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Bø KE, Halvorsen KH, Le AYN, Lehnbom EC. Barriers and facilitators of pharmacists' integration in a multidisciplinary home care team: a qualitative interview study based on the normalization process theory. BMC Health Serv Res 2024; 24:567. [PMID: 38698483 PMCID: PMC11064233 DOI: 10.1186/s12913-024-11014-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 04/18/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND There is a growing recognition of multidisciplinary practices as the most rational approach to providing better and more efficient healthcare services. Pharmacists are increasingly integrated into primary care teams, but there is no universal approach to implementing pharmacist services across healthcare settings. In Norway, most pharmacists work in pharmacies, with very few employed outside this traditional setting. The home care workforce is primarily made up of nurses, assistant nurses, and healthcare assistants. General practitioners (GPs) are not based in the same location as home care staff. This study utilized the Normalization Process Theory (NPT) to conduct a process evaluation of the integration of pharmacists in a Norwegian home care setting. Our aim was to identify barriers and facilitators to optimal utilization of pharmacist services within a multidisciplinary team. METHODS Semi-structured interviews (n = 9) were conducted with home care unit leaders, ward managers, registered nurses, and pharmacists in Norway, in November 2022-February 2023. Constructs from the NPT were applied to qualitative data. RESULTS Findings from this study pertain to the four constructs of the NPT. Healthcare professionals struggled to conceptualize the pharmacists' competencies and there were no collectively agreed-upon objectives of the intervention. Consequently, some participants questioned the necessity of pharmacist integration. Further, participants reported conflicting preferences regarding how to best utilize medication-optimizing services in everyday work. A lack of stakeholder empowerment was reported across all participants. Moreover, home care unit leaders and managers reported being uninformed of their roles and responsibilities related to the implementation process. However, the presence of pharmacists and their services were well received in the setting. Moreover, participants reported that pharmacists' contributions positively impacted the multidisciplinary practice. CONCLUSION Introducing new work methods into clinical practice is a complex task that demands expertise in implementation. Using the NTP model helped pinpoint factors that affect how pharmacists' skills are utilized in a home care setting. Insights from this study can inform the development of tailored implementation strategies to improve pharmacist integration in a multidisciplinary team.
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Affiliation(s)
- Karl-Erik Bø
- Department of Pharmacy, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, N-9037, Norway.
| | - Kjell H Halvorsen
- Department of Pharmacy, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, N-9037, Norway
| | - Anna Yen-Ngoc Le
- Department of Pharmacy, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, N-9037, Norway
| | - Elin C Lehnbom
- Department of Pharmacy, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, N-9037, Norway
- Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, Hus Vita, Kalmar, 431 26, Sweden
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Kanno NDP, Peduzzi M, Germani ACCG, Soárez PCD, Silva ATCD. Interprofessional collaboration in primary health care from the perspective of implementation science. CAD SAUDE PUBLICA 2023; 39:e00213322. [PMID: 37971099 PMCID: PMC10645058 DOI: 10.1590/0102-311xpt213322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 11/19/2023] Open
Abstract
The objective was to analyze the perceptions of primary health care (PHC) workers about interprofessional collaboration from the perspective of implementation science. This is a qualitative study that used in-depth interview as a data production technique. Interviews were conducted with 15 workers (three community health agents, one nursing assistant, three nurses, three managers, three physicians, and two nursing technicians) from basic health units in the Municipality of São Bernardo do Campo, São Paulo State, Brazil. The interview plan was based on three domains of the Consolidated Framework for Implementation Research (CFIR). Thematic content analysis was used. In the interprofessional collaboration characteristics domain, respondents highlighted the complexity, and its possible influence, as to the implementation and sustainability of this practice. In the inner setting domain, factors that influence interprofessional collaboration were identified, namely: how the time allocated to formal communication/team meetings is used; social interactions between professionals; and leadership characteristics, such as feedback, autonomy and participation in decisions. In the individuals characteristics domain, participants noted interprofessional collaboration geared to quality of care and the need for integration between knowledge centers. Thus, measures to enhance the quality of communication, collective team building and leadership can contribute to improve interprofessional collaboration in PHC and leverage its impacts on health care.
