?????????How do Multidisciplinary Team members communicate with older patients who have a cognitive impairment?
An exploration of participation and communication within Family Meetings in a
hospital setting, using an action research approach.
???????????DSIDC Seminar- 29th April 2010
Sarah Donnelly, Social Worker/PhD Student
Adelaide and Meath Hospital Tallaght
School of Social Work and Social Policy, Trinity College Dublin
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??Presentation Overview
! Background to study
! Aims and Objectives of Care and Connect ! Background Literature and Methodology ! Phase I/Pilot Study
! Findings
! Phase II
! Research Questions
! Outcomes
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??‘Family meetings’
! Used more frequently to determine care plans for older people, without:
! any particular protocol for these meetings
! consistency about the participation of the patient
! Carter-Anand et al.,2009
! Are patients intentions / wishes maximised?
! How to balance role/input of family caregivers and wishes of patient?
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??Care and Connect
! Joint initiative (2007)
! Adelaide and Meath Hospital, Tallaght
! School Social Work and Social Policy, TCD.
! Post is a new departure for social work profession in Ireland as it is a practice/research partnership between hospital and university.
! Funded AMNCH
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?Aims and Objectives
! Promote best practices in person-centered care planning for older people through a process of investigation, trial and consultation
! Promote partnership in decision making between older people, families and health care professionals and to gain a deeper understanding of this process
! Develop strong practice/research partnership for hospital based social work
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??Care Planning Meeting?
! ..‘involves a number of family members, the patient and the hospital personnel in discussions concerning the patient’s illness, treatment and plans for their discharge or their care outside the hospital’
! Hansen, P 1998
! Increasinglycommondecision-makingforuminthehospital setting but there is limited research into the process and experience of such meetings. Although this forum is intended to encourage active participation and empowerment of older people and their families in decision making, doubts exist as to
! Efraimsson E, 2004
???????whether they effectively carry out this role
??Health Care Practitioners
! Have divergent understandings of what constitutes a ‘family meeting’ and differing terms for this process
???????! family meetings
! family conferences
! discharge planning conferences ! care planning meeting
Griffith et al. 2004
Hansen et al. 1998
Efraimsson et al. 2003
Popejoy. 2005, Hedberg et al. 2008
! HCP’s have a significant role to play in facilitating and enabling active participation of patients in these meetings, but need for
! Hedberg,B 2008
education and training
??Action Research
! Chosen to describe, evaluate and offer a mechanism for the development of service delivery as it is inherently practical, change orientated, cyclical and participatory in nature
! le May & Lathlean,2001
! AR is ‘Any systematic enquiry, large/small, conducted by professionals and focusing on some aspects of their practice in order to find out more about it and eventually to act in ways that they see as better or
more effective’
! Oberg & Mc Cutcheon,1987
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?Action Research Cycle
????????Implement Change Observation
??Reflection/Analysis
?Pilot Study/Phase 1
??METHOD
Participant Observation
?OBJECTIVE
Describe in rich detail the current processes that occur within Care Planning Meetings.
?Gain insight into the subjective experiences of older people and their family members during family meetings.
Questionnaires
Examine staff members experiences of Care Planning Meetings and suggestions for improvements.
Staff Focus Groups
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??Observations
! Informal processes
! body language, eye contact, seating
arrangements, punctuality ! Jargon
! Processes/Interactions
! Information shared/given ! Decisions made
! Other
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?Participant Profiles
???????! 10 Family Meetings ! In-patients over-65 ! 7 men, 3 women
! 5 Stroke Service
! 5 General Medicine
! 7 assessed as cognitively impaired
! 4 out of 7 assessed as ‘without capacity’ and did not attend
! Family Member 2-7 attendees
! Staff 3-6 attendees
??Findings- Observations
! Consistently good eye contact between MDT and family members
! Eye contact often poor with patients, particularly with cognitive impairment
! Circular seating arrangements – inclusive.
! Demarcation – families on one side, staff on the other.
