Team functioning and patient outcomes in stroke rehabilitation

Implementing a tailored, co-designed goal-setting implementation package in rehabilitation services: a process evaluation

PURPOSE

This study aims to evaluate the process of implementing an evidence-based goal-setting package into five rehabilitation services across the continuum of rehabilitation.

MATERIALS AND METHODS

This study used a mixed methods approach guided by Medical Research Council (MRC) recommendations for conducting process evaluations, the RE-AIM framework, and the Theoretical Domains Framework (TDF). This study will evaluate the reach, adoption, implementation, and maintenance of the goal-setting package over six months.

RESULTS

Environmental context and resources, the clinician's social and professional role and identity, social influences and clinician beliefs about goal-setting consequences and individuals' capabilities were all identified as barriers or enablers throughout the implementation process. Community rehabilitation services faced challenges implementing paper-based resources, whilst inpatient rehabilitation sites faced challenges engaging nursing staff in the interdisciplinary approach to goal-setting. Social influences were an enabler in two sites that used the case conference format to facilitate setting common goals. Clinicians in all sites continued to express difficulties implementing shared decision-making with people who had cognitive impairments or were no longer progressing in their rehabilitation.

CONCLUSIONS

A team-based approach to implementing the goal-setting interventions centred around the case conference format appeared to be the most successful mode for implementing interdisciplinary person-centred goal-setting.

A systematic review critically appraising quantitative survey measures assessing power dynamics among multidisciplinary teams in acute care settings

By valuing the knowledge of each discipline holistic patient-centered care can be achieved as decisions arise from expertise rather than established hierarchies. While healthcare has historically operated as a hierarchical power structure (i.e., some voices have more influence), these dynamics are rarely discussed. This review addresses this issue by appraising extant quantitative measures that assess multidisciplinary team (MDT) power dynamics. By identifying psychometrically sound measures, change agents can uncover the collective thought processes informing power structures in practice and develop strategies to mitigate power disparities. Several databases were searched. English language articles were included if they reported on quantitative measures assessing power dynamics among MDTs in acute/hospital settings. Results were synthesized using a narrative approach. In total, 6,202 search records were obtained of which 62 met the eligibility criteria. The review reveals some promising measures to assess power dynamics (e.g., Interprofessional Collaboration Scale). However, the findings also confirm several gaps in the current evidence base: 1) need for further psychometric and pragmatic testing of measures; 2) inclusion of more representative MDT samples; 3) further evaluation of unmatured power dimensions. Addressing these gaps will support the development of future interventions aimed at mitigating power imbalances and ultimately improve collaborative working within MDTs.

Association between volume of patients undergoing stroke rehabilitation at acute care hospitals and improvement in activities of daily living

BACKGROUND

This study aimed to determine the relationship between the annual volume of patients undergoing rehabilitation per hospital and the outcomes of patients admitted for acute stroke.

METHODS

This observational study used nationwide administrative data. Data on stroke patients aged ≥ 20 years who underwent rehabilitation were extracted from 1,182 acute care hospitals in Japan. The exclusion criteria were extended hospital stay exceeding 180 days and death during hospitalization. Hospital volumes were divided into four quartiles of total patients per hospital. The primary outcome was an improvement in activities of daily living from admission to discharge measured using the Barthel index. Poisson regression analysis of activities of daily living improvement was performed using inverse probability of treatment weighting.

RESULTS

High rehabilitation volume was significantly correlated with improvements in activities of daily living using the "very low group" as a reference (risk ratio [95% confidence interval]): 1.06 [1.05-1.08], P<0.001). Low volume was also significantly associated with activities of daily living improvement (risk ratio [95% confidence interval]: 1.04 [1.03-1.06], P<0.001).

CONCLUSIONS

The annual volume of stroke patients undergoing multidisciplinary rehabilitation at a specific hospital may be a factor in the degree of patient improvement in activities of daily living.

What is rehabilitation? An empirical investigation leading to an evidence-based description

BACKGROUND

There is no agreement about or understanding of what rehabilitation is; those who pay for it, those who provide it, and those who receive it all have different interpretations. Furthermore, within each group, there will be a variety of opinions. Definitions based on authority or on theory also vary and do not give a clear description of what someone buying, providing, or receiving rehabilitation can actually expect.

METHOD

This editorial extracts information from systematic reviews that find rehabilitation to be effective, to discover the key features and to develop an empirical definition.

FINDINGS

The evidence shows that rehabilitation may benefit any person with a long-lasting disability, arising from any cause, may do so at any stage of the illness, at any age, and may be delivered in any setting. Effective rehabilitation depends on an expert multidisciplinary team, working within the biopsychosocial model of illness and working collaboratively towards agreed goals. The effective general interventions include exercise, practice of tasks, education of and self-management by the patient, and psychosocial support. In addition, a huge range of other interventions may be needed, making rehabilitation an extremely complex process; specific actions must be tailored to the needs, goals, and wishes of the individual patient, but the consequences of any action are unpredictable and may not even be those anticipated.

CONCLUSION

Effective rehabilitation is a person-centred process, with treatment tailored to the individual patient's needs and, importantly, personalized monitoring of changes associated with intervention, with further changes in goals and actions if needed.

Examining subacute nurses' roles in a changing healthcare context

AIMS AND OBJECTIVES

To explore and describe nurses' role in the rehabilitation and care of patients in one subacute care facility in Melbourne, Australia.

BACKGROUND

The role of nurses in subacute care and within the rehabilitation team is evolving and remains unclear.

DESIGN

Mixed methods.

METHODS

Fourteen nurses from seven rehabilitation and geriatric evaluation and management wards in one subacute facility in Melbourne, Australia, were observed in practice for two hours and then interviewed. Activities were recorded electronically. Interviews were audio-recorded and transcribed. Data were analysed using content analysis. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ).

