Understanding palliative care on the heart failure care team: an innovative research methodology

Measuring Interprofessional Collaboration's Impact on Healthcare Services Using the Quadruple Aim Framework: A Protocol Paper

Despite decades of research on the impact of interprofessional collaboration (IPC), we still lack definitive proof that team-based care can lead to a tangible effect on healthcare outcomes. Without return on investment (ROI) evidence, healthcare leaders cannot justifiably throw their weight behind IPC, and the institutional push for healthcare manpower reforms crucial for facilitating IPC will remain variable and fragmentary. The lack of proof for the ROI of IPC is likely due to a lack of a unifying conceptual framework and the over-reliance on the single-method study design. To address the gaps, this paper describes a protocol which uses as a framework the Quadruple Aim which examines the ROI of IPC using four dimensions: patient outcomes, patient experience, provider well-being, and cost of care. A multimethod approach is proposed whereby patient outcomes are measured using quantitative methods, and patient experience and provider well-being are assessed using qualitative methods. Healthcare costs will be calculated using the time-driven activity-based costing methodology. The study is set in a Singapore-based national and regional center that takes care of patients with neurological issues.

Preparing future physicians for complexity: a post-graduate elective in HIV psychiatry

BACKGROUND

Patients with complex care needs have multiple concurrent conditions (medical, psychiatric, social vulnerability or functional impairment), interfering with achieving desired health outcomes. Their care often requires coordination and integration of services across hospital and community settings. Physicians feel ill-equipped and unsupported to navigate uncertainty and ambiguity caused by multiple problems. A HIV Psychiatry resident elective was designed to support acquisition of integrated competencies to navigate uncertainty and disjointed systems of care - necessary for complex patient care.

METHODS

Through qualitative thematic analysis of pre- and post-interviews with 12 participants - residents and clinic staff - from December 2019 to September 2022, we explored experiences of this elective.

RESULTS

This educational experience helped trainees expand their understanding of what makes patients complex. Teachers and trainees emphasize the importance of an approach to "not knowing" and utilizing integrative competencies for navigating uncertainty. Through perspective exchange and collaboration, trainees showed evidence of adaptive expertise: the ability to improvise while drawing on past knowledge.

CONCLUSIONS

Postgraduate training experiences should be designed to facilitate skills for caring for complex patients. These skills help residents fill in practice gaps, improvise when standardization fails, and develop adaptive expertise. Going forward, findings will be used to inform this ongoing elective.

Discharging the complex patient - changing our focus to patients' networks of care providers

Background

A disconnect exists between the idealized model of every patient having a family physician (FP) who acts as the central hub for care, and the reality of health care where patients must navigate a network of different providers. This disconnect is particularly evident when hospitalized multimorbid patients transition back into the community. These discharges are identified as high-risk due to lapses in care continuity. The aim of this study was to identify and explore the networks of care providers in a sample of hospitalized, complex patients, and better understand the nature of their attachments to these providers as a means of discovering novel approaches for improving discharge planning.

Methods

This was a constructivist grounded theory study. Data included interviews from 30 patients admitted to an inpatient internal medicine service of a midsized academic hospital in Ontario, Canada. Analysis and data collection proceeded iteratively with sampling progressing from purposive to theoretical.

Results

We identified network of care configurations commonly found in patients with multiple medical comorbidities receiving care from multiple different providers admitted to an internal medicine service. FPs and specialists form the network’s scaffold. The involvement of physicians in the network dictated not only how patients experienced transitions in care but the degree of reliance on social supports and personal capacities. The ideal for the multimorbid patient is an optimally involved FP that remains at the centre, even when patients require more subspecialized care. However, in cases where a rostered FP is non-existent or inadequate, increased involvement and advocacy from specialists is crucial.

Conclusions

Our results have implications for transition planning in hospitalized complex patients. Recognizing salient network features can help identify patients who would benefit from enhanced discharge support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06841-2.

Opioid safety recommendations in adult palliative medicine: a North American Delphi expert consensus

OBJECTIVES

Despite the escalating public health emergency related to opioid-related deaths in Canada and the USA, opioids are essential for palliative care (PC) symptom management.Opioid safety is the prevention, identification and management of opioid-related harms. The Delphi technique was used to develop expert consensus recommendations about how to promote opioid safety in adults receiving PC in Canada and the USA.

