Collaboration improves the quality of care: methodological challenges and evidence from US health care research

Lung Cancer Patients' Conceptualization of Care Coordination in Selected Public Health Facilities of KwaZulu-Natal, South Africa

BACKGROUND

Cancer patients commonly receive care, including comprehensive treatment options, from multiple specialists within and across facilities offering varying levels of care. Given this multi-layered approach to cancer care, there is a need for coordinated care enhanced through integrated information flow for optimal patient care and improved health outcomes.

OBJECTIVE

This study aimed to explore how patients conceptualized cancer care coordination in an integrated health care system in KwaZulu-Natal.

METHODS

The study employed a grounded theory design to qualitatively explore the patients' experiences and views on cancer care coordination using in-depth interviews. Guided by the grounded theory principles, data generation and analysis were conducted iteratively, followed by systematic thematic analysis to organize data, and review and interpret comprehensive findings. This process culminated in the development of themes relating to barriers to cancer care coordination and the interface between the primary and tertiary settings. Theoretical saturation was achieved at 21 in-depth interviews with consenting respondents.

RESULTS

This study revealed that care coordination was affected by multilevel challenges, including pertinent health system-level factors, such as difficulty accessing specialty care timeously, weak communication between patients and healthcare providers, and unmet needs concerning supportive care. We found that negative experiences with cancer care erode patient trust and receptiveness to cancer care, and patients advocated for better and proactive coordination amongst different care facilities, services, and providers.

CONCLUSIONS

An integrated care coordination setup is essential to create and sustain a high-performance health care system. These findings make a case for developing, implementing, and evaluating interventions to enhance the quality of cancer care for patients and ultimately improve health outcomes for patients in KwaZulu-Natal. This study will provide comprehensive data to inform professionals, policymakers, and related decisionmakers to manage and improve cancer care coordination.

An unprecedented and large-scale support mission to assist residential care facilities during the COVID-19 pandemic

Background

In March 2020, COVID-19 cases occurred in residential care facilities. To assist these facilities, the regional health agency of the Meurthe-et-Moselle administrative district ordered a support mission.

Methods

Infection prevention and control mobile teams were formed under the coordination of the infection prevention and control department (IPCD) of a university hospital. Teams went to residential care facilities for the elderly, to facilities for people with disabilities (FPD) and independent living communities (ILC). They visited the facilities and met with the management and the ward staff to assess the situation and to identify any potential support needs.

Results

Over two non-consecutive weeks, 104 residential care facilities were visited (9025 residents). If urgent needs were identified, the IPCD was directly informed by the teams to initiate an extensive assistance operation. Thereby, additional staff and equipment were provided for every facility in need. Although most of them had implemented good management to face the pandemic, four emergency field support operations took place in facilities with uncontrolled outbreaks.

Conclusions

This is the first reported support action for residential care facilities during the pandemic in France. As no major outbreaks were noticed later, this mission was deemed a success and met the residential care facilities' needs for support. Many facilities have expressed the need to cooperate with infection prevention and control specialists in the future, both during outbreaks, also in routine daily practice. This report highlights the need to maintain support for residential care facilities and to implement a permanent collaboration between hospitals and residential care facilities.

Infection control teams for reducing healthcare-associated infections in hospitals and other healthcare settings: a protocol for systematic review

INTRODUCTION

Healthcare-associated infections (HCAIs) are a worldwide problem. Infection control in hospitals is usually implemented by an infection control team (ICT). Initially, ICTs consisted of doctors, nurses, epidemiologists and microbiologists; then, in the 1980s, the infection control link nurse (ICLN) system was introduced. ICTs (with or without the ICLN system) work to ensure the health and well-being of patients and healthcare professionals in hospitals and other healthcare settings, such as acute care clinics, community health centres and care homes. No previous study has reported the effects of ICTs on HCAIs. This systematic review aims to assess the effectiveness of ICTs with or without the ICLN system in reducing HCAIs in hospitals and other healthcare settings.

METHODS AND ANALYSIS

We will perform a comprehensive literature search for randomised controlled trials in four databases: PubMed, Embase, CINAHL and the Cochrane Library. The primary outcomes are: patient-based/clinical outcomes (rate of HCAIs, death due to HCAIs and length of hospital stay) and staff-based/behavioural outcomes (compliance with infection control practices). The secondary outcomes include the costs to the healthcare system or patients due to extended lengths of stay. Following data extraction, we will assess the risk of bias by using the Cochrane Effective Practice and Organization of Care risk of bias tool. If data can be pooled across all the studies, we will perform a meta-analysis.

ETHICS AND DISSEMINATION

We will use publicly available data, and therefore, ethical approval is not required for this systematic review. The findings will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

CRD42020172173.

