Journal of Telemedicine and Telecare > Volume 14, Number 8 > Pp. 427-434

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RESEARCH Original articles

Assessing interprofessional teamwork in a videoconference-based telerehabilitation setting

Emmanuelle Careau ^*  , Claude Vincent   and Luc Noreau  

^* Faculty of Medicine, Laval University, Québec; Centre for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Québec; Department of Rehabilitation, Laval University, Québec, Canada

Correspondence: Emmanuelle Careau, Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Institut de réadaptation en déficience physique de Québec, 525 Wilfrid-Hamel Blvd. East, Québec G1M 2S8, Canada (Fax: +1 418 529 3548; Email: emmanuelle.careau{at}rea.ulaval.ca)

	Summary

Top Summary Introduction Methods Results Discussion Acknowledgements References

 
We studied the workings of a rehabilitation team in a videoconference setting to note the pros and cons of videoconferencing in the development of interprofessional care plans (ICPs). We recorded every videoconference held by the teams of the specialized centre and the regional centre for clients with traumatic brain injuries over an 18-month period. Thirteen recorded videoconferences, lasting for 30–98 min, were analysed through an observation grid. On the whole, efficient teamwork was observed: the mean productivity level was 96%, while the percentage of time dedicated to the resolution of technical issues was 2%. During the videoconferences, the clinical coordinator and the client addressed the group most often. One of the most commonly mentioned advantages was the good visual contact provided by videoconferencing. The most often quoted disadvantage was the poor sound quality. The findings from the study support the adoption of videoconferencing and suggest a few guidelines for the development of ICPs.

	Introduction

Top Summary Introduction Methods Results Discussion Acknowledgements References

 
The incidence of traumatic brain injuries is estimated to be 200 cases per 100,000 inhabitants.^1–4 The condition affects young adults between the ages of 15 and 30 years more than any other age group.^1,5 Given the multisystemic damage sustained in traumatic brain injuries (TBI) and their serious effect on the victims and their family, rehabilitation may be complex and require the involvement of several health-care providers over a long period of time.

It is not uncommon for a specialized rehabilitation centre to be located outside the TBI client's area of residence. Once a return to community living is anticipated, the client is transferred from the specialized centre to the local or regional rehabilitation centre. This involves a restructuring of the client's care plan. Preparing for the transfer requires the active involvement and cooperation of the specialized centre, the regional centre, the client's relatives and obviously the client himself or herself. In the field of rehabilitation, interprofessional care plans (ICPs) are the underpinning of teamwork.⁶ The ICP is a planning, coordinating and communication tool used to meet objectives and develop intervention methods for rehabilitation and community reintegration.⁷ It is also used to manage family and patient expectations⁸ and to guide the interprofessional team's observations.⁹ Participation in face-to-face transfer meetings by regional health-care workers, community partners and the client's relatives is often limited due to distance and scheduling conflicts.

To counter these challenges, videoconferencing was considered in order to foster a stronger commitment and a better contact between the participants.¹⁰ However, very little scientific data was identified in the area of videoconferencing teamwork dynamics and even less in the context of interprofessional care.¹¹ According to Aas, teamwork is efficient in a videoconference setting.¹² In a comparison between unidisciplinary care plans implemented in a videoconferencing setting and through face-to-face meetings for 12 patients with diminished independence, Guilfoyle et al. found no significant difference.¹³ In contrast, when questioned, health-care workers maintained that the development of complete unidisciplinary care plans in a videoconference setting was less efficient due to the absence of physical contact during assessment (it should be noted that in the case of unidisciplinary care plans, the assessment and plan happen simultaneously).¹³ On the other hand, Savard et al., in their study on 117 multidisciplinary care plans, contended that videoconferencing permits realtime discussion and planning between individuals resulting in an efficient teamwork approach which is satisfactory in caring for rehabilitation patients.¹⁴ In an interprofessional context, Grisé stated that videoconference meetings lead to the optimization of realtime interinstitutional communications and to the development of an efficient ICP for spinal cord injury victims.¹⁵ Subjective results are one of the limitations facing studies on videoconference-based care plans since they are essentially extracted from participant questionnaires and interviews. As yet, no study has made external and objective observations of rehabilitation team dynamics during videoconferencing.

