Interventions to promote collaboration between nurses and doctors

Interprofessional Learning in Multidisciplinary Healthcare Teams Is Associated With Reduced Patient Mortality: A Quantitative Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study is to identify quantitative evidence for the efficacy of interprofessional learning (IPL) to improve patient outcomes.

METHODS

We conducted a systematic review and meta-analysis of quantitative patient outcomes after IPL in multidisciplinary healthcare teams reported in the Medline, Scopus, PsycInfo, Embase, and CINAHL databases.

RESULTS

In 2022, we screened 15,248 reports to include 20 and extracted rates of mortality and primary outcomes in conventional care groups and intervention groups (involving initiatives to promote IPL in multidisciplinary teams). The meta-analysis of the 13 studies reporting mortality outcomes demonstrated that the 7166 patients in the intervention group had a significant 28% (95% confidence interval [CI], 40%-14%; P < 0.0003) reduced risk of dying compared with the 6809 patients in the conventional care group. The meta-analysis of the 14 studies reporting other treatment-related adverse outcomes demonstrated that the 4789 patients in the intervention group had a significant 23% (95% CI, 33%-12%; P < 0.0001) reduced risk of experiencing an adverse outcome during care compared with the 4129 patients in the conventional care group. Sensitivity analysis, involving the exclusion of the 20% of individual studies with the widest 95% CIs, confirmed the precision and reliability of our findings.

CONCLUSIONS

We believe that our results are the first to demonstrate significant quantitative evidence for the efficacy of IPL to translate into changes in clinical practice and improved patient outcomes. Our results reinforce earlier qualitative work of the value of IPL, but further prospective quantitative and mixed-methods research is needed to better define such benefits.

Checklists for interpreting chest radiographs: a scoping review protocol

INTRODUCTION

What is known about checklists for interpreting chest radiographs? The question will guide the development of the inclusion criteria for the scoping review. Breaking down the scoping review question will allow the evaluation of inclusion and exclusion criteria for the protocol. The eligibility of the proposed research question will be assessed using the Population or Participants, Concept and Context (PCC) framework.

BACKGROUND

X-ray reporting can be standardised using checklists. Checklists may reduce the time needed to produce a comprehensive X-ray report and improve the quality and consistency of detecting abnormalities on chest radiographs. This scoping review aims to map the available literature on what is known about checklists for interpreting chest radiographs.

METHODS

We will follow the methodological framework for scoping reviews originally described by Arksey and O'Malley. The scoping review will include articles that describe checklists for reducing diagnostic errors, checklists for analysing chest radiographs, checklists for identifying abnormalities on chest radiographs and checklists for reporting chest radiographs in all settings. Search terms are chest radiographs, checklists, and chest X-rays. We will search for peer-reviewed articles and grey literature including dissertations and theses. We will search online databases including Ovid Medline and Ebscohost, to identify articles published in English from 1994 to 2022. The searched articles will undergo two levels of screening, first the title and abstract screening, then a full-text screening by two reviewers. Data from the selected articles will be extracted, using a tested extraction form and charted using the Joanna Briggs Institute guidelines.

RESULTS

The results will be collated, summarised and discussed including any limitations of the included articles. The articles will be summarised in a table, as well as narratively. The distribution of studies will be summarised quantitatively and the numerical analysis will provide an overview and identify knowledge gaps. Content analysis will map different checklists available for chest interpretation.

DISCUSSION

The results of the scoping review will be used to develop a checklist that will be used by medical doctors in collaboration with radiographers working in settings where there are no radiologists on-site, for interpreting chest radiographs.

SYSTEMATIC REVIEW REGISTRATION

Scoping review protocol registered with Open Science Framework on 27 July 2022. Registration https://doi.org/10.17605/OSF.IO/JS5PQ.

[Measuring individual competencies and team performance in clinical learning settings of interprofessional collaborative practice: Empirical development of the Interprofessional Ward Round Individual and Team Assessment Tool (IP-VITA)]

BACKGROUND

Interprofessional training wards (IPTW) can contribute to the development of interprofessional competencies. In order to evaluate the acquisition of competencies, instruments are needed that record both team performance and individual competencies in the clinical teaching setting in third-party assessment. This paper describes the Interprofessional Ward Round Individual and Team Assessment-Tool, IP-VITA ("Interprofessionelle Visiten Individual und Team Assessment Tool") and its development.

METHOD

Based on the empirical exploration of the three observation instruments "Teamwork Assessment Scale" (TAS), "McMaster-Ottawa Scale" and "Individual Teamwork Observation and Feedback Tool" (iTOFT) in at least four rounds each at the HIPSTA (with n=8 students and trainees each), a preliminary version of the IP-VITA was created. This preliminary version was then refined in subsequent empirical steps: a consensual validation in the research team was followed by a "member check" with the clinical colleagues of the HIPSTA, the input from external experts and an empirical test in an alternative setting.

RESULTS

The IP-VITA is an empirically developed multimodal instrument to assess the interprofessional competencies of trainees and students as well as their team performance in clinical settings with patient interaction. It comprises three parts. In part A, structural data, the persons involved and the essential patient characteristics are recorded. Part B consists of 12 items and a free-text field for recording behaviour at the individual level. Part C also consists of 12 items and evaluates behaviour at team level.

DISCUSSION

The IP-VITA instrument was developed specifically for the context of evaluating interprofessional ward rounds in a clinical educational setting. The instrument takes into account the ambiguous position of the assessment of interprofessional collaboration between individual competence and team performance. Beyond the HIPSTA, it can be used as a formative assessment instrument, and it may also be useful for summative assessments.

Effects of Continuous Care Combined with Evidence-Based Nursing on Mental Status and Quality of Life and Self-Care Ability in Patients with Liver from Breast Cancer: A Single-Center Randomized Controlled Study

Objective

To explore the multidisciplinary collaborative extended care combined with EBN to improve breast cancer liver metastasis patients' psychological status and self-care ability.

Background

In the past ten years, the number of breast cancer patients with liver metastases has increased year by year, becoming a global public health problem. Studies have shown that 30% of breast cancer patients with liver metastases show varying degrees of anxiety and depression, and their quality of life is significantly lower than that of the normal population. Multidisciplinary collaborative continuous care can improve the prognosis of breast cancer treatment to a certain extent and is the key to meeting the needs of cancer patients.

Materials and Methods

The clinical data of 96 patients with liver metastases from breast cancer were selected as the study subjects and divided into a comparison group and an observation group of 48 cases each according to a random number table. Among them, the comparison group implemented evidence-based nursing (EBN) and the observation group implemented multidisciplinary collaborative extended care based on the comparison group. The effects of psychological status, quality of life, self-care ability, and sleep quality were compared between the two groups before and after nursing care.

Results

After nursing, the sleep quality scores, increased awakening scores, sleep quality that shows weakness because important things are not steady or strong scores, and night terrors scores of the two groups of breast cancer patients with liver the spread of diseases through the body were very much improved, and the sleep quality scores of the instance of watching, noticing, or making a statement group were much lower than those of the comparison group (P < 0.05). After nursing, the fear and stress-related score, depression score, tiredness and distress score, and anger score of the two groups of breast cancer patients with liver (the spread of diseases through the body) were very much improved, and the mental state score of the instance of watching, noticing, or making a statement group was much lower than that of the comparison group (P < 0.05). The scores of self-care skills, self-responsibility, health knowledge, and self-idea of patients in the instance of watching, noticing, or making a statement group after nursing were higher than those in the comparison group (P < 0.05). After nursing, the scores of mental energy, social interaction, emotional restriction, and mental status of patients in (instance of watching, noticing, or making a statement) were much higher than those in the comparison group (P < 0.05).

Conclusion

Multidisciplinary collaborative continuous nursing combined with EBN can effectively improve the sleep quality and psychological state of patients with breast cancer and liver metastases and improve self-care ability.