RESULTS

Three main themes are as follows: (a) Nurses as rehabilitators; (b) Teamwork in rehabilitation; and (c) The changing context of subacute care. Nurses prioritised patient personal and clinical care above other responsibilities. They were largely excluded from team decision-making because clinical responsibilities precluded them from attending team meetings. Unsuitable buildings, increased patient acuity and time constraints were further challenges.

CONCLUSIONS

Nurses have a multifaceted role in patient rehabilitation that is poorly understood. An evaluation of the nursing role within the interdisciplinary team, skills and processes of care may increase understanding, and improve communication and relationships between disciplines potentially benefiting patients. Role clarity and differentiation in nursing skills are required within the nursing workforce.

RELEVANCE TO CLINICAL PRACTICE

Nurses have a unique role in both clinical care and rehabilitation of patients, and as part of the interdisciplinary team. Respectful professional relationships need fostering within the interdisciplinary team to achieve optimal patient outcomes. The way that team meetings and decision-making occur in the subacute wards requires adjustment to ensure that the valuable contribution of nurses, both to the interdisciplinary team and to the rehabilitation of patients, is used and acknowledged to improve patient care.

Interprofessional collaboration in hospitals: a critical, broad-based review of the literature

Interprofessional collaboration (IPC) is a common term applied in the healthcare literature, with suggestions it contributes to improved quality and safety of patient care across the globe. Despite worldwide implementation of models of IPC, past systematic or meta-reviews on this topic have concluded that the evidence is mixed. However, these reviews are yet to adequately consider the qualitative and mixed-methods literature on this topic. In this critical review, we synthesize the outcomes and key findings of IPC in hospitals, taking a broader approach by including diverse study designs. A total of 4,776 abstracts were screened from three major databases (Medline, CINAHL, Embase). Thirty-four studies fulfilled inclusion criteria. Although outcomes and key findings (e.g., staff turnover, error rates) were mostly positive, there were inconsistencies in the results. The included studies reflected a variety of study designs and different methodological approaches. Overall, our review revealed moderate evidence that IPC can positively influence patient, staff and organizational factors in hospitals, and that inconsistent findings may be due to variation in context (e.g., the cohort of patients). Recommendations from the review are to incorporate qualitative- and mixed-methods approaches to studying IPC in healthcare and tailor evaluations of IPC outcomes specific to the context.

Team functioning as a predictor of patient outcomes in early medical home implementation

BACKGROUND

New models of patient-centered primary care such as the patient-centered medical home (PCMH) depend on high levels of interdisciplinary primary care team functioning to achieve improved outcomes. A few studies have qualitatively assessed barriers and facilitators to optimal team functioning; however, we know of no prior study that assesses PCMH team functioning in relationship to patient health outcomes.

PURPOSE

The aim of the study was to assess the relationships between primary care team functioning, patients' use of acute care, and mortality.

METHODOLOGY/APPROACH

Retrospective longitudinal cohort analysis of patient outcomes measured at two time points (2012 and 2013) after PCMH implementation began in Veterans Health Administration practices. Multilevel models examined practice-level measures of team functioning in relationship to patient outcomes (all-cause and ambulatory care-sensitive condition-related hospitalizations, emergency department visits, and mortality). We controlled for practice-level factors likely to affect team functioning, including leadership support, provider and staff burnout, and staffing sufficiency, as well as for individual patient characteristics. We also tested the model among a subgroup of vulnerable patients (homeless, mentally ill, or with dementia).

RESULTS

In adjusted analyses, higher team functioning was associated with lower mortality (OR = 0.92, p = .04) among all patients and with fewer all-cause admissions (incidence rate ratio [IRR] = 0.90, p < 0.01), ambulatory care-sensitive condition-related admissions (IRR = 0.91, p = .04), and emergency department visits (IRR = 0.91, p = .03) in the vulnerable patient subgroup.

CONCLUSION

These early findings give support for the importance of team functioning within PCMH models for achieving improved patient outcomes.

PRACTICE IMPLICATIONS

A focus on team functioning is important especially in the early implementation of team-based primary care models.

Profiling mental health professionals in relation to perceived interprofessional collaboration on teams

OBJECTIVES

This study aims at identifying profiles of mental health professionals based on individual, interactional, structural and professional role characteristics related to interprofessional collaboration.

METHODS

Mental health professionals (N = 315) working in primary health care and specialized mental health teams in four Quebec local service networks completed a self-administered questionnaire eliciting information on individual, interactional, structural and professional role characteristics.

RESULTS

Cluster analysis identified four profiles of mental health professionals. Those with the highest interprofessional collaboration scores comprised two profiles labeled "highly collaborative female professionals with fewer conflicts and more knowledge sharing and integration" and "highly collaborative male professionals with fewer conflicts, more participation in decision-making and mutual trust." By contrast, the profile labeled "slightly collaborative professionals with high seniority, many conflicts and less knowledge integration and mutual trust" had the lowest interprofessional collaboration score. Another profile positioned between these groups was identified as "moderately collaborative female psychosocial professionals with less participation in decision-making."

DISCUSSION AND CONCLUSION

Organizational support, participation in decision-making, knowledge sharing, knowledge integration, mutual trust, affective commitment toward the team, professional diversity and belief in the benefits of interdisciplinary collaboration were features associated with profiles where perceived interprofessional collaboration was higher. These team qualities should be strongly encouraged by mental health managers for improving interprofessional collaboration. Training is also needed to promote improvement in interprofessional collaboration competencies.

Effects of an Implementation Intervention to Promote Use of Patient-Reported Outcome Measures on Clinicians' Perceptions of Evidence-Based Practice, Implementation Leadership, and Team Functioning

INTRODUCTION

Patient-reported outcome measures (PROMs) are administered rarely during rehabilitation hospitalizations because clinicians are unfamiliar with their use and the technology to integrate PROMs into electronic medical records is nascent. This study evaluated an implementation intervention that targeted teams' perceptions of evidence-based practice (EBP), implementation leadership, and team functioning that might facilitate PROM use.

METHODS

We compared clinicians' perceptions on three inpatient rehabilitation units, with sequential implementation across units. Clinicians completed the EBP Attitudes Scale, Implementation Leadership Scale, and the Team Functioning Survey before, shortly after, and 1 month after training.

