Older adults are the majority of health care recipients in a wide range of health care contexts (Denton & Spencer, Reference Denton and Spencer2010). Caring for the older population is complex as a result of atypical presentations of acute illness, underlying chronic diseases associated with reduced physical and cognitive function, and precarious health conditions subject to rapid deterioration (Arbaje et al., Reference Arbaje, Maron, Yu, Wendel, Tanner, Boult and Durso2010; Fedarko, Reference Fedarko2011; Hartgerink et al., Reference Hartgerink, Cramm, Bakker, van Eijsden, Mackenbach and Nieboer2014). These factors often present as an acute confusion – known as delirium (Holroyd-Leduc, Khandwala, & Sink, Reference Holroyd-Leduc, Khandwala and Sink2010). Delirium (a symptom of an acute illness), depression, and dementia (a chronic condition) can all present in older adults as confusion, complicating assessment of their needs and their care (Arbaje et al., Reference Arbaje, Maron, Yu, Wendel, Tanner, Boult and Durso2010; Holroyd-Leduc, Khandwala, & Sink, Reference Holroyd-Leduc, Khandwala and Sink2010). Evidence suggests that the expertise of multiple disciplines is particularly important when health needs and social circumstances are complicated, as is the case with an aging population (Arbaje et al., Reference Arbaje, Maron, Yu, Wendel, Tanner, Boult and Durso2010; Hartgerink et al., Reference Hartgerink, Cramm, Bakker, van Eijsden, Mackenbach and Nieboer2014; Johansson, Eklund, & Gosman-Hedstrom, Reference Johansson, Eklund and Gosman-Hedstrom2010). However, older adults who are experiencing confusion (from delirium, dementia, or depression) are at risk of becoming confused and challenged in answering questions posed by multiple professionals. Although there are potential benefits to interprofessional team involvement in older adult care, it is not well understood how teams collaborate with one another (Reeves, Lewin, Espin, & Zwarenstein, Reference Reeves, Lewin, Espin and Zwarenstein2010) and how this collaboration affects the care of older adults experiencing cognitive challenges.
Background
Interprofessional teams have gained widespread acceptance as important to the provision of quality care, safety, and efficiencies within health care settings (Health Canada, 2007; World Health Organization, 2010; Reeves et al., Reference Reeves, Zwarenstein, Goldman, Barr, Freeth, Hammirck and Koppel2009b). Teams consisting of more than one discipline have been called a variety of names, with the term interprofessional being used more consistently since the 2000s (Paradis & Reeves, Reference Paradis and Reeves2013). Collaboration has also been used to describe a variety of processes among more than one discipline, from parallel practice with consultation to full team integration (Perreault & Careau, Reference Perreault and Careau2012). In this study, we have used the term interprofessional and define interprofessional collaboration as two or more disciplines communicating with one another about older adults’ care (Fox & Reeves, Reference Fox and Reeves2015).
Interprofessional collaboration has been identified as an important factor in preventing adverse effects within health care institutions (Martin, Ummenhofer, Manser, & Spirig, Reference Martin, Ummenhofer, Manser and Spirig2010). Effective interprofessional collaboration is believed to reduce duplication and clinical errors, as well as to enhance the quality of care (Morey et al., Reference Morey, Simon, Jay, Wears, Salisbury, Dukes and Berns2002; Schmitt, Reference Schmitt2001; Schmitt, Reference Schmitt2006). After reviewing the literature about patient safety and teamwork, Manser (Reference Manser2009) concluded that although effective teamwork plays an important role in preventing adverse effects, teams require patterns of communication, coordination, and leadership to support their effectiveness. Other scholars suggest that effective team members require social competence and the willingness to share information, negotiate, and solve problems (Mickan & Rodger, Reference Mickan and Rodger2005).
Professionals are working within complex social, political, and economic health care environments (Essen, Freshwater, & Cahill, Reference Essen, Freshwater and Cahill2015; Fox & Reeves, Reference Fox and Reeves2015), so it is not surprising that there are challenges associated with interprofessional collaboration. For example, professionals’ patterns of behaviour (or routines) differ from one another, which makes effectively collaborating with one another a formidable effort (Duner, Reference Duner2013; Elissen, van Raak, & Paulus, Reference Elissen, van Raak and Paulus2011). Other challenges include professional hierarchies, insufficient time to effectively collaborate (Reeves et al., Reference Reeves, Rice, Conn, Miller, Kenaszchuk and Zwarenstein2009a), and team members having different professional knowledge and identity (Baxter & Brumfitt, Reference Baxter and Brumfitt2008). Consequently, a common language to effectively communicate is lacking (Mickan & Rodger, Reference Mickan and Rodger2005), which explains why there are reported challenges with communication and collaboration among interprofessional team members (Reeves, Reference Reeves2012; Rowlands & Callen, Reference Rowlands and Callen2013).