Inter-Sectoral Management of Suicidal Persons in Ghana: Tensions and Prospects

Inter-sectoral collaboration health care model is essential for effective suicide prevention and treatment. This brief report presents three cases to illustrate two important facts in suicidology and related observed dynamics working as suicide researchers in Ghana. The first fact is that suicidal work is a multidisciplinary approach. The second: there may be contextual factors which may make a multidisciplinary approach in working with a suicidal person difficult in Ghana. The first two cases involved the work of a Clinical Psychologist/Suicidologist (First author), while the third involved the work of a Community Psychologist/Suicidologist (Second Author). Thematic analysis of experiences showed the trajectories of tensions and prospects involved when working as a team in providing help for persons in suicidal crisis in Ghana. Based on the findings, we make recommendations for scaling up mental health education and suicide training for allied professionals towards enriching and expanding inter-sectoral collaboration in preventing and treating suicidality.

No. 396-Fetal Health Surveillance: Intrapartum Consensus Guideline

OBJECTIVE

To present evidence and recommendations regarding use, classification, interpretation, response, and documentation of fetal surveillance in the intrapartum period and to provide information to help minimize the risk of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention.

INTENDED USERS

Members of intrapartum care teams, including but not limited to obstetricians, family physicians, midwives and nurses, and their learners TARGET POPULATION: Intrapartum women OPTIONS: All methods of uterine activity assessment and fetal heart rate surveillance were considered in developing this document.

OUTCOMES

The impact, benefits, and risks of different methods of surveillance on the diverse maternal-fetal health conditions have been reviewed based on current evidence and expert opinion. No fetal surveillance method will provide 100% detection of fetal compromise; thus, all FHS methods are viewed as screening tests. As the evidence continues to evolve, caregivers from all disciplines are encouraged to attend evidence-based Canadian educational programs every 2 years.

EVIDENCE

Literature published between January 1976 and February 2019 was reviewed. Medline, the Cochrane Database, and international guidelines were used to search the literature for all studies on intrapartum fetal surveillance.

VALIDATION METHODS

The principal and contributing authors agreed to the content and recommendations. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care.

BENEFITS, HARM, AND COSTS

Consistent interdisciplinary use of the guideline, appropriate equipment, and trained professional staff enhances safe intrapartum care. Women and their support person(s) should be informed of the benefits and harms of different methods of fetal health surveillance.

RECOMMENDATIONS

CommunicationSupport During Active LabourPrinciples of Intrapartum Fetal SurveillanceSelecting the Method of Fetal Heart Rate Monitoring: Intermittent Auscultation or Electronic Fetal MonitoringPaper SpeedAdmission AssessmentsEpidural AnalgesiaIntermittent Auscultation in LabourElectronic Fetal Monitoring in LabourClassification of Intrapartum Fetal SurveillanceMaternal Heart RateFetal Health Surveillance Assessment in the Active Second Stage of LabourIntrauterine ResuscitationDigital Fetal Scalp StimulationFetal Scalp Blood SamplingUmbilical Cord Blood GasesDocumentationFetal Surveillance Technology Not RecommendedFetal Health Surveillance Education.

Bolstering clinician resilience through an interprofessional, web-based nightly debriefing program for emergency departments during the COVID-19 pandemic

The COVID-19 pandemic has instigated significant changes for health care systems. With clinician burnout rising, efforts to promote clinician resilience are essential. Within this quality improvement project, an interprofessional debriefing program (Brigham Resilience in COVID-19-pandemic Emergency Forum-BRIEF) was developed within two emergency departments (EDs). An interprofessional group of ED providers led optional, nightly debriefings using a web-based portal to connect with ED clinicians for six weeks. In total, 81 interprofessional staff participated in nightly debriefings with a 47% attendance rate. On average, three participants attended the BRIEF nightly (range = 2-8) to discuss the challenges of social distancing, scarce resources, high acuity, clinician burnout and mental health. Participation increased as rates of COVID-19 positive patients rose. Debriefing leaders provided ED leadership with summaries of clinician experiences and suggestions for improvements. Feedback supported quality improvement initiatives within the ED and greater mental health support for staff. Clinicians and administrators provided positive feedback regarding the program's impact on clinician morale, and clinical processes that promoted the safety and quality of patient care. Optional debriefing with receptive departmental leadership may be a successful tool to support clinicians and hospitals during critical events.

Building Pre-Professional Students' Interprofessional Skills and Confidence: A Population Health Approach

BACKGROUND

Many graduates of health science programs lack the skills and confidence to incorporate multiple providers' perspectives when designing coordinated care outcomes.

METHOD

This longitudinal cross-sectional study used the Interprofessional Attitude Scale (IPAS) to study prelicensure nursing students' perceptions of interprofessional (IP) work. Between 2015 and 2018, IPAS scores and anecdotal data were collected for four consecutive semesters.

RESULTS

Data suggest students' (n = 162) attitudes changed significantly toward teamwork, community centeredness, and biases with medium to large effect sizes (r = .33 to .51). Anecdotal findings echoed these shifts in student attitudes.

CONCLUSION

There is no one ideal approach to build IP practice into curricula that is content saturated. With the shared commitment of IP faculty and the use of creative educational approaches, weaving IP processes into population health curricula encourages students to engage in IP work and develop the skills and confidence needed for IP practice. [J Nurs Educ. 2020;59(3):169-172.].

Education Milestones for Newly Diagnosed Pediatric, Adolescent, and Young Adult Cancer Patients: A Quality Improvement Initiative

The diagnosis of cancer in a child, adolescent, or young adult is an emotionally overwhelming time. To improve the quality of education and support provided to patients and caregivers with a new cancer diagnosis, we executed a quality improvement initiative to (a) define key education milestones for the delivery of essential education during the first 2 months following diagnosis and (b) to define role accountability within the multidisciplinary team for delivery of content and execution of tasks. To develop education milestones, we (a) identified educational content from review of the literature, (b) determined the sequence of content delivery through qualitative interviews with patients and caregivers, and (c) developed education milestones by evaluation of existing workflows. To develop task lists, we (a) determined which multidisciplinary team member was best suited to deliver specific content and (b) defined discrete tasks required to execute education milestones. Key content topics and preferred sequence are as follows: Emotional Adjustment to Diagnosis, When and How to Call the Doctor, Medication Management, Practical Needs, Line Care, and Access to Nontherapeutic Clinical Trials. Eight education milestones were defined across the initial 2 months following cancer diagnosis. The education milestones are paired with task lists. The education milestones and task lists guide the execution of complex education across a multidisciplinary service line in an emotionally challenging time. Early information focuses on essential content, role responsibility is clearly defined, and psychosocial support services are purposefully and iteratively integrated into care during the initial weeks following a cancer diagnosis.

The intersection of professionalism and interprofessional care: development and initial testing of the interprofessional professionalism assessment (IPA)

Valid assessment of interprofessional education and collaborative practice (IPECP) is challenging. The number of instruments that measure various aspects of IPECP, or in various sites is growing, however. The Interprofessional Professionalism Assessment (IPA) measures observable behaviors of health care professionals-in-training that demonstrate professionalism and collaboration when working with other health care providers in the context of people-centered care. The IPA instrument was created by the Interprofessional Professionalism Collaborative (IPC), a national group representing 12 entry-level health professions and one medical education assessment organization. The instrument was created and evaluated over several years through a comprehensive, multi-phasic process: 1) development of construct and observable behaviors, 2) instrument design, expert review and cognitive interviews, and 3) psychometric testing. The IPA contains 26 items representing six domains of professionalism (altruism and caring, excellence, ethics, respect, communication, accountability), and was tested by 233 preceptors rating health profession learners in the final year of their practical training. These preceptors represented 30 different academic institutions across the U.S., worked in various types of practice sites, and evaluated learners representing 10 different entry-level health professions. Exploratory factor analysis suggested four factors (communication, respect, excellence, altruism and caring) using 21 items with the least amount of missing data, and confirmed, for the most part, a priori expectations. Internal consistency reliability coefficients for the entire instrument and its four subscales were high (all greater than 0.9). Psychometric results demonstrate aspects of the IPA's reliability and validity and its use across multiple health professions and in various practice sites.

