beyond reward, cost and profit, the social actor also considers the exchange's value (60). Value is the social actor's satisfaction from performing the activity and the positive feelings derived from another social actor during the exchange (58). Beyond the immediate and relational rewards, in the study (55), oncologists felt that early palliative care adds value to patients and their families in terms of rapport building with the palliative care team, smooth transitions of care and an opportunity to receive symptom control and supportive care concurrently during cancer treatment. There is a value addition to oncologists in terms of having a partner in the care process whom they can trust, work together and share responsibilities. According to the reciprocity norm, the benefit should be returned, and one who gives the benefit should not be harmed (62). Oncologists participating in the study (55) felt that palliative care providers should feel valued. According to the oncologists, requesting palliative care providers to be part of the oncology team and inviting them to participate in joint clinics might improve family acceptance of palliative care. Families may identify them as part of the oncology services (55). These align with earlier findings corresponding to power relationships and cost. Inviting palliative care providers to be part of the oncology team represents a form of power relationship to avoid a mixed message delivered to patients and their families, which oncologists identified as a cost of palliative care referral.

Initially, the utility of social exchange theory was limited to describing a transactional economic relationship in business exchanges (86). Social exchange theory (56) has been critiqued as a theory with overlapping constructs (61), poor characterisation of the domains (87), and representing the exchange as an economic phenomenon (88). However, its utility is presently expanded to describe various human relationships beyond the economic purview (89–92). Social exchange theory has been previously used to understand physician referral behaviour in different clinical settings (25–29). This is the first paper studying the utility of social exchange theory in a cancer setting by exploring oncologists' palliative care referral behaviour.

Our purpose was to know if oncologists' palliative care referral behaviour could be described using tenets of social exchange theory (56). A theoretical framework facilitates a deeper understanding and interpretation of the study or review findings (93). However, a theory is critically evaluated based on the data, and the empirical study or systematic review findings may support, reject or modify the theory with an explanation (94). We critically evaluated social exchange theory in the context of cancer palliative care using a systematic review (54) and original research (55).

Step 7.2. Theory Revision Underpinned by Data Analysis

The first three study themes (55) and the initial four review themes (54) mentioned before fit well with social exchange theory (56). However, we felt that social exchange theory was inadequate to discuss the study and review themes concerning strategies provided by the oncologists to enhance palliative care integration. Therefore, we would like to propose a critique and modification to the theory (56).

One of the social exchange theory elements is a comparison level for alternatives (64). The comparison level and comparisons level for alternatives are the two levels of the appraisal (95). The comparison level is the benefit-cost appraisal of the social exchange. The social actor assesses the exchange relationship to determine how far it satisfies the individual (64). The comparison level for alternatives is the exploration of other potential relationships that are more rewarding than the existing relationship (95). It depends on the social actor's knowledge of other available relationships and the possible reward-cost potential believed to exist in those (58). Social actors continue their commitment to the relationship as long as they find them more profitable than the alternatives (64).

In both the systematic review (54) and study findings (55), oncologists appraised the exchange relationship regarding benefit and cost. However, they never discussed the possibility of choosing an alternative approach to referral or palliative care services for their patients. Instead, they provided strategies through which relationships between oncology and palliative care teams can be fostered and bettered, and the exchange process of referral may be improved. People can continue to stay in the relationship for want of better alternatives or due to dependency in a relationship (96, 97). However, in both the systematic review (54) and study findings (55), the oncologists valued the benefit of the relationship. They indicated their voluntary continuation of the relationship by providing strategies to enable integration.

Therefore, it is suggested that adding feedback and solutions alongside a comparison level for alternatives represents a modification to the social exchange theory resulting from the data of the systematic review (54) and original research (55). (See Fig. 1)

Limitation and Strengths

In the systematic review (54), the findings from the surveys, qualitative studies and mixed methods studies mirrored each other. The review examined studies from adult and paediatric settings and included participants from diverse oncology backgrounds, traversing four continents making the review findings generalisable. However, the data from the original study (55) used for theory testing had only paediatric oncologists as the participants, which could be a limitation. Furthermore, in both the systematic review (54) and the original research (55), the phenomenon of referral behaviour is explored from oncologists' perspective. However, the views of family members, palliative care providers and other organisational factors were not explored in the study.

