INTERDISCIPLINARY HEALTH CARE TEAMS:

PROCEEDINGS OF THE SIXTEENTH ANNUAL CONFERENCE

September 22-24,1994

Chicago, Illinois

Editor

John R. Snyder

1994

School of Allied Health Sciences

Indiana University School of Medicine

Indiana University Medical Center

THE QUALITY OF GERIATRIC TEAM FUNCTIONING:MODEL AND METHODOLOGY

Gloria D. HeinemannVeterans Affairs Medical Center

Buffalo. NY

Madeline H. SchmittUniversity of Rochester

Rochester, NY

Michael P. Farrell

University of New York at Buffalo, SUNYBuffalo, NY

The purpose ofthis paper isto outline the theoretical underpinnings, objectives, and methodologyofa national study ofgeriatric health care teams in theVeterans Affairs (VA) system. This project, fundedby the National Institute on Aging {NIA)from June 1991 through November 1994, was designed to:(1) identify factorsthat influence the quality of team functioning; (2) examine the effectquality 'functioning has onjobstressamong team members; and (3) explore differences among typei ; teamsand team members from different disciplines/ professions.

When patients' health problems and health care needs are complex and overlapping, as theyarein geriatrics, the inter-disciplinary team approach has been advocated as the preferred modeof health caredelivery. Researchers, presently, are attempting to determine whether this approach has a more positiveimpact than traditional delivery of care.

Theresearch on health care teams has moved from eariydescriptive accountsof how particularteams evolved to more sophisticated designs where patients are randomized into team versus traditionaldelivery ofcare,and after a specified time period, patients' outcomes are compared for the two groups. Inthe majority of these studies, however, quality of team functioning has been ignored, and the "team" hasbeen treated as a nominal variable (i.e., either present or absent). Furthermore, few standardizedmeasures of team functioning have been developed. Yet, teams do vary with regard to their structure andqualityof functioning, and priorto comparing patients' outcomes, research is needed that focuses on these"team process"variablesand the factors that affect them. Team process measures (i.e., team structureand functioning), then,can be linked to patients' outcomes for a morerefined and moreaccurate analysisof the impact of the team approach to care.

Ina few exceptional studies, tfie relationship between process measures and patients' outcomeshas been examined, and findings support such a relationship. Feiger and Schmitt (1979) and Schmittandcolleagues (1982) conducted a randomized experiment comparing patients' outcomes in fourinterdisciplinary long-termcare teams. They found that highcollegiality among team members—a processvariable defined as the degree of equalityof participation in team meetings-was related to positivechanges in patients after a one year period. Outside the geriatric literature. Gavett and colleagues (1985)concluded that lack of communication and coordination among health care providersis an importantcauseof unnecessarily highcost hospital stays. Ina study of 13 intensivecare units (ICUs), Knaus andcolleagues (1986) found that increased interaction and coordination between nurses and physicianspositively influenced the effectiveness of care to patients. More recently, Baggs and colleagues (1992)found collaboration between ICU nurses and physicians regarding the decision to transfer patients fromICU was related to positive patient outcomes after controlling for severityof illness; specifically, highcollaboration resulted in fewer readmissions and deaths.

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While findings from these studies are encouraging, they have limitations that should be addressed.That is, researchers have; (1) studied small numbers of teams with a limited number of disciplines ordyadic relationships between only two health professionals: (2) rarely examined the same components ofteam process; and (3) used observational data collection techniques that preclude large scale studies ofteams. Further research on team process needs to incorporate a much larger number of teams, be drivenby an integrative theory that identifies important constructs, and use more efficient measurement and datacollection procedures.

Background, Framework, and Hypotheses

Specific aims of this study are to; (1) test the relation-ship between team development p.e.,anomie and collegiality as measured by Bales 980) SYMLOG scale] and quality of team functioning {i.e.,openness of communication, organizational efficiency, and solidarity): (2) test hypotheses about the factorsrelated to team development; (3) test the relationship tietween team development/quality of teamfunctioning and job stress/burnout among team members; and (4) explore differences among types ofteams and the various health professionals on the teams. The model for this project is depicted in Figure 1.A second phase of this research program is to linkteam process measures to quality of care measures andpatients' outcomes as shown in Figure 1 by the box within the broken lines.