RESULTS

Forty-seven clinicians participated, including nurses (27.7%), occupational (21.3%) and physical therapists (21.3%), and two physicians. They worked on spinal cord injury (46.8%), neurologic (40.4%), or pediatric (12.8%) units. EBP Attitude Scale scores improved from preintervention to postintervention and remained above baseline levels at follow-up. The interaction between time and unit was statistically significant for the Divergence subscale such that Pediatric Unit scores increased from preintervention to postintervention and follow-up, while on the spinal cord injury, unit scores increased from preintervention to postintervention, and on the Neurologic Unit scores declined from preintervention to postintervention and follow-up. The EBP Attitudes Requirements score increased at postintervention and follow-up. The Implementation Leadership Scale Proactive score and team functioning survey scores decreased slightly.

DISCUSSION

Implementing PROMs had varied effects on EBP attitudes and perceptions of leadership and team functioning. Perceptions across units were distinctive on the Evidence-Based Practice Attitudes Scale Divergence subscale. Introduction of PROMs should consider clinician attitudes regarding EBP as well as implementation leadership and team functioning.

Importance of Team Functioning as a Target of Quality Improvement Initiatives in Nursing Homes: A Qualitative Process Evaluation

INTRODUCTION

Quality improvement interventions demonstrate variable degrees of effectiveness. The aim of this work was to (1) qualitatively explore whether, how, and why an academic detailing intervention could improve evidence uptake and (2) identify perceived changes that occurred to inform outcomes appropriate for quantitative evaluation.

METHODS

A qualitative process evaluation was conducted involving semistructured interviews with nursing home staff. Interviews were analyzed inductively using the framework method.

RESULTS

A total of 29 interviews were conducted across 13 nursing homes. Standard processes to reduce falls are well-known but not fully implemented due to a range of mostly postintentional factors that influence staff behavior. Conflicting expectations around professional roles impeded evidence uptake; physicians report a disconnection between the information they would like to receive and the information communicated; and a high proportion of casual and part-time staff creates challenges for those looking to effect change. These factors are amenable to change in the context of an active, tailored intervention such as academic detailing. This seems especially true when the entire care team is actively engaged and when the intervention can be tailored to the varied determinants of behaviors across different team members.

DISCUSSION

Interventions aiming to increase evidence-based practice in the nursing home sector need to move beyond education to explicitly address team functioning and communication. Variability in team functioning requires a flexible intervention with the ability to tailor to individual- and home-level needs. Evaluations in this setting may benefit from measuring changes in team functioning as an early indicator of success.

Inter-professional communication and interaction in the neurological rehabilitation team: a literature review

Background: Neurological early rehabilitation aims at regaining cooperativity and acquiring rehabilitation capability with brain-injured patients, most of whom are transferred from Intensive Care Units, most of whom still require intensive care and suffer from disorders of consciousness. In neurological early rehabilitation, therapeutic nursing is an integral part of the therapeutic team. Other than the specialized therapists, nurses are present on the ward 24/7, which gives them a closer perspective on the patient. The research question was how do nurses, physiotherapists, occupational therapists and speech therapists communicate and interact as teams in neurological rehabilitation wards. A literature review was conducted aiming at inter-professional communication and interaction with special regard to the role of these four professionals being the core team members in these settings.Methods: A literature search was conducted in the period from August to October 2016 within the following electronic Databases: Medline, CINAHL, PSYNDEX, SpeechBITE, PEDro und OTseeker. Further searches were undertaken in the reference lists of obtained studies to locate other relevant material. The aim was to gather and evaluate the evidence about inter-professional teamwork in neurological early rehabilitation. The main inclusion criterion was the presence of the following professionals as participants in the study: Nurses, physiotherapists, occupational therapists and speech therapists. Twenty-seven studies were found relevant, of which 17 (12 qualitative and five quantitative) bore empirical results that related to the research questions. These 17 studies were qualitatively analysed for the grade of evidence, methods and the relevance for the conditions and processes in rehabilitation units. Out of 17 studies, four were performed in neurological rehabilitation settings, five in stroke units, six in general rehabilitation, one in short-term care rehabilitation and one in geriatric rehabilitation. Due to the scarcity of material, all these studies were analysed under the perspective of relevance for neurological early rehabilitation.Results: The results of this exploratory literature review indicate that the efficiency and quality of cooperation in rehabilitation teams could be improved through a better patient-oriented inter-professional communication. This is achieved through cross-professional team organization, team supervision and by including team communication in vocational and on-the-job-training. Profession-specific terminologies and differences in understanding of roles could be barriers for collaboration in teams.Conclusions: According to this literature review, successful inter-professional patient-orientated care is promoted by being informed about the various functions of team members from different disciplines, about the role each member plays within the team and communication styles. Means of improving communication are being outlined.Implications for RehabilitationInter-professional communication is promoted by cross-professional team organization.Inter-professional communication should be included in vocational and on-the-job-training and supervision.Barriers for communication in teams are different terminologies and differences in role perception.

An examination of current stroke rehabilitation practice in Peru: Implications for interprofessional education

This study aimed to better understand current clinical practice of rehabilitation professionals in Lima, Peru, and to explore the existence of and potential for interprofessional collaboration. A secondary purpose was to assess rehabilitation professionals' agreement with evidence-based stroke rehabilitation statements and confidence performing stroke rehabilitation tasks prior to and following an interprofessional stroke rehabilitation training. Current clinical practice for rehabilitation professionals in Peru differs from high-income counties like the United States, as physical therapists work with dysphagia and feeding, prosthetist orthotists serve a strictly technical role, and nurses have a limited role in rehabilitation. Additionally, while opportunity for future interprofessional collaboration within stroke rehabilitation exists, it appears to be discouraged by current health system policies. Pre- and post-training surveys were conducted with a convenience sample of 107 rehabilitation professionals in Peru. Survey response options included endorsement of professionals for rehabilitation tasks and a Likert scale of agreement and confidence. Training participants largely agreed with evidence-based stroke rehabilitation statements. Differences in opinion remained regarding the prevalence of dysphagia and optimal frequency of therapy post-stroke. Substantially increased agreement post-training was seen in favour of early initiation of stroke rehabilitation and ankle foot orthosis use. Participants were generally confident performing traditional profession-specific interventions and educating patients and families. Substantial increases were seen in respondents' confidence to safely and independently conduct bed to chair transfers and determine physiological stability. Identification of key differences in rehabilitation professionals' clinical practice in Peru is a first step toward strengthening the development of sustainable rehabilitation systems and interprofessional collaboration.