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Affiliation(s)
- Natália de Paula Kanno
- Prefeitura do Município de São Bernardo do Campo, São Bernardo do Campo, Brasil
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Marina Peduzzi
- Escola de Enfermagem, Universidade de São Paulo, São Paulo, Brasil
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Grace M, Azim A, Blissett S, Keuhl A, Wojkowski S, Sibbald M. Framing asynchronous interprofessional education: a qualitative study on medical, physiotherapy and nursing students. INTERNATIONAL JOURNAL OF MEDICAL EDUCATION 2023; 14:155-167. [PMID: 37930800 PMCID: PMC10693952 DOI: 10.5116/ijme.6531.02ac] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 10/19/2023] [Indexed: 11/07/2023]
Abstract
Objectives To explore how virtual, asynchronous modules can be used in interprofessional health education curricula and to identify any advantages and shortcomings of asynchronous interprofessional education. Methods A sample of 27 health professional students who attended in-person interprofessional education workshops at the McMaster Centre for Simulation-Based Learning from 2019-2020 were recruited through email discourse. Participants were asked to complete an asynchronous interprofessional education module and take part in a semi-structured interview that was recorded and transcribed verbatim. Techniques of direct content analysis were used to analyze the qualitative data from recorded transcripts. Results The following emergent themes from participants' responses were identified: 1) the modules, as well as the features interspersed throughout, taught strategies for conflict resolution and interprofessional communication, 2) the modules have utility in preparing students for future interprofessional learning, 3) the convenience of virtual asynchronous modules introduces a sense of learner safety, and 4) a sense of isolation and fatigue was identified as a consequence of the lack of face-to-face interaction in these modules. Conclusion Asynchronous interprofessional education modules may be best suited to prepare students for future interprofessional learning in a synchronous setting. Asynchronous modules effectively provide an introduction to interprofessional objectives such as conflict resolution and role clarification, yet the competency of team functioning is more difficult to achieve in an asynchronous environment. Future studies may focus on establishing a sequence of completing asynchronous modules for ideal development of interprofessional competencies in health professions learners.
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Affiliation(s)
- Matthew Grace
- Faculty of Health Sciences, McMaster University, Canada
| | - Arden Azim
- Department of Medicine, Western University, Canada
| | | | - Amy Keuhl
- Faculty of Health Sciences, McMaster University, Canada
| | - Sarah Wojkowski
- School of Rehabilitation Sciences, McMaster University, Canada
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Van Hecke A, Vlerick I, Akhayad S, Daem M, Decoene E, Kinnaer LM. Dynamics and processes influencing role integration of advanced practice nurses and nurse navigators in oncology teams. Eur J Oncol Nurs 2023; 62:102257. [PMID: 36634592 DOI: 10.1016/j.ejon.2022.102257] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 12/06/2022] [Accepted: 12/14/2022] [Indexed: 12/26/2022]
Abstract
PURPOSE Exploring the persisting presence of underlying processes, dynamics, experienced barriers and facilitators of Advanced Practice Nurses (APN) in oncology and Oncology Nurse Navigators (ONN) during their role integration in an interprofessional team over a research period of seven years. METHODS A qualitative study based on the principles of Grounded Theory, in which individual semi-structured interviews and focus groups were conducted with 51 ONN and APN from 11 university and local hospitals in Belgium between 2011-2018. Data were analyzed to develop a framework that consists of different themes. RESULTS ONN and APN experienced a lonely journey during role integration. They were searching for partners, medical knowledge and acknowledgement from the interprofessional team. ONN and APN had a watchful attitude and tried to make themselves visible to ensure they were involved in the team and to preserve their role and responsibilities. An unclear role description to the interprofessional team, and a lack of coaching and guidance were influencing factors in the experience of ONN and APN. CONCLUSION ONN and APN in oncology feel difficulties to integrate their role in existing interprofessional teams. A lack of role clarity, the interprofessional team environment and a desire for coaching and guidance are influencing factors to implement APN roles. Coaching and mentorship of novice ONN/APN and their interprofessional team and healthcare managers are needed to address these issues. These findings could form the basis for a mentorship program for ONN/APN and their interprofessional team to enhance role integration.