Stability ofMembenhip

Physicians' Attitudestowaid Teams

Team Heterogeneity

FIGURE 1. Proposed Research Model

Team Size

Degree of TeamDevelopment:

•Anomie

•Collegiality

Patient Cenvis/Workload

Team Eveats/Sticss

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Quality of Care/Patieois'Outcomes

Job Stress/Burnout

Quality of Team Functjonino

Research on work groups and literature on health care teams suggest that groups may be eitherassets or liabilities in accomplishing work goals, but those with certain properties are more effective incarrying out the kind of work required of health care teams (for a review of work group literature, see Hare1976; Janis, 1972,1982; Janis &Mann, 1977; Pelz &Andrews, 1976; Shaw, 1982, Tuckman. 1965;Tuckman &Jensen, 1977, and for reviews of team literature, see Bass, 1980; Ducanis &Golin, 1979-Kane, 1975). An effective team is likely to have the following properties; (1) openness of communication,where members easily express disagreements and share information and expertise relevant to problem-solving, decision-making, and coordination oftheir work; (2) organizational efficiency, where members areefficient in their meetings and cooperate to avoid duplication and fragmentation of efforts; and (3) solidarity,where members have positive feelings about being in the team, trust one another, and provide support toeach other when dealing with stressful demands. Previous research (Bass, 1980) suggests that opennessofcommunication, efficiency, and solidarity are positively related to one anotherand constitute anunderlying latent variable, towhich werefer in this study as "quality ofteam functioning."

Team Development and Quality of Team Functioning

Researchers have found thatgroups pass through a seriesofstages before they reach theirmaximum degree of openness ofcommunication, organizational efficiency, and solidarity. In a review ofover seventy studies ofgroup development, Tuckman (1965) and Tuckman and Jensen (1977) reportedthat most researchers have identified four stages of group development. The stages are: (1) testing anddependency; (2) conflict; (3)cohesionand consensus; and (4)functional role relatedness. Asteamsdevelop, they show changes in their culture and informal role structure. In the early stages (stages oneand two) of development, the team's culture is not well defined; members are uncertain about the team'smission andtheir roles In the team. This uncertainty and lack ofclarity, towhich we refer as anomie,generates anxiety and defensive behavior.

Teams inthe early stages of development are likely to manifest a particular constellation ofinformal roles (Farrell, Heinemann, &Schmitt, 1986). In stage one, most team members are likely tobehavedependentiy and relinquish authority to a dominant member, who plays the formal role of leader.This leader may employ anynumber ofinformal roles or leadership styles (e.g., superman, wondenA/oman,tyranti The authority ofthis member-based on professional prestige, position in thehospital hierarchy, orcharisma-often spills over into decision-making areas where his/her expertise isnot relevant (Berger,Fisek, Norman, &Zeldltch, 1977; Janis, 1972,1982). As strains develop, a secondary set ofinformal rolesemerges (e.g., scape-goat, hatchetman, clown, caring ear) to express and constrain the negative feelingsthat build in this atmosphere, of uncertainty (Farrell et al., 1986).

In the laterstages ofdevelopment (stages three and four), a coalition ofcolleagues emerges-aset of members who have come to respect one another and participate relatively equallyIn the team. Thiscoalition consciously negotiates a team culture~a set of rulesand procedures foroperating thatisunderstood and legitimated by membersand provides guidelines for their behaviors. Through open,reflective discussions of critical episodes of their history, members gaina clearer understanding of theteam's mission, each member's professional skills and abilities, whatis expected of memberswith regardto organizing and coordinating the team's efforts, and the limits of authority. Thisclarification of the team'sculture leads to moreorderly and effective movements through cycles ofwork and reintegration (stagefour). Anomie decreases; informal roles change such that theyfacilitate team functioning rather thancreate barriers to it, and each member shares responsibility and participates when his/herexpertise isrelevant. Developments inthe measurement of the structureof informal roles in groups (Bales &Cohen,1979; Bales, 1980; Farrell, Schmitt, &Heinemann, 1988) enable us to assess this aspect of teamdevelopment by locating members' informal role positions ina three dimensional space (i.e., prominence,sociability, and task orientation versus expressiveness). Thus, we hypothesize (HI): as team developmentin-creases, quality of team functioning increases p.e., as a team's informal role structure converges on atheoretically optimal point in the three dimensional space (stage 4) and as the level of anomie decreases,openness of communication, organizational efficiency, and solidarity increase].

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Team Stability and Team Development

At times teams experience high turnover of membership; at other times, their membership remainsrelatively stable. Members of stable teams have spent more timetogether and have had greateropportunity to pass through the early stages ofdevelopment and becomea cohesive and effective group(Farrell et al.. 1986; Tucl<man &Jensen, 1977). Prescott and Bowen (1985) found stability to be animportant dimension of effective nurse/ physician relationships. Thus,we propose (H2a): the greater theaverage length of team members' service on a team, the more developed the team (i.e., the team'sinformal role structure approaches stage 4, and members report less anomie).