! Punctuality of MDT an issue in one third of observations
! Generally open body language
! Jargon seldom used, explanation if used
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?Findings- Questionnaires
! Each meeting was first for participant and family
! 1 family were unclear about purpose of meeting
! All attending patients believed they had been included in decision-making process.
! 2 families believed final decisions had already been made by Medical Team and MDT prior to meeting
! 8 families reported they had been actively involved in the decision making process.
! All patients and family members felt they had been given adequate opportunities to ask questions and express their opinions.
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??Focus Groups- Emerging Themes
“# Descriptions of meetings
$# Pre- meeting preparation
%# Seating, meeting time and punctuality &# Facilitation and minute-taking
‘# Participation of patient and family
(# Decision-making process
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??Challenges
! Participation levels of patients varied: those with higher levels of cognitive impairment had lower levels of participation.
! Family members – higher levels of participation than patients
! Consistently good eye contact between staff and family
! Poor eye contact with patients
! Pt’s with cognitive impairment were ‘talked over’ with usage of 3rd person by HCP’s and family members
! Family members often surprised that older person with cognitive impairment included in the meeting
! Only in one meeting were staff observed to be overtly checking Pt’s understanding and paraphrasing what had been discussed
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?Synthesis
! Patients and families considered meetings to be a positive experience
! Some fundamental differences in opinion emerging between health care professionals about purpose and outcomes of family meetings.
! ? ‘tokenism’ of patient participation?
! Need for more research into investigating how language and behaviours of HCPs potentially impede patient participation through informal processes and poor communication
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?Phase I Changes Implemented
! MDT Critical Reference Group established.
! Name changed to ‘Care Planning Meetings’
! Further examine Care Planning meetings held with inpatients with cognitive impairment.
! Patient Information Leaflet developed
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??Phase II- AR Cycle
! InpatientsofStrokeServicerequiringCarePlanningmeeting
! Allages
! Cognitiveimpairment/communicationdifficulties.
! MMSEandWesternAphasiaBattery
! 10meetings
! In-depthsemi-structuredinterviewswithstrokepatient.
! Semi-structuredinterviewwithnominatedfamily member/support person
! PatientProfiles
! FeedbackandEvaluationofPatientInformationLeaflet
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?MDT Involvement- Phase II
! MDT form a Critical Reference Group where findings will be fed back and MDT will participate in analyses of data.
! MDT will become ‘co-researchers’ and work together to explore ways of further improving practice within Care Planning Meetings.
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??Phase III
! Development and implementation of Education and Training Programme for
MDT
! Teodorczuk 2009, Kurtz,SM., 2009
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?What we can learn!
! Whatdoestheconceptofparticipationmeanforeachindividual patient?
! Istherearelationshipbetweentheparticipationlevelsoffamily members and patients?
! How does the role of healthcare professionals relate to the participation levels of patients?
! Whatarethebarrierstoparticipationforstrokepatientswho have cognitive/communication difficulties?
! Whatcanbelearntfromtheexperienceoftryingtochangethe practice of healthcare professionals using an action research cycle?
! Willchangestopracticeresultinamorepositiveandsatisfying meetings experience for patients, family members and healthcare professionals?
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?What we can achieve!
! Improve our understanding of Care Planning Meetings as small group processes in a hospital setting.
! Develop best practice guidelines for Care Planning Meetings through staff training and development.
! Identify new ways of communicating with patients in meetings – implications for language and methods of communication in hospital settings.
! Improve and increase patient participation levels in Care Planning Meetings
! Develop a framework for participation that can be applied to other clinical groups.
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??Closing thought
! …the skill and effort that we put into our clinical communication does make an indelible impression on our patients, their families and their friends. If we do it badly, they may never forgive us; if we do it well they may never forget us.
! Buckman BMJ 2002
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?Thanks to…
! Patients and families
! Team
! Stroke Service, AMNCH
! Care and Connect Steering Committee ! Dr S Cahill, Prof D O’Neill
! Funding ! AMNCH
! Living with Dementia Programme/Atlantic Philanthropies
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