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Affiliation(s)
- Ann Van Hecke
- Department of Public Health and Primary Care, University Centre for Nursing and Midwifery, Ghent University, Ghent, Belgium; Staff Member Nursing Department, Ghent University Hospital, Ghent, Belgium
| | - Isabel Vlerick
- Nursing Department, Ghent University Hospital, Ghent, Belgium.
| | - Soumaya Akhayad
- Nursing Department, Ghent University Hospital, Ghent, Belgium
| | - Michiel Daem
- Nursing Department, Ghent University Hospital, Ghent, Belgium
| | - Elsie Decoene
- Staff Member Nursing Department, Ghent University Hospital, Ghent, Belgium
| | - Lise-Marie Kinnaer
- Department of Public Health and Primary Care, University Centre for Nursing and Midwifery, Ghent University, Ghent, Belgium
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Joseph R, Hart NH, Bradford N, Agbejule OA, Koczwara B, Chan A, Wallen MP, Chan RJ. Diet and exercise advice and referrals for cancer survivors: an integrative review of medical and nursing perspectives. Support Care Cancer 2022; 30:8429-8439. [PMID: 35616734 PMCID: PMC9512858 DOI: 10.1007/s00520-022-07152-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/13/2022] [Indexed: 12/02/2022]
Abstract
Purpose To examine the perspectives of medical and nursing health professionals concerning their roles and responsibilities in providing dietary and exercise advice to cancer survivors, and referrals to allied health professionals. Methods An integrative review. PubMed, CINAHL, PsycINFO, Embase, Web of Science databases, and bibliographies of relevant studies were searched from December 2011 to June 2021. All studies were eligible for inclusion. The Mixed-Methods Appraisal Tool (MMAT) was used to critically appraise included studies. Data were extracted and synthesised regarding the perspectives of medical and nursing health professionals on their roles, responsibilities, barriers, and facilitators. Results Twenty-one studies involving 3401 medical and nursing health professionals and 264 cancer survivors of diverse cancer types were included. Ten quantitative, nine qualitative, and two mixed-methods studies were eligible. All included studies met at least 80% of the quality criteria in the MMAT. Major findings include the following: (1) medical and nursing health professionals were unclear on their roles in providing dietary and exercise advice to cancer survivors but agreed they play a key role in referrals to dietitians and exercise professionals; (2) most cancer survivors valued the involvement of their general practitioner when receiving dietary and exercise advice. Conclusion Although medical and nursing health professionals understand that referrals to allied health professionals form part of their role, there is a lack of clarity regarding their roles to provide dietary and exercise advice to cancer survivors. Future studies should address barriers and facilitators of dietary and exercise advice and referral by medical and nursing health professionals. Supplementary Information The online version contains supplementary material available at 10.1007/s00520-022-07152-w.
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Affiliation(s)
- Ria Joseph
- Caring Futures Institute, College and Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.