Embeddedness in Team Networks and Team Development

Teams are relatively new structures inthe hospital system. Some researchers (Kaluzny, 1985;Temkin-Greener, 1983; Wise, Beckhard, Rubin, &Kyte, 1974) have suggested that the tension between themore traditional "vertical" disciplinary hierarchies and the "horizontal" matrix structure of teams limits teammembers' abilities to work together. To a varying extent, team members are caught in a dilemma ofconflicting loyalties (i.e., loyalty to the team versus loyalty to their respectivedisciplines/professions). Themore embedded members are in their teams as opposed to their discipline-specific hierarchies, the morelikely they are to resolve conflicting demands infavor of their teams. Inaddition to bending theirprofessional roles to fit perceived needs of the team, team-embedded members also are more likely toresolve mundane conflicts in favor of the team. As a consequence of the increased commitment to theteam, we hypothesize (H2b): the higher the average team embeddedness, the more developed the team,and the higher the average discipline-specific embeddedness, the less developed the team.

Team Size and Team Development

Previous research on scientificteams (Pelz &Andrews, 1976) and other groups (Bass, 1980; Hare,1976;Shaw, 1982)has shown that the largerthe size of a group,the more subgrouping, the less solidarity,and the more centralized the authority. Too large a team decreases available time for individualparticipation and decreases the intimacy of the group. This, inturn, leads to decreased satisfaction amongmembers. Alternatively, with cutbacks in federal agencies and health professional positions within the VAsystem, a team could be too small and lack the full component of skillsand abilitiesamong members toeffectivelyserve its patient population. Thus, we hypothesize (H2c): size is inversely related to teamdevelopment, or the relationship between size and team development is curvilinear.

Heterogeneity in Team Composition and Team Development

Heterogeneity with regard to the disciplines/professions is one of the defining characteristics ofteams, and this type of heterogeneity is a key contributor to the superiority of the team approach in dealingwithcomplex issues and problems. However, health care teams also vary in terms of demographicheterogeneity of members. Members who differ witii regard to gender, age, social class, and race mayhave different value priorities that can lead to increased conflict and scapegoating in groups. Berger andcolleagues (1977) have shown that differences in diffuse status characteristics lead to lower statusmembers inappropriately conforming to the judgments of higher status members. These findings suggest(H2d); demographic heterogeneity in a team is inversely related to team development

Physicians' Attitudes Toward Teams and Team Development

Physicians occupy pivotal positions in health care teams. In most cases, they act as gatekeepersfor teams by using diagnostic skills todecide whether a patient is eligible for care by ^e team and/or whenthe patient can be discharged from tfie team's care. Physicians also have much influence in prioritizingpatients' problems and coordinating treatment plans. Furthermore, either through tradition or currentlegitimation, physicians usually have more diffuse authority than other members of the team. This enablesthem to influence decisions even when these decisions are outside their areas of expertise (Berger et al..

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1977; Feiger &Schmitt, 1979). Physicians also vat7 with regard to their investment in and valuing of theteam approach to care. Some physicians experience teams as arenas in which medicine loses status andinfluence, while other disciplines gain status and influence (Brown, 1982). Others resent the time lost inmeetings and in coordinating their efforts with professionals from other disciplines. Because of their pivotalposition in teams, physicians' attitudes and beliefs about teams and their behaviors related tothese beliefsare likely to have an Important effect on the team's structure and quality offunctioning. Thus, wehypothesize (H2e): the more positively physicians value teams, the greater the team development.

Team Work Load and Team Development

One source ofvariation in teams' properties is thework load or ratio of patient census tothenumber ofteam members. It seems reasonable to propose that, in an attempt to maintain control over anunwieldy work load, larger average work loads may lead to more centralized authority, increaseddemoralization among members as a result ofthework demands, and eventually, strain onintermemberrelations and reduced solidarity among members. Thus, we hypothesize (H2f): the larger the averagework load of the team, the less developed the team.