In a cancer setting, oncologists may act as gatekeepers, and their gatekeeping behaviour might facilitate or hinder referral to palliative care. Social exchange theory has been used to explain physician referral behaviour in various healthcare settings other than cancer. Popper's hypothetico-deductive method demonstrated the utility of social exchange theory as an explanatory framework to describe oncologists' palliative care referral behaviour in a cancer setting. Most of the findings of the systematic review (54) and the original research (55) used to test the hypothesis correlated well with the tenets of social exchange theory. However, social exchange theory was limited by its lack of utility in interpreting study (55) and review (54) findings concerning strategies provided by the oncologists to enhance palliative care integration. Therefore, a theory revision is suggested by adding feedback and solutions alongside a comparison level for alternatives representing a modification to the social exchange theory resulting from the data used to test the hypothesis.

Ethics Approval and Consent to Participate

The study was approved by the Indian (Kasturba Medical College/Kasturba Hospital Institutional Ethics Committee 292/2018) and United Kingdom (Lancaster University- Faculty of Health and Medicine Research Ethics Committee 17089). A written informed consent was obtained from the study participants during the study. The authors confirm that all methods were performed in accordance with the relevant guidelines and regulations or in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable

Availability of Data and Material (ADM)

All data generated or analysed during this study are included in this published article.

Competing Interests

None

Funding

Naveen Salins acknowledges the support from the Tata Trusts, Narotam Sekhsaria Foundation, Hamied Foundation and Cipla Foundation for conducting this study. Nancy Preston and Sean Hughes has not received any funding towards this research.

Author’s Contribution

NS, SH, and NP contributed towards formulation of the research and review questions, and development of review and research protocols. NS, SH, and NP contributed equally towards the systematic review. NS conducted all the research interviews and coded the transcripts. NS, SH, and NP contributed towards data analysis and theme generation. All authors contributed equally towards manuscript writing. The manuscript has been read and approved by all the authors, and all the authors meet ICJME requirements for authorship.

Acknowledgements

We would like to acknowledge the support from the Tata Trusts, Narotam Sekhsaria Foundation, Hamied Foundation and Cipla Foundation for conducting this study. We would like to thank faculty and staff of the International Observatory on End-of-Life Care, Lancaster University, and Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal who have directly and indirectly helped us in this research.