METHODS

Through a Delphi process comprised of two rounds, USA and Canadian panellists in PC, addiction and pain medicine developed expert consensus recommendations. Elected Canadian Society of Palliative Care Physicians (CSPCP) board members then rated how important it is for PC physicians to be aware of each consensus recommendation.They also identified high-priority research areas from the topics that did not achieve consensus in Round 2.

RESULTS

The panellists (Round 1, n=23; Round 2, n=22) developed a total of 130 recommendations from the two rounds about the following six opioid-safety related domains: (1) General principles; (2) Measures for healthcare institution and PC training and clinical programmes; (3) Patient and caregiver assessments; (4) Prescribing practices; (5) Monitoring; and (6) Patients and caregiver education. Fifty-nine topics did not achieve consensus and were deemed potential areas of research. From these results, CSPCP identified 43 high-priority recommendations and 8 high-priority research areas.

CONCLUSIONS

Urgent guidance about opioid safety is needed to address the opioid crisis. These consensus recommendations can promote safer opioid use, while recognising the importance of these medications for PC symptom management.

Can a complex adaptive systems perspective support the resiliency of the heart failure patient - informal caregiver dyad?

PURPOSE OF REVIEW

A holistic palliative approach for heart failure care emphasizes supporting nonprofessional informal caregivers. Informal caregivers play a vital role caring for heart failure patients. However, caregiving negatively affects informal caregivers' well being, and in turn heart failure patients' health outcomes. This opinion article proposes that complex adaptive systems (CAS) theory applied to heart failure models of care can support the resiliency of the heart failure patient - informal caregiver dyad.

RECENT FINDINGS

Heart failure care is enacted within a complex system composed of patients, their informal caregivers and a variety of health professionals. In a national study, we employed a CAS perspective to explore how all parts of the heart failure team function interdependently in emergent and adaptive ways. Salient in our data were the severe vulnerability of elderly heart failure patients and their long-term partners who suffered from a chronic illness. Novel approaches are needed that can quickly adapt and reorganize care when unpredictable disturbances occur in the couples' functional capacity.

SUMMARY

The linear protocol-driven care models that shape heart failure guidelines, training and care delivery initiatives do not adequately capture heart failure patients' social environment. CAS is a powerful theoretical tool that can render visible the most vulnerable members of the heart failure team, and incite robust specialized holistic palliative heart failure care models.

A Context-oriented Communication Algorithm for Advance Care Planning: A Model to Assist Palliative Care in Heart Failure

BACKGROUND

Access to consultation or referral for decisions about advance care planning (ACP) is limited, particularly for nonmalignant models pertinent to palliative care in heart failure (HF).

OBJECTIVES

The aim of this study was to solicit professional opinions about the feasibility of using an exemplary context-oriented communication algorithm for ACP discussions.

METHODS

Using a panel of expert physicians and nurses in cardiovascular care, a 3-round Delphi study was conducted to evaluate the proposed model.

RESULTS

A consensus was determined based on a content validity ratio (CVR) of 0.318 or greater, a critical value for selection of an item scored as important (≥4 on a 5-point Likert scale). A total of 50, 44, and 38 experts in Korea completed each round, respectively. Item evaluation did not differ across rounds (Friedman χ > P = .05), except for timing of the ACP discussion. A lack of consensus was observed on the issue of after HF diagnosis for right timing of the ACP discussion across rounds (CVRs from -0.80 to -0.83); consensus was reached on the expectation of a terminal state (CVRs from 0.60 to 0.78). Content validity ratios were moderately high for Korean advance directive, ranging from 0.59 to 0.91. Experts also reached consensus about each of 5 steps of a communication model-patients' determination of decisional capacity (CVR, 0.72-1.0), awareness (CVR, 0.95-1.0), willingness for advance care planning (CVR, 0.76-0.84), family dynamics (CVR, 0.92-1.0) and patient readiness for advance care planning (CVR, 0.76-0.95).

CONCLUSIONS

A context-oriented communication model could be used to facilitate the decision-making process for palliative care and continuity of care in HF.

An Exploratory Study of Children's Mental Health Providers' Perspectives on the Transition to Adult Care for Young Adolescents in the Canadian Context

PURPOSE

Many youth who receive specialized children's mental health treatment might require additional treatment as young adults. Little is known about how to prepare these youth for transitions to adult care.