Does the readiness for interprofessional education reflect students' dominance orientation and professional commitment? Evidence from a sample of nursing students

BACKGROUND

Interprofessional education is an important factor in facilitating subsequent interprofessional collaboration. Therefore, implementing this teaching strategy is important to increase the chances that future professionals will work effectively together. Group membership, status and the power differential among professional groups are factors that can hinder both interprofessional education and collaboration. From a psychosocial point of view, interprofessional education may be described as an intergroup context in which members of different status groups interact. It involves at least two main psychosocial processes: commitment to the profession and acceptance or challenge of interprofessional hierarchy.

OBJECTIVES

The purpose of this research was to analyse the effects of professional commitment and social dominance orientation on attitudes toward interprofessional education.

DESIGN

A cross-sectional design was conducted.

PARTICIPANTS

A total of 137 nursing science students from an Italian university were enrolled in this research.

METHODS

Participants were surveyed using a questionnaire measuring attitudes toward interprofessional education, professional commitment and social dominance orientation.

RESULTS

The more that students showed social dominance orientation, the less they were willing to engage in interprofessional education. This effect was qualified by an interaction with professional commitment. When professional commitment was higher, social dominance orientation was weakly related to attitude toward interprofessional learning.

CONCLUSIONS

These results suggest that there is a belief that professional hierarchy is deserved and that this may decrease a nursing student's engagement in interprofessional education; however, this may be contrasted by an increased professional commitment.

Examining interprofessional team interventions designed to improve nursing and team outcomes in practice: a descriptive and methodological review

Effective interprofessional (IP) team-based care is critical to enhance the delivery of efficient care and improve nursing and IP team outcomes. This study aims to review the most recent IP team intervention studies that focused on outcomes related to nursing and IP teams. PubMed, CINAHL, PsycINFO, and Embase were searched for existing literature published between January 2011 and December 2016. The search strategy was developed through both literature review and consultation with a health sciences librarian. This review included IP team intervention studies published in peer-reviewed journals and written in English. Studies were included if they conducted an IP team intervention for healthcare teams that include nurses and examined outcomes related to nursing and the IP teams. Based on inclusion and exclusion criteria, 41 articles were included for the final review. Two authors extracted data on the characteristics of IP team interventions, assessment methods, and their outcomes related to nursing and IP teams using a data abstraction tool developed by the research team. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. We found that most of the included studies were conducted in the US and on inpatient units. A quasi-experimental study design was most commonly employed. Most studies conducted IP team training such as TeamSTEPPS® as a one-time activity. The most common outcomes measured were attitudes or perceptions about IP teamwork or communication, followed by patient-related outcomes, and knowledge or skills about IP competencies. The quality of the included studies was generally low. The findings from this review will contribute to understanding the characteristics of current IP intervention studies and call for IP scholars to design more rigorous yet realistic IP intervention studies.

Collaboration and patient safety at an emergency department - a qualitative case study

Purpose The purpose of this paper is to examine how conflicts about collaboration between staff at different departments arose during the establishment of a new emergency department and how these conflicts affected the daily work and ultimately patient safety at the emergency department. Design/methodology/approach This qualitative single case study draws on qualitative semi-structured interviews and participant observation. The theoretical concepts "availability" and "receptiveness" as antecedents for collaboration will be applied in the analysis. Findings Close collaboration between departments was an essential precondition for the functioning of the new emergency department. The study shows how a lack of antecedents for collaboration affected the working relation and communication between employees and departments, which spurred negative feelings and reproduced conflicts. This situation was seen as a potential threat for the safety of the emergency patients. Research limitations/implications This study presents a single case study, at a specific point in time, and should be used as an illustrative example of how contextual and situational factors affect the working environment and through that patient safety. Originality/value Few studies provide an in-depth investigation of what actually takes place when collaboration between professional groups goes wrong and escalates, and how problems in collaboration may affect patient safety.

Relational Climate and Health Care Costs: Evidence From Diabetes Care

Quality of care worries and rising costs have resulted in a widespread interest in enhancing the efficiency of health care delivery. One area of increasing interest is in promoting teamwork as a way of coordinating efforts to reduce costs and improve quality, and identifying the characteristics of the work environment that support teamwork. Relational climate is a measure of the work environment that captures shared employee perceptions of teamwork, conflict resolution, and diversity acceptance. Previous research has found a positive association between relational climate and quality of care, yet its relationship with costs remains unexplored. We examined the influence of primary care relational climate on health care costs incurred by diabetic patients at the U.S. Department of Veterans Affairs between 2008 and 2012. We found that better relational climate is significantly related to lower costs. Clinics with the strongest relational climate saved $334 in outpatient costs per patient compared with facilities with the weakest score in 2010. The total outpatient cost saving if all clinics achieved the top 5% relational climate score was $20 million. Relational climate may contribute to lower costs by enhancing diabetic treatment work processes, especially in outpatient settings.

An overview of systematic reviews on the collaboration between physicians and nurses and the impact on patient outcomes: what can we learn in primary care?

Background

Primary care needs to be strengthened in order to address the many societal challenges. Group practices in primary care foster collaboration with other health care providers, which encourages care co-ordination and leads to a higher quality of primary care. Nursing roles and responsibilities expanded over time and nurses have been found to often provide equal high-quality chronic patient care compared to physicians, even with higher patient satisfaction. Inter-professional collaboration between primary care physicians and nurses is a possible strategy to achieve the desired quality outcomes in a strengthened primary care system. The objective of this research is to synthesize the evidence presented in literature on the impact of collaboration between physicians and nurses on patient outcomes in primary care or in comparable care settings.

Methods

A systematic review of peer-reviewed reviews was performed in four databases: COCHRANE, MEDLINE, EMBASE and CINAHL. All studies from 1970 until May 22 2016 were included in the search strategy. Titles, abstracts and full texts were respectively reviewed. At least two of the three authors independently reviewed each of the 277 abstracts and 58 full texts retrieved in the searches to identify those which contained all the inclusion criteria. Two authors independently appraised the methodological quality of the reviews, using the AMSTAR quality appraisal tool.

Results

A total of eleven systematic reviews met all the inclusion criteria and almost fifty different patient outcomes were described. In most reviews, it was concluded that nurses do have added value. Blood pressure, patient satisfaction and hospitalization are patient outcomes where three or more systematic reviews concluded better results when physicians and nurses collaborated, compared to usual care. Colorectal screening, hospital length of stay and health-related quality of life are outcomes where collaboration appeared not to be effective.

Conclusions

Collaboration between physicians and nurses may have a positive impact on a number of patient outcomes and on a variety of pathologies. To address future challenges of primary care, there is a need for more integrated inter-professional collaboration care models with sufficiently educated nurses.

Electronic supplementary material

The online version of this article (10.1186/s12875-017-0698-x) contains supplementary material, which is available to authorized users.

Interprofessional collaboration to improve professional practice and healthcare outcomes

BACKGROUND

Poor interprofessional collaboration (IPC) can adversely affect the delivery of health services and patient care. Interventions that address IPC problems have the potential to improve professional practice and healthcare outcomes.

OBJECTIVES

To assess the impact of practice-based interventions designed to improve interprofessional collaboration (IPC) amongst health and social care professionals, compared to usual care or to an alternative intervention, on at least one of the following primary outcomes: patient health outcomes, clinical process or efficiency outcomes or secondary outcomes (collaborative behaviour).

SEARCH METHODS

We searched CENTRAL (2015, issue 11), MEDLINE, CINAHL, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform to November 2015. We handsearched relevant interprofessional journals to November 2015, and reviewed the reference lists of the included studies.

SELECTION CRITERIA

We included randomised trials of practice-based IPC interventions involving health and social care professionals compared to usual care or to an alternative intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of each potentially relevant study. We extracted data from the included studies and assessed the risk of bias of each study. We were unable to perform a meta-analysis of study outcomes, given the small number of included studies and their heterogeneity in clinical settings, interventions and outcomes. Consequently, we summarised the study data and presented the results in a narrative format to report study methods, outcomes, impact and certainty of the evidence.