Stressful Team Events and Team Development

For individuals, life events have been shown tobepredictors ofpsychological distress and physicalhealth problems In numerous studies (Dohrenwend &Dohrenwend, 1974; Holmes &Rahe, 1967; Lopata,1979, Myers, Lindenthal, &Pepper, 1971; Ross &Mirowsky, 1989). Recently, researchers haveexaminedthe collective experience of stressful events in groups, especially families (McCubbin &Patterson, 1983).Like families, interdisciplinary health care teams are bounded groups with histories and relatively stablememberships. Also like families, teams areconfronted by stressful events that require change in routinesand division oflabor as well as the acquisition ofnew coping skills. For example, teams lose and gainmembers; experience changesin their leadership, patient population, and physical environment; andconfront conflict within the team orin relationships with other providers and programs in the larger hospital.Most likely, teams vary in their response tostressful events, and for some, such events may underminetheir development and functioning. Thus, wehypothesize (H2g): thegreater theaverage number ofstressful events experienced by the team, the less developed the team, and (H2h): the greater the averageperceived stress from these events, the less developed the team.

Team Development. Quality of Functioning, and Job Stress/Burnout

Researchers have suggested that a majorsource of stress experienced bystaff in health caresettings is poor interdisciplinary team work (Browner, 1987; Steffen. 1980; Vachon, 1987). Workgrouprelations have beenimplicated In burnout in other human service occupations as well (Maslach, 1982).Conversely, well functioning interdisciplinary work groups have beenreported as a major sourceofjobsatisfaction (Baggs &Ryan. 1990; Steffen, 1980; Vachon. 1987). The theory ofsmall group developmentsuggests that early stages ofteam development are morelikely to be characterized by interpersonal strainsthatcontribute tojobstress and burnout Based ontheory and prior research, we hypothesize (H3): bothteam development and quality of team functioning are inversely related to job stress/burnout amongteammembers.

Exploratory Questions

Differencesamong Types of Teams. Inaddition to testing the hypotheses, we will conductexploratory analysis ofthe differences among the typesofteams. Given the trendtoward containinghospital costs by emphasizing ambulatory care and outpatient services, we will be especially interested inthe developmentand functioning among ADHC and HBHC teams as well as the kinds of strains theyexperience. These teams, serving patientswho live at home, are located on the peripheryof the hospitalbureaucracy, and may be less constricted bydiscipline-specific responsibilities. Members, too, are likely tobe less dependent on professionals in their own respective disciplinesin delivering care. We are interestedinthe consequences thisgreater autonomyhas for team developmentand quality of functioning.

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GEM teams provideconsiderable medical education for housestaff. This heavy medical emphasismay create strains inthe team that negatively affect team development, functioning, and job stress amongteam members. Evers (1981) suggested that nursing home care teams are likely to have unique strains.When patients require extended care, she found that nurses carried the major responsibility for patients,but were not given the requisite authority to make necessary decisions. Physicians retreated from suchpatients when they found them unmanageable by traditional treatment approaches. Such strains mayimpede team development and lead to lower qualityof functioning and greater job stress among theseteam members.

Differences among Disciplines/Professions. Some literature suggests that embeddednessin discipline-specific hierarchies and attitudes toward and perceptions of the team may vary bydiscipline/profession. Team members from lower status disciplines, who feel they are gaining status andinfluence by participating on the team, may perceive teams more positively than higher statusprofessionals, who perceive teams as vehicles for others to encroach on their areas of competence andcontrol.

Method

Testing the hypotheses about factors related to quality of team functioning required a cross-sectional survey design with a large enough sample of teams to allow variation in the dependent andindependent variables and to meet the power requirements for analysis. To answer the exploratoryquestions about differences among types of teams, sufficient numbers of each type had to be present Inthe sample. To correct for problems in previous research in which small demonstration projects weresubject to a Hawthorne effect, we required a setting where team structures are well established. Finally,confounding variables extraneous to our theory that might affect qualityof team functioning needed to beminimized or controlled. The VA system was chosen as the site for this study because its geriatric teamprograms provide a large number of teams operating withinone relatively stable organizational structureand treat patients who are relatively similar on characteristics such as age, gender, and social class. Inaddition, the types of teams to be studied are administered through programs based in VA Central Office,which provides consistency in structure and administration by type of team.

Sample

The universe for this project consisted of all ADHC, GEM, HBHC, and NHC teams in the VAsystem at the time of the study's initiation. These team programs were distributed relatively equally acrossthe four VA regions. Within each region, they were clustered within medical centers so that some hadthree or four types of teams, while others had one or two. Stratifiedcluster sampling was appropriate inthis study to: (1) obtain a large sample of teams in as cost-effective a way as possible and (2) obtainrelatively equal and sufficient numbers of each type of team so comparisons could be made among them.Our goal was not to generalize to all VA teams from our sample findings, but to obtain enough variationonour major dependent variables to test our hypotheses.