DESIGN AND METHODS

This study gained perspectives from children's mental health providers (n = 10) about the process of caring for younger adolescents (aged 12-15) with mental health problems (e.g., depression, anxiety), who might require mental health services after age 18. Providers were asked about their clients' future mental health needs and the possibility of transition to adult care.

RESULTS

Using Grounded Theory analysis, an over-arching theme was providers' reluctance to consider the transition process for their younger clients (<16 years old). This stemmed from uncertainty among providers about: (1) who [which youth] will need adult mental health services; (2) when this discussion would be appropriate; and (3) what adult services would be available.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Findings indicate a lack of treatment capacity within children's mental health to routinely monitor youth as they approach the age of transfer (18 years old). In the absence of routine monitoring (post-treatment), it may be difficult to predict who will need adult care. A comprehensive evaluation of existing follow-up practices, in children's mental health and beyond, is needed to identify strategies for ensuring adolescents with recurring conditions receive optimal transition care.

Perspectives on Monitoring Youth with Ongoing Mental Health Problems in Primary Health Care: Family Physicians Are "Out of the Loop"

Children's mental health (CMH) problems often recur. Following specialized mental health treatment, youth may require monitoring and follow-up. For these youth, primary health care is highly relevant, as family physicians (FPs) are the only professionals who follow patients across the lifespan. The current study gained multiple perspectives about (1) the role of FPs in caring for youth with ongoing/recurring CMH problems and (2) incorporating routine mental health monitoring into primary health care. A total of 33 interviews were conducted, including 10 youth (aged 12-15) receiving CMH care, 10 parents, 10 CMH providers, and 3 FPs. Using grounded theory methodology, a theme of FPs being "out of the loop" or not involved in their patient's CMH care emerged. Families perceived a focus on the medical model by their FPs and believed FPs lacked mental health expertise. Findings indicate a need for improved collaboration between CMH providers and FPs in caring for youth with ongoing CMH problems.

Palliative Care Provision for Patients with Advanced Chronic Obstructive Pulmonary Disease: A Systematic Integrative Literature Review

Although chronic obstructive pulmonary disease (COPD) is recognized as being a life-limiting condition with palliative care needs, palliative care provision is seldom implemented. The disease unpredictability, the misconceptions about palliative care being only for people with cancer, and only relevant in the last days of life, prevent a timely integrated care plan. This systematic review aimed to explore how palliative care is provided in advanced COPD and to identify elements defining integrated palliative care. Eight databases, including MEDLINE, EMBASE and CINAHL, were searched using a comprehensive search strategy to identify studies on palliative care provision in advanced COPD, published from January 1, 1960 to November 30, 2017. Citation tracking and evaluation of trial registers were also performed. Study quality was assessed with a critical appraisal tool for both qualitative and quantitative data. Of the 458 titles, 24 were eligible for inclusion. Experiences about advanced COPD, palliative care timing, service delivery and palliative care integration emerged as main themes, defining a developing taxonomy for palliative care provision in advanced COPD. This taxonomy involves different levels of care provision and integrated care is the last step of this dynamic process. Furthermore, palliative care involvement, holistic needs' assessment and management and advance care planning have been identified as elements of integrated care. This literature review identified elements that could be used to develop a taxonomy of palliative care delivery in advanced COPD. Further research is needed to improve our understanding on palliative care provision in advanced COPD.

It's Time to Talk: Challenges in Providing Integrated Palliative Care in Advanced Congestive Heart Failure. A Narrative Review

Background:

Congestive heart failure is an increasingly prevalent terminal illness in a globally aging population. Prognosis for this disease remains poor despite optimal therapy. Evidence suggests that a palliative care approach may be beneficial – and is currently recommended – in advanced congestive heart failure but these services remain underutilized.

Objectives:

To identify the main challenges to the access and delivery of palliative care in patients with advanced congestive heart failure, and to summarize recommendations for clinical practice based on the available literature.

Methods:

MEDLINE and EMBASE were searched for articles published from 1995-2017 pertaining to end of life care in individuals suffering from CHF. Only four randomized controlled trials were found.

Results:

We identified ten key challenges to access and delivery of palliative care services in this patient population: (1) Prognostic uncertainty, (2) Provider education/training, (3) Ambiguity surrounding coordination of care, (4) Timing of palliative care referral, (5) Inadequate community supports, (6) Difficulty communicating uncertainty, (7) Fear of taking away hope, (8) Insufficient advance care planning, (9) Inadequate understanding of illness, and (10) Discrepant patient/family care goals. Provider and patient education, early discussion about prognosis, and a multidisciplinary team-based approach are recommended as we move towards a model where symptom palliation exists concurrently with active disease-modifying therapies.