Fraser LK, Miller M, McKinney PA, Parslow RC, Feltbower RG. Referral to a specialist paediatric palliative care service in oncology patients. Pediatr Blood Cancer. 2011;56(4):677-80.
Johnston DL, Vadeboncoeur C. Palliative care consultation in pediatric oncology. Support Care Cancer. 2012;20(4):799-803.
Levine DR, Johnson LM, Snyder A, Wiser RK, Gibson D, Kane JR, et al. Integrating palliative care in pediatric oncology: Evidence for an evolving paradigm for comprehensive cancer care. JNCCN Journal of the National Comprehensive Cancer Network. 2016;14(6):741-8.
Menon BS, Mohamed M, Juraida E, Ibrahim H. Pediatric cancer deaths: curative or palliative? J Palliat Med. 2008;11(10):1301-3.
Tzuh Tang S, Hung YN, Liu TW, Lin DT, Chen YC, Wu SC, et al. Pediatric end-of-life care for Taiwanese children who died as a result of cancer from 2001 through 2006. J Clin Oncol. 2011;29(7):890-4.
Ullrich CK, Lehmann L, London WB, Guo D, Sridharan M, Koch R, et al. End-of-Life Care Patterns Associated with Pediatric Palliative Care among Children Who Underwent Hematopoietic Stem Cell Transplant. Biology of Blood and Marrow Transplantation. 2016;22(6):1049-55.
Adusumilli P, Nayak L, Viswanath V, Digumarti L, Digumarti RR. Palliative care and end-of-life measure outcomes: Experience of a tertiary care institute from South India. South Asian J Cancer. 2018;7(3):210-3.
Atreya S. Referral Patterns of Gynecological Cancer Patients to a Palliative Medicine Unit: A 2 Years Retrospective Analysis. Indian J Palliat Care. 2017;23(4):409-12.
Chatterjee A, Nimje G, Jain PN. Referral Pattern to a Tertiary Care Cancer Pain Clinic in India. Journal of Pain & Palliative Care Pharmacotherapy. 2019;33(1-2):6-14.
Ghoshal A, Salins N, Damani A, Deodhar J, Muckaden M. Specialist pediatric palliative care referral practices in pediatric oncology: A large 5-year retrospective audit. Indian Journal of Palliative Care. 2016;22(3):266-73.
Sharma K, Mohanti BK, Rath GK, Bhatnagar S. Pattern of palliative care, pain management and referral trends in patients receiving radiotherapy at a tertiary cancer center. Indian J Palliat Care. 2009;15(2):148-54.
Sinha S, Matharu JK, Jacob J, Palat G, Brun E, Wiebe T, et al. Cancer Treatment and End-of-Life Care. J Palliat Med. 2018;21(8):1100-6.
Feudtner C, Kang TI, Hexem KR, Friedrichsdorf SJ, Osenga K, Siden H, et al. Pediatric palliative care patients: a prospective multicenter cohort study. Pediatrics. 2011;127(6):1094-101.
Jalmsell L, Kreicbergs U, Onelöv E, Steineck G, Henter J-I. Symptoms affecting children with malignancies during the last month of life: a nationwide follow-up. Pediatrics. 2006;117(4):1314-20.
Jordan RI, Allsop MJ, ElMokhallalati Y, Jackson CE, Edwards HL, Chapman EJ, et al. Duration of palliative care before death in international routine practice: a systematic review and meta-analysis. BMC Medicine. 2020;18(1).
Clark D, Centeno C, Clelland D, Garralda E, López-Fidalgo J, Downing J, et al. How are palliative care services developing worldwide to address the unmet need for care? Second ed. Connor SR, editor. London, UK: Worldwide Hospice Palliative Care Alliance; 2020.
Downing J, Boucher S, Daniels A, Nkosi B. Paediatric Palliative Care in Resource-Poor Countries. Children (Basel, Switzerland). 2018;5(2):27.
Rost M, Acheson E, Kühne T, Ansari M, Pacurari N, Brazzola P, et al. Palliative care in Swiss pediatric oncology settings: a retrospective analysis of medical records. Supportive Care in Cancer. 2018;26(8):2707-15.
Bradshaw G, Hinds PS, Lensing S, Gattuso JS, Razzouk BI. Cancer-related deaths in children and adolescents. J Palliat Med. 2005;8(1):86-95.
De Graves S, Aranda S. Exploring documentation of end-of-life care of children with cancer. International Journal of Palliative Nursing. 2002;8(9):435-43.
Howell DA, Shellens R, Roman E, Garry AC, Patmore R, Howard MR. Haematological malignancy: are patients appropriately referred for specialist palliative and hospice care? A systematic review and meta-analysis of published data. Palliat Med. 2011;25(6):630-41.