MAIN RESULTS

We included nine studies in total (6540 participants); six cluster-randomised trials and three individual randomised trials (1 study randomised clinicians, 1 randomised patients, and 1 randomised clinicians and patients). All studies were conducted in high-income countries (Australia, Belgium, Sweden, UK and USA) across primary, secondary, tertiary and community care settings and had a follow-up of up to 12 months. Eight studies compared an IPC intervention with usual care and evaluated the effects of different practice-based IPC interventions: externally facilitated interprofessional activities (e.g. team action planning; 4 studies), interprofessional rounds (2 studies), interprofessional meetings (1 study), and interprofessional checklists (1 study). One study compared one type of interprofessional meeting with another type of interprofessional meeting. We assessed four studies to be at high risk of attrition bias and an equal number of studies to be at high risk of detection bias.For studies comparing an IPC intervention with usual care, functional status in stroke patients may be slightly improved by externally facilitated interprofessional activities (1 study, 464 participants, low-certainty evidence). We are uncertain whether patient-assessed quality of care (1 study, 1185 participants), continuity of care (1 study, 464 participants) or collaborative working (4 studies, 1936 participants) are improved by externally facilitated interprofessional activities, as we graded the evidence as very low-certainty for these outcomes. Healthcare professionals' adherence to recommended practices may be slightly improved with externally facilitated interprofessional activities or interprofessional meetings (3 studies, 2576 participants, low certainty evidence). The use of healthcare resources may be slightly improved by externally facilitated interprofessional activities, interprofessional checklists and rounds (4 studies, 1679 participants, low-certainty evidence). None of the included studies reported on patient mortality, morbidity or complication rates.Compared to multidisciplinary audio conferencing, multidisciplinary video conferencing may reduce the average length of treatment and may reduce the number of multidisciplinary conferences needed per patient and the patient length of stay. There was little or no difference between these interventions in the number of communications between health professionals (1 study, 100 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Given that the certainty of evidence from the included studies was judged to be low to very low, there is not sufficient evidence to draw clear conclusions on the effects of IPC interventions. Neverthess, due to the difficulties health professionals encounter when collaborating in clinical practice, it is encouraging that research on the number of interventions to improve IPC has increased since this review was last updated. While this field is developing, further rigorous, mixed-method studies are required. Future studies should focus on longer acclimatisation periods before evaluating newly implemented IPC interventions, and use longer follow-up to generate a more informed understanding of the effects of IPC on clinical practice.

Interprofessional peer-assisted learning as a low-threshold course for joint learning: Evaluation results of the interTUT Project

BACKGROUND AND OBJECTIVE

The delivery of needs-based health care services requires a team-based and collaborative approach of different health professionals, which is not yet sufficienctliy implemented on a day to day basis. Interprofessional learning activities aim to respond to this in future. The cross-university pilot project interTUT used peer-assisted learning approaches and extracurricular tutorials in order address this issue.

METHODOLOGY

During the pilot phase, eight students and trainees have been acquired. Together, they prepared and led four extracurricular tutorials on core topics of interprofessional cooperation and documented them in procedure manuals. The course was evaluated using a standardized participant survey (n=72) and two focus groups (n=3, n=5) in which participants were asked to reflect on their individual learning experiences. Descriptive statistics were used to analyze the survey data and the focus group material was interpreted using qualitative content analysis.

RESULTS

The results indicated a high level of satisfaction, acceptance of and further demand for peer-supported learning activities. The students and trainees reported changed attitudes and subjective knowledge growth regarding the other professional groups. The constructive learning atmosphere as well as having access to a forum for interprofessional exchange were equally valued.

CONCLUSIONS

Extracurricular tutorials offer a low-threshold and very promising point of contact for the facilitation of interprofessional teaching and learning. However, this should be viewed against the background that, as part of the pilot project, only a small number of students and trainees who were already interested in the topic could be reached by this optional course. A comprehensive, long-term trial of this teaching and learning format, its linkage to curricular courses, and further research on its education-specific and practice-related effects are, therefore, necessary.

Conditions for production of interdisciplinary teamwork outcomes in oncology teams: protocol for a realist evaluation

BACKGROUND

Interdisciplinary teamwork (ITW) is designed to promote the active participation of several disciplines in delivering comprehensive cancer care to patients. ITW provides mechanisms to support continuous communication among care providers, optimize professionals' participation in clinical decision-making within and across disciplines, and foster care coordination along the cancer trajectory. However, ITW mechanisms are not activated optimally by all teams, resulting in a gap between desired outcomes of ITW and actual outcomes observed. The aim of the present study is to identify the conditions underlying outcome production by ITW in local oncology teams.

METHODS

This retrospective multiple case study will draw upon realist evaluation principles to explore associations among context, mechanisms and outcomes (CMO). The cases are nine interdisciplinary cancer teams that participated in a previous study evaluating ITW outcomes. Qualitative data sources will be used to construct a picture of CMO associations in each case. For data collection, reflexive focus groups will be held to capture patients' and professionals' perspectives on ITW, using the guiding question, 'What works, for whom, and under what circumstances?' Intra-case analysis will be used to trace associations between context, ITW mechanisms, and patient outcomes. Inter-case analysis will be used to compare the different cases' CMO associations for a better understanding of the phenomenon under study.

DISCUSSION

This multiple case study will use realist evaluation principles to draw lessons about how certain contexts are more or less likely to produce particular outcomes. The results will make it possible to target more specifically the actions required to optimize structures and to activate the best mechanisms to meet the needs of cancer patients. This project could also contribute significantly to the development of improved research methods for conducting realist evaluations of complex healthcare interventions. To our knowledge, this study is the first to use CMO associations to improved empirical and theoretical understanding of interdisciplinary teamwork in oncology, and its results could foster more effective implementation in clinical practice.

Confronting human papilloma virus/oropharyngeal cancer: a model for interprofessional collaboration

A collaborative practice model related to Human Papilloma Virus (HPV) associated oropharyngeal cancer highlights the role of the dental hygienist in addressing this condition.

BACKGROUND

The incidence of HPV associated head and neck cancer is rising. Multiple professionals including the dental hygienist can work collaboratively to confront this growing public health concern.

METHODS

A critical review applies the growth and utilization of interprofessional education (IPE) and interprofessional collaboration (IPC) to multi-disciplinary models addressing the human papilloma virus and oropharyngeal cancers.

CONCLUSIONS

A model related to HPV associated oropharyngeal cancer addresses an oral systemic condition that supports the inclusion of a dental hygienist on collaborative teams addressing prevention, detection, treatment and cure of OPC.

Evaluation of an interprofessional clinician-patient communication workshop utilizing standardized patient methodology

OBJECTIVE

Communication and interpersonal skills (CIS) are one of the 6 general competencies required by the Accreditation Council for Graduate Medical Education (ACGME). The clinician-patient communication (CPC) workshop, developed by the Institute for Healthcare Communication, provides an interactive opportunity to practice and develop CIS. The objectives of this study were to (1) determine the impact of a CPC workshop on orthopedic surgery residents' CIS (2) determine the impact of physician alone or incorporation of nursing participation in the workshop, and (3) incorporate standardized patients (SPs) in resident training and assessment of CIS.

METHODS

Stratified by training year, 18 residents of an Orthopaedic Surgery Residency Program were randomized to a CPC workshop with only residents (group A, n = 9) or a CPC workshop with nurse participants (group B, n = 9). Data included residents' (1) CIS scores as evaluated by SPs and (2) self-reports from a 25-question survey on perception of CIS. Data were collected at baseline and 3 weeks following the workshop.

RESULTS

Following the workshop, the combined group (group A and B) felt more strongly that the ACGME should require a communication training and evaluation curriculum (post mean = 52.7, post-pre difference = 15.94, p = 0.026). Group A residents felt more strongly that communication is a learned behavior (post mean = 82.7, post-pre difference = 17.67, p = 0.028), and the addition of SPs was a valuable experience (post mean = 59.3, post-pre difference = 16.44, p = 0.038). Group B residents reported less willingness to improve on their communication skills (post-mean = 79.7, post-pre difference = -7.44, p = 0.049) and less improvement in professional satisfaction in effective communication than group A (post mean group A = 81.9, group B = 83.6, post-pre difference group A = 7.11, group B = 1.89, p = 0.047). Few differences between groups regarding CIS scores were detected.