Profiles of mental health care professionals based on work role performance

The worldwide burden of mental disorders is considerable, and on the rise, putting pressure on health care systems. Current reforms aim to improve the efficiency of mental health care systems by increasing service integration in communities and strengthening primary mental health care. In this context, mental health care professionals (MHPs) are increasingly required to work on interdisciplinary teams in a variety of settings. Little is known, however, about the profiles of MHPs in relation to their perceived work role performance. MHPs in Quebec (N = 315) from four local service networks completed a self-administered questionnaire eliciting information on individual and team characteristics, as well as team processes and states. Profiles of MHPs were created using a two-step cluster analysis. Five profiles were generated. MHPs belonging to profiles labelled senior medical outpatient specialized care MHPs and senior psychosocial outpatient specialized care MHPs perceived themselves as more performing than MHPs in other profiles. The profile labelled low-collaborators was significantly less performing than all other groups. Two other profiles were identified, positioned between the aforementioned groups in terms of the perceived performance of MHPs: the junior primary care MHPs and the diversified specialized care MHPs. Seniority within the team, delivering specialized type of care, and positive team processes were all features associated with profiles where perceived work performance was high. Overall, this study supports the case for initiatives aimed at improving stability and interdisciplinary collaboration in health teams, especially in primary care.

Postacute Care Setting, Facility Characteristics, and Poststroke Outcomes: A Systematic Review

OBJECTIVES

To synthesize research comparing poststroke health outcomes between patients rehabilitated in skilled nursing facilities (SNFs) and those in inpatient rehabilitation facilities (IRFs) as well as to evaluate relations between facility characteristics and outcomes.

DATA SOURCES

PubMed and CINAHL searches spanned January 1, 1998, to October 6, 2016, and encompassed MeSH and free-text keywords for stroke, IRF/SNF, and study outcomes. Searches were restricted to peer-reviewed research in humans published in English.

STUDY SELECTION

Observational and experimental studies examining outcomes of adult patients with stroke rehabilitated in an IRF or SNF were eligible. Studies had to provide site of care comparisons and/or analyses incorporating facility-level characteristics and had to report ≥1 primary outcome (discharge setting, functional status, readmission, quality of life, all-cause mortality). Unpublished, single-center, descriptive, and non-US studies were excluded. Articles were reviewed by 1 author, and when uncertain, discussion with study coauthors achieved consensus. Fourteen titles (0.3%) were included.

DATA EXTRACTION

The types of data, time period, size, design, and primary outcomes were extracted. We also extracted 2 secondary outcomes (length of IRF/SNF stay, cost) when reported by included studies. Effect measures, modeling approaches, methods for confounding adjustment, and potential confounders were extracted. Data were abstracted by 1 author, and the accuracy was verified by a second reviewer.

DATA SYNTHESIS

Two studies evaluating community discharge, 1 study evaluating the predicted probability of readmission, and 3 studies evaluating all-cause mortality favored IRFs over SNFs. Functional status comparisons were inconsistent. No studies evaluated quality of life. Two studies confirmed increased costs in the IRF versus SNF setting. Although substantial facility variation was described, few studies characterized sources of variation.

CONCLUSIONS

The few studies comparing poststroke outcomes indicated better outcomes (with higher costs) for patients in IRFs versus those in SNFs. Contemporary research on the role of the postacute care setting and its attributes in determining health outcomes should be prioritized to inform reimbursement system reform.

Advanced practice nursing, health care teams, and perceptions of team effectiveness

This article summarizes the results of an extensive review of the organizational and health care literature of advanced practice nursing (APN) roles, health care teams, and perceptions of team effectiveness. Teams have a long history in health care. Managers play an important role in mobilizing resources, guiding expectations of APN roles in teams and within organizations, and facilitating team process. Researchers have identified a number of advantages to the addition of APN roles in health care teams. The process within health care teams are dynamic and responsive to their surrounding environment. It appears that teams and perceptions of team effectiveness need to be understood in the broader context in which the teams are situated. Key team process are identified for team members to perceive their team as effective. The concepts of teamwork, perceptions of team effectiveness, and the introduction of APN roles in teams have been studied disparately. An exploration of the links between these concepts may further our understanding the health care team's perceptions of team effectiveness when APN roles are introduced. Such knowledge could contribute to the effective deployment of APN roles in health care teams and improve the delivery of health care services to patients and families.

Improving practice with integration of patient directed activity during inpatient rehabilitation

BACKGROUND

Early initiation of rehabilitation following stroke promotes better long-term outcomes than delayed onset, emphasizing the importance of inpatient therapy. However, literature indicates that following stroke individuals in inpatient rehabilitation spend the majority of their day in their bedroom and inactive. Consequently, since amount of functional activity is posited to relate to outcomes, the current rehabilitation model needs to be challenged with innovative solutions to maximize recovery.

RATIONALE

In an attempt to promote greater activity and higher doses of therapy during inpatient rehabilitation, we implemented the "Patient Directed Activity Program" to facilitate specific movement and improve outcomes for patients post stroke. Our interdisciplinary activity program was conceptualized on a theoretical model for stroke recovery and principles of experience-dependent neural plasticity.