| | - Nicolas H Hart
- Caring Futures Institute, College and Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia.,Exercise Medicine Research Institute, School of Medical and Health Science, Edith Cowan University, Perth, WA, Australia.,Institute for Health Research, The University of Notre Dame Australia, Perth, WA, Australia
| | - Natalie Bradford
- Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia
| | | | - Bogda Koczwara
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Alexandre Chan
- Department of Clinical Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University of California, Irvine, USA
| | - Matthew P Wallen
- Caring Futures Institute, College and Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,School of Science, Psychology and Sport, Federation University Australia, Ballarat, VIC, Australia
| | - Raymond J Chan
- Caring Futures Institute, College and Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia
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Poot CC, Meijer E, Kruis AL, Smidt N, Chavannes NH, Honkoop PJ. Integrated disease management interventions for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2021; 9:CD009437. [PMID: 34495549 PMCID: PMC8425271 DOI: 10.1002/14651858.cd009437.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People with chronic obstructive pulmonary disease (COPD) show considerable variation in symptoms, limitations, and well-being; this often complicates medical care. A multi-disciplinary and multi-component programme that addresses different elements of care could improve quality of life (QoL) and exercise tolerance, while reducing the number of exacerbations. OBJECTIVES To compare the effectiveness of integrated disease management (IDM) programmes versus usual care for people with chronic obstructive pulmonary disease (COPD) in terms of health-related quality of life (QoL), exercise tolerance, and exacerbation-related outcomes. SEARCH METHODS We searched the Cochrane Airways Group Register of Trials, CENTRAL, MEDLINE, Embase, and CINAHL for potentially eligible studies. Searches were current as of September 2020. SELECTION CRITERIA Randomised controlled trials (RCTs) that compared IDM programmes for COPD versus usual care were included. Interventions consisted of multi-disciplinary (two or more healthcare providers) and multi-treatment (two or more components) IDM programmes of at least three months' duration. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. If required, we contacted study authors to request additional data. We performed meta-analyses using random-effects modelling. We carried out sensitivity analyses for the quality of included studies and performed subgroup analyses based on setting, study design, dominant intervention components, and region. MAIN RESULTS Along with 26 studies included in the 2013 Cochrane Review, we added 26 studies for this update, resulting in 52 studies involving 21,086 participants for inclusion in the meta-analysis. Follow-up periods ranged between 3 and 48 months and were classified as short-term (up to 6 months), medium-term (6 to 15 months), and long-term (longer than 15 months) follow-up. Studies were conducted in 19 different countries. The mean age of included participants was 67 years, and 66% were male. Participants were treated in all types of healthcare settings, including primary (n =15), secondary (n = 22), and tertiary care (n = 5), and combined primary and secondary care (n = 10). Overall, the level of certainty of evidence was moderate to high. We found that IDM probably improves health-related QoL as measured by St. George's Respiratory Questionnaire (SGRQ) total score at medium-term follow-up (mean difference (MD) -3.89, 95% confidence interval (CI) -6.16 to -1.63; 18 RCTs, 4321 participants; moderate-certainty evidence). A comparable effect was observed at short-term follow-up (MD -3.78, 95% CI -6.29 to -1.28; 16 RCTs, 1788 participants). However, the common effect did not exceed the minimum clinically important difference (MCID) of 4 points. There was no significant difference between IDM and control for long-term follow-up and for generic QoL. IDM probably also leads to a large improvement in maximum and functional exercise capacity, as measured by six-minute walking distance (6MWD), at medium-term follow-up (MD 44.69, 95% CI 24.01 to 65.37; 13 studies, 2071 participants; moderate-certainty evidence). The effect exceeded the MCID of 35 metres and was even greater at short-term (MD 52.26, 95% CI 32.39 to 72.74; 17 RCTs, 1390 participants) and long-term (MD 48.83, 95% CI 16.37 to 80.49; 6 RCTs, 7288 participants) follow-up. The number of participants with respiratory-related admissions was reduced from 324 per 1000 participants in the control group to 235 per 1000 participants in the IDM group (odds ratio (OR) 0.64, 95% CI 0.50 to 0.81; 15 RCTs, median follow-up 12 months, 4207 participants; high-certainty evidence). Likewise, IDM probably results in a reduction in emergency department (ED) visits (OR 0.69, 95%CI 0.50 to 0.93; 9 RCTs, median follow-up 12 months, 8791 participants; moderate-certainty evidence), a slight reduction in all-cause hospital admissions (OR 0.75, 95%CI 0.57 to 0.98; 10 RCTs, median follow-up 12 months, 9030 participants; moderate-certainty evidence), and fewer hospital days per person admitted (MD -2.27, 95% CI -3.98 to -0.56; 14 RCTs, median follow-up 12 months, 3563 participants; moderate-certainty evidence). Statistically significant improvement was noted on the Medical Research Council (MRC) Dyspnoea Scale at short- and medium-term follow-up but not at long-term follow-up. No differences between groups were reported for mortality, courses of antibiotics/prednisolone, dyspnoea, and depression and anxiety scores. Subgroup analysis of dominant intervention components and regions of study suggested context- and intervention-specific effects. However, some subgroup analyses were marked by considerable heterogeneity or included few studies. These results should therefore be interpreted with caution. AUTHORS' CONCLUSIONS This review shows that IDM probably results in improvement in disease-specific QoL, exercise capacity, hospital admissions, and hospital days per person. Future research should evaluate which combination of IDM components and which intervention duration are most effective for IDM programmes, and should consider contextual determinants of implementation and treatment effect, including process-related outcomes, long-term follow-up, and cost-effectiveness analyses.