Scholars have developed a theoretical framework to reflect that relational, processual, organizational, and contextual issues all influence interprofessional teamwork (Reeves et al., Reference Reeves, Lewin, Espin and Zwarenstein2010). Reeves et al. (Reference Reeves, Lewin, Espin and Zwarenstein2010) suggested that relational issues include professions’ use of power, team roles, processes, and/or composition. Processual issues include the time and space to meet, routines, urgency of the patient/client needs, and/or tasks being shifted to less educated health care workers. Organizational issues include the support within the institution for teamwork and professional representation. Contextual issues include gender, the diversity of the team, and/or the organizational or unit culture. These complex issues underpinning interprofessional collaboration could explain why, despite four decades of research, an understanding of the processes by which professionals collaborate (the how) is missing from the literature (Jones & Jones, Reference Jones and Jones2011; Lemieux-Charles & McGuire, Reference Lemieux-Charles and McGuire2006; Paradis et al., Reference Paradis, Leslie, Puntillo, Gropper, Aboumatar, Kitto and Reeves2014; Reeves et al., Reference Reeves, Lewin, Espin and Zwarenstein2010). Also missing is the impact of interprofessional collaboration on outcomes of older adults with cognitive challenges – those experiencing delirium, dementia, depression, or any combination of these conditions.
The aim of this study was to conduct a scoping review of the literature to examine how interprofessional teams are able to improve outcomes for older adults experiencing cognitive challenges. In other words, we were interested in the processes that interprofessional teams use to collaborate with one another to achieve positive outcomes with these older adults in community, long-term care, and acute care settings.
Methods
We conducted a scoping review of the literature to map out and identify the extent, range, and nature of research activity by interprofessional health care teams in their reported successes caring for older adults experiencing cognitive challenges, as well as to identify research gaps in the existing literature (Levac, Colquhoun, & O’Brien, Reference Levac, Colquhoun and O’Brien2010). The review followed Arksey and O’Malley’s (Reference Arksey and O’Malley2005) methodological framework for scoping reviews. The stages in this framework included (1) identifying the research aim and questions; (2) identifying relevant studies; (3) selecting the studies; (4) charting the data; and (5) collating, summarizing and reporting the results. In stage one, our broad research aim was “how do interprofessional health care teams improve the outcomes of older adults experiencing cognitive challenges?” (Levac et al., Reference Levac, Colquhoun and O’Brien2010). To help us identify the elements that could influence interprofessional teams’ success, we identified the following questions to guide our data collection and analysis:
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1) What team composition(s) influences positive outcomes?
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2) What did the teams consider as positive outcomes?
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3) What fostered teams’ success?
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4) What constrained teams’ success?
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5) How were older adults and their families’ perspectives included?
In stage two, we applied three main concepts to search: multidisciplinary or interdisciplinary care teams, confusion or cognitive impairment, and older adults. The databases we searched were Ovid, Medline 1946, and MEDLINE In-Process & other non-indexed citations, Ovid Embase 1974, Ovid PsycINFO 1806, Ovid EMB Reviews, Cochrane Central Register for Controlled Trials, EBSCOhost CINAHL, Conference Proceedings Citation Index – Science 1990, Conference Proceedings Citation Index – Social Science & Humanities 1990 SocINDEX, Academic Search Complete and Web of Science. In retrieving literature from our searches, we used appropriate subject headings and keywords. Table 1 lists our search strategies and terms.
Search terms
Inclusion and Exclusion Criteria
Inclusion criteria included research studies related to interprofessional health care teams and older adults with cognitive challenges – those with delirium, dementia, or depression. Articles in the English language and published between the years 1966 and 2015 were included. Articles that were protocols of a proposed study, or reported on educational interventions with health care teams, or opinion papers were excluded.
Applying the Criteria
Two researchers (SD and MS) independently reviewed the titles and abstracts of all the articles. Full text review and hand searches of references were then performed by the first two authors. In systematic review articles and Cochrane reviews, primary studies were examined for appropriateness using the inclusion criteria (Figure 1).
Process of Scoping Review
Data Extraction
Data were charted using a tailored data extraction form, identifying the purpose of the article, method, results, and comments about the processes that the interprofessional teams used to ascribe success in working with older adults experiencing cognitive challenges (Table 2).