MAIN FEATURES

The "Patient Directed Activity Program" includes distinct activity stations designed to increase repetition, stimulation, attention, and activity of the affected upper extremities, lower extremities, and trunk. Each task-specific activity was easily graded to achieve moderate- to high-intensity. The activity program prescribed individuals up to three additional 30-minute bouts of activities daily that were to be completed independently, and in addition to standard of care. Clinical application: After implementing this program in our facility for one year as a quality improvement project, the intervention has been delivered as an Institutional Review Board approved randomized controlled trial (Clinical Trial #NCT02446197). Challenges with people and facilities have been overcome, resulting in a feasible program that can be delivered in an inpatient setting. High satisfaction has been reported by patients and clinicians.

Geographic and facility variation in inpatient stroke rehabilitation: multilevel analysis of functional status

OBJECTIVE

To examine geographic and facility variation in cognitive and motor functional outcomes after postacute inpatient rehabilitation in patients with stroke.

DESIGN

Retrospective cohort design using Centers for Medicare and Medicaid Services (CMS) claims files. Records from 1209 rehabilitation facilities in 298 hospital referral regions (HRRs) were examined. Patient records were analyzed using linear mixed models. Multilevel models were used to calculate the variation in outcomes attributable to facilities and geographic regions.

SETTING

Inpatient rehabilitation units and facilities.

PARTICIPANTS

Patients (N=145,460) with stroke discharged from inpatient rehabilitation from 2006 through 2009.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Cognitive and motor functional status at discharge measured by items in the CMS Inpatient Rehabilitation Facility-Patient Assessment Instrument.

RESULTS

Variation profiles indicated that 19.1% of rehabilitation facilities were significantly below the mean functional status rating (mean ± SD, 81.58±22.30), with 221 facilities (18.3%) above the mean. Total discharge functional status ratings varied by 3.57 points across regions. Across facilities, functional status values varied by 29.2 points, with a 9.1-point difference between the top and bottom deciles. Variation in discharge motor function attributable to HRR was reduced by 82% after controlling for cluster effects at the facility level.

CONCLUSIONS

Our findings suggest that variation in motor and cognitive function at discharge after postacute rehabilitation in patients with stroke is accounted for more by facility than geographic location.

The effect of a structured model for stroke rehabilitation multi-disciplinary team meetings on functional recovery and productivity: a Phase I/II proof of concept study

Objective:

Regular multidisciplinary team meetings are the main way that teams operate, yet our earlier research found they can sometimes be suboptimal. We developed a model to structure multidisciplinary team meetings and assessed the feasibility, acceptability and impact of its implementation on meeting quality and patient outcomes.

Design:

Longitudinal cohort design with non-participant observation of multidisciplinary team meetings before and after implementation of the intervention.

Setting:

Inpatient stroke rehabilitation units.

Subjects:

Members of the multidisciplinary inpatient stroke rehabilitation teams.

Intervention:

A model to structure multidisciplinary team meetings.

Main measures:

Quality of multidisciplinary team meetings (using a predefined checklist); change in independence (Barthel Index) during admission; length of stay; meeting duration and the number of patients discussed.

Results:

At baseline, meeting quality was generally low. Following implementation, all aspects of meeting quality improved by 5%–58%. This was achieved without loss of staff productivity or additional resources: The mean number of patients treated during the observation periods was 36 (SD 17.6), which was unchanged after implementation. Nor were there any significant changes in the length of meetings (mean = 76 minutes), time spent discussing each patient (5.4 vs. 7 minutes) or length of stay (26.7 vs. 30.3 days), but there was a greater increase in Barthel Index score after implementation (3.8 vs. 4.7) indicating greater functional recovery.

Conclusions:

A feasible and acceptable model to structure multidisciplinary stroke team meetings has been developed and implemented. This increased meeting quality without increase in resources and may increase patient recovery.

Improving medical leadership and teamwork: an iterative process

Purpose

– This paper aims to present a two-decade effort to improve team functioning and patient outcomes in inpatient stroke rehabilitation settings.

Design/methodology/approach

– The principal improvement effort was conducted over a nine-year period in 50 Veterans Administration Hospitals in the USA. A comprehensive team-based model was developed and tested in a series of empirical studies. A leadership development intervention was used to improve team functioning, and a follow-up cluster-randomized trial documented patient outcome improvements associated with the leadership training.

Findings

– Iterative team and leadership improvements are presented in summary form, and a set of practice-proven development observations are derived from the results. Details are also provided on the leadership training intervention that improved teamwork processes and resulted in improvements in patient outcomes that could be linked to the intervention itself.

Research limitations/implications

– The practice-proven development observations are connected to leadership development theory and applied in the form of suggestions to improve leadership development and teamwork in a broad array of medical treatment settings.

Practical implications

– This paper includes suggestions for leadership improvement in medical treatment settings using interdisciplinary teams to meet the customized needs of the patient populations they serve.

Originality/value

– The success of the team effectiveness model and the team-functioning domains provides a framework and best practice for other health care organizations seeking to improve teamwork effectiveness.

Toward spanning the quality chasm: an examination of team functioning measures

OBJECTIVE

To examine the effect of 5 measures of team functioning on patient outcomes.

DESIGN

Observational, exploratory, measurement. Team functioning surveys and patient outcomes collected 1 year apart in a clinical trial were analyzed. The findings are discussed in context of the domains of team functioning, team effectiveness, and quality improvement.

SETTING

27 Veterans Affairs medical centers.

PARTICIPANTS

Staff (t1: N=356; t2: N=273) on inpatient teams and patients (t1: N=4266; t2: N=3213) treated by the teams.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Five measures of team functioning (Physician Engagement, Shared Leadership, Supervisor Team Support, Teamness, and Team Effectiveness scales) and 3 measures of patient outcomes (functional improvement, discharge destination, and length of stay) were assessed at 2 time points with hierarchical generalized linear models to evaluate the association between team functioning measures and changes in patient outcomes.

RESULTS

Associations (P<.05) between team functioning measures and patient outcomes were found for 3 of the 15 analyses over the study period. Higher Physician Engagement scale score was associated with lower length of stay (P=.017), and increased scores on Teamness and Team Effectiveness scales correlated with higher rates of community discharge (P=.044 and .049, respectively).