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Affiliation(s)
- Charlotte C Poot
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Eline Meijer
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Annemarije L Kruis
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Nynke Smidt
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Niels H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Persijn J Honkoop
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, Netherlands
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Fukui S, Salyers MP, Morse G, Rollins AL. Factors that affect quality of care among mental health providers: Focusing on job stress and resources. Psychiatr Rehabil J 2021; 44:204-211. [PMID: 33539113 PMCID: PMC8376230 DOI: 10.1037/prj0000469] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Objective: High-quality, person-centered care is a priority for mental health services. The current study conducted secondary data analysis to examine the impact of job stress (i.e., interaction with high-risk consumer cases, increased caseload, emotional exhaustion) and resources (i.e., increased organizational and supervisory support, autonomy, role clarity) on providers' perceived quality of care. Methods: Data consisted of 145 direct care providers from an urban community mental health center. Structural equation modeling was used for testing the hierarchical regression model, sequentially adding job stress and resource variables in the prediction models for the quality of care (i.e., person-centered care, discordant care [conflict with consumers and tardiness]). Results: Person-centered care was positively associated with increased role clarity, organizational support, and larger caseload size, while a lower level of discordant care was associated with lower emotional exhaustion, smaller caseload size, less interaction with high-risk consumer cases, and with increased role clarity. Conclusions and Implications for Practice: Resources on the job may be particularly important for improved person-centered care, and lowering job stress may help reduce discordant care. The current study suggests the need for the mental health organizations to attend to both job stress and resources for providers to improve the quality of care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
| | - Michelle P Salyers
- Department of Psychology, Indiana University-Purdue University Indianapolis
| | | | - Angela L Rollins
- Department of Psychology, Indiana University-Purdue University Indianapolis
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Silva E Silva V, Hornby L, Lotherington K, Rochon A, Regina Silva A, Pearson H, MacNutt L, Robertson A, Werestiuk K, Kuhl D, John P, Dhanani S, Sarti A. Burnout, compassion fatigue and work-related stressors among organ donation and transplantation coordinators: A qualitative study. Intensive Crit Care Nurs 2021; 68:103125. [PMID: 34454831 DOI: 10.1016/j.iccn.2021.103125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 07/07/2021] [Accepted: 07/17/2021] [Indexed: 11/05/2022]
Abstract
AIM Organ and Tissue Donation Coordinators (OTDCs) are healthcare professionals who manage deceased organ donation cases. This study investigated the experiences and perceptions of OTDCs, pertaining to compassion fatigue, burnout, and resilience as it relates to their daily work. METHODOLOGY A qualitative descriptive study was undertaken using semi-structured interviews conducted with a convenience sample of OTDCs. SETTING A Canadian Organ Donation Organization. FINDINGS Seven out of the ten OTDCs contacted participated in this study. Coordinators all agreed that they work in a high-pressure and demanding environment and the constant exposure to work-related stress and grief has resulted in the majority of them experiencing signs and symptoms of burnout and compassion fatigue occurring throughout their career. Participants described that the emotional toll of work-related stressors and difficult cases led them to use a variety of defence strategies to protect and support their well-being. They also recognised that more strategies to help mitigate work-related stressors and to prevent burnout and compassion fatigue are needed and that management and institutions should lead the development of such interventions. CONCLUSION Our results describe how coordinators' mental health is affected by their daily work. Further research is needed to comprehensively examine these work-related stressors and to generate additional data to support the development of interventions to mitigate burnout and compassion fatigue among OTDCs.