Case-Based e-Learning Experiences of Second-Year Veterinary Students in a Clinical Medicine Course at the Ontario Veterinary College

Exposure to real-life clinical cases has been regarded as the optimal method of achieving deep learning in medical education. Case-based e-learning (CBEL) has been considered a promising alterative to address challenges in the availability of teaching cases and standardizing case exposure. While the use of CBEL has been positive in veterinary medical education, insight into students' learning experience with a CBEL tool have not been considered. This article investigates students' views around the utility and usability of a CBEL tool, as well as perceived effectiveness, clinical confidence, and impact of veterinary students' learning preferences on CBEL use. Through focus groups as well as pre- and post-use questionnaires, students expressed that the design and utility of the online cases, including their authenticity, played an instrumental role in perspectives and acceptance of the CBEL tool. Students perceived the CBEL tool as highly effective in both achieving CBEL outcomes and teaching a methodical approach to a clinical case. CBEL elements were also perceived to potentially contribute to increased clinical confidence after CBEL use. Additionally, exploration of students' preferred approach to learning revealed that hands-on learners and those who prefer to learn by practicing and applying knowledge were more likely to show positive perceptions of a CBEL tool. This article's findings can help guide educators in the future design and implementation of online cases in various capacities and provide a platform for further exploration of the effectiveness and use of CBEL in veterinary medical education.

Inter-professional teamwork and its association with patient safety in German hospitals-A cross sectional study

BACKGROUND

Inter-professional teamwork is a prominent factor in quality of care and may lead to improved patient safety. Although team members' points of view are highly relevant when trying to improve inpatient procedures, there is a lack of systematic assessment of their perceptions. Therefore, study aims were to explore inter-professional teamwork, safety-related behavior, and patient safety in German hospitals from team members' point of view. Furthermore, we wanted to examine the association between inter-professional teamwork and safety-related behavior as well as the association between inter-professional teamwork and patient safety.

METHODS

We used cross-sectional pre-intervention data of a multicenter longitudinal study (German KOMPAS project). We gathered descriptive statistics for sample characteristics and to describe the current state of inter-professional teamwork, safety-related behavior, and patient safety. We used one-way variance analyses to assess differences between groups, and linear regression analyses to examine the association between inter-professional teamwork and the outcomes safety-related behavior, and patient safety.

RESULTS

326 inpatient care team members participated in the study. Participants perceived a moderate to high level of inter-professional teamwork, and a moderate level of patient safety. Moreover, they reached rather high values in safety-related behavior. Professional group, work experience, and period of employment had an impact on the perceptions of inter-professional teamwork, and patient safety. Higher inter-professional teamwork was associated with better patient safety. We did not find an association between inter-professional teamwork and safety-related behavior.

CONCLUSIONS

Based on the association between inter-professional teamwork and patient safety, we recommend the implementation of team interventions. Because professional group, period of employment, and work experience had an impact on the perceptions of inter-professional teamwork and patient safety, we suggest future qualitative research to explore reasons for caregivers' critical evaluation. Moreover, we recommend longitudinal studies to reveal causal relationships, and subsequently to determine areas of improvement for a safer health care.

Creation of a primary care academic collaborative nexus: enabling and interfering factors

With a renewed commitment to interprofessional education and collaborative practice, academic institutions and health care systems are collaborating to provide quality health care education and service delivery. This kind of partnership integrates interprofessional education with clinical practice redesign and strives to create "collaboration ready" graduates in clinical learning environments. In this reflective case analysis, we describe the intentional commitment and collaboration between an academic institution and a clinical health system in the U.S. to form what the U.S. National Center for Interprofessional Practice and Education calls a Nexus. The historical context and shared vision that led to the creation and evolution of the Nexus, as well as a description of the micro, meso, and macro level enabling, and interfering factors are provided.

Perspectives about Interprofessional Collaboration and Patient-Centred Care

Interprofessional collaboration is understood to improve efficiencies and quality of care but is associated with challenges such as professionals' differing routines, knowledge, and identities, as well as professional hierarchies and time constraints. Given these challenges, there is limited understanding of how professionals collaborate effectively in providing patient-centred care. This study, with a convergence triangulation mixed-methods study design, explored interprofessional staffs' perceptions of interprofessional collaboration and patient-centred care when working with hospitalized older adults. Thirty-six staff responded to a survey which included the Patient-Centred Care measure and the Modified Index of Interdisciplinary Collaboration; we also interviewed 14 nursing staff. Although all scores suggested a high value was placed on interprofessional collaboration, scores were low related to activities that facilitated team processes. We identified three themes from the data: knowing the patient/family, functional needs, and communication processes. Staff identified daily rounds with interprofessional teams as supportive of interprofessional collaboration and patient-centred-care.

Effectiveness of Implementing a Collaborative Chronic Care Model for Clinician Teams on Patient Outcomes and Health Status in Mental Health: A Randomized Clinical Trial

IMPORTANCE

Collaborative chronic care models (CCMs) have extensive randomized clinical trial evidence for effectiveness in serious mental illnesses, but little evidence exists regarding their feasibility or effect in typical practice conditions.

OBJECTIVE

To determine the effectiveness of implementation facilitation in establishing the CCM in mental health teams and the impact on health outcomes of team-treated individuals.