CONCLUSIONS

This exploratory analysis revealed trends that team functioning corresponds with patient outcomes in clinically relevant patterns. An increase in community discharge and a decrease in length of stay were associated with higher scores of team functioning. Here, we find evidence that modifiable attributes of team functioning have a measurable effect on patient outcomes. Such findings are promising and support the need for further research on team effectiveness.

Multi-disciplinary team meetings in stroke rehabilitation: an observation study and conceptual framework

Objective:

To explore how multi-disciplinary team meetings operate in stroke rehabilitation.

Design:

Non-participant observation of multi-disciplinary team meetings and semi-structured interviews with attending staff.

Setting and participants:

Twelve meetings were observed (at least one at each site) and 18 staff (one psychologist, one social worker; four nurses; four physiotherapists four occupational therapists, two speech and language therapists, one stroke co-ordinator and one stroke ward manager) were interviewed in eight in-patient stroke rehabilitation units.

Results:

Multi-disciplinary team meetings in stroke rehabilitation were complex, demanding and highly varied. A model emerged which identified the main inputs to influence conduct of the meetings were personal contributions of the members and structure and format of the meetings. These were mediated by the team climate and leadership skills of the chair. The desired outputs; clinical decisions and the attributes of apparently effective meetings were identified by the staff. A notable difference between the meetings that staff considered effective and those that were not, was their structure and format. Successful meetings tended to feature a set agenda, structured documentation; formal use of measurement tools; pre-meeting preparation and skilled chairing. These features were often absent in meetings perceived to be ineffective.

Conclusions:

The main features of operation of multi-disciplinary team meetings have been identified which will enable assessment tools and interventions to improve effectiveness to be developed.

Teamwork assessment in internal medicine: a systematic review of validity evidence and outcomes

OBJECTIVE

Valid teamwork assessment is imperative to determine physician competency and optimize patient outcomes. We systematically reviewed published instruments assessing teamwork in undergraduate, graduate, and continuing medical education in general internal medicine and all medical subspecialties.

DATA SOURCES

We searched MEDLINE, MEDLINE In-process, CINAHL and PsycINFO from January 1979 through October 2012, references of included articles, and abstracts from four professional meetings. Two content experts were queried for additional studies.

STUDY ELIGIBILITY

Included studies described quantitative tools measuring teamwork among medical students, residents, fellows, and practicing physicians on single or multi-professional (interprofessional) teams.

STUDY APPRAISAL AND SYNTHESIS METHODS

Instrument validity and study quality were extracted using established frameworks with existing validity evidence. Two authors independently abstracted 30 % of articles and agreement was calculated.

RESULTS

Of 12,922 citations, 178 articles describing 73 unique teamwork assessment tools met inclusion criteria. Interrater agreement was intraclass correlation coefficient 0.73 (95 % CI 0.63-0.81). Studies involved practicing physicians (142, 80 %), residents/fellows (70, 39 %), and medical students (11, 6 %). The majority (152, 85 %) assessed interprofessional teams. Studies were conducted in inpatient (77, 43 %), outpatient (42, 24 %), simulation (37, 21 %), and classroom (13, 7 %) settings. Validity evidence for the 73 tools included content (54, 74 %), internal structure (51, 70 %), relationships to other variables (25, 34 %), and response process (12, 16 %). Attitudes and opinions were the most frequently assessed outcomes. Relationships between teamwork scores and patient outcomes were directly examined for 13 (18 %) of tools. Scores from the Safety Attitudes Questionnaire and Team Climate Inventory have substantial validity evidence and have been associated with improved patient outcomes.

LIMITATIONS

Review is limited to quantitative assessments of teamwork in internal medicine.

CONCLUSIONS

There is strong validity evidence for several published tools assessing teamwork in internal medicine. However, few teamwork assessments have been directly linked to patient outcomes.

The effects of increased therapy time on cognition and mood in frail patients with a stroke who rehabilitate on rehabilitation units of nursing homes in the Netherlands: a protocol of a comparative study

Background

Recovery after stroke is dependent on how much time can be spent on rehabilitation. Recently, we found that therapy time for older stroke patients on a rehabilitation unit of a nursing home could be increased significantly from 8.6 to at least 13 hours a week. This increase was attained by the implementation of interventions, focused on strength, mobility and balance. Nurses carried out these exercises with the patients during their daily activities. The aim of the present study is to investigate if increased therapy time has a positive effect on cognition, mood (depression and anxiety), and ADL in stroke patients.

Methods

A comparative single blind controlled study will be applied. Patients suffering from a stroke and staying on one of the rehabilitation units of the nursing homes are eligible for participation. Participants belong to the intervention group if they stay in two nursing homes where four interventions of the Clinical Nursing Rehabilitation Stroke Guideline were implemented. Participants who stay in two nursing homes where therapy is given according to the Dutch stroke Guideline, are included in the control group. Clinical neuropsychologists will assess patients’ cognitive functioning, level of depression (mood) and anxiety. Nurses will assess a Barthel Index score on a weekly basis (ADL). These variables are measured at baseline, after 8 weeks and at the moment when participants are discharged from the nursing home.

Discussion

The present study evaluates the effect of increased therapy time on cognition, mood (level of depression and anxiety), and ADL in stroke patients. When positive effects will be found this study can guide policy makers and practitioners on how to implement more therapy time on rehabilitation wards of nursing homes.

Trial registration

TNR Our study has been documented in the Dutch Trial Registration, TC = 3871.

Treatment taxonomy for rehabilitation: past, present, and prospects

The idea of constructing a taxonomy of rehabilitation interventions has been around for quite some time, but other than small and mostly ad hoc efforts, not much progress has been made, in spite of articulate pleas by some well-respected clinician scholars. In this article, treatment taxonomies used in health care, and in rehabilitation specifically, are selectively reviewed, with a focus on the need to base a rehabilitation treatment taxonomy (RTT) on the "active ingredients" of treatments and their link to patient/client deficits/problems that are targeted in therapy. This is followed by a description of what we see as a fruitful approach to the development of an RTT that crosses disciplines, settings, and patient diagnoses, and a discussion of the potential uses in and benefits of a well-developed RTT for clinical service, research, education, and service administration.