CONCLUSIONS

While there was no demonstrable difference regarding CIS, our study indicates that participants valued the importance of communication training and found SPs to be a valuable addition. The addition of interprofessional participation appeared to detract from the experience. Further study is warranted to elucidate the variables associated with interprofessional education within the context of CIS training and assessment using SPs in residency.

The impact of team science collaborations in health care: a synopsis and comment on "Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes"

The eighth column on evidence-based behavioral medicine is a synthesis of the study of Zwarenstein et al. (1). which examines the effects of practice-based interventions to improve interprofessional collaboration. Poor interprofessional collaboration may have deleterious effects on quality of care. The purpose of the systematic review was to investigate whether interventions aimed at improving interprofessional collaboration affect patient satisfaction and/or the effectiveness and efficiency of care. Five randomized controlled trials were reviewed, examining studies that differed across setting, interventions, and outcomes. Of the five studies reviewed, three showed improvements in patient care, one found no effect, and one had mixed findings. Findings indicate that interventions aimed at improving interprofessional care may improve outcomes, but interpretation of these findings is limited due to the small sample size and heterogeneity across studies reviewed.

Evaluation of the impact of interdisciplinarity in cancer care

BACKGROUND

Teamwork is a key component of the health care renewal strategy emphasized in Quebec, elsewhere in Canada and in other countries to enhance the quality of oncology services. While this innovation would appear beneficial in theory, empirical evidences of its impact are limited. Current efforts in Quebec to encourage the development of local interdisciplinary teams in all hospitals offer a unique opportunity to assess the anticipated benefits. These teams working in hospital outpatient clinics are responsible for treatment, follow-up and patient support. The study objective is to assess the impact of interdisciplinarity on cancer patients and health professionals.

METHODS/DESIGN

This is a quasi-experimental study with three comparison groups distinguished by intensity of interdisciplinarity: strong, moderate and weak. The study will use a random sample of 12 local teams in Quebec, stratified by intensity of interdisciplinarity. The instrument to measure the intensity of the interdisciplinarity, developed in collaboration with experts, encompasses five dimensions referring to aspects of team structure and process. Self-administered questionnaires will be used to measure the impact of interdisciplinarity on patients (health care utilization, continuity of care and cancer services responsiveness) and on professionals (professional well-being, assessment of teamwork and perception of teamwork climate). Approximately 100 health professionals working on the selected teams and 2000 patients will be recruited. Statistical analyses will include descriptive statistics and comparative analysis of the impact observed according to the strata of interdisciplinarity. Fixed and random multivariate statistical models (multilevel analyses) will also be used.

DISCUSSION

This study will pinpoint to what extent interdisciplinarity is linked to quality of care and meets the complex and varied needs of cancer patients. It will ascertain to what extent interdisciplinary teamwork facilitated the work of professionals. Such findings are important given the growing prevalence of cancer and the importance of attracting and retaining health professionals to work with cancer patients.

The policy and the practice: early-career doctors and nurses as leaders and followers in the delivery of health care

There are increasing calls, from a range of stakeholders in the health sector, for healthcare professionals to work more collaboratively to provide health care. In response, education institutions are adopting an interprofessional education agenda in an attempt to provide health professionals ready to meet such calls. This article considers the nature of and interaction between professional and personal identity, power relations and leadership and followership in relation to the work practices of junior doctors and novice nurses and suggests ways in which understandings from these considerations might influence the educational preparation of students for these professions.

Relationships of the location and content of rounds to specialty, institution, patient-census, and team size

Objective

Existing observational data describing rounds in teaching hospitals are 15 years old, predate duty-hour regulations, are limited to one institution, and do not include pediatrics. We sought to evaluate the effect of medical specialty, institution, patient-census, and team participants upon time at the bedside and education occurring on rounds.

Methods and Participants

Between December of 2007 and October of 2008 we performed 51 observations at Lucile Packard Children's Hospital, Seattle Children's Hospital, Stanford University Hospital, and the University of Washington Medical Center of 35 attending physicians. We recorded minutes spent on rounds in three location and seven activity categories, members of the care team, and patient-census.

Results

Results presented are means. Pediatric rounds had more participants (8.2 vs. 4.1 physicians, p<.001; 11.9 vs. 2.4 non-physicians, p<.001) who spent more minutes in hallways (96.9 min vs. 35.2 min, p<.001), fewer minutes at the bedside (14.6 vs. 38.2 min, p = .01) than internal medicine rounds. Multivariate regression modeling revealed that minutes at the bedside per patient was negatively associated with pediatrics (−2.77 adjusted bedside minutes; 95% CI −4.61 to −0.93; p<.001) but positively associated with the number of non-physician participants (0.12 adjusted bedside minutes per non physician participant; 95% CI 0.07 to 0.17; p = <.001). Education minutes on rounds was positively associated with the presence of an attending physician (2.70 adjusted education minutes; 95% CI 1.27 to 4.12; p<.001) and with one institution (1.39 adjusted education minutes; 95% CI 0.26 to 2.53; p = .02).

Conclusions

Pediatricians spent less time at the bedside on rounds than internal medicine physicians due to reasons other than patient-census or the number of participants in rounds. Compared to historical data, internal medicine rounds were spent more at the bedside engaged in patient care and communication, and less upon educational activities.

Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes

BACKGROUND

Poor interprofessional collaboration (IPC) can negatively affect the delivery of health services and patient care. Interventions that address IPC problems have the potential to improve professional practice and healthcare outcomes.

OBJECTIVES

To assess the impact of practice-based interventions designed to change IPC, compared to no intervention or to an alternate intervention, on one or more of the following primary outcomes: patient satisfaction and/or the effectiveness and efficiency of the health care provided. Secondary outcomes include the degree of IPC achieved.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group Specialised Register (2000-2007), MEDLINE (1950-2007) and CINAHL (1982-2007). We also handsearched the Journal of Interprofessional Care (1999 to 2007) and reference lists of the five included studies.

SELECTION CRITERIA

Randomised controlled trials of practice-based IPC interventions that reported changes in objectively-measured or self-reported (by use of a validated instrument) patient/client outcomes and/or health status outcomes and/or healthcare process outcomes and/or measures of IPC.

DATA COLLECTION AND ANALYSIS

At least two of the three reviewers independently assessed the eligibility of each potentially relevant study. One author extracted data from and assessed risk of bias of included studies, consulting with the other authors when necessary. A meta-analysis of study outcomes was not possible given the small number of included studies and their heterogeneity in relation to clinical settings, interventions and outcome measures. Consequently, we summarised the study data and presented the results in a narrative format.

MAIN RESULTS

Five studies met the inclusion criteria; two studies examined interprofessional rounds, two studies examined interprofessional meetings, and one study examined externally facilitated interprofessional audit. One study on daily interdisciplinary rounds in inpatient medical wards at an acute care hospital showed a positive impact on length of stay and total charges, but another study on daily interdisciplinary rounds in a community hospital telemetry ward found no impact on length of stay. Monthly multidisciplinary team meetings improved prescribing of psychotropic drugs in nursing homes. Videoconferencing compared to audioconferencing multidisciplinary case conferences showed mixed results; there was a decreased number of case conferences per patient and shorter length of treatment, but no differences in occasions of service or the length of the conference. There was also no difference between the groups in the number of communications between health professionals recorded in the notes. Multidisciplinary meetings with an external facilitator, who used strategies to encourage collaborative working, was associated with increased audit activity and reported improvements to care.

AUTHORS' CONCLUSIONS

In this updated review, we found five studies (four new studies) that met the inclusion criteria. The review suggests that practice-based IPC interventions can improve healthcare processes and outcomes, but due to the limitations in terms of the small number of studies, sample sizes, problems with conceptualising and measuring collaboration, and heterogeneity of interventions and settings, it is difficult to draw generalisable inferences about the key elements of IPC and its effectiveness. More rigorous, cluster randomised studies with an explicit focus on IPC and its measurement, are needed to provide better evidence of the impact of practice-based IPC interventions on professional practice and healthcare outcomes. These studies should include qualitative methods to provide insight into how the interventions affect collaboration and how improved collaboration contributes to changes in outcomes.