To achieve this goal, we selected VA medical centers across the four VA regions having all fourtypes of geriatric teams and all medical centers hosting the Interdisciplinary Team Training Program (ITTP).To obtain the remainder of the sample (N = 100 for purposes of analyses), we selected approximately 75%of the medical centers having three of the four types of teams. By sampling across regions and at ITTPand non-lTTP sites, we attempted to minimize sample bias and increase variation in exposure toeducational programs among teams. Our sample included 34 VAMedical Centers~32% from Region 1(Northeast), 23% from Region 2 (Midwest), 21% from Region 3 (South/Southeast), and 23% from Region 4(West/Southwest). The specific sample sites are presented in Figure 2. Our final sample included 111teams made up of 1018 unique Individuals who served on one or more of the teams.*

Data Collection Instruments

A17-page "team" questionnaire was designed to elicit mostly factual Information about the team(i.e., its location within the hospital; length of time it had been operating; number of admissions anddischarges within the past six months; origin of patient referrals; frequency and structure of meetings;documentation of care plans; education received about team development: innovative programs/activities

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'•hf'"' '

for patients and families; resources available to the team and their adequacy; the number of regular,consultant, and student members; and stressful team events over the past six months). At the end of thequestionnaire, team members were identified by name and discipline. This questionnaire wasadministered toa contact person in each team; it took approximately 20to30 minutes toadminister.

A32-page "individual" questionnaire was designed toobtain information from team membersthemselves. This data collection instrument included questions abput attitudes toward health care teams,tearn membership, perceptions and feelings about the team, goals and roles in the team, communicationwithin the team, involvement with coworkers and supervisors atthe medical center, organizing andimplementing the team's tasks, perceived behaviors of team members, feelings about the job and thework, and demographics. This questionnaire took, on average, approximately one hour to complete" therange was from 40 minutes to two hours.

FIGURE 2. SAMPLE OF VA MEDICAL CENTERS

REGION #1 - 32% REGION #3-21%Albany BirminghamBatavia DurhamBrooklyn/St. Albany Little RockBuffalo •' MemphisCoatesville MiamiManchester SanAntonioNorthport TampaPhiladelphiaPittsburgh REGION #4-23%Syracuse DenverWest Haven Palo Alto

PhoenixREGION #2-23% Portland

Chicago (Mines) Salt Lake CityDayton SepulvedaIndianapolis TucsonMadison West Los AngelesMilwaukee

MinneapolisNorth ChicagoSt. Louis

Ethnographic Observations

In addition to the structured sun/ey instruments, the researchers toured each medical center andobserved the context in which tine teamsworked. Informal discussions alsotook place betweenresearchers and key medical center employees and team members at each site. Researchers alsoobsen/ed teams' weekly meetings. This information was written into sets of narrative notes to assist In ourunderstanding and interpretation of the findings from this project.

Someof the medical centers inoursample had morethanone of a particular typeof team (e.g., two orthree nursing home care teams). Iftiiere was minimal overlap among the members of these teams, weoften collected dataon more thanone ofthem. As a result, the number ofteams participating in ourstudyat any given medical center varied from a minimum of one (at one site)to a maximum of six(at twosites).

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Procedures

Conducting a multi-site study outside the purview of the VA Health Services Research andDevelopment's Cooperative Studies Program presented many challenges. We needed entre and cooperation at four levels within the VA system—VA Central Office, each medical center's Research Sen/Ice orCommittee, each team, and each individual team member.

Support from VA Central Office. The VA Central Office staff was supportive to us in thedevelopmental stages of the project and reviewed and commented on an early version of the proposal.Staff also provided a letter in support of the project for the final version of the proposal. Once funded, wetraveled to Washington, D.C. to present our project to VA Central Office staff in the Offices of AcademicAffairs and Geriatrics and Extended Care and to request written letters of support for the project to facilitateentre at the local sites. As a result of this meeting, two support letters were provided to us. One wasaddressed to the Associate Chief of Staff for Research and/or Chair, Research Committee at the medicalcenters; this letter was signed by the Assistant Chief Medical Directors for Academic Affairs, Research andDevelopment, and Geriatrics and Extended Care. The second letter-actually four separate memoranda,one for each type of team-was sent to the contact persons on each team at the medical centers and otheradministrative staff who, we felt, should know about the project and our visit to their medical center tocollect data. This letter was signed by the Director of the E)rtended Care Service and the Director ofGeriatric and Grants Management Sen/ice within the Office of Geriatrics and Extended Care. In eachmemorandum, questions about the study were referred to the VA Central Office staff person whomonitored each of the four respective team programs; his or her name and phone number were providedin the memorandum. These letters of support were extremely helpful in legitimating our project at themedical centers and gaining entre into the Research Services and the teams.