The aim of the current study was to document the workings of a rehabilitation team in a videoconference setting and to note the pros and cons of videoconferencing in the development of ICPs. The objectives were:

1. determine the size of the teams, the members' roles and quantify their respective participation;
   
2. quantify the length of time allocated to productivity, problem-solving and other unrelated topics;
   
3. quantify the discussion time according to the themes of ICPs;
   
4. describe communication within the group by:
   1. quantifying the percentage of time where two sites exchange;
      
   2. quantifying the contribution of each participant discipline type;
      
   3. quantifying the number of verbal interferences;
      
   4. defining the type of facilitation used;
      
   
   
5. note the advantages and disadvantages of videoconferencing according to the participants' comments.
   

Research framework

The framework of the present study was derived from Casto and Julia's Interprofessional Team Process¹⁶ and St-Arnaud's concepts of production, solidarity, problem-solving and residual processes.¹⁷ Teamwork comprises clinic task and maintenance functions. The clinical task functions encompass the 12 topics involved in the development of an ICP, as prescribed by Brousseau et al.¹⁸ This combination forms the team's production process. In the maintenance functions, there are six specific themes. Communication, facilitation, roles and participation of each team member make up the themes of the team's solidarity process. Decision-making, conflict resolution and technical trouble-shooting are the make-up of the problem-solving process. The values and standards of the team shape the theme which ties into the latter two processes since this element directly affects them. The team must properly integrate the clinical task functions and the maintenance functions to achieve its objectives which in the present case are the development of an ICP targeting functional, social, residential and economic independence of a TBI client as well as his or her academic, professional and socio-occupational integration. The residual processes emerge when the members' comments affect neither clinical task functions nor maintenance functions. In other words, these comments are perceived as unrelated topics since they do not fall in line with the pursuit of the common objective or improve the group's cohesiveness. Figure 1 illustrates the contextual framework developed for the purposes of the study.

View larger version (18K): [in this window] [in a new window]   Figure 1 Research framework

 

	Methods

Top Summary Introduction Methods Results Discussion Acknowledgements References

 
We conducted a non-experimental, descriptive study. It was part of a research project aimed at assessing the various features of a telerehabilitation pilot project.¹⁰ The targeted population included everyone who was involved in the ICP meetings for TBI clients of a specialized rehabilitation centre (Quebec City, Province of Quebec, Canada) and a regional rehabilitation centre (Bas-St-Laurent, Province of Quebec, Canada).

We drew a convenience sample. We recorded every videoconference held by the teams of the specialized centre and the regional centre for TBI clients between 1 April 2006 and 20 September 2007. The health-care workers of the specialized centre and the regional centre, the community partners, the TBI clients and the client's relatives who agreed to take part in an ICP meeting via videoconference were all included. Those clients who could not partake in the development of their ICP and those having a disability (e.g. visual or hearing impairments, spinal cord injury) were excluded from the sample. If a participant had refused to take part in the research project, the videoconference would still have taken place, but would not have been recorded, but in this project nobody refused to provide consent. The study was approved by the appropriate ethics committees.

The videoconference rooms were equipped with one or two 107 cm plasma screens. The videoconferencing units (880 mxp, Tandberg) were connected via IP at 384 kbit/s. A single source of data was used, i.e. the recording of ICP videoconferences. Data coding was done afterwards with the DVD recordings through the use of an observation grid consisting of four parts which was developed for the purposes of the study. Every recorded videoconference was viewed twice by the observing health-care professional (occupational therapist) and assessed through the observation grid. To avoid bias, this observer was not present at videoconferencing sessions, she was not an employee of the centres and she did not know the participants. During the first viewing, the observer had to be attentive to the participants' comments and complete the first, second and fourth sections of the grid. During the second viewing, the observer had to be attentive to the origin and direction of the comments in order to complete the third section.