How interprofessional teams collaborate in the care of older adults experiencing cognitive challenges: A scoping review
Note: GP = general practitioner; HF = heart failure; IGCT = inpatient geriatric consultation team; MDT = multidisciplinary team; PT = physical therapist; OT = occupational therapist; RCT = randomised controlled trial
Data Analysis
We then collated data to determine settings, countries, and what types of studies were represented. The research team met to discuss and critically analyse how the data could be used to understand the processes interprofessional teams used, as well as to answer our questions about team composition, what were considered positive outcomes, what fostered teams’ success, what constrained their success, and whether older adults and their families’ perspectives were included, and if so, how.
Results
We conducted the search on November 10, 2014 and updated it in August of 2015. In total, we retrieved 4,554 articles. Of these, 859 were duplicates. Following exclusions (Figure 1), a total of 34 articles were included. Of these, 27 were randomized/controlled trials, five evaluations, and two quasi-experimental studies. Four articles reported data from two studies (Deschodt et al., Reference Deschodt, Braes, Broos, Sermon, Boonen, Flamaing and Milisen2011; Deschodt et al., Reference Deschodt, Braies, Flamaing, Detroyer, Broos, Haentjens and Milisen2012; Shyu et al., Reference Shyu, Tsai, Chen, Cheng, Wu, Su and Chou2012; Shyu et al., Reference Shyu, Tseng, Liang, Tsai, Wu and Cheng2013). The articles represented studies conducted in different countries. We obtained 11 from the United States (Allen et al., Reference Allen, Becker, McVey, Saltz, Feussner and Cohen1986; Bellantonio et al., Reference Bellantonio, Kenny, Fortinsky, Kleppinger, Robison, Gruman and Trella2008; Callahan et al., Reference Callahan, Boustanin, Unverzagt, Austrom, Damush, Perkins and Hendrie2006; Campion, Jette, & Berkman, Reference Campion, Jette and Berkman1983; Chapman & Toseland, Reference Chapman and Toseland2007; Dellasega, Salerno, Lacko, & Wasser, Reference Dellasega, Salerno, Lacko and Wasser2001; Inouye et al., Reference Inouye, Bogardus, Charpentier, Leo-Summer, Acampora, Holford and Cooney1999; Kratz, Reference Kratz2008; Sandhaus et al., Reference Sandhaus, Zalon, Valenti, Dzielak, Smego and Arqamasova2010; Saltz, McVey, Becker, Feussner, & Cohen, Reference Saltz, McVey, Becker, Feussner and Cohen1988; Winograd, Gerety, & Lai, Reference Winograd, Gerety and Lai1993); four from Australia (Crotty et al., Reference Crotty, Halbert, Rowett, Giles, Birks, Williams and Whitehead2004; Llewellyn-Jones et al., Reference Llewellyn-Jones, Baikie, Smithers, Cohen, Snowdon and Tennant1999; Mudge, Mauseen, Duncan, & Denaro, Reference Mudge, Maussen, Duncan and Denaro2012; Opie, Doyle, & O’Connor, Reference Opie, Doyle and O’Connor2002); one from Brazil (Christofoletti et al., Reference Christofoletti, Oliani, Gobbi, Stella, Gobbi and Canineu2008); one from Taiwan (Shyu et al., Reference Shyu, Tsai, Chen, Cheng, Wu, Su and Chou2012; Shyu et al., Reference Shyu, Tseng, Liang, Tsai, Wu and Cheng2013); one from Canada (Cole et al., Reference Cole, McCusker, Bellavance, Primeau, Bailey, Bonnycastle and Laplante2002) and 14 from European countries. The European countries’ studies were represented by three from the Netherlands (Boorsma et al., Reference Boorsma, Frijters, Knol, Ribbe, Nijpels and van Hout2011; van der Marck et al., Reference van der Marck, Bloem, Borm, Overeem, Munneke and Guttman2013; Leontjevas et al., Reference Leontjevas, Teerenstra, Smalbrugge, Vernooij-Dassen, Bohlmeijer, Gerritsen and Koopmans2013); three from England (Banerjee et al., Reference Banerjee, Willis, Matthews, Contell, Chan and Murray2007; Lloyd-Williams & Payne, Reference Lloyd-Williams and Payne2002; O’Connor et al., Reference O’Connor, Pollitt, Brook, Reiss and Roth1991); two from Sweden (Schmidt et al., Reference Schmidt, Claesson, Westerholm, Nilsson and Svarstad1998; Stenvall et al., Reference Stenvall, Berggren, Lundstrom, Gustafson and Olofsson2012); one from Finland (Huusko et al., Reference Huusko, Karppi, Avikainen, Kautiainen and Sulkava2000); two from Belgium (Deschodt et al., Reference Deschodt, Braes, Broos, Sermon, Boonen, Flamaing and Milisen2011; Deschodt et al., Reference Deschodt, Braies, Flamaing, Detroyer, Broos, Haentjens and Milisen2012; Milisen et al., Reference Milisen, Foreman, Abraham, Geest, Godderis, Vandermeulen and Broos2001); one from Germany (Kircher et al., Reference Kircher, Wormstall, Muller, Schwarzler, Buchkremer, Wild and Meisner2007); one from France (Villars et al., Reference Villars, Dupuy, Soler, Gardette, Soto, Gillette and Vellas2013); and one from Italy (Sindaco et al., Reference Sindaco, Pulignana, Lenarda, Tarantini, Cioffi, Tolone and Minardi2012).