Gaining entre into VA Central Office was facilitated through the Interdisciplinary Team TrainingProgram (ITTP) network in that the Deputy Director for Academic Affairs, who developed, implemented,and monitors ITTP, organized our meeting with VA Central Office staff and coordinated the efforts thatresulted in our signed letters of support.

VA Central Office staff also facilitated our entre into many of the medical centers and two of theteam programs by scheduling a presentation about the study and its progress on VA system-wide HBHCand NHC conference calls.

Approval from the Research Services/Committees. To gain entre into the VA medical centers, ourproposal had to be submitted to each facility's local Research Committee for review of human subjects andmerit. At each site, a local investigator had to be identified to sponsor the project before the proposal couldbe submitted. Phone contacts were made to the Research Service or Office at each facility to obtain aresearch packet (i.e., instructions for submitting the proposal and forms to accompany it), the dates ofcommittee meetings, and names of persons who might serve as local investigators. Since we had nofunds in our budget to pay local investigators, we attempted to keep their involvement to a minimum. Theresearch packets were mailed directiy to our research office, completed, and returned, along with the letterof support from VA Central Office, to the local investigators for review, signatures, and forwarding to therespective facility's Research Office.

We found that the procedure for submitting a research proposal for review is not a standardizedone across medical centers. Some facilities required only copies of the proposal, while others requiredconsiderable paper work in addition to the proposal. Those facilities with strong university affiliation oftenrequired a formal review within the university's research committee in addition to their own review. At somesites, the Chair of the Research Committee gave expedited approval without convening a formalcommittee meeting. Because research commit-tees met mon^ly, itsometimes took three tofour monthsfrom the initiation of the review process to the notification of approval. Once the proposal was approved,we began scheduling data collection.

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Entre into the Teams. Each ofthe three researchers took responsibility for data collection atapproximately a third of the medical centers. At each facility, a contact person {e.g., a Program DirectorCoordinator, or Team Manager) was identified for each team through a series of phone calls. Theresearchers contacted these persons by phone to explain the purpose ofthe study, inform them that theirmedical centers were part ofour sample, and request a meeting with the respective teams to solicitmembers' participation in the study. Aphone interview was scheduled with each contact person afterhe/she received a copy of the "team" questionnaire via mail. At the time ofthe phone interview, themeeting with the team was confirmed and scheduled.

Cooperation from Team Members. Aresearcher visited each ofthe 34 VA medical centers for aperiod of two to five days, and usually met with members of each team during the team's weekly patientcare meeting. The researcher was given 20 to30minutes to explain the study and distribute "individual"questionnaires. Team members were assured that data would be kept confidential, that nooneat theirmedical center would seecompleted questionnaires, and that participation in the study was voluntary.

Teams were given two options for completing the individual questionnaire. They could block out a^o-hourperiod oftime in which they completed it In their conference room ortheir respective offices andimmediately returned it tothe researcher, or they could elect tocomplete itontheir own time overa severalday period and return it to the researcher ata specified place and time prior to his/her departure from themedical center. The majority ofteams chose the second option. The completed questionnaires wereedited for completeness and accuracy by the researcher as they were returned.

Questionnaires with mailing envelopesand the researcher's phone numberwere left with the teamcontact person for members who were on sick orannual leave the day of the scheduled meeting. If theydid not return the questionnaires within two tothree weeks, two to three mail orphone reminders wereutilized to encouragethem to participate inthe study.

While wewere not able to pay team members for participating in this study, wedid inform them ofdirect and indirect benefits to their participation. In exchange for their participation in this project, teammembers were promised summary information about their team In comparison to all other like teams (i.e..those of the ?ime type), and to the total number of teams in the study. At several of the medical centers,'researchers aisogaveformal in-service programs orconducted a workshop for team members andVAemployees after data were collected. Team members also were informed that the actofcompleting thequestionnaire iteeif (i.e., taking time to think about the team, their perceptions ofit and their roles onit)might have indirect benefit to the team. Finally, team members were told that findings from this studywould be incorporated into VA educational programs andworkshops thatcould benefit team membersand, hopefully, team functioning.

Cooperation. Response Rates, and Refusals

Our research proposal was approved bythe Research Commit-tees at all 34 of the VA medicalcenters, and ali111 geriatric health care teams in thesample agreed to participate in the study. Theresponse rate for completing the "team" questionnaire was 100%. and each of the 111 teams met with oneof the re-searchers. Oneteam, however, was excluded from analysesat the team level because toofewof its members completed the 'Individual" questionnaire.