In the first section of the grid the observer noted relevant information about the study, such as the number of participants, the duration of the videoconference and the type of moderation used during the meeting (directive or loose). The observer determined the type of moderation through the actions of the facilitator, such as:

1. making a clear suggestion based on the subject at hand;
   
2. managing the process, e.g. the right to speak;
   
3. summarizing the points raised;
   
4. bringing a general solution to the matter being discussed;
   
5. taking stock of the group's progress toward meeting the objective;
   
6. commenting positively or negatively on the group's dynamic.¹⁷
   

It was arbitrarily determined that 0–3 actions equated to a looser type of moderation and that four or more actions were a more directive type of facilitation. In the second section, the observer quantified the production process, i.e. the time allocated to each of the 12 topics of the ICP's development (in 30 s time frames) depending on the site involved. The observer also noted the time allocated to the maintenance and residual processes. It was therefore possible to determine how long the resolution of various matters took or to discuss off-topic items. In the third section, the observer used ‘sociograms’ to note the number and the direction of the interventions, as well as the number of interferences (when there was cross-talking) for each team member. Sociograms were developed to represent the social relations of a person visually. These diagrams can illustrate, for example, personal or professional relations, communication channels. They are generally used to study group dynamics.^19,20 In the present study, a sociogram was used for every 15 min of conversation. In the fourth section, the observer noted the participants' comments (some verbatim) if they dealt with the advantages and disadvantages of videoconferencing (Figure 2).

View larger version (21K): [in this window] [in a new window]   Figure 2 Example of sociograms

 
The second section of the observation grid was previously tested by three different observers with two videoconferences. The duration of topics of discussion noted by the observers were compared. The coefficient of variation was calculated for each item of the grid (topics of discussion). For all topics standing out significantly in terms of duration (more than 2 min), a low variance was obtained (coefficient of variation = 17%). Then, a consensus was reached on modifications to the grid to facilitate the scoring. The pre-test allowed us to validate this section of the observation grid to ensure that it could be used by a single observer during the study. The observer who did the scoring for the whole study was the one who developed the grid.

Descriptive statistics were collected for the four sections of the observation grid. An intervention rate was determined for each member by adding the number of comments made to the number of times each member took part in the exchanges. This was divided by the sum of all the meeting's comments and exchanges. The interference rate was calculated by dividing the total number of interferences between participants (when there was cross-talking) by the sum of comments and exchanges during the meeting. Non-parametric correlation (Spearman's rho) was carried out to verify the associations between animation type and interference rate and between number of participants and interference rate. Non-parametric analyses were also performed to determine if the duration of each discussion topic was significantly different from zero (Wilcoxon test) and to compare each group of participants in terms of participation (Kolmogorov-Smirnov Z). A compilation of verbatim comments on advantages and disadvantages was made for part 4 of the observation grid. Units of meaning were identified in the verbatim comments, then associated with advantages and disadvantages found in literature. This deductive method was derived from qualitative content analyses.²¹

	Results

Top Summary Introduction Methods Results Discussion Acknowledgements References

 
In total, 13 videoconferences were recorded and were analysed. Six videoconferences could not be recorded because of problems such as improperly connected recording equipment, technical problems related to the network, booking of the wrong conference rooms and miscommunication with the recording staff regarding the time and place of the meetings. The recorded videoconferences lasted for a mean of 60 min (range 30–98). A typical videoconference involved 12 participants, i.e. seven from the specialized centre and five from the regional centre. Only seven videoconferences involved the client. The decision to involve the client or not depended on his or her ability and motivation to attend the meeting. The number of participants belonging to each category and the number of videoconferences they attended between April 2006 and September 2007 is summarized in Table 1.

View this table: [in this window] [in a new window]   Table 1 Characteristics of the participants

 
For the 13 videoconferences, a high rate of productivity (i.e. the percentage of time devoted to the development of an ICP) was observed. Very little time was focused on resolving minor problems (e.g. technical issues, personal conflicts). Very little time was wasted (residual process) throughout our observations. Table 2 presents the data for each of the teamwork processes.

