Older people and their families’ perceptions about their experiences with interprofessional teams

Abstract Aim To examine older people and their families’ perceptions about their experiences with interprofessional teams. Design Naturalistic inquiry using qualitative descriptive methods to provide a comprehensive summary of older people and their families’ experiences with interprofessional teams. Methods Interviews were conducted with 22 people from 11 families. The families had experiences with teams in a variety of settings, such as community, residential care and hospital. Data were analysed using inductive content analysis. NiVivo was used to record preliminary codes. Analysis included comparing and contrasting families’ experiences. Results Older people and their families wanted communication about what was going on, regardless of whether the news was good, bad or unknown. They also wanted care that took the concerns of the older person into consideration. Communication was a necessary ingredient to ensuring that the older person's unique concerns were known to the interprofessional team. These percepectives were discussed in the themes of communication and patient‐centred care.


| BACKGROUND
Interprofessional teams are frequently promoted as a means to provide quality, safety and efficiency of care within health care (Health Canada, 2007;Reeves, Lewin, Espin, & Zwarenstein, 2010;WHO, 2010). As well as interprofessional team involvement, actively involving older people in their own care has been associated with improved health and more effective healthcare utilization (Berglund et al., 2013;Hochhalter, Song, Rush, Sklar, & Stevens, 2010). However, older people face obstacles to active engagement in their care, such as low health literacy (Wolf, Gazmararian, & Baker, 2005) or delirium (Holroyd-Leduc, Khandwala, & Sink, 2010). Moreover, there is an increased incidence of dementia with advancing age which can compromise individuals' ability to interact effectively with multiple professionals (WHO, 2015). In cases of dementia, delirium or both, the families or informal caregivers of older people are frequently involved in decision-making on their behalf (Legare et al., 2014). In this situation, family involvement adds to the complexity of care and must be considered by interprofessional teams working in this area.
Scholars who have examined the characteristics of effective interprofessional teamwork suggest that to be effective, team members must have social competence, a willingness to share information, to be able to negotiate and solve problems, (Mickan & Rodger, 2005). Manser's (2009) review of the literature about patient safety and teamwork indicated that teams require patterns of communication, coordination and leadership to support their effectiveness. Yet, there is evidence that power issues, confusion about roles, inconsistent use of language and inadequate organizational supports are common challenges for interprofessional teams (Barrow et al., 2014;Finn, Learmonth, & Reedy, 2010;Fox & Reeves, 2015). These challenges reflect social, political and economic complexities associated with interprofessional collaboration (Essen, Freshwater, & Cahill, 2015;Fox & Reeves, 2015). Scholars have developed an interprofessional framework identifying the complexities to teamwork as: relational (personalities and social interactions); contextual (culture, gender, and economics); organizational challenges; and process issues, such as routines and rituals, complexity, urgency and task shifting (Reeves et al., 2010). Unfortunately, this framework fails to include the perspectives of either care recipients or their families.
All of the challenges and complexities of interprofessional teamwork influence how professionals communicate (Reeves, 2012;Rowlands & Callen, 2013). Thus, although effective interprofessional collaboration is believed to reduce duplication, clinical errors and enhance the quality of care (Morey et al., 2002;Schmitt, 2001Schmitt, , 2006, beliefs about the efficacy of interprofessional teams are shrouded in a lack of understanding about the processes (the how) by which professionals collaborate and communicate (Brandt, Lutfiyya, King, & Chioreso, 2014;Jones & Jones, 2011;Lemieux-Charles & McGuire, 2006;Paradis et al., 2014;Reeves et al., 2010). In other words, despite three decades of literature examining the efficacy of interprofessional teams, there remains an absence of evidence to guide teams in patterns of communication that will support collaboration with older people and their families.
There is also little research examining how interprofessional teams work with older people and their families. In a recent study, a scoping review which examined the factors associated with interprofessional teams' success when working with cognitively impaired older people, only 3 of 34 papers reviewed reported any information-how-be-itscant-about how team members worked with older persons or their families (Dahlke et al., 2017). This suggests that either researchers did not report this information, or that teams did not actively engage with this population. We found only four other studies that examined older people's experiences with interprofessional teams (Berglund et al., 2013;Eloranta, Routasalo, & Arve, 2008;Hochhalter et al., 2010;Lamb et al., 2014). Berglund et al. (2013)

| Design
This was a naturalistic inquiry using qualitative descriptive methods to provide a comprehensive summary of older people and their families' perspectives on their experiences with interprofessional teams (Sandelowski, 2000(Sandelowski, , 2010. Data were collected from June to December 2015 and included individual, dyad and triad interviews.