Fowler K, Poehling K, Billheimer D, Hamilton R, Wu H, Mulder J, et al. Hospice referral practices for children with cancer: A survey of pediatric oncologists. Journal of Clinical Oncology. 2006;24(7):1099-104.
Godin G, Bélanger-Gravel A, Eccles M, Grimshaw J. Healthcare professionals' intentions and behaviours: A systematic review of studies based on social cognitive theories. Implementation Science. 2008;3(1):36.
Matthew B. Perkins MD, M.B.A. ,, Peter S. Jensen MD, James Jaccard PD, Peter Gollwitzer PD, Gabriele Oettingen PD, Elizabeth Pappadopulos PD, et al. Applying Theory-Driven Approaches to Understanding and Modifying Clinicians' Behavior: What Do We Know? Psychiatric Services. 2007;58(3):342-8.
Byrd ME. Social exchange as a framework for client-nurse interaction during public health nursing maternal-child home visits. Public Health Nursing. 2006;23(3):271-6.
Grembowski DE, Cook K, Patrick DL, Roussel AE. Managed care and physician referral. Medical Care Research and Review. 1998;55(1):3-31.
Lamb GS. Two explanations of nurse practitioner interactions and participatory decision making with physicians. Research in Nursing & Health. 1991;14(5):379-86.
Prizer LP, Gay JL, Perkins MM, Wilson MG, Emerson KG, Glass AP, et al. Using social exchange theory to understand non-terminal palliative care referral practices for Parkinson's disease patients. Palliat Med. 2017;31(9):861-7.
Shortell SM. Determinants of physician referral rates: an exchange theory approach. Med Care. 1974;12(1):13-31.
Sprenger J. Hypothetico-Deductive Confirmation. Philosophy Compass. 2011;6(7):497-508.
Tariq MU. Hypothetico-deductive method: A comparative analysis. JOBARI. 2015;7:228-31.
Fardet A, Lebredonchel L, Rock E. Empirico-inductive and/or hypothetico-deductive methods in food science and nutrition research: which one to favor for a better global health? Critical Reviews in Food Science and Nutrition. 2021:1-14.
Popper KR. What is dialectic? Mind. 1940;49(196):403-26.
Mahootian F, Eastman TE. Complementary Frameworks of Scientific Inquiry: Hypothetico-Deductive, Hypothetico-Inductive, and Observational-Inductive. World Futures. 2009;65(1):61-75.
Martini C. Hypothetico‐Deductive Method. The Wiley‐Blackwell Encyclopedia of Social Theory. 2017:1-3.
Brumley R, Enguidanos S, Jamison P, Seitz R, Morgenstern N, Saito S, et al. Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. J Am Geriatr Soc. 2007;55(7):993-1000.
Greer JA, Pirl WF, Jackson VA, Muzikansky A, Lennes IT, Heist RS, et al. Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer. J Clin Oncol. 2012;30(4):394-400.
Mitchell S, Slowther A-M, Coad J, Bertaud S, Dale J. Facilitators and barriers to the delivery of palliative care to children with life-limiting and life-threatening conditions: a qualitative study of the experiences and perceptions of healthcare professionals. Archives of Disease in Childhood. 2021:archdischild-2021-321808.
Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-42.
Weaver MS, Rosenberg AR, Tager J, Wichman CS, Wiener L. A Summary of Pediatric Palliative Care Team Structure and Services as Reported by Centers Caring for Children with Cancer. Journal of Palliative Medicine. 2018;21(4):452-62.
Zernikow B, Szybalski K, Hübner-Möhler B, Wager J, Paulussen M, Lassay L, et al. Specialized pediatric palliative care services for children dying from cancer: A repeated cohort study on the developments of symptom management and quality of care over a 10-year period. Palliative Medicine. 2019;33(3):381-91.
Dalberg T, McNinch NL, Friebert S. Perceptions of barriers and facilitators to early integration of pediatric palliative care: A national survey of pediatric oncology providers. Pediatr Blood Cancer. 2018;65(6):e26996.
Kars MC, van Thiel GJ, van der Graaf R, Moors M, de Graeff A, van Delden JJ. A systematic review of reasons for gatekeeping in palliative care research. Palliat Med. 2016;30(6):533-48.