DESIGN, SETTING, AND PARTICIPANTS

This quasi-experimental, randomized stepped-wedge implementation trial was conducted from February 2016 through February 2018, in partnership with the US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention. Nine facilities were enrolled from all VA facilities in the United States to receive CCM implementation support. All veterans (n = 5596) treated by designated outpatient general mental health teams were included for hospitalization analyses, and a randomly selected sample (n = 1050) was identified for health status interviews. Individuals with dementia were excluded. Clinicians (n = 62) at the facilities were surveyed, and site process summaries were rated for concordance with the CCM process. The CCM implementation start time was randomly assigned across 3 waves. Data analysis of this evaluable population was performed from June to September 2018.

INTERVENTIONS

Internal-external facilitation, combining a study-funded external facilitator and a facility-funded internal facilitator working with a designated team for 1 year.

MAIN OUTCOMES AND MEASURES

Facilitation was hypothesized to be associated with improvements in both implementation and intervention outcomes (hybrid type II trial). Implementation outcomes included the clinician Team Development Measure (TDM) and proportion of CCM-concordant team care processes. The study was powered for the primary health outcome, mental component score (MCS). Hospitalization rate was derived from administrative data.

RESULTS

The veteran population (n = 5596) included 881 women (15.7%), and the mean (SD) age was 52.2 (14.5) years. The interviewed sample (n = 1050) was similar but was oversampled for women (n = 210 [20.0%]). Facilitation was associated with improvements in TDM subscales for role clarity (53.4%-68.6%; δ = 15.3; 95% CI, 4.4-26.2; P = .01) and team primacy (50.0%-68.6%; δ = 18.6; 95% CI, 8.3-28.9; P = .001). The percentage of CCM-concordant processes achieved varied, ranging from 44% to 89%. No improvement was seen in veteran self-ratings, including the primary outcome. In post hoc analyses, MCS improved in veterans with 3 or more treated mental health diagnoses compared with others (β = 5.03; 95% CI, 2.24-7.82; P < .001). Mental health hospitalizations demonstrated a robust decrease during facilitation (β = -0.12; 95% CI, -0.16 to -0.07; P < .001); this finding withstood 4 internal validity tests.

CONCLUSIONS AND RELEVANCE

Implementation facilitation that engages clinicians under typical practice conditions can enhance evidence-based team processes; its effect on self-reported overall population health status was negligible, although health status improved for individuals with complex conditions and hospitalization rate declined.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02543840.

Impact of interprofessional education for medical and nursing students on the nutritional management of in-patients

Introduction: Despite its frequency, malnutrition is underestimated in its importance for morbidity and mortality. Interprofessional nutrition management can improve patient safety and clinical outcomes. An interprofessional education is considered as the basis for good team cooperation. So far, little data is available on the effects of interprofessional education on measurable outcomes for patients. The objective is to determine to what extent student feedback leads to a change of in-patient nutritional management for a selected internal medical ward. Methodology: In a teaching project based on the method of research oriented learning, medical and nursing students conducted an analysis of the nutritional situation of patients and developed individual treatment plans. The students orally reported their findings to the care teams as well as via a poster presentation to decision-makers of the clinic. A prospective cohort intervention study was conducted to assess the nutritional status of patients before and after student interventions using established screening tools. Differences were tested using t-test and Fisher's exact test. Institutional consequences for nutrition management were recorded descriptively. The teaching unit was evaluated by the students before and after. Results: Malnutrition was found in 59% of patients. Inspired by student feedback, institutional consequences followed: a) routine inpatient screening using Nutritional Risk Screening; and b) the use of pie charts to estimate food intake. Conclusion: The feedback from the results of student interprofessional cooperation led to a sensitization of decision-makers and enabled new measures to improve nutritional management. These can increase patient safety.

Older people and their families' perceptions about their experiences with interprofessional teams

Aim

To examine older people and their families’ perceptions about their experiences with interprofessional teams.

Design

Naturalistic inquiry using qualitative descriptive methods to provide a comprehensive summary of older people and their families’ experiences with interprofessional teams.

Methods

Interviews were conducted with 22 people from 11 families. The families had experiences with teams in a variety of settings, such as community, residential care and hospital. Data were analysed using inductive content analysis. NiVivo was used to record preliminary codes. Analysis included comparing and contrasting families’ experiences.

Results

Older people and their families wanted communication about what was going on, regardless of whether the news was good, bad or unknown. They also wanted care that took the concerns of the older person into consideration. Communication was a necessary ingredient to ensuring that the older person's unique concerns were known to the interprofessional team. These percepectives were discussed in the themes of communication and patient‐centred care.

The Care of Older Adults Experiencing Cognitive Challenges: How Interprofessional Teams Collaborate

We conducted a scoping study to examine how interprofessional health care teams improve the outcomes of older adults experiencing cognitive challenges. We searched Ovid, Medline 1946, and MEDLINE In-Process and other non-indexed citations, using the concepts multi or interdisciplinary care teams, confusion or cognitive impairment, and elderly adults. Of 4,554 articles the review yielded, 34 relevant to our inquiry, using Arksey and O'Malley's methodological framework. Twenty-nine per cent of authors reported on the processes interprofessional teams use to achieve positive outcomes for older adults. They highlighted the importance of communication, staff strategies, and education interventions in achieving outcomes with older adults and in supporting interprofessional collaboration. The review revealed knowledge gaps about the processes teams use to collaborate in caring for older adults experiencing cognitive challenges, and how to best incorporate older adults and their families' perspectives in team decisions. More research to understand processes interprofessional teams use is needed.