The study breakdown developed as follows: (1) Five studies were related to community-dwelling older adults, (Banerjee et al., Reference Banerjee, Willis, Matthews, Contell, Chan and Murray2007; Callahan et al., Reference Callahan, Boustanin, Unverzagt, Austrom, Damush, Perkins and Hendrie2006; van der Marck et al., Reference van der Marck, Bloem, Borm, Overeem, Munneke and Guttman2013; O’Connor, Pollitt, Brook, Reiss, & Roth, 1991; Sindaco et al., Reference Sindaco, Pulignana, Lenarda, Tarantini, Cioffi, Tolone and Minardi2012); (2) 23 studies concerned hospitalized older adults (Allen et al., Reference Allen, Becker, McVey, Saltz, Feussner and Cohen1986; Campion et al., Reference Campion, Jette and Berkman1983; Cole et al., Reference Cole, McCusker, Bellavance, Primeau, Bailey, Bonnycastle and Laplante2002; Dellasega et al., Reference Dellasega, Salerno, Lacko and Wasser2001; Deschodt et al., Reference Deschodt, Braes, Broos, Sermon, Boonen, Flamaing and Milisen2011; Deschodt et al., Reference Deschodt, Braies, Flamaing, Detroyer, Broos, Haentjens and Milisen2012; Huusko, Karppi, Avikainen, Kautiainen, & Sulkava, Reference Huusko, Karppi, Avikainen, Kautiainen and Sulkava2000; Inouye et al., Reference Inouye, Bogardus, Charpentier, Leo-Summer, Acampora, Holford and Cooney1999; Kircher et al., Reference Kircher, Wormstall, Muller, Schwarzler, Buchkremer, Wild and Meisner2007; Kratz, Reference Kratz2008; Milisen et al., Reference Milisen, Foreman, Abraham, Geest, Godderis, Vandermeulen and Broos2001; Mudge et al., Reference Mudge, Maussen, Duncan and Denaro2012; Saltz et al., Reference Saltz, McVey, Becker, Feussner and Cohen1988; Sandhaus et al., Reference Sandhaus, Zalon, Valenti, Dzielak, Smego and Arqamasova2010; Shyu et al., Reference Shyu, Tsai, Chen, Cheng, Wu, Su and Chou2012; Shyu et al., Reference Shyu, Tseng, Liang, Tsai, Wu and Cheng2013; Stenvall, Berggren, Lundstrom, Gustafson, & Olofsson, Reference Stenvall, Berggren, Lundstrom, Gustafson and Olofsson2012; Villars et al., Reference Villars, Dupuy, Soler, Gardette, Soto, Gillette and Vellas2013; Lloyd-Williams & Payne, Reference Lloyd-Williams and Payne2002; Winograd et al, Reference Winograd, Gerety and Lai1993); and (3) eight studies related to long-term care or assisted living (Bellantonio et al., Reference Bellantonio, Kenny, Fortinsky, Kleppinger, Robison, Gruman and Trella2008; Boorsma et al., Reference Boorsma, Frijters, Knol, Ribbe, Nijpels and van Hout2011; Chapman & Toseland, Reference Chapman and Toseland2007; Christofoletti et al., Reference Christofoletti, Oliani, Gobbi, Stella, Gobbi and Canineu2008; Crotty et al., Reference Crotty, Halbert, Rowett, Giles, Birks, Williams and Whitehead2004; Leontjevas et al., Reference Leontjevas, Teerenstra, Smalbrugge, Vernooij-Dassen, Bohlmeijer, Gerritsen and Koopmans2013; Llewellyn-Jones et al.,Reference Llewellyn-Jones, Baikie, Smithers, Cohen, Snowdon and Tennant1999; Opie et al., Reference Opie, Doyle and O’Connor2002; Schmidt, Claesson, Westerholm, Nilsson, & Svarstad, Reference Schmidt, Claesson, Westerholm, Nilsson and Svarstad1998).