With regard tothe "individual" questionnaire, 1018 unique individuals were eligible to complete itand 973 actually did for a response rateof96%. Because someindividuals in the sample served on morethan one team, the total number of team members eligible to complete this questionnaire was greater thanthe number of individuals in the sample;insome instancesthese personscompleted an 'Individual"questionnaire for onlyone of theirteams, and for this reason, we computeda response rate for teammembers as well as unique individuals. Ofthe 1088 eligible team members, 1033 did complete"individual" questionnaires for a response rate of 95%. In those instances where these individualscompleted the questionnaire foronly one of their teams, we duplicated their data thatwas notteam-specificso they became partial respondents for their second team.

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Persons most likely to refuse to participate in the study were those not present at the team'smeeting with the researcher (e.g.. on annual or sick leave) and those who served on more than one team.These latter individuals, because of time pressures, sometimes completed a questionnaire for only one ofthe teams on which they served. Physicians who refused to participate frequently stated that they were toobusy. Other reasons for refusing were concern that the information would get back to others (e.g.,administrators, supervisors, co-workers) at the medical center and unwillingness to providing personalinformation to the federal government.

Characteristics of the Teams

Adult Day Health Care (ADHC) teams made up 10% of the sample (n = 10); Geriatric Evaluation &Management (GEM) teams, 26% (n = 29); Hospital Based Home Care (HBHC) teams, 31% (n = 34);Nursing Horn'? '.are (NHC) teams, 32% (n = 36); and other geriatric teams, one percent (n = 1). The healthcare teams a'.rjraged nine regularly participating members. An average of eight different disciplines wererepresented on the teams. Nonwhite team membership averaged 20% with ADHC teams having thegreatest proportion of nonwhite members, 32%, and GEM teams the lowest, 15%. The average length oftime the health care teams had been in existence was eight years. HBHC teams' average longevity wasthe longest, 11 years. Teams carried an average patient census of 50; this ranged from a high of 72among ADHC teams to a low of 29 among GEM teams. The average number of admissions during thepast six months was 51. GEM teams had the highest number of admissions, 66, and ADHC teams, thelowest, 26. These mean sc'-'es reflect a shorter length of stay or faster turnover of patients in the GEMprogram in comparison to the ADHC program, the latter of which emphasizes considerable strengthening,conditioning, and rehabilitation. The average number of health professional students on the teams over thepast year was 11; the range was from six to16across the four ^pes ofteams. GEM and HBHC teamswere most often the sites for educating these students. Also relevant from Table 1, is the considerablevariation found within types of teams regarding racial composition, patient census, number of admissionsduring the past year, and number of health professional students in the past year.

The majority of the health care teams, 70 to 100%, were located administratively within geriatrics,extended care, or a Geriatric Research, Education, and Clinical Center (GRECC).While most teams had a conference room in which to conduct meetings, 83%, a smaller proportion hadsupport staff assigned to them, 69%. The lack of support staff was most problematic for GEM and NHCteams. Some 35% of the teams reported at least one vacant position on the team as well. ADHC teamswere most likely to have members' offices in close geographic proximity to one another, 100%; GEM teamswere the least likely to report close proximity of offices, 33%. The vast majority of teams, 94%, held patientcare/treatment planning meetings at least weekly, but a smaller proportion, 72%, also met on a regularbasis to discuss administrative issues and attend to program planning. GEM and NHC teams were theleast likely to have this latter type of meeting (see Table 1).

Table 1

Team Characteristics by Type of Team

Characteristic ADHC gIm HBHC NHC TOTAL

(Means)Team Size

M - 10 8 9 10 9

SD 1.44 2.05 1.98 2.49 2.23

# DisciplinesM 8 8 6 9 8

SD 1.95 1.81 1.19' 1.97 2.02

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't ' ' !

Table 1 (continued)

Characteristic AOHC GEM HBHC NHC TOTAL

# Members NonwhiteM

SD

32

23.7015

14.48

28

19.4922

20.12

20

19.22

# Years in Existence

M

SD

7

2.507

4.00

11

5.40

7

4.90

8

5.03

Patient Census

M

SD

72

19.78

29

63.70

64

21.68

49

15.82

50

38.80

# Admissions in Past

Six Months

M

SD

26

12.88

66

49.84

44

29.94

44

41.30

51

47.61

# Health Professional/

Students in Past YearM

SD

6

6.41

16

21.38

14

13.17

6

9.01

11

15.19

(Percentages)Located under

AOCS/Extended Care,Geriatrics, GRECC 70 100 70 71 78

With a Conference 90 85 76 85 83

With Support Staff 100 59 94 44 69

With Vacant Positions 30 37 30 41 35

Offices in Close 100 33 91 53 64

Have Patient Care/TreatmentPlanning Meetings atLeast Weekly 100 100 100 82 94

Have Administrative/Program

Planning Meetings 100 59 100 50 62

N= (10) (29) (34) (36) (109) *

•One of the teams In our sample was an acute geriatric team; data from Itare excluded In this table.