The Effect of Interprofessional Student-Led Reproductive Health Education on Youths in Juvenile Detention

STUDY OBJECTIVE

To assess the effects of an interprofessional student-led comprehensive sexual education curriculum in improving the reproductive health literacy among at-risk youths in detention.

DESIGN, SETTING, AND PARTICIPANTS

We performed a prospective cohort study involving 134 incarcerated youth and an interprofessional team of 23 medical, nursing, and social work students, who participated in a comprehensive reproductive health curriculum over the course of 3 days.

INTERVENTIONS, AND MAIN OUTCOME MEASURES

Basic reproductive health knowledge, confidence in condom use with a new partner, and self-efficacy with regard to contraception use and sexual autonomy were assessed before and after completion of the curriculum. We also assessed the student teachers' level of comfort with teaching reproductive health to adolescents and their perception of interprofessionalism.

RESULTS

Incarcerated youth showed a statistically significant increase in knowledge regarding sexually transmitted infections as well as self-reported confidence in condom use (P = .002). Self-efficacy in contraception use and sexual autonomy did not show significant improvement. Qualitative analysis of student teachers' surveys revealed theme categories regarding perception of youth, perception of self in teaching youth, perception of interacting with youth, and perception of working in interprofessional teams.

CONCLUSIONS

Our program might represent a mutually beneficial community relationship to improve reproductive health literacy in this high-risk youth population.

Improving nurse-physician teamwork through interprofessional bedside rounding

Background

Teamwork between physicians and nurses has a positive association with patient satisfaction and outcomes, but perceptions of physician–nurse teamwork are often suboptimal.

Objective

To improve nurse–physician teamwork in a general medicine inpatient teaching unit by increasing face-to-face communication through interprofessional bedside rounds.

Intervention

From July 2013 through October 2013, physicians (attendings and residents) and nurses from four general medicine teams in a single nursing unit participated in bedside rounding, which involved the inclusion of nurses in morning rounds with the medicine teams at the patients’ bedside. Based on stakeholder analysis and feedback, a checklist for key patient care issues was created and utilized during bedside rounds.

Assessment

To assess the effect of bedside rounding on nurse–physician teamwork, a survey of selected items from the Safety Attitudes Questionnaire (SAQ) was administered to participants before and after the implementation of bedside rounds. The number of pages to the general medicine teams was also measured as a marker of physician–nurse communication.

Results

Participation rate in bedside rounds across the four medicine teams was 58%. SAQ response rates for attendings, residents, and nurses were 36/36 (100%), 73/73 (100%), and 32/73 (44%) prior to implementation of bedside rounding and 36 attendings (100%), 72 residents (100%), and 14 (19%) nurses after the implementation of bedside rounding, respectively. Prior to bedside rounding, nurses provided lower teamwork ratings (percent agree) than residents and attendings on all SAQ items; but after the intervention, the difference remained significant only on SAQ item 2 (“In this clinical area, it is not difficult to speak up if I perceive a problem with patient care”, 64% for nurses vs 79% for residents vs 94% for attendings, P=0.02). Also, resident responses improved on SAQ item 1 (“Nurse input is well received in this area”, 62% vs 82%, P=0.01).

Conclusion

Increasing face-to-face communication through interprofessional bedside rounding can improve the perceptions of nurse–physician teamwork, particularly among residents and nurses.

Balancing Patient Access to Fetoscopic Laser Photocoagulation for Twin-to-Twin Transfusion Syndrome With Maintaining Procedural Competence: Are Collaborative Services Part of the Solution?

The benefits of fetoscopic laser photocoagulation (FLP) for treatment of twin-to-twin transfusion syndrome (TTTS) have been recognized for over a decade, yet access to FLP remains limited in many settings. This means at a population level, the potential benefits of FLP for TTTS are far from being fully realized. In part, this is because there are many centers where the case volume is relatively low. This creates an inevitable tension; on one hand, wanting FLP to be readily accessible to all women who may need it, yet on the other, needing to ensure that a high degree of procedural competence is maintained. Some of the solutions to these apparently competing priorities may be found in novel training solutions to achieve, and maintain, procedural proficiency, and with the increased utilization of 'competence based' assessment and credentialing frameworks. We suggest an under-utilized approach is the development of collaborative surgical services, where pooling of personnel and resources can improve timely access to surgery, improve standardized assessment and management of TTTS, minimize the impact of the surgical learning curve, and facilitate audit, education, and research. When deciding which centers should offer laser for TTTS and how we decide, we propose some solutions from a collaborative model.

Exploring a Peer Nomination Process, Attributes, and Responses of Health Professionals Nominated to Facilitate Interprofessional Collaboration

BACKGROUND:When significant changes are required across an organization, a collaborative approach with wide stakeholder engagement may be beneficial. One of the challenges of stakeholder engagement lies with identifying the most appropriate participants who can most effectively facilitate the process of change.