Conclusion:

Despite evidence that palliative care may improve symptom control and quality of life in patients with advanced congestive heart failure, a multitude of current challenges hinder access to these services. Education, early discussion of prognosis and advance care planning, and multidisciplinary team-based care may be a helpful initial approach as further targeted work addresses these challenges.

Patients with heart failure and their partners with chronic illness: interdependence in multiple dimensions of time

Background

Informal caregivers play a vital role in supporting patients with heart failure (HF). However, when both the HF patient and their long-term partner suffer from chronic illness, they may equally suffer from diminished quality of life and poor health outcomes. With the focus on this specific couple group as a dimension of the HF health care team, we explored this neglected component of supportive care.

Materials and methods

From a large-scale Canadian multisite study, we analyzed the interview data of 13 HF patient-partner couples (26 participants). The sample consisted of patients with advanced HF and their long-term, live-in partners who also suffer from chronic illness.

Results

The analysis highlighted the profound enmeshment of the couples. The couples' interdependence was exemplified in the ways they synchronized their experience in shared dimensions of time and adapted their day-to-day routines to accommodate each other's changing health status. Particularly significant was when both individuals were too ill to perform caregiving tasks, which resulted in the couples being in a highly fragile state.

Conclusion

We conclude that the salience of this couple group's oscillating health needs and their severe vulnerabilities need to be appreciated when designing and delivering HF team-based care.

"I Think He Will Have It Throughout His Whole Life": Parent and Youth Perspectives About Childhood Mental Health Problems

Children's mental health (CMH) problems can be long-lasting. Even among children and youth who receive specialized CMH treatment, recurrence of problems is common. It is unknown whether youth and their parents view the possibility of future mental health problems. This has important implications for how CMH services should be delivered. This grounded theory study gained perspectives from youth (aged 12-15 years) who received CMH treatment ( n = 10) and their parents ( n = 10) about the expected course of CMH problems. Three disorder trajectories emerged: (a) not chronic, (b) chronic and persistent, and (c) chronic and remitting, with the majority of youth falling in the third trajectory. A gap in available services between CMH and adult care was perceived by parents, leaving them either help hopeful or help hungry about their child's future care. Improving care for youth with ongoing mental health problems is needed to minimize costs to families and the system.

Beyond the realist turn: a socio-material analysis of heart failure self-care

For patients living with chronic illnesses, self-care has been linked with positive outcomes such as decreased hospitalisation, longer lifespan, and improved quality of life. However, despite calls for more and better self-care interventions, behaviour change trials have repeatedly fallen short on demonstrating effectiveness. The literature on heart failure (HF) stands as a case in point, and a growing body of HF studies advocate realist approaches to self-care research and policymaking. We label this trend the 'realist turn' in HF self-care. Realist evaluation and realist interventions emphasise that the relationship between self-care interventions and positive health outcomes is not fixed, but contingent on social context. This paper argues socio-materiality offers a productive framework to expand on the idea of social context in realist accounts of HF self-care. This study draws on 10 interviews as well as researcher reflections from a larger study exploring health care teams for patients with advanced HF. Leveraging insights from actor-network theory (ANT), this study provides two rich narratives about the contextual factors that influence HF self-care. These descriptions portray not self-care contexts but self-care assemblages, which we discuss in light of socio-materiality.

Pulling together and pulling apart: influences of convergence and divergence on distributed healthcare teams

Effective healthcare requires both competent individuals and competent teams. With this recognition, health professions education is grappling with how to factor team competence into training and assessment strategies. These efforts are impeded, however, by the absence of a sophisticated understanding of the the relationship between competent individuals and competent teams . Using data from a constructivist grounded theory study of team-based healthcare for patients with advanced heart failure, this paper explores the relationship between individual team members' perceived goals, understandings, values and routines and the collective competence of the team. Individual interviews with index patients and their healthcare team members formed Team Sampling Units (TSUs). Thirty-seven TSUs consisting of 183 interviews were iteratively analysed for patterns of convergence and divergence in an inductive process informed by complex adaptive systems theory. Convergence and divergence were identifiable on all teams, regularly co-occurred on the same team, and involved recurring themes. Convergence and divergence had nonlinear relationships to the team's collective functioning. Convergence could foster either shared action or collective paralysis; divergence could foster problematic incoherence or productive disruption. These findings advance our understanding of the complex relationship between the individual and the collective on a healthcare team, and they challenge conventional narratives of healthcare teamwork which derive largely from acute care settings and emphasize the importance of common goals and shared mental models. Complex adaptive systems theory helps us to understand the implications of these insights for healthcare teams' delivery of care for the complex, chronically ill.