Nyirő J, Zörgő S, Enikő F, Hegedűs K, Hauser P. The timing and circumstances of the implementation of pediatric palliative care in Hungarian pediatric oncology. Eur J Pediatr. 2018;177(8):1173-9.
Prod'homme C, Jacquemin D, Touzet L, Aubry R, Daneault S, Knoops L. Barriers to end-of-life discussions among hematologists: A qualitative study. Palliat Med. 2018;32(5):1021-9.
Sarradon-Eck A, Besle S, Troian J, Capodano G, Mancini J. Understanding the Barriers to Introducing Early Palliative Care for Patients with Advanced Cancer: A Qualitative Study. J Palliat Med. 2019;22(5):508-16.
Cherny NI, Catane R. Attitudes of medical oncologists toward palliative care for patients with advanced and incurable cancer: report on a survery by the European Society of Medical Oncology Taskforce on Palliative and Supportive Care. Cancer. 2003;98(11):2502-10.
Hay CM, Lefkowits C, Crowley-Matoka M, Bakitas MA, Clark LH, Duska LR, et al. Gynecologic Oncologist Views Influencing Referral to Outpatient Specialty Palliative Care. Int J Gynecol Cancer. 2017;27(3):588-96.
Horlait M, Chambaere K, Pardon K, Deliens L, Van Belle S. What are the barriers faced by medical oncologists in initiating discussion of palliative care? A qualitative study in Flanders, Belgium. Support Care Cancer. 2016;24(9):3873-81.
Rhondali W, Burt S, Wittenberg-Lyles E, Bruera E, Dalal S. Medical oncologists' perception of palliative care programs and the impact of name change to supportive care on communication with patients during the referral process. A qualitative study. Palliat Support Care. 2013;11(5):397-404.
Schenker Y, Crowley-Matoka M, Dohan D, Rabow MW, Smith CB, White DB, et al. Oncologist factors that influence referrals to subspecialty palliative care clinics. J Oncol Pract. 2014;10(2):e37-44.
Wright B, Forbes K. Haematologists' perceptions of palliative care and specialist palliative care referral: a qualitative study. BMJ Support Palliat Care. 2017;7(1):39-45.
McGorty EK, Bornstein BH. Barriers to physicians' decisions to discuss hospice: insights gained from the United States hospice model. J Eval Clin Pract. 2003;9(3):363-72.
Salins N, Ghoshal A, Hughes S, Preston N. How views of oncologists and haematologists impacts palliative care referral: a systematic review. BMC Palliat Care. 2020;19(1):175.
Salins N, Hughes S, Preston N. Presuppositions, cost-benefit, collaboration, and competency impacts palliative care referral in paediatric oncology: a qualitative study. BMC Palliat Care. 2022;21(1):215.
Ekeh PP. Social exchange theory: The two traditions: Heinemann London; 1974.
Lawler EJ, Thye SR, editors. Social Exchange Theory of Emotions2006.
Chadwick-Jones JK. Social exchange theory : its structure and influence in social psychology: Published in cooperation with European Association of Experimental Social Psychology by Academic Press; 1976.
Emerson R. Social exchange theory, annual review of sociology. Annuals Reviews. 1976.
Gergen KJ, Greenberg MS, Willis RH. Social exchange : advances in theory and research: Plenum Press; 1980.
Cropanzano R, Anthony EL, Daniels SR, Hall AV. Social exchange theory: A critical review with theoretical remedies. Academy of Management Annals. 2017;11(1):479-516.
Blau P. Social Exchange//International Encyclopedia of the Social Sciences. V. 7. NY: Macmillan. 1968.
Homans GC. Social behavior as exchange. American journal of sociology. 1958;63(6):597-606.
Thibaut J, Kelley H. Social exchange theory. A first look at communication theory. 2008:196-205.
Hawker S, Payne S, Kerr C, Hardey M, Powell J. Appraising the evidence: reviewing disparate data systematically. Qual Health Res. 2002;12(9):1284-99.
Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, et al. Guidance on the conduct of narrative synthesis in systematic reviews. A product from the ESRC methods programme Version. 2006;1:b92.
Braun V, Clarke V, Hayfield N, Terry G. Thematic Analysis. In: Liamputtong P, editor. Handbook of Research Methods in Health Social Sciences. Singapore: Springer Singapore; 2019. p. 843-60.