The results reflect our inquiry into interprofessional team composition, successes and challenges identified by teams, team processes (how they collaborated), and how older adults and their families’ perspectives were taken into account.
Team Composition(s)
Team composition varied, with 10 studies (31%) describing geriatric consultation teams and 19 (59%) describing programs or approaches to care that had been developed by an interprofessional team. Three of the authors did not identify the composition of the team (Banerjee et al., Reference Banerjee, Willis, Matthews, Contell, Chan and Murray2007; Boorsma et al., Reference Boorsma, Frijters, Knol, Ribbe, Nijpels and van Hout2011; Mudge et al., Reference Mudge, Maussen, Duncan and Denaro2012). The remaining 31 articles identified a wide range of disciplines. The represented disciplines ranged from only two – a geriatrician and geriatric nurse specialist (Shyu et al., Reference Shyu, Tsai, Chen, Cheng, Wu, Su and Chou2012, Reference Shyu, Tseng, Liang, Tsai, Wu and Cheng2013) – to larger teams encompassing many disciplines, such as geriatrician, geropsychiatrist, social worker, occupational therapist, physiotherapist, speech therapist, recreational therapist, nutritionist, and discharge planning nurse (Campion et al., Reference Campion, Jette and Berkman1983). Table 3 identifies the team composition and the context for each of the articles. The type of interventions targeted influenced the types of professionals involved. For example, when the focus was mobility, occupational therapists and physiotherapists were involved (Christofoletti et al., Reference Christofoletti, Oliani, Gobbi, Stella, Gobbi and Canineu2008). When the focus was on decreasing depression, general practitioners and nursing home staff were involved (Llewellyn-Jones et al., Reference Llewellyn-Jones, Baikie, Smithers, Cohen, Snowdon and Tennant1999). Team composition related to the purpose of the team and the context – hospital, home, or residential care – rather than a formula of particular professionals.
Interprofessional team composition and context
Reported Successes
Reported successes were as diverse as the composition of the teams and are identified in Table 2; under the results column, each study’s reported success is identified. Eight (24%) of the articles reported on improved cognition (Allen et al., Reference Allen, Becker, McVey, Saltz, Feussner and Cohen1986; Deschodt et al., Reference Deschodt, Braies, Flamaing, Detroyer, Broos, Haentjens and Milisen2012; Inouye et al., Reference Inouye, Bogardus, Charpentier, Leo-Summer, Acampora, Holford and Cooney1999; Kratz, Reference Kratz2008; Llewellyn-Jones et al., Reference Llewellyn-Jones, Baikie, Smithers, Cohen, Snowdon and Tennant1999; Milisen et al., Reference Milisen, Foreman, Abraham, Geest, Godderis, Vandermeulen and Broos2001; Mudge et al., Reference Mudge, Maussen, Duncan and Denaro2012; Shyu et al., Reference Shyu, Tseng, Liang, Tsai, Wu and Cheng2013); six (18 %) reported on improvements in psychosocial functioning (Banerjee et al., Reference Banerjee, Willis, Matthews, Contell, Chan and Murray2007; Callahan et al., Reference Callahan, Boustanin, Unverzagt, Austrom, Damush, Perkins and Hendrie2006; Dellasega et al., Reference Dellasega, Salerno, Lacko and Wasser2001; Leontjevas et al., Reference Leontjevas, Teerenstra, Smalbrugge, Vernooij-Dassen, Bohlmeijer, Gerritsen and Koopmans2013; van der Marck et al., Reference van der Marck, Bloem, Borm, Overeem, Munneke and Guttman2013; Opie et al., Reference Opie, Doyle and O’Connor2002); five (15%) on physical functioning (Chapman & Toseland, Reference Chapman and Toseland2007; Christofoletti et al., Reference Christofoletti, Oliani, Gobbi, Stella, Gobbi and Canineu2008; Sindaco et al., Reference Sindaco, Pulignana, Lenarda, Tarantini, Cioffi, Tolone and Minardi2012; Shyu et al., Reference Shyu, Tsai, Chen, Cheng, Wu, Su and Chou2012; Stenvall et al., Reference Stenvall, Berggren, Lundstrom, Gustafson and Olofsson2012); four (12%) on decreased use of health care services or medications (Campion et al., Reference Campion, Jette and Berkman1983; Crotty et al., Reference Crotty, Halbert, Rowett, Giles, Birks, Williams and Whitehead2004; Huusko et al., Reference Huusko, Karppi, Avikainen, Kautiainen and Sulkava2000; Schmidt et al., Reference Schmidt, Claesson, Westerholm, Nilsson and Svarstad1998); two (6%) on improved quality of care (Boorsma et al., Reference Boorsma, Frijters, Knol, Ribbe, Nijpels and van Hout2011; Lloyd-Williams & Payne, Reference Lloyd-Williams and Payne2002); and one (3%) on family satisfaction (Sandhaus et al., Reference Sandhaus, Zalon, Valenti, Dzielak, Smego and Arqamasova2010).