AIM:This article aims to provide insight into a process of identifying individuals, and their attributes, who staff perceive to be effective collaborators, and change agents to decrease intervention in childbirth in one maternity setting in New South Wales, Australia.

METHODS:Midwives and obstetricians were invited to nominate a peer from each discipline who they believed to be an effective collaborator and describe the associated personal attributes of these individuals. The 5 highest scoring midwives and obstetricians were then invited to participate in a collaborative project.

FINDINGS:The attributes that were most recognized in the collaborators were their effective communication and overall positive attitudes. Collaborator’s skills and knowledge were described less frequently. The nominees chosen identified that they were not usually selected by management for projects with some respondents feeling visible for the first time among their peers.

CONCLUSION:This method of peer nomination to recruit participants to facilitate collaborative organizational change may offer an effective method of engaging the whole team in such processes.

Contextualizing the Effectiveness of a Collaborative Care Model for Primary Care Patients with Diabetes and Depression (Teamcare): A Qualitative Assessment Using RE-AIM

OBJECTIVE

We evaluated the implementation of an efficacious collaborative care model for patients with diabetes and depression in a controlled trial in 4 community-based primary care networks (PCNs) in Alberta, Canada. Similar to previous randomized trials, the nurse care manager-led TeamCare intervention demonstrated statistically significant improvements in depressive symptoms compared with usual care. We contextualized TeamCare's effectiveness by describing implementation fidelity at the organizational and patient levels.

METHODS

We used the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate TeamCare. Qualitative methods used to collect data regarding the RE-AIM dimensions of Implementation and Effectiveness included interviews with PCN staff and specialists (n=36), research team reflections (n=4) and systematic documentation. We used content analysis, and Nvivo 10 for data management.

RESULTS

TeamCare was implemented as intended but with suboptimal fidelity. Deviations from the model included limited degrees of collaborative care practised within the PCNs, including varying physician participation, limited comfort in practising collaborative care and discontinuity of care managers. Despite suboptimal fidelity, respondents identified several implementation facilitators at the organizational level: training, ongoing implementation support, professional and personal qualities of the care manager and pre-existing relationships. Without knowledge of the effectiveness of the intervention in our controlled trial, respondents anticipated improved patient outcomes due to the main intervention components, including active patient follow up, specialist consultation and treat-to-target principles.

CONCLUSIONS

Despite suboptimal implementation in Alberta's primary care context, TeamCare resulted in improved outcomes similar to those demonstrated in previous randomized trials. A stronger culture of collaborative care would likely have yielded greater implementation fidelity and possibly better outcomes.

Interprofessionalism: Educating to meet patient needs

Interprofessional teams in health care are showing promise in achieving the triple aim-providing better care for the individual patient, reducing costs, and improving population health. To complement current changes in health care delivery in the United States, there is a growing consensus among health professions educators that students should be trained in interprofessional models prior to entering clinical practice. Current interprofessional education (IPE) efforts in anatomy education are producing positive results in enhancing professional respect, collaboration, and teamwork among health professions students. In spite of existing structural and cultural barriers to IPE, health professions educators must continue to lead and grow IPE efforts as a critical component to improving the health of our nation.

Measuring teamwork in health care settings: a review of survey instruments

BACKGROUND

Teamwork in health care settings is widely recognized as an important factor in providing high-quality patient care. However, the behaviors that comprise effective teamwork, the organizational factors that support teamwork, and the relationship between teamwork and patient outcomes remain empirical questions in need of rigorous study.

OBJECTIVE

To identify and review survey instruments used to assess dimensions of teamwork so as to facilitate high-quality research on this topic.

RESEARCH DESIGN

We conducted a systematic review of articles published before September 2012 to identify survey instruments used to measure teamwork and to assess their conceptual content, psychometric validity, and relationships to outcomes of interest. We searched the ISI Web of Knowledge database, and identified relevant articles using the search terms team, teamwork, or collaboration in combination with survey, scale, measure, or questionnaire.

RESULTS

We found 39 surveys that measured teamwork. Surveys assessed different dimensions of teamwork. The most commonly assessed dimensions were communication, coordination, and respect. Of the 39 surveys, 10 met all of the criteria for psychometric validity, and 14 showed significant relationships to nonself-report outcomes.

CONCLUSIONS

Evidence of psychometric validity is lacking for many teamwork survey instruments. However, several psychometrically valid instruments are available. Researchers aiming to advance research on teamwork in health care should consider using or adapting one of these instruments before creating a new one. Because instruments vary considerably in the behavioral processes and emergent states of teamwork that they capture, researchers must carefully evaluate the conceptual consistency between instrument, research question, and context.