Poonamallee L, Goltz S, editors. Beyond Social Exchange Theory: An Integrative Look at Transcendent Mental Models for Engagement2012.
Lawler EJ. An affect theory of social exchange. American journal of sociology. 2001;107(2):321-52.
Cook K, Rice E, editors. Social Exchange Theory1989.
Simons M. On the Conversational Basis of Some Presuppositions. Semantics and Linguistic Theory. 2013;11:329-48.
Domaneschi F, Carrea E, Penco C, Greco A. The cognitive load of presupposition triggers: mandatory and optional repairs in presupposition failure. Language, Cognition and Neuroscience. 2014;29:136 - 46.
Nunkoo R, Ramkissoon H. Power, trust, social exchange and community support. Annals of Tourism Research. 2012;39:997-1023.
Kim S, Kuo M-H. Examining the Relationships Among Coaching, Trustworthiness, and Role Behaviors: A Social Exchange Perspective. The Journal of Applied Behavioral Science. 2015;51(2):152-76.
Lee H. The role of competency based trust and organizational identification in continuous improvement. Journal of Managerial Psychology. 2004;19:623-39.
Colquitt J, Rodell JB. Justice, Trust, and Trustworthiness: A Longitudinal Analysis Integrating Three Theoretical Perspectives. Academy of Management Journal. 2011;54:1183-206.
Bandura A, editor Self-Efficacy: The Exercise of Control1997.
Lawler EJ, Thye SR. BRINGING EMOTIONS INTO SOCIAL EXCHANGE THEORY. Review of Sociology. 1999;25:217-44.
Yukl G, Falbe CM. Importance of different power sources in downward and lateral relations. Journal of Applied Psychology. 1991;76:416-23.
Major B, O brien L. The social psychology of stigma. Annual review of psychology. 2005;56:393-421.
Vogel DL, Bitman RL, Hammer J, Wade N. Is stigma internalized? The longitudinal impact of public stigma on self-stigma. Journal of counseling psychology. 2013;60 2:311-6.
Strickland KD, editor Label avoidance: a measurement of stigma2018.
Link BG, Phelan J. Stigma power. Social science & medicine (1982). 2014;103:24-32.
Lin T-C, Huang C-C. Withholding effort in knowledge contribution: The role of social exchange and social cognitive on project teams. Inf Manag. 2010;47:188-96.
Janssen O. Job demands, perceptions of efforî reward fairness and innovative work behaviour. Journal of Occupational and Organizational Psychology. 2000;73:287-302.
Lambe CJ, Wittmann CM, Spekman RE. Social Exchange Theory and Research on Business-to-Business Relational Exchange. Journal of Business-to-Business Marketing. 2001;8(3):1-36.
Davies PS. Logical reasoning and domain specificity - A critique of the social exchange theory of reasoning. Biology & philosophy. 1995;10(1):1-37.
Zafirovski M. Social exchange theory under scrutiny: A positive critique of its economic-behaviorist formulations. Electronic Journal of Sociology. 2005.
Bishop JW, Scott KD. An examination of organizational and team commitment in a self-directed team environment. Journal of applied Psychology. 2000;85(3):439.
Bowling NA, Beehr TA, Swader WM. Giving and receiving social support at work: The roles of personality and reciprocity. Journal of Vocational Behavior. 2005;67(3):476-89.
Nakonezny PA, Denton WH. Marital Relationships: A Social Exchange Theory Perspective. The American Journal of Family Therapy. 2008;36(5):402-12.
Ward C, Berno T. Beyond social exchange theory: Attitudes Toward Tourists. Annals of Tourism Research. 2011;38(4):1556-69.
Fletcher AJ. Applying critical realism in qualitative research: methodology meets method. International Journal of Social Research Methodology. 2017;20(2):181-94.
Sayer A. Method in social science : a realist approach. 2nd ed. ed: Routledge; 1992.
Smith RH, Diener E, Garonzik R. The roles of outcome satisfaction and comparison alternatives in envy. British Journal of Social Psychology. 1990;29(3):247-55.
Gelles RJ. An exchange/social control theory. The dark side of families: Current family violence research. 1983:151-65.
Sabatelli RM, Cecil-Pigo EF. Relational interdependence and commitment in marriage. Journal of Marriage and the Family. 1985:931-7.