Modelling innovative interventions for optimising healthy lifestyle promotion in primary health care: "prescribe Vida Saludable" phase I research protocol

BACKGROUND

The adoption of a healthy lifestyle, including physical activity, a balanced diet, a moderate alcohol consumption and abstinence from smoking, are associated with large decreases in the incidence and mortality rates for the most common chronic diseases. That is why primary health care (PHC) services are trying, so far with less success than desirable, to promote healthy lifestyles among patients. The objective of this study is to design and model, under a participative collaboration framework between clinicians and researchers, interventions that are feasible and sustainable for the promotion of healthy lifestyles in PHC.

METHODS AND DESIGN

Phase I formative research and a quasi-experimental evaluation of the modelling and planning process will be undertaken in eight primary care centres (PCCs) of the Basque Health Service--OSAKIDETZA, of which four centres will be assigned for convenience to the Intervention Group (the others being Controls). Twelve structured study, discussion and consensus sessions supported by reviews of the literature and relevant documents, will be undertaken throughout 12 months. The first four sessions, including a descriptive strategic needs assessment, will lead to the prioritisation of a health promotion aim in each centre. In the remaining eight sessions, collaborative design of intervention strategies, on the basis of a planning process and pilot trials, will be carried out. The impact of the formative process on the practice of healthy lifestyle promotion, attitude towards health promotion and other factors associated with the optimisation of preventive clinical practice will be assessed, through pre- and post-programme evaluations and comparisons of the indicators measured in professionals from the centres assigned to the Intervention or Control Groups.

DISCUSSION

There are four necessary factors for the outcome to be successful and result in important changes: (1) the commitment of professional and community partners who are involved; (2) their competence for change; (3) the active cooperation and participation of the interdisciplinary partners involved throughout the process of change; and (4) the availability of resources necessary to facilitate the change.

Rhetorical skills as a component of midwifery care

OBJECTIVE

this article argues that rhetorical skills are an important quality factor of midwifery care. In particular, it aims to identify and discuss the relevance of three classical means of persuasion: ethos, pathos and logos.

DESIGN

secondary analysis, rhetorical analysis of semi-structured interviews.

SETTING

Slovenia. Interviews were carried out predominantly in 2006. Data refer to childbirths in 2005 and 2006.

PARTICIPANTS

four women with recent experience of childbirth.

FINDINGS

analysis identified the presence of all three means of persuasion in the interaction between midwives and women. Focusing on midwives, the quality of their awareness and command of rhetorical skills remains questionable. In particular, women experienced lack of a rational account of the situation and decisions made by health-care professionals involved in maternity care.

KEY CONCLUSIONS

acknowledging professional ethics, awareness and good command of all three means of persuasion [but above all, argumentative persuasion (logos)] is an integral component of midwifery care. It can contribute to collaborative relations between midwives and women, and thus promote women-centred midwifery care.

IMPLICATIONS FOR PRACTICE

knowledge of the three classical rhetorical means of persuasion should be integrated into professional midwifery curricula.

Fever, hyperglycaemia and swallowing dysfunction management in acute stroke: a cluster randomised controlled trial of knowledge transfer

Background

Hyperglycaemia, fever, and swallowing dysfunction are poorly managed in the admission phase of acute stroke, and patient outcomes are compromised. Use of evidence-based guidelines could improve care but have not been effectively implemented. Our study aims to develop and trial an intervention based on multidisciplinary team-building to improve management of fever, hyperglycaemia, and swallowing dysfunction in patients following acute stroke.

Methods and design

Metropolitan acute stroke units (ASUs) located in New South Wales, Australia will be stratified by service category (A or B) and, within strata, by baseline patient recruitment numbers (high or low) in this prospective, multicentre, single-blind, cluster randomised controlled trial (CRCT). ASUs then will be randomised independently to either intervention or control groups. ASUs allocated to the intervention group will receive: unit-based workshops to identify local barriers and enablers; a standardised core education program; evidence-based clinical treatment protocols; and ongoing engagement of local staff. Control group ASUs will receive only an abridged version of the National Clinical Guidelines for Acute Stroke Management. The following outcome measures will be collected at 90 days post-hospital admission: patient death, disability (modified Rankin Score); dependency (Barthel Index) and Health Status (SF-36). Additional measures include: performance of swallowing screening within 24 hours of admission; glycaemic control and temperature control.

Discussion

This is a unique study of research transfer in acute stroke. Providing optimal inpatient care during the admission phase is essential if we are to combat the rising incidence of debilitating stroke. Our CRCT will also allow us to test interventions focussed on multidisciplinary ASU teams rather than individual disciplines, an imperative of modern hospital services.

Trial Registration

Australia New Zealand Clinical Trial Registry (ANZCTR) No: ACTRN12608000563369

Interprofessional education and working in mental health: in search of the evidence base

AIM

To explore interprofessional attitudes arising from shared learning in mental health.

BACKGROUND

Inter-professional education in healthcare is a priority area for improving team-working and communication. Many studies have attempted to evaluate its benefits and challenges, although few emanate from the mental health arena. However, producing evidence to link educational input with clinical outcomes is notoriously difficult. This project attempted to produce evidence for changes in interprofessional attitudes and stereotypes.

METHOD(S)

Mental health nursing students and clinical psychology trainees participated in inter-professional education. An evaluation tool was designed to evaluate the experience and outcomes, and to consider implications for interprofessional working.

RESULTS

There was an increase in clarity regarding roles, approaches and resources, and how to collaborate in practice. There was no significant change in professional identity. Many challenges were identified, including differences in academic level, previous experience, expectations, assessment, motivation and effort.

CONCLUSION

Despite the challenges, it remains important to offer collaboration with future mental health colleagues as a foundation for effective team-working. Recommendations are made for creating inter-professional education opportunities for diverse student groups.

IMPLICATIONS FOR NURSING MANAGEMENT

Mental health professionals need to work effectively in multidisciplinary teams. Drawing on available guidance, managers should encourage and support team members to undertake shared learning where possible, both within clinical settings and through more formal educational provision. In this way, managers can facilitate collaborative relationships which will pay dividends for the provision of effective mental health care. This project adds to the limited knowledge currently available on interprofessional learning and attitudes within a mental health context.

A systematic review of teamwork training interventions in medical student and resident education

BACKGROUND

Teamwork is important for improving care across transitions between providers and for increasing patient safety.

OBJECTIVE

This review's objective was to assess the characteristics and efficacy of published curricula designed to teach teamwork to medical students and house staff.

DESIGN

The authors searched MEDLINE, Education Resources Information Center, Excerpta Medica Database, PsychInfo, Cumulative Index of Nursing and Allied Health Literature, and Scopus for original data articles published in English between January 1980 and July 2006 that reported descriptions of teamwork training and evaluation results.

MEASUREMENTS

Two reviewers independently abstracted information about curricular content (using Baker's framework of teamwork competencies), educational methods, evaluation design, outcomes measured, and results.

RESULTS

Thirteen studies met inclusion criteria. All curricula employed active learning methods; the majority (77%) included multidisciplinary training. Ten curricula (77%) used an uncontrolled pre/post design and 3 (23%) used controlled pre/post designs. Only 3 curricula (23%) reported outcomes beyond end of program, and only 1 (8%) >6 weeks after program completion. One program evaluated a clinical outcome (patient satisfaction), which was unchanged after the intervention. The median effect size was 0.40 (interquartile range (IQR) 0.29, 0.61) for knowledge, 0.38 (IQR 0.32, 0.41) for attitudes, 0.41 (IQR 0.35, 0.49) for skills and behavior. The relationship between the number of teamwork principles taught and effect size achieved a Spearman's correlation of .74 (p = .01) for overall effect size and .64 (p = .03) for median skills/behaviors effect size.

CONCLUSIONS

Reported curricula employ some sound educational principles and appear to be modestly effective in the short term. Curricula may be more effective when they address more teamwork principles.

Effects of policy options for human resources for health: an analysis of systematic reviews

BACKGROUND

Policy makers face challenges to ensure an appropriate supply and distribution of trained health workers and to manage their performance in delivery of services, especially in countries with low and middle incomes. We aimed to identify all available policy options to address human resources for health in such countries, and to assess the effectiveness of these policy options.