Beyond Simple Planning: Existential Dimensions of Conversations With Patients at Risk of Dying From Heart Failure

CONTEXT

Despite the recent promotion of communication guides to improve decision making with patients nearing the end of their lives, these conversations remain challenging. Deeper and more comprehensive understanding of communication barriers that undermine discussions and decisions with patients at risk of dying from heart failure (HF) is vital for informing communication in health care.

OBJECTIVES

To explore experiences and perspectives of patients with advanced HF, their caregivers, and providers, regarding conversations for patients at risk of dying from HF.

METHODS

Following Research Ethics Board approval, index patients with advanced HF (New York Heart Association III or IV) and consenting patient-identified care team members were interviewed. A team sampling unit was formed when the patient plus at least two additional team members participated in interviews. Team members included health professionals (e.g., cardiologist, family physician, HF nurse practitioner, social worker, and specialists, such as respirologist, nephrologist, palliative care physician), family caregivers (e.g., daughter, spouse, roommate, close friend), and community members (e.g., minister, neighbor, regular taxi driver). Our data set included 209 individual interviews clustered into 50 team sampling units at five sites from three Canadian provinces. Key informants, identified as practicing experts in the field, reviewed our initial findings with attention to relevance to practice as a form of triangulation. Iterative data collection and analysis followed constructivist grounded theory procedures with sensitizing concepts drawn from complexity theory. To ensure confidentiality, all participants were given a pseudonym.

RESULTS

Participants' reports of their perceptions and experiences of conversations related to death and dying suggested two main dimensions of such conversations: instrumental and existential. Instrumental dimensions included how these conversations were planned and operationalized as well as the triggers and barriers to these discussions. Existential dimensions of these conversations included evasive maneuvers, powerful emotions, and the phenomenon of death without dying. Existential dimensions appeared to have a basis in issues of mortality and could strongly influence conversations related to death and dying.

CONCLUSION

Conversations for patients at risk of dying from HF have both instrumental and existential dimensions, in which routines and relationships are inseparable. Our current focus on the instrumental aspects of these conversations is necessary but insufficient. The existential dimensions of conversations related to death are profound and may explain why these conversations have struggled to achieve their desired effect. To improve this communication, we need to also attend to existential dimensions, particularly in terms of their impact on the occurrence of these conversations, the nature of relationships and responses within these conversations, and the fluidity of meaning within these conversations.

'Who is on your health-care team?' Asking individuals with heart failure about care team membership and roles

BACKGROUND

Complex, chronically ill patients require interprofessional teams to address their multiple health needs; heart failure (HF) is an iconic example of this growing problem. While patients are the common denominator in interprofessional care teams, patients have not explicitly informed our understanding of team composition and function. Their perspectives are crucial for improving quality, patient-centred care.

OBJECTIVES

To explore how individuals with HF conceptualize their care team, and perceive team members' roles.

SETTING AND PARTICIPANTS

Individuals with advanced HF were recruited from five cities in three Canadian provinces.

DESIGN

Individuals were asked to identify their HF care team during semi-structured interviews. Team members' titles and roles, quotes pertaining to team composition and function, and frailty criteria were extracted and analysed using descriptive statistics and content analysis.

RESULTS

A total of 62 individuals with HF identified 2-19 team members. Caregivers, nurses, family physicians and cardiologists were frequently identified; teams also included dentists, foot care specialists, drivers, housekeepers and spiritual advisors. Most individuals met frailty criteria and described participating in self-management.

DISCUSSION

Individuals with HF perceived being active participants, not passive recipients, of care. They identified teams that were larger and more diverse than traditional biomedical conceptualizations. However, the nature and importance of team members' roles varied according to needs, relationships and context. Patients' degree of agency was negotiated within this context, causing multiple, sometimes conflicting, responses.

CONCLUSION

Ignoring the patient's role on the care team may contribute to fragmented care. However, understanding the team through the patient's lens - and collaborating meaningfully among identified team members - may improve health-care delivery.