Examples of how interventions led to success include individually tailored medical, nursing, and psychosocial interventions that led to reductions in responsive behaviours in nursing home residents with dementia (Opie et al., Reference Opie, Doyle and O’Connor2002). One team that developed protocols to manage specific care issues reported improved orientation, nonpharmacological management of sleep, early mobilization, decreased fall rate, and lower restraint and sedative use (Kratz, Reference Kratz2008). Another team achieved significant improvements in medication use with residents as a result of case conferencing (Crotty et al., Reference Crotty, Halbert, Rowett, Giles, Birks, Williams and Whitehead2004). Geriatric consultation services teams improved awareness of older adults’ functional problems (Campion et al., Reference Campion, Jette and Berkman1983) and improved quality of life (Boorsma et al., Reference Boorsma, Frijters, Knol, Ribbe, Nijpels and van Hout2011) through comprehensive assessments.
Although all of the articles suggested that interprofessional teams had the potential for success in working with older adults experiencing cognitive challenges, there was considerable variation in the reported successes. Eight (24%) of the articles either did not report success or reported no significant changes in desired outcomes (Bellantonio et al., Reference Bellantonio, Kenny, Fortinsky, Kleppinger, Robison, Gruman and Trella2008; Cole et al., Reference Cole, McCusker, Bellavance, Primeau, Bailey, Bonnycastle and Laplante2002; Deschodt et al., Reference Deschodt, Braes, Broos, Sermon, Boonen, Flamaing and Milisen2011; Kircher et al., Reference Kircher, Wormstall, Muller, Schwarzler, Buchkremer, Wild and Meisner2007; O’Connor et al., Reference O’Connor, Pollitt, Brook, Reiss and Roth1991; Saltz et al., Reference Saltz, McVey, Becker, Feussner and Cohen1988; Villars et al., Reference Villars, Dupuy, Soler, Gardette, Soto, Gillette and Vellas2013; Winograd et al., Reference Winograd, Gerety and Lai1993). Moreover, authors rarely provided detailed information about how successes were achieved. In other words, the processes that teams used to achieve their success were not consistently mentioned.
Reported Challenges
Only six authors (16 %) reported barriers to success. These authors reported on geriatric consultation teams and identified a lack of adherence to team recommendations (Callahan et al., Reference Callahan, Boustanin, Unverzagt, Austrom, Damush, Perkins and Hendrie2006; Cole et al., Reference Cole, McCusker, Bellavance, Primeau, Bailey, Bonnycastle and Laplante2002; Deschodt et al., Reference Deschodt, Braes, Broos, Sermon, Boonen, Flamaing and Milisen2011; Reference Deschodt, Braies, Flamaing, Detroyer, Broos, Haentjens and Milisen2012; O’Connor et al., Reference O’Connor, Pollitt, Brook, Reiss and Roth1991; Winograd et al., Reference Winograd, Gerety and Lai1993). Winograd et al. (Reference Winograd, Gerety and Lai1993) reported that recommendations requiring staff time, effort, or understanding of geriatric syndromes were least likely to be followed. They noted that staffing levels and processes by which professionals on the units work together were outside the influence of a geriatric consultation team. Moreover, O’Connor et al. (Reference O’Connor, Pollitt, Brook, Reiss and Roth1991) reported that families often did not accept recommendations made by the geriatric consultation team. Most authors (84%) did not provide any information about the challenges to their interprofessional team’s success.