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Affiliation(s)
- Vanessa Silva E Silva
- Canadian Blood Services, 1800 Alta Vista Drive, Ottawa, Ontario K1G 4J5, Canada; Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Rd, Ottawa, Ontario K1H 5B2, Canada.
| | - Laura Hornby
- University of Ottawa,75 Laurier Ave. E, Ottawa, ON K1N 6N5, Canada
| | - Ken Lotherington
- Canadian Blood Services, 1800 Alta Vista Drive, Ottawa, Ontario K1G 4J5, Canada; Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Rd, Ottawa, Ontario K1H 5B2, Canada
| | - Andrea Rochon
- Canadian Blood Services, 1800 Alta Vista Drive, Ottawa, Ontario K1G 4J5, Canada; Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Rd, Ottawa, Ontario K1H 5B2, Canada
| | - Amina Regina Silva
- Canadian Blood Services, 1800 Alta Vista Drive, Ottawa, Ontario K1G 4J5, Canada; Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Rd, Ottawa, Ontario K1H 5B2, Canada
| | - Hilary Pearson
- HDL Consulting, 120 S. State College Blvd, CA 92821, Canada
| | - Linda MacNutt
- HDL Consulting, 120 S. State College Blvd, CA 92821, Canada
| | - Adrian Robertson
- Manitoba Transplant Program, 820 Sherbrook St, Winnipeg, MB R3A 1R9, Canada
| | - Kim Werestiuk
- Manitoba Transplant Program, 820 Sherbrook St, Winnipeg, MB R3A 1R9, Canada
| | - David Kuhl
- HDL Consulting, 120 S. State College Blvd, CA 92821, Canada; University of British Columbia, Department of Family Practice, 3rd Floor David Strangway Building, 5950 University Boulevard, Vancouver, British Columbia V6T 1Z3, Canada
| | - Peggy John
- Canadian Blood Services, 1800 Alta Vista Drive, Ottawa, Ontario K1G 4J5, Canada; Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Rd, Ottawa, Ontario K1H 5B2, Canada
| | - Sonny Dhanani
- Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Rd, Ottawa, Ontario K1H 5B2, Canada; University of Ottawa,75 Laurier Ave. E, Ottawa, ON K1N 6N5, Canada
| | - Aimee Sarti
- Canadian Blood Services, 1800 Alta Vista Drive, Ottawa, Ontario K1G 4J5, Canada; Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Rd, Ottawa, Ontario K1H 5B2, Canada
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Iriarte-Roteta A, Lopez-Dicastillo O, Mujika A, Antoñanzas-Baztán E, Hernantes N, Galán Espinilla MJ, Pumar-Méndez MJ. Building capacity for health promotion by addressing nurses' role confusion: Study protocol of a pilot clustered randomised controlled trial. J Adv Nurs 2021; 77:4574-4585. [PMID: 34418139 DOI: 10.1111/jan.15018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/24/2021] [Indexed: 11/30/2022]
Abstract
AIM To describe the protocol for the pilot phase of a complex intervention, designed to address primary care nurses' role confusion in health promotion. DESIGN A pilot clustered randomized controlled trial, with control and intervention groups. METHODS The study will be conducted in a primary care setting. Participants will be nurses from the primary care health service working in a primary care team (PCT, 15 control group; 15 intervention group). Nurses in the experimental group will receive the ROLE-AP programme over a 3-week period. The control group will continue with the normal routine. The pilot will help determine the intervention's feasibility, acceptability, fidelity and quality of the programme components. Data collected preintervention, postintervention and 3 months after intervention will provide estimates of the intervention's preliminary effects on the main variable, nurses' degree of agreement concerning their expected role in health promotion. The study received funding from the local government in December 2019. DISCUSSION Role confusion is promoting primary care nurses' omissions in their health-promoting practice, which is far from the ideal portrayed by the Ottawa Charter. Interventions are needed that reveal the most appropriate mechanisms for addressing role confusion, which requires reaching an intraprofessional agreement about the expectations for role activities. Healthcare organisations could benefit from the incorporation of a programme of these characteristics into standard practice. IMPACT This study will produce a novel and comprehensive complex intervention that is expected to build nurses' capacity in primary healthcare organizations for health promotion, which is key to increasing the quality, efficiency and sustainability of the National Health System. The programme evaluation and feasibility study will reveal how to better use existing resources in a full-scale clinical trial. TRIAL REGISTRATION ClinicalTrials.gov (ID: NCT04726696).