Collaboration and entanglement: An actor-network theory analysis of team-based intraprofessional care for patients with advanced heart failure

Despite calls for more interprofessional and intraprofessional team-based approaches in healthcare, we lack sufficient understanding of how this happens in the context of patient care teams. This multi-perspective, team-based interview study examined how medical teams negotiated collaborative tensions. From 2011 to 2013, 50 patients across five sites in three Canadian provinces were interviewed about their care experiences and were asked to identify members of their health care teams. Patient-identified team members were subsequently interviewed to form 50 "Team Sampling Units" (TSUs), consisting of 209 interviews with patients, caregivers and healthcare providers. Results are gathered from a focused analysis of 13 TSUs where intraprofessional collaborative tensions involved treating fluid overload, or edema, a common HF symptom. Drawing on actor-network theory (ANT), the analysis focused on intraprofessional collaboration between specialty care teams in cardiology and nephrology. The study found that despite a shared narrative of common purpose between cardiology teams and nephrology teams, fluid management tools and techniques formed sites of collaborative tension. In particular, care activities involved asynchronous clinical interpretations, geographically distributed specialist care, fragmented forms of communication, and uncertainty due to clinical complexity. Teams 'disentangled' fluid in order to focus on its physiological function and mobilisation. Teams also used distinct 'framings' of fluid management that created perceived collaborative tensions. This study advances collaborative entanglement as a conceptual framework for understanding, teaching, and potentially ameliorating some of the tensions that manifest during intraprofessional care for patients with complex, chronic disease.

Mapping communication spaces: The development and use of a tool for analyzing the impact of EHRs on interprofessional collaborative practice

INTRODUCTION

Members of the healthcare team must access and share patient information to coordinate interprofessional collaborative practice (ICP). Although some evidence suggests that electronic health records (EHRs) contribute to in-team communication breakdowns, EHRs are still widely hailed as tools that support ICP. If EHRs are expected to promote ICP, researchers must be able to longitudinally study the impact of EHRs on ICP across communication types, users, and physical locations.

OBJECTIVE

This paper presents a data collection and analysis tool, named the Map of the Clinical Interprofessional Communication Spaces (MCICS), which supports examining how EHRs impact ICP over time, and across communication types, users, and physical locations.

METHODS

The tool's development evolved during a large prospective longitudinal study conducted at a Canadian pediatric academic tertiary-care hospital. This two-phased study [i.e., pre-implementation (phase 1) and post implementation (phase 2)] of an EHR employed a constructivist grounded theory approach and triangulated data collection strategies (i.e., non-participant observations, interviews, think-alouds, and document analysis). The MCICS was created through a five-step process: (i) preliminary structural development based on the use of the paper-based chart (phase 1); (ii) confirmatory review and modification process (phase 1); (iii) ongoing data collection and analysis facilitated by the map (phase 1); (iv) data collection and modification of map based on impact of EHR (phase 2); and (v) confirmatory review and modification process (phase 2).

RESULTS

Creating and using the MCICS enabled our research team to locate, observe, and analyze the impact of the EHR on ICP, (a) across oral, electronic, and paper communications, (b) through a patient's passage across different units in the hospital, (c) across the duration of the patient's stay in hospital, and (d) across multiple healthcare providers. By using the MCICS, we captured a comprehensive, detailed picture of the clinical milieu in which the EHR was implemented, and of the intended and unintended consequences of the EHR's deployment. The map supported our observations and analysis of ICP communication spaces, and of the role of the patient chart in these spaces.

CONCLUSIONS

If EHRs are expected to help resolve ICP challenges, it is important that researchers be able to longitudinally assess the impact of EHRs on ICP across multiple modes of communication, users, and physical locations. Mapping the clinical communication spaces can help EHR designers, clinicians, educators and researchers understand these spaces, appreciate their complexity, and navigate their way towards effective use of EHRs as means for supporting ICP. We propose that the MCICS can be used "as is" in other academic tertiary-care pediatric hospitals, and can be tailored for use in other healthcare institutions.

The EHR and building the patient's story: A qualitative investigation of how EHR use obstructs a vital clinical activity

BACKGROUND

Recent research has suggested that using electronic health records (EHRs) can negatively impact clinical reasoning (CR) and interprofessional collaborative practices (ICPs). Understanding the benefits and obstacles that EHR use introduces into clinical activities is essential for improving medical documentation, while also supporting CR and ICP.

