Inviting the absent members: examining how caregivers’ participation affects hospice team communication

Abstract

This paper is a secondary observation of a larger pilot study. The Assessing Caregivers for Team Intervention via Video Encounters intervention project enabled caregiver participation in hospice interdisciplinary team meetings. This paper used the team observation scale to assess the impact of caregiver involvement on team structure, process, and outcome. Comparisons were made between traditional team meetings and the team meetings that involved caregivers by using videotapes of both. Analysis found that team meetings with participating caregivers had better team outcomes, with more patient-centered goals, increased discussion of biopsychosocial problems, and the development of interdisciplinary care plans occurring more often than in the traditional hospice team meetings. Findings from this study show benefits for inclusion of caregivers in hospice team meetings.

Introduction

Interdisciplinary teams (IDT) comprise medical and non-medical healthcare providers working collaboratively to address the full spectrum of a patient’s health. In the USA, routine IDT meetings are held in hospice to provide a setting for interdisciplinary collaboration and enable the development of holistic care plans.¹ It has been surmised that family involvement in team meetings can influence team functioning, especially assessment, care planning, and implementation of plans.² The Assessing Caregivers for Team Intervention via Video Encounters (ACTIVE) intervention³ used videophone technology to enable informal, family caregiver participation in team meetings. A videophone was placed in the caregiver’s home and hospice, and when it was time for the particular patient to be discussed a call was made to the caregiver and a video connection established, allowing their participation.³ The purpose of this study is to analyze the impact of caregiver participation on the hospice team meeting using a specific tool, the team observation scale (TOS).⁴ The research questions for this study involved: (i) what is the traditional structure, processes and outcomes of hospice IDT?; (ii) how are structures, processes, and outcomes of hospice teams changed with caregiver participation?

Method

Procedures

This study is a secondary analysis of videotaped hospice team meetings from a larger intervention project funded by the National Cancer Institute.⁵ The study consisted of two types of meetings: (i) traditional meetings with staff only; (ii) meetings involving hospice caregivers (and sometimes patients) who attended remotely using videophone technology. Nurse case managers facilitated meetings for their patients. All meetings averaged six to eight team members including nurses, social workers, chaplains, and a medical director. With the written consent of caregivers, staff, and patients, IDT meetings were video-recorded for meetings with and without caregiver participation.

Protection of human subjects

Informed consent was obtained from hospice staff, caregivers, and (when possible) patients in two rural hospices. Following initial consent to refer from the caregiver and patient, a Graduate Research Assistant (GRA) would visit the caregiver’s home, obtain informed consent, and if appropriate install the video-phone. All patients had to be enrolled in the hospice, and caregivers had to be without cognitive impairment (assessed by the hospice nurse using the short portable mental status questionnaire),^6,7 consent to participate, and be over 18 years of age. Participants were not randomized into the study. Approval for the study was gained through the Institutional Review Boards of the university and participating hospices.

Data collection and instrumentation

Team meetings of both groups were videotaped by the GRAs. These videotapes were reviewed by GRAs using an adapted version of the TOS.⁴ The TOS is an observational measure of the structure, process, and outcome of interdisciplinary care teams.⁴ It consists of 67 quantifiable variables using a binary ‘yes’ or ‘no’ for each category. Based on prior research in the hospice setting,⁸ the instrument was modified and items deemed not applicable were eliminated.

Data analysis

A session was held for two GRAs who were trained on the adapted TOS coding sheet. The session included watching videotapes, discussing examples for each category, and notes were made to clarify any questions. They independently coded 20 meetings, achieving 100% intercoder reliability. Then each student independently coded approximately half of the data. TOS scores were entered into SPSS and descriptive statistics were computed for analysis. Time calculations were assessed using a stop-watch.

Results

Video-recorded meetings consisted of traditional hospice team meetings from group one (n = 152), and team meetings that included caregiver participation via videophone conference in group two (n = 74). The average time of discussion per patient was 3 min 20 s (group one) and 7 min 55 s when caregivers participated. An extra time calculation for the second group involved ‘offline time’ when discussion of the patient occurred prior to and/or after a videophone call with caregivers. In addition to the average discussion time, the average offline time per discussion was 4 min 13 s.

Process variables revealed that while speakers are actively listened to (76.4%) and body language (91.4%) and physical position convey active involvement (95.3%), disruptions to the team process are not appropriately addressed (3.2%), and roles are not clearly negotiated (4.6%). Disruptions included not having the patient’s medical chart accessible when it was time to discuss the patient. Quieter team members (e.g. social workers and chaplains) are not regularly encouraged to participate (7.2%), and goals are not introduced during team meetings (3.9%). The goal of team meetings is to review and address problems with the care plan. Negative process variables detailed that disruptive interrupting occurs (31%), and team members excessively leave team meetings (15.7%).