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Affiliation(s)
- Andrea Iriarte-Roteta
- Department of Community and Maternity/Pediatric Nursing, Faculty of Nursing, University of Navarra, Pamplona, Spain.,Health Sciences Department, Universidad Pública de Navarra (UPNA), Pamplona, Spain.,Navarra Primary Health Care Service, Pamplona, Spain.,Research Group CreaP, Pamplona, Spain
| | - Olga Lopez-Dicastillo
- Health Sciences Department, Universidad Pública de Navarra (UPNA), Pamplona, Spain.,Research Group CreaP, Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - Agurtzane Mujika
- Faculty of Medicine and Nursing, Department of Nursing, University of the Basque Country (UPV/EHU), Donostia, Spain, Donostia, Spain
| | - Elena Antoñanzas-Baztán
- Health Sciences Department, Universidad Pública de Navarra (UPNA), Pamplona, Spain.,Research Group CreaP, Pamplona, Spain.,Department of Health, Government of Navarra, Pamplona, Spain
| | - Naia Hernantes
- Faculty of Medicine and Nursing, Department of Nursing, University of the Basque Country (UPV/EHU), Donostia, Spain, Donostia, Spain
| | - María José Galán Espinilla
- Health Sciences Department, Universidad Pública de Navarra (UPNA), Pamplona, Spain.,Navarra Primary Health Care Service, Pamplona, Spain
| | - María Jesús Pumar-Méndez
- Health Sciences Department, Universidad Pública de Navarra (UPNA), Pamplona, Spain.,Research Group CreaP, Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
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Nyboer EA, Nguyen VM, Young N, Rytwinski T, Taylor JJ, Lane JF, Bennett JR, Harron N, Aitken SM, Auld G, Browne D, Jacob AI, Prior K, Smith PA, Smokorowski KE, Alexander S, Cooke SJ. Supporting Actionable Science for Environmental Policy: Advice for Funding Agencies From Decision Makers. FRONTIERS IN CONSERVATION SCIENCE 2021. [DOI: 10.3389/fcosc.2021.693129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Successful incorporation of scientific knowledge into environmental policy and decisions is a significant challenge. Although studies on how to bridge the knowledge-action gap have proliferated over the last decade, few have investigated the roles, responsibilities, and opportunities for funding bodies to meet this challenge. In this study we present a set of criteria gleaned from interviews with experts across Canada that can be used by funding bodies to evaluate the potential for proposed research to produce actionable knowledge for environmental policy and practice. We also provide recommendations for how funding bodies can design funding calls and foster the skills required to bridge the knowledge-action gap. We interviewed 84 individuals with extensive experience as knowledge users at the science-policy interface who work for environmentally-focused federal and provincial/territorial government bodies and non-governmental organizations. Respondents were asked to describe elements of research proposals that indicate that the resulting research is likely to be useful in a policy context, and what advice they would give to funding bodies to increase the potential impact of sponsored research. Twenty-five individuals also completed a closed-ended survey that followed up on these questions. Research proposals that demonstrated (1) a team with diverse expertise and experience in co-production, (2) a flexible research plan that aligns timelines and spatial scale with policy needs, (3) a clear and demonstrable link to a policy issue, and (4) a detailed and diverse knowledge exchange plan for reaching relevant stakeholders were seen as more promising for producing actionable knowledge. Suggested changes to funding models to enhance utility of funded research included (1) using diverse expertise to adjudicate awards, (2) supporting co-production and interdisciplinary research through longer grant durations and integrated reward structures, and (3) following-up on and rewarding knowledge exchange by conducting impact evaluation. The set of recommendations presented here can guide both funding agencies and research teams who wish to change how applied environmental science is conducted and improve its connection to policy and practice.