METHODS

This qualitative study was a longitudinal pre/post investigation of the impact of EHR implementation on CR and ICP at a large pediatric hospital. We collected data via observations, interviews, document analysis, and think-aloud/-after sessions. Using constructivist Grounded Theory's iterative cycles of data collection and analysis, we identified and explored an emerging theme that clinicians described as central to their CR and ICP activities: building the patient's story. We studied how building the patient's story was impacted by the introduction and implementation of an EHR.

RESULTS

Clinicians described the patient's story as a cognitive awareness and overview understanding of the patient's (1) current status, (2) relevant history, (3) data patterns that emerged during care, and (4) the future-oriented care plan. Constructed by consolidating and interpreting a wide array of patient data, building the patient's story was described as a vitally important skill that was required to provide patient-centered care, within an interprofessional team, that safeguards patient safety and clinicians' professional credibility. Our data revealed that EHR use obstructed clinicians' ability to build the patient's story by fragmenting data interconnections. Further, the EHR limited the number and size of free-text spaces available for narrative notes. This constraint inhibited clinicians' ability to read the why and how interpretations of clinical activities from other team members. This resulted in the loss of shared interprofessional understanding of the patient's story, and the increased time required to build the patient's story.

CONCLUSIONS

We discuss these findings in relation to research on the role of narratives for enabling CR and ICP. We conclude that EHRs have yet to truly fulfill their promise to support clinicians in their patient care activities, including the essential work of building the patient's story.

Adaptive practices in heart failure care teams: implications for patient-centered care in the context of complexity

BACKGROUND

Heart failure (HF), one of the three leading causes of death, is a chronic, progressive, incurable disease. There is growing support for integration of palliative care's holistic approach to suffering, but insufficient understanding of how this would happen in the complex team context of HF care. This study examined how HF care teams, as defined by patients, work together to provide care to patients with advanced disease.

METHODS

Team members were identified by each participating patient, generating team sampling units (TSUs) for each patient. Drawn from five study sites in three Canadian provinces, our dataset consists of 209 interviews from 50 TSUs. Drawing on a theoretical framing of HF teams as complex adaptive systems (CAS), interviews were analyzed using the constant comparative method associated with constructivist grounded theory.

RESULTS

This paper centers on the dominant theme of system practices, how HF care delivery is reported to work organizationally, socially, and practically, and describes two subthemes: "the way things work around here", which were commonplace, routine ways of doing things, and "the way we make things work around here", which were more conscious, effortful adaptations to usual practice in response to emergent needs. An adaptive practice, often a small alteration to routine, could have amplified effects beyond those intended by the innovating team member and could extend to other settings.

CONCLUSION

Adaptive practices emerged unpredictably and were variably experienced by team members. Our study offers an empirically grounded explanation of how HF care teams self-organize and how adaptive practices emerge from nonlinear interdependencies among diverse agents. We use these insights to reframe the question of palliative care integration, to ask how best to foster palliative care-aligned adaptive practices in HF care. This work has implications for health care's growing challenge of providing care to those with chronic medical illness in complex, team-based settings.

The impact of adopting EHRs: how losing connectivity affects clinical reasoning

CONTEXT

As electronic health records (EHRs) are adopted by teaching hospitals, educators must examine how this change impacts trainee development.

OBJECTIVES

We investigate this influence by studying clinician experiences of a hospital's move from paper charts to an EHR. We ask: how does each chart modality present conceptions of time and data interconnections? How do these conceptions affect clinical reasoning?

METHODS

This two-phase, longitudinal study employed constructivist grounded theory. Data were collected at a paediatric teaching hospital before (Phase 1), during and after (Phase 2) the transition from a paper chart to an EHR system. Data collection consisted of field observations (146 hours involving 300 health care providers, 22 patients and 32 patient family members), think-aloud (n = 13) and think-after (n = 11) sessions, interviews (n = 39) and document retrieval (n = 392). Theories of rhetorical genre studies and visual rhetoric informed analysis.

RESULTS

In the paper flowsheet, clinicians recorded and viewed patient data in chronologically organised displays that emphasised data interconnections. In the EHR flowsheet, clinicians viewed and recorded individual data points that were largely chronologically and contextually isolated. Clinicians reported that this change resulted in: (i) not knowing the patient's evolving status; (ii) increased cognitive workload, and (iii) loss of clinical reasoning support mechanisms.