Interprofessional collaboration and family member involvement in intensive care units: emerging themes from a multi-sited ethnography

This article presents emerging findings from the first year of a two-year study, which employed ethnographic methods to explore the culture of interprofessional collaboration (IPC) and family member involvement in eight North American intensive care units (ICUs). The study utilized a comparative ethnographic approach - gathering observation, interview and documentary data relating to the behaviors and attitudes of healthcare providers and family members across several sites. In total, 504 hours of ICU-based observational data were gathered over a 12-month period in four ICUs based in two US cities. In addition, 56 semi-structured interviews were undertaken with a range of ICU staff (e.g. nurses, doctors and pharmacists) and family members. Documentary data (e.g. clinical guidelines and unit policies) were also collected to help develop an insight into how the different sites engaged organizationally with IPC and family member involvement. Directed content analysis enabled the identification and categorization of major themes within the data. An interprofessional conceptual framework was utilized to help frame the coding for the analysis. The preliminary findings presented in this paper illuminate a number of issues related to the nature of IPC and family member involvement within an ICU context. These findings are discussed in relation to the wider interprofessional and health services literature.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

Development and psychometric properties of a scale for measuring internal participation from a patient and health care professional perspective

Background

Effective patient-centred health care requires internal participation, which is defined as interprofessional patient-centred teamwork. Many scales are designed for measuring teamwork from the perspective of one type of health care professional (e.g. physician or nurse), rather than for the use for all health care professionals as well as patients. Hence, this paper’s purpose is to develop a scale for measuring internal participation from all relevant perspectives and to check its psychometric properties.

Methods

In a multicentre cross-sectional study, a 6-item Internal Participation Scale (IPS) was developed and administered to 661 health care professionals (staff) and 1419 patients in 15 rehabilitation clinics to test item characteristics, acceptance, reliability (internal consistency) and construct validity. Additionally, we performed an exploratory factor analysis (EFA) to determine the factorial structure and explained variance. Confirmatory factor analysis (CFA) was used to verify the theoretically assumed one-dimensional factorial structure.

Results

A total of 275 health care professionals and 662 patients participated, and the complete data sets of 272 staff members and 536 patients were included in the final analysis. The discrimination index was above .4 for all items in both samples. Internal consistency was very good, with Cronbach’s alpha equalling .87 for the staff and .88 for the patient sample. EFA supported a one-dimensional structure of the instrument (explained variance: 61.1% (staff) and 62.3% (patients)). CFA verified the factorial structure, with the factor loadings exceeding .4 for five of six items in both samples. Global goodness-of-fit indices indicated a good model fit, with a Tucker-Lewis index (TLI) of .974 (staff) and .976 (patients) and a comparative fit index (CFI) of .988 (staff) and .989 (patients). The root mean square error of approximation (RMSEA) amounted to .068 for the patient sample and .069 for the staff sample. There is evidence of construct validity for both populations.

Conclusions

The analysis of the scale’s psychometric properties resulted in good values. The scale is a promising instrument to assess internal participation from the perspective of both patients and staff. Further research should investigate the scale’s psychometric properties in other interprofessional health care settings to examine its generalizability as well as its sensitivity to change.

Healthy work environments and staff nurse retention: the relationship between communication, collaboration, and leadership in the pediatric intensive care unit

BACKGROUND

A healthy work environment can improve patient outcomes and registered nurse (RN) turnover. Creating cultures of retention and fostering healthy work environments are 2 major challenges facing nurse leaders today.

SPECIFIC AIMS

Examine the effects of the healthy work environment (communication, collaboration, and leadership) on RN turnover from data collected from a research study.

METHODS

Descriptive, cross-sectional, correlational design. Pediatric critical care RNs from 10 pediatric intensive care units (PICU) completed the Practice Environment Scale of the Nursing Work Index Revised and a subscale of the Intensive Care Unit Nurse-Physician Communication Questionnaire. These staff nurses were asked whether they intend to leave their current job in the next 6 months. Statistical analysis included correlations, multiple linear regression, t tests (2-tailed), and 1-way analysis of variance.

RESULTS

A total of 415 RNs completed the survey. There was a statistically significant relationship between leadership and the intent to leave (P < .05). There was also an inverse relationship between years of experience and intent to leave. None of the communication variables between RNs and among RNs and MDs or collaboration were significantly associated with PICU nurses' intention to leave.

CONCLUSION

Effective leadership in the PICU is important to PICU RNs and significantly influences their decisions about staying in their current job.

Analyzing the effects of shared decision-making, empathy and team interaction on patient satisfaction and treatment acceptance in medical rehabilitation using a structural equation modeling approach

OBJECTIVES

The aims of the study are: (1) To develop and test a theory-based model for the predictive power of "Shared decision making (SDM)", "Empathy" and "Team interaction" for "Patient satisfaction" and "Treatment acceptance". (2) To identify mediating effects of "Compliance" and "Satisfaction with decision".

METHODS

Within a multi-center cross-sectional study (11 inpatient rehabilitation clinics at different indication fields), the model was evaluated in descriptive and structure analytical terms based on survey data of N=402 inpatients.

RESULTS

The structural equation model proved to exhibit an appropriate data fit. A high proportion of variance of "Patient satisfaction" (61%) and "Treatment acceptance" (67%) can be predicted by "SDM", "Empathy", "Satisfaction with decision" and "Team interaction". While no mediating effects were found for the two subcomponents of "Compliance" ("Patient cooperation", "Adherence"), "Satisfaction with decision" showed a full mediation for "Treatment acceptance" and a partial mediation for "Patient satisfaction".

CONCLUSION

"Team interaction" should be considered as an important predictor of process and patient-centered outcome characteristics.