View this table: [in this window] [in a new window]   Table 2 Data for each of the teamwork processes

 
During the videoconferences each of the 12 topics of the ICP was not raised every time and those that were broached did not all take the same length of time. Figure 3 shows the median value for the 12 topics of ICP development in decreasing order according to the length of time spent during the 13 videoconferences. Although the discussion time was quite variable between the topics, six of these stood out significantly (P < 0.05) in terms of duration (Figure 3). Conversations on ‘other topics’ were those relating to the development of an ICP, i.e. doing presentations, exchanging business information or filling out administrative forms.

View larger version (13K): [in this window] [in a new window]   Figure 3 Percentage of time dedicated to the topics of discussion. The boxes show the 25th and 75th centiles, with the median inside the box; the whiskers indicate the 90th and the 10th percentiles. The topics were: (a) Client's situation and significant changes; (b) Recommendations to the regional team; (c) Client's expectation and priorities; (d) Prognosis for social participation; (e) Welcome and meeting; (f) Relatives' expectation and priorities; (g) Progress toward meeting the objectives; (h) Intervention methods; (i) New objectives; (j) Next meeting plan; (k) Summary of last meeting; and (l) Other topics *P < 0.05

 
Various findings enable us to describe communication within the group (Table 3). The average percentage of time dedicated to exchanges was 31%. The style of moderation was deemed directive in six cases and loose in seven others. The rate of interference during the videoconferences varied from 0 to 28%. A lower rate of interference was moderately correlated with a more directive animation (r = –0.50, P < 0.05). The number of participants at the meeting did not seem to have an effect on the rate of interference (r = 0.04, P > 0.05).

View this table: [in this window] [in a new window]   Table 3 Animation type, interference rate and time dedicated to exchanges between the two sites for each videoconference

 
With regard to each individual's intervention rate (Figure 4), the clinical coordinator of the specialized centre was the one who showed by far the highest intervention rate followed by the clients and the occupational therapists from the specialized centre, respectively.

View larger version (13K): [in this window] [in a new window]   Figure 4 Intervention rate for each participant. The boxes show the 25th and 75th centiles, with the median inside the box; the whiskers indicate the 90th and the 10th percentiles. The participant types were: (a) Clinic coordinators (specialized centre); (b) Clinic coordinators (regional centre); (c) Clients; (d) Relatives; (e) Occupational therapists (specialized centre); (f) Physician (specialized centre); (g) Physiotherapists (specialized centre); (h) Neuropsychologists (specialized centre); (i) Social workers (specialized centre); (j) Other health-care workers *P < 0.05

 
Six advantages and nine disadvantages were identified in the participants' comments. These benefits were divided into six different themes (Table 4). One of the most commonly mentioned advantages was the good visual contact provided by videoconferencing. The most often quoted disadvantage was the poor sound quality. On eight occasions, the regional centre's staff complained that the sound was so poor they could not make out what the specialized centre's staff were saying. Table 4 shows the six topics identified as well as the verbatim comments (positive or negative) and the number of times each participant expressed them.

View this table: [in this window] [in a new window]   Table 4 Advantages and disadvantages of videoconferencing according to participants' comments

 

	Discussion

Top Summary Introduction Methods Results Discussion Acknowledgements References

 
The aim of the study was to document the workings of a rehabilitation team in a videoconference setting and to note the advantages and disadvantages of this procedure. The observed productivity rate suggests that videoconferencing was an efficient way to hold ICP meetings. The low percentage of time dedicated to troubleshooting was directly linked to the user-friendly technology, which facilitated teamwork in a videoconference setting.¹² Although there were some technical problems, they generally did not interfere with the meeting, which supported Grisé's findings.¹⁵

The time allocation for each of the ICP's topics has not previously been documented. The present findings demonstrate that discussions revolved around a common objective: the development of an ICP. Recent papers suggest that the pursuit of common objectives facilitates efficient teamwork.^6,22–24 The four most frequently raised topics (significant changes, recommendations, prognosis, client expectations and priorities) truly reflect the basis of an ICP and foster progress towards the team's objectives which are to provide an interprofessional summary of relevant information to the ICP and a complete general profile of the client,^25,26 to foster the client's participation (‘empower’ the client)^8,9,15,26 and provide the necessary support to the regional centre staff.^15,27