| Sampling
We used purposeful sampling to include older people and/or his or her family who had experiences with an interprofessional team. The clinicians from three interprofessional teams (an acute care team, a community team and a rehabilitation team) provided older people and their families with an information letter about the study that included the purpose of the study, information on potential risks, and the researchers' contact information. Older people and/or family members who were interested in participating contacted the researcher or consented to have the clinician share their contact information with the researcher.
Whenever possible we interviewed the older person and their family member together. Unfortunately, this was not always possible either due to family members availability, or because the older person with dementia was unable to remember or describe their experiences

| Ethical considerations
Research Ethics Committee approval was obtained from the University of record and operational approval from the participating health authority. All families were informed about the study, the voluntary nature of participation and confidentiality. All signed consent forms prior to their participation. Consent was obtained from older people when family and healthcare professionals agreed that they could provide informed consent. When the older person was unable to provide informed consent, their family provided consent and the older person received a simple explanation of the study and was asked for their assent prior to data collection.

| Data collection
Interviews occurred at a place of participants' choosing. Most of the interviews were conducted in participants' homes. Two were conducted in a quiet corner of a coffee shop at a hospital. The first author conducted all of the interviews using a semi-structured interview guide after obtaining informed consent. Questions were open-ended, focusing on exploring participants' experiences and perspectives.
Questions included but were not limited to: "tell me about your (or your family member's) experiences being cared for by a variety of healthcare professionals"; "How were your perspectives considered by the professionals?"; "How were your family's perspectives included?"; and "How would you like to engage with interprofessional teams?" The last question was included due to Eloranta et al. (2008) finding that despite professionals belief that they were collaborating with older people, the older people did not recognize the engagement as collaboration, leaving questions about what type of engagement older people want with interprofessional teams.

| Data analysis
Data were audio-recorded and then transcribed verbatim; all identifiers were removed prior to data analysis. When interviews provided no new perspectives, data were considered saturated. Inductive content analysis was used to analyse the data (Hsieh & Shannon, 2005;Sandelowski, 2000). The aim of content analysis is to interpret participants' perspectives as close to the data as possible, avoiding the use of preconceived codes or categories (Hsieh & Shannon, 2005). Analysis

| Validity and reliability
Analytical rigour was assured through incorporating general considerations for qualitative research. The trustworthiness of this study was enhanced by attending to the characteristics described by Grove, Gray, and Burns (2015). The credibility of the findings was enriched by triangulation of the data among the researchers. Moreover, that data for

| FINDINGS
Eleven families (22 individuals) participated in this study. They also wanted care that took the unique concerns of the older person into consideration. Communication was a necessary ingredient to ensuring that the older person's concerns were known to the interprofessional team. These perspectives are discussed further in the themes of communication and patient-centred care.

| Communication
Older  Her observations at her husband's bedside lead her to believe that the healthcare providers were not talking to one another and therefore, she had to stay as close to him as possible to make sure he would receive appropriate care. The communication gaps resulted in care that did not appear to be focused on Bob's needs, which included dementia, a broken arm and broken hip-the reason he was in the hospital. These gaps in communication also contributed to Louise's belief that she had to be a strong advocate for her husband.