Team Processes
Ten articles (29%) reported on processes, which fostered success in implementing teams’ recommendations or programs (Allen et al., Reference Allen, Becker, McVey, Saltz, Feussner and Cohen1986; Dellasega et al., Reference Dellasega, Salerno, Lacko and Wasser2001; Callahan et al., Reference Callahan, Boustanin, Unverzagt, Austrom, Damush, Perkins and Hendrie2006; Chapman & Toseland, Reference Chapman and Toseland2007; Llewellyn-Jones et al., Reference Llewellyn-Jones, Baikie, Smithers, Cohen, Snowdon and Tennant1999; Lloyd-Williams & Payne, Reference Lloyd-Williams and Payne2002; van der Marck, Reference van der Marck, Bloem, Borm, Overeem, Munneke and Guttman2013; Mudge et al., Reference Mudge, Maussen, Duncan and Denaro2012; Schmidt et al., Reference Schmidt, Claesson, Westerholm, Nilsson and Svarstad1998; Villars et al., Reference Villars, Dupuy, Soler, Gardette, Soto, Gillette and Vellas2013). These authors identified the importance of communication, staff involvement strategies, and education interventions. Mudge et al. (Reference Mudge, Maussen, Duncan and Denaro2012) reported that monthly care rounds, frequently seeking feedback from unit staff, using a communication book, and frequent one-on-one team interaction improved staff’s detection of older adults with (or at risk for) delirium. Lloyd-Williams and Payne (Reference Lloyd-Williams and Payne2002) identified that staff involvement in developing interprofessional guidelines aided in guideline implementation. Villars et al. (Reference Villars, Dupuy, Soler, Gardette, Soto, Gillette and Vellas2013) used a resource person (nurse or caregiver) to facilitate communication about care plans between the interprofessional team and caregivers. Llewellyn-Jones et al. (Reference Llewellyn-Jones, Baikie, Smithers, Cohen, Snowdon and Tennant1999) trained general practitioners in detecting depression and held education programs for older adults about managing depression. Dellasega et al. (Reference Dellasega, Salerno, Lacko and Wasser2001) reported that weekly team meetings focused on how to evaluate and make recommendations about their older adult patients served to build team confidence and motivation to implement the recommendations. Unfortunately, exactly how confidence and motivation were fostered was not described. Other authors identified the importance of encouraging team members’ participation (Allen et al., Reference Allen, Becker, McVey, Saltz, Feussner and Cohen1986; Schmidt et al., Reference Schmidt, Claesson, Westerholm, Nilsson and Svarstad1998) and supporting team members (Callahan et al., Reference Callahan, Boustanin, Unverzagt, Austrom, Damush, Perkins and Hendrie2006; Chapman & Toseland, Reference Chapman and Toseland2007; van der Marck, Reference van der Marck, Bloem, Borm, Overeem, Munneke and Guttman2013), but did not describe how supporting team members and their participation occurred.
Older Adults and Their Families
Only three of the articles (9%) reported involving older adults and their families’ perspectives in health care teams’ care planning. These included (1) a study which reported on the incorporation of residents and families in the planning of interventions for residents with dementia (Chapman & Toseland, Reference Chapman and Toseland2007), (2) a trial reporting that patients and families were satisfied with a volunteer program to decrease delirium (Sandhaus et al., Reference Sandhaus, Zalon, Valenti, Dzielak, Smego and Arqamasova2010), and (3) an examination of discussions about care plans with older adults and their family members in order to adjust plans according to personal wishes (Boorsma et al., Reference Boorsma, Frijters, Knol, Ribbe, Nijpels and van Hout2011). Unfortunately, Chapman and Toseland did not provide enough information for us to understand how residents and families were incorporated, nor did Sandhaus et al. identify why patients and families were satisfied with their volunteer program. The lack of information about how teams worked with older adults and their families in 91 per cent of the articles suggests that either authors are not reporting these details, or that older adults and their families’ perspectives are not being solicited. Ultimately, this lack of information suggests gaps in our understanding about how interprofessional teams can best work with older adults experiencing cognitive challenges and their families.
Discussion
Because 71 per cent of authors did not report on interprofessional team processes, our results highlight a gap in authors’ reporting how interprofessional teams achieve positive outcomes for older adults experiencing cognitive challenges. Moreover, 91 per cent of authors did not report on how interprofessional teams worked with older adults and their families, suggesting that not only do we have gaps in understanding how interprofessional teams achieve success, but we also do not understand how to best to work with older adults and their families. Other scholars have noted the lack of understanding of team processes (Jones & Jones, Reference Jones and Jones2011; Lemieux-Charles & McGuire, Reference Lemieux-Charles and McGuire2006; Paradis et al., Reference Paradis, Leslie, Puntillo, Gropper, Aboumatar, Kitto and Reeves2014; Reeves et al, Reference Reeves, Lewin, Espin and Zwarenstein2010). The 29 per cent of authors who did report on process highlighted the importance of communication, staff involvement strategies, and education interventions to support success both in achieving outcomes with older adults and in supporting interprofessional collaboration.