METHODS

We searched Medline and Embase from 1979 to September, 2006, the Cochrane Library, and the Human Resources for Health Global Resource Center database. We also searched up to 10 years of archives from five relevant journals, and consulted experts. We included systematic reviews in English which assessed the effects of policy options that could affect the training, distribution, regulation, financing, management, organisation, or performance of health workers. Two reviewers independently assessed each review for eligibility and quality, and systematically extracted data about main effects. We also assessed whether the policy options were equitable in their effects; suitable for scaling up; and applicable to countries with low and middle incomes.

FINDINGS

28 of the 759 systematic reviews of effects that we identified were eligible according to our criteria. Of these, only a few included studies from countries with low and middle incomes, and some reviews were of low quality. Most evidence focused on organisational mechanisms for human resources, such as substitution or shifting tasks between different types of health workers, or extension of their roles; performance-enhancing strategies such as quality improvement or continuing education strategies; promotion of teamwork; and changes to workflow. Of all policy options, the use of lay health workers had the greatest proportion of reviews in countries with a range of incomes, from high to low.

INTERPRETATION

We have identified a need for more systematic reviews on the effects of policy options to improve human resources for health in countries with low and middle incomes, for assessments of any interventions that policy makers introduce to plan and manage human resources for health, and for other research to aid policy makers in these countries.

An action research protocol to strengthen system-wide inter-professional learning and practice [LP0775514]

BACKGROUND

Inter-professional learning (IPL) and inter-professional practice (IPP) are thought to be critical determinants of effective care, improved quality and safety and enhanced provider morale, yet few empirical studies have demonstrated this. Whole-of-system research is even less prevalent. We aim to provide a four year, multi-method, multi-collaborator action research program of IPL and IPP in defined, bounded health and education systems located in the Australian Capital Territory (ACT). The project is funded by the Australian Research Council under its industry Linkage Program.

METHODS/DESIGN

The program of research will examine in four inter-related, prospective studies, progress with IPL and IPP across tertiary education providers, professional education, regulatory and registration bodies, the ACT health system's streams of care activities and teams, units and wards of the provider facilities of the ACT health system. One key focus will be on push-pull mechanisms, ie, how the education sector creates student-enabled IPP and the health sector demands IPL-oriented practitioners. The studies will examine four research aims and meet 20 research project objectives in a comprehensive evaluation of ongoing progress with IPL and IPP.

DISCUSSION

IPP and IPL are said to be cornerstones of health system reforms. We will measure progress across an entire health system and the clinical and professional education systems that feed into it. The value of multi-methods, partnership research and a bi-directional push-pull model of IPL and IPP will be tested. Widespread dissemination of results to practitioners, policymakers, managers and researchers will be a key project goal.

Communication during ward rounds in internal medicine. An analysis of patient-nurse-physician interactions using RIAS

OBJECTIVE

Describe the content and of mode of patient-physician-nurse interactions during ward-rounds in Internal Medicine.

METHODS

In 267/448 patients, 13 nurses, and 8 physicians from two wards in General Internal Medicine 448 interactions on ward rounds were tape recorded by observers. After exclusion of interactions with more than three participants (N=150), a random sample of 90 interactions was drawn. Data were analysed with a modified RIAS version that allowed for the registration of a third contributor and for the assessment of the direction of a communicative action (e.g.: nurse-->patient, etc.). Furthermore, time spent per individual patient was registered with a stop-watch.

RESULTS

A total of 12,078 utterances (144 per ward round) were recorded. Due to problems with the comprehensibility of some interactions the final data set contains 71 ward round interactions with 10,713 utterances (151 per ward round interaction). The average time allotted to an individual patient during ward-rounds was 7.5 min (range: 3-16 min). The exchange of medical information is the main topic in physicians (39%) and nurses (25%), second common topic in patients (28%), in whom communicative actions like agreement or checking are more common (30% patients/25% physicians/22% nurses). Physicians and patients use a substantial number of communicative actions (1397/5531 physicians; 1119/3733 patients). Patients receive about 20 bits of medical or therapeutic information per contact during ward-rounds.

CONCLUSIONS

If ward rounds serve as the central marketplace of information nurses' knowledge is under-represented. Further research should try to determine whether the quality of patient care is related to a well balanced exchange of information, to which nurses, physicians, and patients contribute their specific knowledge.

PRACTICE IMPLICATIONS

Given the fact that in-patients in Interna Medicine usually present complex problems, the exchange of factual information, expectations, and concepts is of paramount importance. We hope that this paper is going to direct the attention of the scientific community to the characteristics of ward-rounds because they will remain the central marketplace of communication in hospital.

[Evaluation of a multifaceted intervention for implementing national guidelines: the case of physical restraint in geriatric care]

BACKGROUND

There is a growing interest in developing guidelines. The French Agency for accreditation and Evaluation (Anaes) published in October 2000 guidelines on the use of restraint in geriatric care settings because in spite of the risks this practice remains widespread in that type of care setting. A multifaceted intervention was conducted in a Parisian geriatric hospital in order to improve the implementation of the published guidelines. An epidemiological study was conducted to assess the outcomes of this intervention.

METHODS

The intervention consisted in distributing educational materials and a specific prescription sheet, and in staff training sessions. A time series study was used to assess outcomes. The three time points were: before the intervention, just after the end of the intervention and one year later. Two dimensions were studied: implementation of the guidelines using markers collected from patients' charts and restraining practices noted in an observational study of hospitalized patients.

RESULTS

The results of the study suggest that five recommendations were followed better: restraint prescription (8.7 to 57.4%), writing in the patient chart the reasons for restraining (3.5 to 35.3%), follow-up prescription, assessment of potential benefits and risks for the patient and patient information (0% to 19-34%). Nevertheless, the prevalence of restraint and of devices employed (around 70%) remained unchanged after the intervention. The various outcomes of the intervention might be explained by the guidelines themselves, which were variably practical or precise. Moreover, the effect of certain factors directly related with the use of restraint, a routine practice strongly supported by myths about its efficacy, as well as factors related to intervention design may merely have prevented any decrease in the use of restraint practices.

CONCLUSION

Multifaceted intervention can favour implementation of certain national guidelines such as prescribing restraint, but can also fail in stimulating the implementation of others such as decreasing the prevalence of restraint in geriatric practice. Therefore the next intervention should emphasize alternatives to physical restraint practices.

Improving care through collaborative working in tissue viability

Collaboration is necessary in order to achieve the government aim of seamless care, but research has tended to focus on inter-professional, rather than intra-professional collaboration. A group of tissue viability nursesfrom across Manchester formed a collaborative group to strengthen their influence across their trusts and to achieve improvements in care through targeting specific objectives. This article discusses the rationale for collaboration, and reports an evaluation of the tissue viability nurse group's first year.

Qualitative evaluation of a form for standardized information exchange between orthopedic surgeons and occupational physicians

Background

Both occupational physicians and orthopedic surgeons can be involved in the management of work relevant musculoskeletal disorders. These physicians hardly communicate with each other and this might lead to different advices to the patient. Therefore, we evaluated a standardized information exchange form for the exchange of relevant information between the orthopedic surgeon and the occupational physician. The main goals of this qualitative study are to evaluate whether the form improved information exchange, whether the form gave relevant information, and to generate ideas to further improve this information exchange.

Methods

The information exchange form was developed in two consensus meetings with five orthopedic surgeons and five occupational physicians. To evaluate the information exchange form, a qualitative evaluation was set up. Structured telephone interviews were undertaken with the patients, interviews with the physicians were face-to-face and semi-structured, based on a topic list. These interviews were recorded and literally transcribed. Each interview was analyzed separately in Atlas-Ti.