‘Can practice undertaken by patients be increased simply through implementing agreed national guidelines?’ An observational study

Objective:

To increase autonomous practice time of patients on the stroke unit of a nursing home.

Intervention:

Nurses stimulated and coached patients with the help of four interventions (muscle strengthening, sitting balance and reach, getting up from a chair, walking) from the evidence-based Clinical Nursing Rehabilitation Stroke Guidelines.

Design:

An observational study. Practice time of elderly stroke patients in this study was compared with the time observed in our previous study in the same setting.

Setting:

Rehabilitation units of a nursing home in the Netherlands.

Subjects:

Seventeen frail stroke patients, including 8 men, 9 women, with a mean age of 75.8 (SD ± 9) and 17 subjects with the same characteristics who participated in a previous observational study.

Main measures:

Time spent on therapeutic activities was measured using the Behavioral Mapping method.

Results:

The time spent on therapeutic activities increased significantly from 103.5 minutes measured in our previous study to 156.5 minutes in this study ( Z = 2.86; P < 0.005; d′ = 1.09) The mean Barthel Index score was 8.8 (SD ± 4.1). The patients with more possibilities were more active, resulting in a significant positive Barthel Index–therapy time relationship ( r = 0.73, P ≤ 0.001).

Conclusions:

The autonomous practice time of older fragile comorbid stroke patients increased during the weekdays. Patients, stimulated and challenged by nurses, exercise harder and more according to their possibilities. Since this guideline was developed especially for nurses, nurses can stimulate stroke patients to contribute more to autonomous practice and therefore help their recovery.

Team size in spinal cord injury inpatient rehabilitation and patient participation in therapy sessions: the SCIRehab project

CONTEXT/OBJECTIVE

Rehabilitation teams generally are described as consisting of a single representative of 6-8 disciplines, but research suggests that the number of individuals involved may be much larger. This study aimed to determine the size of teams in spinal cord injury (SCI) rehabilitation, and the effect of team size on patients' active participation in their treatment sessions.

DESIGN

Prospective observational study.

SETTING

Six SCI rehabilitation centers.

PARTICIPANTS

A total of 1376 patients with traumatic SCI admitted for first rehabilitation.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Number of treatment sessions, by discipline and overall clinician rating of active participation of the patient; Treatment Concentration Index (TCI) calculated as Σp(k)(2) (where p refers to the proportion of treatment sessions delivered by team member k).

RESULTS

The average patient was treated by 39.3 different clinicians. The numbers were especially high for physical therapy (mean: 8.8), occupational therapy (7.2), and nursing (16.1). TCI was 0.08 overall; it varied by discipline. TCI was negatively correlated with length of stay, except for psychology. Participation ratings were minimally affected by the number of sessions the patient and the therapist had worked together.

CONCLUSIONS

In SCI rehabilitation, teams are at least as large as suggested by previous research. However, this may not mean lack of familiarity of patient and therapist with one another, or alternatively, the possibly weak therapeutic alliance does not affect the patients' active participation in their sessions. Further research is needed to determine whether there are negative effects on rehabilitation outcomes.

Interdisciplinary communication in inpatient rehabilitation facility: evidence of under-documentation of spatial neglect after stroke

PURPOSE

Spatial neglect commonly occurs after stroke and predicts poor rehabilitation outcomes. However, this disorder is under-recognized in clinical practices, which may result from the failure to document its presence. This study aimed to identify the predictors for documentation of spatial neglect in inpatient rehabilitation facilities.

METHOD

We performed a comprehensive chart review to investigate whether the presence of spatial neglect was documented in 74 neglect patients' clinical notes recorded by physicians, nurses, or occupational therapists (OTs), or in team conference notes. Independent variables included neglect severity, length of stay, Functional Independence Measure at admission and discharge.

RESULTS

Of the 74 neglect patients, 75.7% were documented by OTs, 63.5% by physicians, and 17.6% by nurses. Although 93.2% of neglect patients were recognized by at least one clinician group, only 31.1% were discussed in multidisciplinary team conferences. Neglect patients who were documented by physicians were more likely to be documented in team conferences. While no factors predicted whether a neglect patient would be documented by nurses or OTs, we found significant predictors for neglect documentation in physician and team conference notes. The odds of being documented by physicians were increasingly greater with poorer efficiency of cognitive rehabilitation (odds ratio = 0.70). The odds of being discussed in team conferences were increasingly greater with more severe neglect (odds ratio = 0.98), and with longer stay in hospitalization (odds ratio = 1.06).

CONCLUSIONS

Multidisciplinary care may not involve as much interdisciplinary communication as needed to document important disease states. Stroke rehabilitation professionals should be able to recognize spatial neglect independently and document it consistently.

Design and implementation of clinical trials in rehabilitation research

The growth of evidence-based medicine means that both researchers and clinicians must grasp the complex issues involved in implementing clinical trials, which are especially challenging for the behavioral (experience-based) treatments that predominate in rehabilitation. In this article we discuss selected issues germane to the design, implementation, and analysis of group-level clinical trials in rehabilitation. We review strengths, weaknesses, and best applications of 1-sample, between-subjects, and within-subjects study designs, including newer models such as practical clinical trials and point-of-care trials. We also discuss the selection of appropriate control conditions against which to test rehabilitation treatments, as well as issues related to trial blinding. In a section on treatment definition, we discuss the challenges of specifying the active ingredients in the complex interventions that are widely used in rehabilitation, and present an illustration of 1 approach to defining treatments via the learning mechanisms that underlie them. Issues related to treatment implementation are also discussed, including therapist allocation and training, and assessment of treatment fidelity. Finally we consider 2 statistical topics of particular importance to many rehabilitation trials: the use of multiple or composite outcomes, and factors that must be weighed in estimating sample size for clinical trials.