We considered how these results fit within Reeves et al.’s (Reference Reeves, Lewin, Espin and Zwarenstein2010) theoretical framework, which identifies relational, contextual, organizational, and process issues regarding interprofessional collaboration. Their organizational and process issues can be found in Winograd et al.’s (Reference Winograd, Gerety and Lai1993) report of staffing levels and work processes as barriers to having the interprofessional teams’ recommendations followed. Moreover, details about relational issues were provided by four authors, as follows: Mudge et al. (Reference Mudge, Maussen, Duncan and Denaro2012) discussed meetings and one-on-one interactions, and Lloyd-Williams and Payne (Reference Lloyd-Williams and Payne2002) discussed staff involvement in developing guidelines. Dellasega et al. (Reference Dellasega, Salerno, Lacko and Wasser2001) stressed the importance of weekly team meetings, and Villars et al. (Reference Villars, Dupuy, Soler, Gardette, Soto, Gillette and Vellas2013) suggested that one-on-one human interaction could facilitate communication about care plans. In addition, although they did not provide details, five other authors supported relational issues by suggesting the importance of encouraging and supporting team members (Allen et al., Reference Allen, Becker, McVey, Saltz, Feussner and Cohen1986; Callahan et al., Reference Callahan, Boustanin, Unverzagt, Austrom, Damush, Perkins and Hendrie2006; Chapman & Toseland, Reference Chapman and Toseland2007; van der Marck et al., Reference van der Marck, Bloem, Borm, Overeem, Munneke and Guttman2013; Schmidt et al., Reference Schmidt, Claesson, Westerholm, Nilsson and Svarstad1998). These findings support Manser’s (Reference Manser2009) suggestion that effective teamwork requires communication and, coordination. We suggest that our findings support the importance of organizational, process, and relational issues that have been identified by Reeves et al. (Reference Reeves, Lewin, Espin and Zwarenstein2010).
The theoretical framework of relationship-centred care aides in conceptualizing health care as embedded in human relationships, between care recipients and health care providers, and among health care providers (Soklaridis, Ravitz, Nevo, & Lieff, Reference Soklaridis, Ravitz, Nevo and Lieff2016; Tresolini et al., Reference Tresolini, Inui, Candib, Cunningham, England, Frankel and Watson1994). Our findings add to these scholars’ findings and highlight the importance of relationships to patients, health care professionals, and the organization in providing collaborative care to improve both patient care and organizational performance (Soklaridis et al., Reference Soklaridis, Ravitz, Nevo and Lieff2016). Yet engaging in relationships requires trust, which is also a necessary ingredient for effective teamwork affected by organizational culture (Cox, Reference Cox2012). More research to understand how health care professionals are able to form team relationships that foster trust and how organizational processes can support the development of these trusting relationships would inform strategies to improve interprofessional collaboration.
Although scholars have suggested that interprofessional teams experience power conflict, confusion about their roles, differences in use of language, and inadequate organizational supports (Barrow, McKimm, Gasquoine, & Rowe, Reference Barrow, McKimm, Gasquoine and Rowe2014; Finn, Learmonth, & Reedy, Reference Finn, Learmonth and Reedy2010; Fox & Reeves, Reference Fox and Reeves2015), insufficient detail was provided by the authors to determine if these issues affected the interprofessional collaboration of the teams in the studies. We wonder if an emphasis on reporting the outcomes of a research study eclipses the need to provide information about processes. We implore researchers to include these details in their publications in order to build an evidence base about team processes – what does not work, what works, and how it works.
We contend that understanding how (the process by which) interprofessional teams achieve success working with older adults experiencing cognitive challenges is of paramount importance, particularly when there are multiple voices (from multiple disciplines) communicating with older adults who may be physically and cognitively frail – as is the case with delirium, dementia, and depression. The dearth of information provided about team processes suggests that either authors are not reporting these details, or their complex nature has not been given adequate consideration. More research is needed to examine the processes of interprofessional teams that are having success in working with older adults experiencing cognitive challenges and their families. Understanding how successful teams interact with one another and with older adults, as well as how organizational supports influence their collaboration, would provide practical strategies for guiding interprofessional teams working with older adults experiencing cognitive challenges.
This study was limited by inclusion of English-only articles and by the scoping review structure; the rigor of the studies included as data were not analysed. Rather, data were critically examined for how authors reported on their success, challenges, the process teams used to achieve their outcomes (how), and older adult and family involvement. This study points to significant gaps in our understanding about the ways in which relationships, processes, context, and organizational support influence how interprofessional teams can best work with these vulnerable older adults and their families.
Conclusion
This scoping review of the literature about how interprofessional teams successfully work with older adults experiencing cognitive challenges and their families revealed gaps in our understanding about successful processes. Twenty-nine per cent of authors identified communication, education, and staff involvement as important processes that support team success. More research is needed to understand the processes that influence interprofessional team’s success with this population.