Outcome variables in traditional hospice team meetings included actively addressing functional/behavioral problems (86%), biopsychosocial problems (24%), and clear discussion about patient visits (31%) by staff who used clinical jargon (51.3%) and stories to share information (51.9%). Still, jargon was not identified and translated for caregivers, patients, and non-medical team members (4.6%), little teaching occurred across disciplines (10.5%), and care plans were scarcely shared with the patient/family (1.9%). Tables 1 and 2 display the percentage of team meetings exhibiting the variables across observations for each group.

Table 1.

Structural and outcome variables in teams across both groups of observation

Group (number of team meetings observed)	Group 1 (n = 152)	Group 2 (n = 74)
Structural variables
Flexibility in following agendas	2.6%	6.7%
Room size adequate for number of people	15.7%	16.2%
Furniture placed to facilitate discussion	100%	98%
Roles are approximately shared	34.2%	47.2%
Recorder role identified	6.5%	4%
Trainees fully integrated into information sharing	1.9%	4%
Trainees just observers (seen not heard)	18.4%	17.5%
Outcome variables
Functional/behavioral problems	86%	93%
Biopsychosocial problems (emotional, social, spiritual)	24%	50%
Patient-centered goals	3.2%	17.5%
Interventions interdisciplinary in scope (two people)	10.5%	24.3%
Staff responsibility clearly made (talk about visits)	31%	78.3%
Evidence of patient/family involvement	0%	94.5%
Care plan shared with patient/family	1.9%	40.5%
Productivity
Jargon presented to convey clinical information	51.3%	46%
Jargon identified and translated	4.6%	12%
Other knowledge freely shared in meeting (stories)	51.9%	62%
Teaching occurs across disciplinary lines	10.5%	25.6%

Table 2.

Process variables in teams across both groups of observation

Group (number of team meetings observed)	Group 1 (n = 152)	Group 2 (n = 74)
Positive process variables
Negotiation of roles	4.6%	12.1%
Speakers are actively listened to	76.4%	95.9%
Decision points are clearly identified (e.g. hospice appropriateness)	23%	14.8%
Identification of conflict is made	15.1%	47.2%
Attempt made to resolve conflict	13.1%	44.5%
Encouragement of quieter members	7.2%	22.9%
Making suggestions of goals, etc.	3.9%	18.9%
Addressing ‘outside’ members	38.8%	37.8%
Body language conveys interest	91.4%	95.9%
Physical position conveys involvement	95.3%	98.6%
Appropriate addressing of disruptions	3.2%	1.3%
Negative process variables
Disruptive interrupting occurs	31%	33.7%
Negative statements	7.2%	14.8%
‘Story-telling’ breaking meeting format	3.9%	8.1%
Absent members negatively discussed	2.6%	14.8%
Excessive leaving to answer pagers, etc.	15.7%	14.8%

Comparisons between team meeting observations between group one and group two were then made. The structural variables that improved across group one to group two included flexibility in agenda, adequate room size, shared roles, and the integration of trainees. There were increases in all positive team processes from group one to group two, with the exception of clear decision points (−8.2%), addressing outside members (−1%), and addressing appropriate disruptions (−1.9%). Interestingly, the presence of all negative process variables increased across both groups.

Finally, observations on outcome variables showed the most improvement across the two groups. Table 1 displays these findings, documenting that the discussion of biopsychosocial problems doubled across phases jumping from 24% to 50%, and the development of interdisciplinary interventions (where two or more team members worked together to create a solution) also doubled (10.5% to 24.3%). There was also a substantial increase in the discussion of patient-centered goals (3.2% to 17.5%). Productivity variables also revealed positive increases in sharing other knowledge and teaching as well as an increase in translating jargon.

Discussion

Our assessment of traditional hospice team meetings suggests that improvement is primarily needed in team meeting structure and process. Adequate room size was only present in 15% of team meetings. There was little evidence of the team’s flexibility in following agendas (2.6%), to clearly identify a recorder for the team meeting (6.5%), and to integrate trainees into the team meeting structure (1.9%). Without a clear agenda to follow, there was a greater tendency for disruptions and excessive leaving and a failure to adequately address disruptions. While team members demonstrated active involvement, listening, and discussion of patient problems, weak team structure impeded the interdisciplinary communication process yielding few interdisciplinary interventions. More research is needed to determine if these processes impact patient outcomes.

In contrast, the inclusion of caregivers in group two revealed an improvement in outcome variables. Observation of the development of interdisciplinary interventions doubled across groups. While standard reporting in IDT meetings is nurse-driven and typically focuses on physical pain,^8,9 information shared by caregivers shifted these discussions to include more psychosocial information. Consequently, patient-centered goals were five times higher when caregivers were involved in team meetings.

Overall this study offers support for a healthcare team that includes caregivers as enabled by the ACTIVE intervention. This study found greatest improvement in team outcomes characterized by the development of interdisciplinary care plans. Although the time spent per case discussion increased between groups, the prevalence of offline time in group two suggests that research is needed to determine what elements of care planning are considered to be for staff and which elements are considered by staff to include caregivers.