Our findings demonstrate that there are several indicators of efficient communication that corroborate the literature, i.e. productive communication based on common objectives,⁶ establishment of clear roles for all participants,^23,28 and active involvement of all members of the team, including the client,⁶ which is in step with the principles of empowerment that are emphasized in the clinical setting. The presence of a leader (the specialized centre's clinical coordinator) to ensure the meeting is disciplined and structured is also an indicator of efficient teamwork.^6,23,29 In this respect, Aas insisted that videoconferences should be facilitated by someone who ensures a sound structure and manages everyone's right to speak.¹² Our findings fall in line with this statement since the interference rate seemed to be tied to the style of moderation adopted by the specialized centre's clinical coordinator. These interferences did not affect the team's productivity, but could result in an uncomfortable climate where comments were difficult to hear. Despite this, we observed efficient communication during the videoconference-based meetings which supports the literature on the subject.^12,14,15

The average meeting time indicated that videoconference-based ICP meetings were similar in length to face-to-face meetings. The 60-min duration of videoconferencing meetings was similar to those of Grisé¹⁵ and is in line with our literature review findings which indicated that videoconference-based meetings and face-to-face meeting are similar in duration.^11,14 The size of the team appeared to be slightly too large for some videoconferences. Tremblay et al. suggested that an interprofessional team should not be larger than a dozen people in order to foster constructive communication focused on the objectives.⁶

Among the six themes generated from the verbatim portions, five corroborated findings in the literature. One well-recognized advantage of videoconference based ICPs is visual contact between the participants, which is not afforded by other technologies such as telephone conferencing.^30,31 Visual contact is widely recognized as an enabler for teamwork. It fosters memory retrieval and helps to establish a relationship of trust between client and health-care worker,³² which are of particular importance in the case of pre-transfer ICPs to the regional centre.

Regarding the most commonly mentioned disadvantages of videoconferencing, both the literature and our findings point to the poor audio-visual quality of the technology.^{11,15,29,33,34} Poor positioning of the microphone was largely responsible for the deficient sound level. A multidirectional microphone should therefore be positioned at the end of the videoconference table (near the screens) when the meeting is attended by several people.

Strengths and limitations of the study

The strengths of the present study consisted of the post-meeting observation and analysis, the conceptual framework, the conciseness of the observation grid, the use of sociograms and verbatim records. These processes bolster the internal validity of the study. As regards external validity, all videoconferences were met with a very high rate of consent from health-care workers, clients, family and partners alike. In fact, no participant refused to participate in the study.

There were two major limitations of the study: the use of a single data source and the limited number of videoconferences. Although the study was exploratory and descriptive in nature, the number of viewed conferences was very satisfactory. The data collection method, although innovative, also limited the internal validity of the study since it did not make allowances for the documentation of the participants' emotional experiences or the organizational environment in which the videoconferences were held. The conclusions of the study were therefore solely based on what was observed during the recorded meetings. Moreover, even though the observation grid was pre-tested, the intra-rater and the inter-rater reliability were not determined.

In conclusion, the findings support the adoption of videoconferencing and suggest some guidelines for the development of ICPs.

	Acknowledgements

Top Summary Introduction Methods Results Discussion Acknowledgements References

 
We thank everyone who took part in the study. Financial support was provided by the Centre de réadaptation InterAction, the Institut de réadaptation en déficience physique de Québec, the Agence de développement de réseaux locaux de services de santé et de services sociaux de la Capitale Nationale et du Bas-St-Laurent and University Laval's Centre for Interdisciplinary Research in Rehabilitation and Social Integration. The first author holds a doctoral scholarship from the Canadian Institute of Health Research (2008–2011).

Accepted September 29, 2008

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Top Summary Introduction Methods Results Discussion Acknowledgements References

 

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