CONCLUSIONS

Understanding how patient data are interconnected is essential to clinical reasoning. The use of EHRs supports this goal because the EHR is a tool for collecting dispersed data; however, these collections often deconstruct data interconnections. Where the paper flowsheet emphasises chronology and interconnectedness, the EHR flowsheet emphasises individual data values that are largely independent of time and other patient data. To prepare trainees to work with EHRs, the ways of thinking and acting that were implicitly learned through the use of paper charts must be made explicit. To support clinical reasoning, medical educators should provide lessons in connectivity – the chronologically framed data interconnections upon which clinicians rely to provide patient care.

Development of a practice tool for community-based nurses: the Heart Failure Palliative Approach to Care (HeFPAC)

BACKGROUND

Patients living with advanced heart failure (HF) require a palliative approach to reduce suffering. Nurses have described significant knowledge gaps about the disease-specific palliative care (PC) needs of these patients. An intervention is required to facilitate appropriate end-of-life care for HF patients.

AIMS

The purpose of this study was to develop a user-friendly, evidence-informed HF-specific practice tool for community-based nurses to facilitate care and communication regarding a palliative approach to HF care.

METHODS

Guided by the Knowledge to Action framework, we identified key HF-specific issues related to advanced HF care provision within the context of a palliative approach to care. Informed by current evidence and subsequent iterative consultation with community-based and specialist PC and HF nurses, a pocket guide tool for community-based nurses was created.

RESULTS

We developed the Heart Failure Palliative Approach to Care (HeFPAC) pocket guide to promote communication and a palliative approach to care for HF patients. The HeFPAC has potential to improve the quality of care and experiences for patients with advanced HF. It will be piloted in community-based practice and in a continuing education program for nurses.

CONCLUSION

The HeFPAC pocket guide offers PC nurses a concise, evidence-informed and practical point-of care tool to communicate with other clinicians and patients about key HF issues that are associated with improving disease-specific HF palliative care and the quality of life of patients and their families. Pilot testing will offer insight as to its utility and potential for modification for national and international use.

Palliative care for those with heart failure: nurses' knowledge, attitude, and preparedness to practice

BACKGROUND

Palliative care is an important element of holistic care but has received little attention in cardiac disease patients. The purpose of the paper is (a) to investigate nurses' knowledge of palliative care, attitudes toward care of the dying, coping with death, and preparedness to practice palliative care for those with heart failure, and (b) to evaluate influencing factors on preparedness to practice on palliative care.

METHODS

A cross-sectional descriptive design employed a structured questionnaire that tested nurses' knowledge, attitude, coping, and preparedness to practice on palliative care for patients with heart failure. Ninety nurses in two tertiary university hospitals in South Korea participated in the survey. Data were analyzed with descriptive statistics, correlation, and multiple regression.

RESULTS

Results showed low levels of knowledge reported (an average of 48.3% correct answers), attitude (134.8±110.1), coping (117.2±24.3), and preparedness to practice (17.3±4.7) relating to palliative care. The extent of knowledge was related to both attitudes and coping. These attitudes and coping skills were related to preparedness to practice. The multiple regression analysis showed that preparedness to practice was explained by coping and attitude (R (2) =0.46, F=6.1, p<0.001).

CONCLUSIONS

Palliative care training is urgently needed to improve knowledge, attitude, coping, and preparedness to practice. Guidance to assist healthcare professionals involved in palliative care for those with cardiac disease needs to be developed and provided.

Palliative care for people with heart failure: summary of current evidence and future direction

BACKGROUND

Heart failure is a common condition with a significant physical and psychological burden for patients and their families. The need for supportive and palliative care: It is well recognised that palliative care is important in patients with advanced heart failure.

WHAT IS KNOWN

Heart failure patients have limited access to palliative care services. Barriers to palliative care include difficult prognostication due to the unpredictable disease trajectory and inadequate initiation of conversations about end-of-life care. WHAT IS NOT KNOWN: There are gaps in the evidence for symptom control, especially for symptoms other than pain or dyspnoea, but recommendations are becoming increasingly evidence based. IMPLICATIONS FOR RESEARCH, POLICY AND PRACTICE: There are challenges to research in this area although progress is being made with increasing numbers of trials and use of novel research methods. Integrated models of care based on symptom triggers rather than prognosis are recommended. At the centre is excellent communication both with the patient and between services to ensure the best possible care.