Results

The form was used for 8 patients, 7 patients agreed to participate in the qualitative evaluation. All three orthopedic surgeons involved and three of the six involved occupational physicians agreed to be interviewed. The form was transferred to 4 occupational physicians, the other 3 patients recovered before they visited the occupational physician. The information on the form was regarded to be useful. All orthopedic surgeons agreed that the occupational physician should take the initiative. Most physicians felt that the form should not be filled out for each patient visiting an orthopedic surgeon, but only for those patients who do not recover as expected. Orthopedic surgeons suggested that a copy of the medical information provided to the general practitioner could also be provided to occupational physicians.

Conclusion

The information exchange form was regarded to be useful and could be used in practice. The occupational physician should take the initiative for using this form and most physicians felt the information should only be exchanged for patients who do not recover as expected. That means that the advantage of giving information early in the treatment is lost.

Organizational interventions to implement improvements in patient care: a structured review of reviews

BACKGROUND

Changing the organization of patient care should contribute to improved patient outcomes as functioning of clinical teams and organizational structures are important enablers for improvement.

OBJECTIVE

To provide an overview of the research evidence on effects of organizational strategies to implement improvements in patient care.

DESIGN

Structured review of published reviews of rigorous evaluations.

DATA SOURCES

Published reviews of studies on organizational interventions.

REVIEW METHODS

Searches were conducted in two data-bases (Pubmed, Cochrane Library) and in selected journals. Reviews were included, if these were based on a systematic search, focused on rigorous evaluations of organizational changes, and were published between 1995 and 2003. Two investigators independently extracted information from the reviews regarding their clinical focus, methodological quality and main quantitative findings.

RESULTS

A total of 36 reviews were included, but not all were high-quality reviews. The reviews were too heterogeneous for quantitative synthesis. None of the strategies produced consistent effects. Professional performance was generally improved by revision of professional roles and computer systems for knowledge management. Patient outcomes was generally improved by multidisciplinary teams, integrated care services, and computer systems. Cost savings were reported from integrated care services. The benefits of quality management remained uncertain.

CONCLUSION

There is a growing evidence base of rigorous evaluations of organizational strategies, but the evidence underlying some strategies is limited and for no strategy can the effects be predicted with high certainty.

Effect of a Multidisciplinary Intervention on Communication and Collaboration Among Physicians and Nurses

• Background Improving communication and collaboration among doctors and nurses can improve satisfaction among participants and improve patients’ satisfaction and quality of care.

• Objective To determine the impact of a multidisciplinary intervention on communication and collaboration among doctors and nurses on an acute inpatient medical unit.

• Methods During a 2-year period, an intervention unit was created that differed from the control unit by the addition of a nurse practitioner to each inpatient medical team, the appointment of a hospitalist medical director, and the institution of daily multidisciplinary rounds. Surveys about communication and collaboration were administered to personnel in both units. Physicians were surveyed at the completion of each rotation on the unit; nurses, biannually.

• Results Response rates for house staff (n = 111), attending physicians (n = 45), and nurses (n = 123) were 58%, 69%, and 91%, respectively. Physicians in the intervention group reported greater collaboration with nurses than did physicians in the control group (P &lt; .001); the largest effect was among the residents. Physicians in the intervention group reported better collaboration with the nurse practitioners than with the staff nurses (P &lt; .001). Physicians in the intervention group also reported better communication with fellow physicians than did physicians in the control group (P = .006). Nurses in both groups reported similar levels of communication (P = .59) and collaboration (P = .47) with physicians. Nurses in the intervention group reported better communication with nurse practitioners than with physicians (P &lt; .001).

• Conclusions The multidisciplinary intervention resulted in better communication and collaboration among the participants.

Collaborative quality improvement to promote evidence based surfactant for preterm infants: a cluster randomised trial

OBJECTIVE

To test a multifaceted collaborative quality improvement intervention designed to promote evidence based surfactant treatment for preterm infants of 23-29 weeks' gestation.

DESIGN

Cluster randomised controlled trial.

SETTING AND PARTICIPANTS

114 neonatal intensive care units (which treated 6039 infants of 23-29 weeks gestation born in 2001).

MAIN OUTCOME MEASURES

Process of care measures: proportion of infants receiving first surfactant in the delivery room, proportion receiving first surfactant more than two hours after birth, and median time from birth to first dose of surfactant. Clinical outcomes: death before discharge home, and pneumothorax.

INTERVENTION

Multifaceted collaborative quality improvement advice including audit and feedback, evidence reviews, an interactive training workshop, and ongoing faculty support via conference calls and email.

RESULTS

Compared with those in control hospitals, infants in intervention hospitals were more likely to receive surfactant in the delivery room (adjusted odds ratio 5.38 (95% confidence interval 2.84 to 10.20)), were less likely to receive the first dose more than two hours after birth (adjusted odds ratio 0.35 (0.24 to 0.53)), and received the first dose of surfactant sooner after birth (median of 21 minutes v 78 minutes, P < 0.001). The intervention effect on timing of surfactant was larger for infants born in the participating hospitals than for infants transferred to a participating hospital after birth. There were no significant differences in mortality or pneumothorax.

CONCLUSION

A multifaceted intervention including audit and feedback, evidence reviews, quality improvement training, and follow up support changed the behaviour of health professionals and promoted evidence based practice.

Predictors of patient satisfaction with inpatient hospital nursing care

The purpose of this predictive nonexperimental study was to investigate the influence of registered nurse (RN) job satisfaction, context of care, structure of care, patient-perceived nurse caring, and patient characteristics on patient satisfaction with inpatient hospital nursing care in an academic medical center in north-central West Virginia. Convenience samples of patients (N = 362) and RNs (N = 90) were recruited from two medical units, two surgical units, and three intensive care step-down units. Causal modeling identified patient-perceived nurse caring as the major predictor of patient satisfaction, with nurse/physician (RN/MD) collaboration as the only other direct predictor. Age had an indirect influence on patient satisfaction. Strategies to achieve and maintain patient satisfaction should address the enhancement of patient-perceived nurse caring and RN/MD collaboration.

Skill mix, doctors and nurses: substitution or diversification?

This commentary surveys the current arguments for and against modifying the work of doctors and nurses by placing the main viewpoints - substitution and diversification - within the policy background, particularly that of the UK. We discuss the forces for modification: cost effectiveness, professional development, quality improvement and pragmatic management and how each provides a stand-point for evaluation of the issues. Policy makers and managers in the health sector should be aware of the rather fragmented evidence base for doctor-nurse substitution and should consider skill mix changes only when they are clear about: purpose, evidence base, acceptable risks, accountability and quality assurance. Doctor-nurse substitution is not necessarily cost effective, nor is it unfailingly a gain in nurse professionalism or in quality of care. Of the management perspectives available - advocacy, skepticism or pragmatism - the current evidence and policy base favours pragmatism over evaluations of the rightness or wrongness of a general policy.

Working together but apart: barriers and routes to nurse--physician collaboration

The authors argue that the aircraft safety model may be of limited relevance for health care and suggest strategies for greater collaboration between nurses and physicians in the care of patients.

Are teamwork and professional autonomy compatible, and do they result in improved hospital care?

A postal questionnaire survey of 10 022 staff nurses in 32 hospitals in England was undertaken to explore the relationship between interdisciplinary teamwork and nurse autonomy on patient and nurse outcomes and nurse assessed quality of care. The key variables of nursing autonomy, control over resources, relationship with doctors, emotional exhaustion, and decision making were found to correlate with one another as well as having a relationship with nurse assessed quality of care and nurse satisfaction. Nursing autonomy was positively correlated with better perceptions of the quality of care delivered and higher levels of job satisfaction. Analysis of team working by job characteristics showed a small but significant difference in the level of teamwork between full time and part time nurses. No significant differences were found by type of contract (permanent v short term), speciality of ward/unit, shift length, or job title. Nurses with higher teamwork scores were significantly more likely to be satisfied with their jobs, planned to stay in them, and had lower burnout scores. Higher teamwork scores were associated with higher levels of nurse assessed quality of care, perceived quality improvement over the last year, and confidence that patients could manage their care when discharged. Nurses with higher teamwork scores also exhibited higher levels of autonomy and were more involved in decision making. A strong association was found between teamwork and autonomy; this interaction suggests synergy rather than conflict. Organisations should therefore be encouraged to promote nurse autonomy without fearing that it might undermine teamwork.