| Person-centred care
Older

| Consistency
Family members viewed professionals talking among one another as evidence that they were concerned about providing uniform care that took the unique needs of the older person into consideration. They recognized that it took a team to provide around the clock care for their family member and to do that effectively professionals would need to communicate with one another. When interprofessional team members were talking to one another, it was viewed as evidence that "everybody wanted to make sure they were looking after him properly, and it was a wonderful example of teamwork" (Louise, wife). Another daughter identified that interprofessional communication fostered consistency in the care her father received. "Consistency. I think the team actually works as a team" (Sandy, daughter). Consistency was only possible if the members of the team were talking and listening to one another as well as to the family. If care was perceived as consistent, or if something happened and it was explained, then families were less anxious and were less likely to feel the need to strongly advocate for their older family member. The consistent communication among the interprofessional team was seen as evidence that there was a unit culture of concern for older patients.
Unfortunately, not all of the participants' experiences were of a culture that exhibited concern for the older person.

| Devaluing of older people
Many of the family members shared their belief that there was a devaluing of older people within healthcare institutions. This belief was linked to experiences in which their older family member's needs were not communicated among the healthcare team and/or they perceived that the older person did not have their needs met. This inadequate communication was viewed as a reflection of the healthcare system not supporting care of older people. "Don't spend money on a senior, because they're on their way out. Spend money on someone younger.
They are more valuable to society" (Ray, son). Families believed that fiscal restraints caused time pressures, which contributed to rushed or diminished communication with older people and their families. This resulted in, older people feeling like "you're not a person. You're a task" (Brent, son). Another wife echoed these sentiments when she suggested that lack of communication contributed to "patients not feeling that they are cared about. They feel like a burden and the families, they feel like they are in the way" (Louise, wife). When healthcare providers failed to communicate about his needs, which necessitated him to be mobilized in an unusual manner, the older person's perception was: "they didn't give a damn about you" (Bob, older person). It would seem that lack of communication was viewed as a lack of concern for the older person.
Families identified that they did expect that sometimes care or communication would be less than perfect. However, if care provided did not take the care needs of the older person into consideration and healthcare providers communicated what had gone wrong, then the family felt reassured that healthcare providers did consider the needs of their older family member overall. Families' belief that they needed to assume strong advocacy for their older family member to ensure that their needs were considered hinged on whether or not healthcare providers communicated openly when unexpected things happened or if something went wrong. This study contributes to an emerging body of literature examining family caregiving for older people (Funk, 2010;Jacelon, 2006;Li et al., 2003). Similar to the families in this study, others have identified that families consider it part of their responsibility to be involved in supporting family members as they age (Funk, 2010;O'Connor, Pollitt, Brook, Reiss, & Roth, 1991). Jacelon's (2006)  Much of the literature about interprofessional collaboration focuses on issues among professionals, rather than how care recipients (not necessarily older people) and their families' perspectives are incorporated. One exception is a study that examined families' involvement in intensive care units, which identified that family members provided continuity when communication among interprofessional team members was inadequate (Reeves et al., 2016). Similarly, in this study, families felt it was necessary to step in and advocate for their family member, when they were unable to advocate for themselves and when interprofessional team communication was fractured. Communication and team cohesion can support older people and families' experiences with interprofessional teams (Jacelon, 2006;Kilpatrick, Jabbour, & Fortin, 2016

| LIMITATIONS
This study is limited in size, scope and context. Although we endeavoured to sample broadly, all but one of the older participants experienced some type of dementia. The existence of dementia limited older peoples' ability to reflect on their experiences and, as a result, family members strongly influenced the findings. Moreover, most of the participants described their experiences as either good or bad, rather than somewhere in between. There may, therefore, have been bias in recruitment, families with either strongly positive or negative experiences being more likely to participate. Further research that includes larger number of families, a variety of cultures and in different contexts, such as rural and urban settings, could add to an understanding about how interprofessional teams could best interact with older people and their families.

| CONCLUSIONS
This study's examination of older people and their families' perspectives of interprofessional teams revealed that families are a necessary and integral part of the care of older people, particularly in the context of impaired cognition. Older people and their families wanted interprofessional teams to recognize their important role as advocates, communicate openly and provide person-centred care. More research is needed to understand the interprofessional teams' processes in order to better support collaboration with older people and their families.