PRACTICE IMPLICATIONS

The current findings can be used to derive measures as well as interventions to optimize the organization of participatory care within teams in order to strengthen patient centeredness and to ensure a high quality of care.

Locking-in effects due to early interventions? An evaluation of a multidisciplinary screening programs for avoiding long-term sickness

OBJECTIVE

In this article, we estimate the effect of a multidisciplinary collaborationprogram on the length of sickness absence. The intention with the programwas to avoid long-term sickness absence by providing an early and holistic evaluation of the sick-listed individuals' conditions. The target group was individuals who were at risk of becoming long-term sick. The eligibility criteria were mainly based on register information that we have access to.

METHODS

Using this register information, we estimate different Cox regression models and apply a nonparametric matching estimator. We have also conducted a small randomized experiment.

RESULTS

The result from the randomized experiment is not statistically significant, but the point estimate provides the same result as was found in the observational study: The program prolongs rather than shortens the sickness absence spell. That is, the average sickness absence spell is prolonged by about 3 months.

CONCLUSIONS

Our main explanation for this discouraging result is that the team focuses too much on rehabilitation rather than encouraging the sick-listed individual to return to work.

Integrated transitional care: patient, informal caregiver and health care provider perspectives on care transitions for older persons with hip fracture

Introduction

Complex older adults, such as those with hip fracture, frequently require care from multiple professionals across a variety of settings. Integrated care both between providers and across settings is important to ensure care quality and patient safety. The purpose of this study was to determine the core factors related to poorly integrated care when hip fracture patients transition between care settings.

Methods

A qualitative, focused ethnographic approach was used to guide data collection and analysis. Patients, their informal caregivers and health care providers were interviewed and observed at each care transition. A total of 45 individual interviews were conducted. Interview transcripts and field notes were coded and analysed to uncover emerging themes in the data.

Results

Four factors related to poorly integrated transitional care were identified: confusion with communication about care, unclear roles and responsibilities, diluted personal ownership over care, and role strain due to system constraints.

Conclusions

Our research supports a broader notion of collaborative practice that extends beyond specific care settings and includes an appropriate, informed role for patients and informal caregivers. This research can help guide system-level and setting-specific interventions designed to promote high-quality, patient-centred care during care transitions.

New partnerships in health and social care for an era of public spending cuts

This article discusses a research partnership framework based on a collaborative relationship that was initially established between a carers' organisation and a university with the aim of maximising the efficacy and cost-effectiveness of health and social care research in an era of public spending cuts. As each partner gradually formed several similar partnerships, it was developed into a framework for research partnerships between third sector organisations and academic institutions. The framework is contextualised within the concepts of collaboration and partnership working more generally and then within the development of third sector and university partnerships specifically. This is followed by a description and discussion of the framework together with a critical reflection on how it operated in practice. The ways in which it enhances research conducted by third sector organisations and universities and facilitates the best use of more limited research funds are also explored. Suggestions are then made as to how it can be used and adapted to generate new thinking about other similar partnerships at both a national and international level during the next few years of considerably reduced public sector expenditure.

Assessing an interdisciplinary health care model: the Governor's Wellmobile Program

This article assesses the applicability of Bronstein's (2003) generic model of interdisciplinary collaboration in the context of a newly created collaboration providing community-based health care services, the Governor's Wellmobile Program. An analysis of the program's quarterly reports and interviews with faculty and students involved in the collaboration offers an assessment of the model and implications for interdisciplinary social work practice in community health care delivery.

How can we improve cancer care? A review of interprofessional collaboration models and their use in clinical management

BACKGROUND

Multimodal cancer care requires collaboration among different professionals in various settings. Practice guidelines provide little direction on how this can best be achieved. Research shows that collaborative cancer management is limited, and challenged by numerous issues. The purpose of this research was to describe conceptual models of collaboration, and analyze how they have been applied in the clinical management of cancer patients.

METHODS

A review of the literature was performed using a two-phase meta-narrative approach. The first phase involved searching for conceptual models of collaboration. Their components and limitations were summarized. The second phase involved targeted searching for empirical research on evaluation of these concepts in the clinical management of cancer patients. Data on study objective, design, and findings were tabulated, and then summarized according to collaborative model and phase of clinical care to identify topics warranting further research.

RESULTS

Conceptual models for teamwork, interprofessional collaboration, integrated care delivery, interorganizational collaboration, continuity of care, and case management were described. All concepts involve two or more health care professionals that share patient care goals and interact on a continuum from consultative to integrative, varying according to extent and nature of interaction, degree to which decision making is shared, and the scope of patient management (medical versus holistic). Determinants of positive objective and subjective patient, team and organizational outcomes common across models included system or organizational support, team structure and traits, and team processes. Twenty-two studies conducted in ten countries examining these concepts for cancer care were identified. Two were based on an explicit model of collaboration. Many health professionals function through parallel or consultative models of care and are not well integrated. Few interventions or strategies have been applied to promote models that support collaboration.

CONCLUSIONS

Ongoing development, implementation and evaluation of collaborative cancer management, in the context of both practice and research, would benefit from systematic planning and operationalization. Such an approach is likely to improve patient, professional and organizational outcomes, and contribute to a collective understanding of collaborative cancer care.