Characteristics of T.eam Members

Mostteam members served on onlyone of the health care team Inour study. Approximatelyseven percent of them had over-lapping membership on two teams and one team member served onthree teams. Seventy-five percent of the team members were female; and theirmean age was 44 fSD =10.3). Racia! composition included 79% Whites, 14% Blacks, and six percent Asian. Some 17% had astrong ethnicidentification of whichfour percent was Hispanic. As expected, the majority of team members

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were well educated—38% had a bachelors degree, 18% had a masters degree, and 18% had an advanceddegree beyond the masters (e.g., M.D., Ph.D., Pharm.D., D.S.W., D.D.S.). Slightly 1-^-^ than two thirds ofteam members, 64%, were married; some 41 % were involved in religious activities i, sast weekly: and themedian household Income category among team members was $50,000 to $74,999.

Characteristics of team members varied little by type of team. Blacks made up a larger proportion,24%, of ADHC team members; members of ADHC teams had a slightly lower household Income levelthan did members of the other types of teams. GEM team members included a larger proportion, 29%, ofmembers educated beyond the masters degree (see Table 2).

No significant nonresponse biases existed with regard to team members' gender or occupation.Females represented 76% of the respondents and 78% of the nonrespondents. Among the variousoccupations among team members, physicians and social workers were most likely to refuse to participate.Physicians made up 12% of the respondents and 15% of the nonrespondents; social workers, 12% and17%, respectively. The percentages of respondents and nonrespondents for these two respectivedisciplines were not significantly different, however. Nonwhites and Hispanics were also less likely thanWhites to participate in the study; however, we do not have adequate racial/ethnic data on nonrespondentsto determine if this is a significant nonresponse bias.

Table 2. Characteristics of Team Members

Characteristic ADHC GEM HBHC NHC TOTAL

% Female 78 71 79 72 75

Age - MSD

44

9.7

42

10.6

46

9.5

43

10.7

44

10.3

% White 66 83 81 79 79

% Black 24 9 14 14 14

% Asian 6 6 4 7 6

% Hispanic ethnicity 5 1 5 4 4

% Identify with otherethnic group 9 14 16 11 13

% Bachelors degree 27 30 30 39 33

% Masters degree 38, 37 42 36 38

% Doctorate or equivalent 11 29 14 16 18

% Married 63 67 67 62 64

% Religious involvementat least weekly 44 37 42 43 41

Median household

Income category $40,000-$40,999

$50,000-$74,999

$50,000-$74,999

$50,000-$74,999

$50,000-$74,999

*Data weighted up to include overlaoping team membership. Information on refusals also included whereavailable.

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Conclusion

This research project isthefirst large scale study of health care teams; it focused specifically onteam processes as dependent variables. The model was conceived and developed over a seven yearperiod during which time thethree researchers coilaboratively educated, consulted with, and attempted tounderstand the dynamics existing ina wide variety of health care teams. Gaining cooperation within thevarious levels of the VA system was facilitated by VA Central Office and the Directors of theInterdisciplinary Team Training Program (ITTP). The personal, face-to-face contact between theresearchers and respondents was a major factor in attaining the high response rateswe had among teamsandteam members. Team members often were eager todiscuss both successes and failures with regardto their team workand many of them were sincerelyinterested in changing and improving teamfunctioning. The next two papers (Farrell, Schmitt, &Heinemann, 1995; Schmitt, Heinemann, &Farrell,1995) represent early analyses of data from this project.

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Acknowledgement

Preparation of this paper was supported in part by Grant 1R01AG08957-03 from the NationalInstitute onAging and in part by the Department ofVeterans Affairs. Its contents are solely theresponsibility ofthe authors and do not necessarily represent the views ofthe National Institute onAging orthe Department ofVeterans Affairs. The authors gratefully acknowledge the assistance of Sharon Fish.Carol Crane,Rachael Eberle. Sara Brallier. Laurie Krupski, Marina Belaya, Nancy Reynolds, and AliceWilkinson. In addition we wish to recognize facilitation of this research bythree consultants, KlausRoghmann, Ruth Ann Tsukuda and Theresa Drinka, the VA Central Office, the local investigators at the 34VAMC's, and all the participating team members.

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