Table 1: Components of Social Exchange Theory

Sl. No	Component	Description
1	Sentiment	Sentiments are the views and attitudes of one social actor towards another involved in the exchange (57). Presuppositions, power and motivation are the common social exchange sentiments (58). Presuppositions are a preformed notion about the exchange or the persons involved in the exchange based on previous experiences, knowledge or biases (58). Power in social exchange is linked to the social actor's virtues in the society or situation and depends upon another person's dependency on the social actor (59). Therefore, it creates a power dependency relationship (59). Motivation is the desire of the social actor to achieve something of value that is closely associated with the satisfaction of achieving it (60).
2	Task	The task corresponds to the effort required to achieve an activity. Structural and contextual conditions determine the efforts needed to accomplish the task (61). Moreover, emotions triggered by the task activities also determine the person's involvement in the task (57). Therefore, the jointness of exchange does not only depends upon the reward of the exchange but also on the structural and contextual conditions constraining or enabling the task and the emotions triggered by it (57).
3	Interaction	Interaction relates to the process of exchange (58). There are three kinds of exchange. The trade exchange is purely in terms of economic gains and losses, and the power exchange is hierarchical, where there is limited choice and freedom to the persons participating in the exchange (58). As the act of referral is a social behaviour (29), in this research, I am focusing on the behavioural exchange, where the relationships are voluntary and interdependent, and behaviours act as tendencies in the exchange process (60). The person participating in the exchange takes into account the task, reward and cost of interacting and will continue to interact if the interaction is in alignment with the person's expected outcomes (60).
4	Reward	The rewards are the benefits of exchange. In the social exchange, rewards are discussed in terms of a person's gains and its influence on the exchange process (62, 63). There are several dimensions to the reward. Immediate rewards are based on the behavioural choices associated with a single event or an outcome. In contrast, long-term rewards are relational rewards based on the long-term association of social actors and cumulative outcomes of interaction (60). Anticipatory rewards are the potential future rewards expected by the person in the exchange process (60). Rewards are a form of reinforcement, and social relationships cease to exist unless the exchange reinforces the person's expectations (56).
5	Cost	Cost in social exchange corresponds to the negative effects or losses sustained during achieving the reward (59, 62). When costs involved in achieving the reward are high, then there is less chance of a person taking up the task (59). The person's decision to choose an activity, forego it or choose an alternative depends upon the costs associated with it (59).
6	Profit	Profit relates to a person's expectation of rewards and the costs incurred in the process. Moreover, in a social exchange, the proportion of rewards to the costs should be a fair process (59, 62).
7	Value	Value means not just the assessment of profit due to interaction but the feelings of satisfaction achieved by doing that activity (58). The value associated with doing an activity and the sentiments the person gets from another person during the process of activity determines the long-term association with the activity (58). The person continues to do the activity even if the activity does not bring profit if it provides satisfaction and adds value (60).
8	Comparison Level	Comparison level is the standard against which the social actor measures the utility of the rewards (64). The standard could be based on the previous or current experience of rewards and alternate choices that are available (64). This perception is based not just on the magnitude of immediate rewards but also on the cumulative slope of the reward (58). Therefore, one activity or an outcome of a single palliative referral is unlikely to make a person choose an alternative or influence the referral behaviour (58). If the cumulative perception is negative and an alternative is more profitable, then the person may choose to terminate the relationship and choose the alternative (58, 64).

No competing interests reported.

Download PDF

Journal Publication

published 24 Jul, 2024

Read the published version in BMC Palliative Care →

Editorial decision: Major revision
04 Jul, 2023
Editor assigned by journal
29 Jun, 2023
Submission checks completed at journal
28 Jun, 2023
First submitted to journal
25 Jun, 2023

You are reading this latest preprint version

Oncologists' Palliative Care Referral Behaviour: Testing Utility of Social Exchange Theory as an Explanatory Framework

Status:

Journal Publication

Version 1

Abstract

Figures

Introduction

Methods

Results

Discussion

Step 7.2. Theory Revision Underpinned by Data Analysis

Limitation and Strengths

Conclusion

Declarations

Ethics Approval and Consent to Participate

Consent for publication

Availability of Data and Material (ADM)

Competing Interests

Funding

Author’s Contribution

Acknowledgements

References

Table

Additional Declarations

Status:

Journal Publication

Version 1