Interprofessional Education, Collaborative Practice and Primary Care

A diverse range of professionals work within the primary care setting in order to provide for and meet the health and social care needs of patients. Effective communication, collaboration and team working are crucial to ensure that patients receive high-quality cost-effective care. Interprofessional education both at undergraduate and at postgraduate levels has the potential to improve communication, collaboration and team working.

A longitudinal study of the effect of an interprofessional education curriculum on student satisfaction and attitudes towards interprofessional teamwork and education

There has been limited research on the effect of interprofessional education (IPE) over time on the attitudes of undergraduate health and human service professional students. Previous research in this area has suggested that students from different professions report differing attitudes towards IPE and interprofessional teamwork, and such attitudes may also be influenced by other background characteristics of the students themselves (e.g., gender, age). The purpose of this study was to evaluate the longitudinal effect of the introduction of an IPE curriculum on students' attitudes towards IPE and teamwork. A time series study design was conducted to assess the attitudes of undergraduate health and human service professional students towards IPE and teamwork, and students were also asked to complete satisfaction surveys after IPE curriculum activities. Significant differences in the attitudes of students from different professions and their satisfaction with participation in IPE were reported over the duration of the study. Overall, student satisfaction with IPE participation was relatively positive; however the introduction of IPE curriculum during their undergraduate education did not appear to have a significant longitudinal effect on attitudes towards IPE or interprofessional teamwork. The findings have implications for the design and integration of IPE curriculum within existing uni-professional curriculum.

Systematic review of practice guideline dissemination and implementation strategies for healthcare teams and team-based practice

AIM

To synthesis the literature relevant to guideline dissemination and implementation strategies for healthcare teams and team-based practice.

METHODS

Systematic approach utilising Joanna Briggs Institute methods. Two reviewers screened all articles and where there was disagreement, a third reviewer determined inclusion.

RESULTS

Initial search revealed 12,083 of which 88 met the inclusion criteria. Ten dissemination and implementation strategies identified with distribution of educational materials the most common. Studies were assessed for patient or practitioner outcomes and changes in practice, knowledge and economic outcomes. A descriptive analysis revealed multiple approaches using teams of healthcare providers were reported to have statistically significant results in knowledge, practice and/or outcomes for 72.7% of the studies.

CONCLUSION

Team-based care using practice guidelines locally adapted can affect positively patient and provider outcomes.

Community pharmacists' involvement in smoking cessation: familiarity and implementation of the National smoking cessation guideline in Finland

BACKGROUND

Guidelines on smoking cessation (SC) emphasize healthcare cooperation and community pharmacists' involvement. This study explored the familiarity and implementation of the National SC Guideline in Finnish community pharmacies, factors relating to Guideline familiarity, implementation and provision of SC services.

METHODS

A nationwide mail survey was sent to a systematic, sample of community pharmacy owners and staff pharmacists (total n = 2291). Response rate was 54% (n = 1190). Factors related to the SC Guideline familiarity were assessed by bivariate and multivariate analysis.

RESULTS

Almost half (47%) of the respondents (n = 1190) were familiar with the SC Guideline and familiarity enhanced Guideline implementation. The familiarity was associated with the respondents' perceptions of their personal SC skills and knowledge (OR 3.8); of customers' value of counseling on nicotine replacement therapy (NRT) (OR 3.3); and regular use of a pocket card supporting SC counseling (OR 3.0). Pharmacists' workplaces' characteristics, such as size and geographical location were not associated with familiarity. In addition to recommending NRT, the pharmacists familiar with the Guideline used more frequently other Guideline-based SC methods, such as recommended non-pharmacological SC aids, compared to unfamiliar respondents.

CONCLUSIONS

SC Guideline familiarity and implementation is crucial for community pharmacists' involvement in SC actions in addition to selling NRT products. Pharmacists can constitute a potential public health resource in SC easily accessible throughout the country.

Achieving teamwork in stroke units: the contribution of opportunistic dialogue

Collaborative interdisciplinary working is central to contemporary health policy. The specialized and co-ordinated multidisciplinary care provided in stroke units is considered to contribute to improved patient outcomes in such units. However, how stroke unit teams co-ordinate their work is not clearly understood. This paper reports on a grounded theory study which explains how health professionals in two stroke units in northern England achieved teamwork. Data were generated through 220 hours of participant observation and 34 semi-structured interviews. Interviews were undertaken during and following participant observations. A basic social process common to teamworking in both units was identified; this was termed "opportunistic dialogue". The division of labour in respect of rehabilitation activities was negotiated through this interactional process. Co-location of most team members led to repeated engagement in sharing patient information and in exploring different perspectives. Opportunistic dialoguing contributed to mutual learning and explained the shift in thinking and team culture as team members moved from concern with discrete disciplinary actions to dialogue and negotiations focused on meeting patients' needs. The findings indicate that routinely incorporating periods of joint working in which team members articulate the reasoning for their decisions and interventions, contributes to achieving interdisciplinary teamworking in rehabilitation settings.