The effect of rehabilitation in a comprehensive inpatient rehabilitation unit on mobility outcome after dysvascular lower extremity amputation

OBJECTIVES

To (1) compare the total volume of rehabilitation therapy for patients ever attending a comprehensive inpatient rehabilitation unit (CIRU) versus never during the 12 months after amputation; (2) determine whether rehabilitation in a CIRU at any time in the first year after amputation results in greater mobility success compared with other types of rehabilitation environments of care; and (3) determine for those patients treated in a CIRU, which specific patient characteristics were associated with improved mobility outcome.

DESIGN

Prospective cohort study.

SETTING

Two Veterans Affairs medical centers.

PARTICIPANTS

Patients (N=199) with peripheral vascular disease or diabetes undergoing a first unilateral major amputation were screened for participation between September 2005 and December 2008. Among these, 113 (57%) met study criteria; of these, 72 (64%) participated.

INTERVENTION

Ever attending a CIRU versus never attending a CIRU in first 12 months after amputation.

MAIN OUTCOME MEASURES

Number of rehabilitation therapy visits, Locomotor Capability Index scores, and mobility success.

RESULTS

The mean number of all therapy visits for patients ever attending a CIRU was significantly greater than that for those never attending over a 12-month period (48.6 vs 22.6; P=.001). Mean total time per any rehabilitation visit was .83±.27 hours for those ever attending and .60±.20 hours for those never attending (P<.001). Patients who ever were treated in a CIRU were 17% more likely to achieve mobility success than those who were not, controlling for amputation level, major depressive episode, alcohol use, social support, total number of rehabilitation visits, and hospital site (risk difference=.17; 95% confidence interval, .09-.25; P<.001).

CONCLUSIONS

Rehabilitation in a CIRU resulted in improved mobility success for veterans undergoing major lower extremity amputation secondary to peripheral vascular disease or diabetes. Among those admitted to a CIRU, younger patients with greater social support, healthy weight, and without chronic obstructive pulmonary disease had the greatest probability of mobility success.

An evaluation of the influence of primary care team functioning on the health of Medicare beneficiaries

In service industries other than health care, unit employees who report a favorable service climate--characterized by commitment to a team concept and intrateam interactions that are supportive, collegial, and collaborative--have high levels of consumer satisfaction and work unit productivity. The authors evaluated whether similar primary care team (PCT) functioning influenced the short-term future health (SF-36) of elderly Medicare beneficiaries (N = 991) in a group model managed care organization (MCO). PCT functioning was assessed by surveys of practitioners and support staff on the MCO's 14 primary care practices and included measures of perceived task delegation, role collaboration, patient orientation, and team ownership. On average, patient physical and emotional health declined over 2 years. Medicare beneficiaries empanelled to relatively high functioning PCTs had significantly better physical and emotional health at 2 years following baseline assessment than those empanelled to relatively low functioning PCTs.

The relationship between staff skill mix, costs and outcomes in intermediate care services

Background

The purpose of this study was to assess the relationship between skill mix, patient outcomes, length of stay and service costs in older peoples' intermediate care services in England.

Methods

We undertook multivariate analysis of data collected as part of the National Evaluation of Intermediate Care Services. Data were analysed on between 337 and 403 older people admitted to 14 different intermediate care teams. Independent variables were the numbers of different types of staff within a team and the ratio of support staff to professionally qualified staff within teams. Outcome measures include the Barthel index, EQ-5D, length of service provision and costs of care.

Results

Increased skill mix (raising the number of different types of staff by one) is associated with a 17% reduction in service costs (p = 0.011). There is weak evidence (p = 0.090) that a higher ratio of support staff to qualified staff leads to greater improvements in EQ-5D scores of patients.

Conclusions

This study provides limited evidence on the relationship between multidisciplinary skill mix and outcomes in intermediate care services.

Increasing delivery of an outdoor journey intervention to people with stroke: A feasibility study involving five community rehabilitation teams

Background

Contrary to recommendations in a national clinical guideline, baseline audits from five community-based stroke rehabilitation teams demonstrated an evidence-practice gap; only 17% of eligible people with stroke were receiving targeted rehabilitation by occupational therapists and physiotherapists to increase outdoor journeys. The primary aim of this feasibility study was to design, test, and evaluate the impact of an implementation program intended to change the behaviour of community rehabilitation teams. A secondary aim was to measure the impact of this change on client outcomes.

Methods

A before-and-after study design was used. The primary data collection method was a medical record audit. Five community rehabilitation teams and a total of 12 professionals were recruited, including occupational therapists, physiotherapists, and a therapy assistant. A medical record audit was conducted twice over 12 months (total of 77 records pre-intervention, 53 records post-intervention) against a guideline recommendation about delivering outdoor journey sessions to people with stroke. A behavioural intervention (the 'Out-and-About Implementation Program') was used to help change team practice. Active components of the intervention included feedback about the audit, barrier identification, and tailored education to target known barriers. The primary outcome measure was the proportion of medical records containing evidence of multiple outdoor journey sessions. Other outcomes of interest included the proportion of medical records that contained evidence of screening for outdoor journeys and driving by team members, and changes in patient outcomes. A small sample of community-dwelling people with stroke (n = 23) provided pre-post outcome data over three months. Data were analysed using descriptive statistics and t-tests.

Results

Medical record audits found that teams were delivering six or more outdoor journeys to 17% of people with stroke pre-intervention, rising to 32% by 12 months post-intervention. This change represents a modest increase in practice behaviour (15%) across teams. More people with stroke (57%) reported getting out of the house as often as they wanted after receiving the outdoor journey intervention compared to 35% one year earlier; other quality of life outcomes also improved.

Conclusions

The 'Out-and-About Implementation Program' helped rehabilitation teams to change their practice, implement evidence, and improve client outcomes. This behavioural intervention requires more rigorous evaluation using a cluster randomised trial design.