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Kilpatrick K, Tchouaket E, Fernandez N, Jabbour M, Dubois CA, Paquette L, Landry V, Gauthier N, Beaulieu MD. Patient and family views of team functioning in primary healthcare teams with nurse practitioners: a survey of patient-reported experience and outcomes. BMC FAMILY PRACTICE 2021; 22:76. [PMID: 33866963 PMCID: PMC8054435 DOI: 10.1186/s12875-021-01406-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 03/07/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Nurse practitioners (NPs) have been added to primary healthcare teams to improve access to care. Team processes, including communication and decision-making, explicate how patients and families view team functioning. Yet, important gaps exist in our understanding of patient-reported experience and outcomes at the level of the healthcare team. We aimed to examine the influence of individual, team, and organizational characteristics, and role clarity on outcomes of care mediated by team processes in primary healthcare teams that include NPs. METHODS A cross-sectional survey across six sites representing practices with NPs in Québec, Canada, was conducted between March 2018 and April 2019 as part of a multiple-case study. Patients and families (n = 485; response rate: 53%) completed a validated questionnaire, which included a patient-reported experience measure (PREM) and a patient-reported outcome measure (PROM) of team functioning (Cronbach alpha: 0.771 (PROM) to 0.877 (PREM)). We performed logistic regression and mediation analyses to examine relationships between the individual, team, and organizational characteristics, role clarity, and outcomes of care mediated by team processes. RESULTS Patients and families expressed positive perceptions of team functioning (mean 4.97/6 [SD 0.68]) and outcomes of care (5.08/6 [0.74]). Also, high team processes (adjusted odds ratio [AOR] 14.92 [95% CI 8.11 to 27.44]) was a significant predictor of high outcomes of care. Role clarity (indirect effect coefficient ab = 6.48 [95% CI 3.79 to 9.56]), living in an urban area (-1.32 [-2.59 to -0.13]), patient as respondent (-1.43 [-2.80 to -0.14]), and income (1.73 [0.14 to 3.45]) were significant predictors of outcomes of care mediated by team processes. CONCLUSIONS This study provides key insights on how primary healthcare teams with NPs contribute to team functioning, using a validated instrument consistent with a conceptual framework. Results highlight that high role clarity, living in a non urban area, family as respondent, and adequate income were significant predictors of high outcomes of care mediated by high team processes. Additional research is needed to compare teams with and without NPs in different settings, to further explicate the relationships identified in our study.
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Affiliation(s)
- Kelley Kilpatrick
- Susan E. French Chair in Nursing Research and Innovative Practice, Ingram School of Nursing, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada.
| | - Eric Tchouaket
- Department of Nursing, Université du Québec en Outaouais (UQO), St-Jérôme Campus, Saint-Jérôme, Québec, Canada
| | - Nicolas Fernandez
- Centre for Pedagogy Applied to the Health Sciences, Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Mira Jabbour
- Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, Maisonneuve-Rosemont Hospital Site, Montréal, Québec, Canada
| | - Carl-Ardy Dubois
- Department of Management, Evaluation and Health Policy, School of Public Health, Université de Montréal, Montréal, Québec, Canada
| | - Lysane Paquette
- Faculty of Nursing, Université de Montréal, Montréal, Québec, Canada
| | - Véronique Landry
- Faculty of Nursing, Université de Montréal, Montréal, Québec, Canada
| | - Nathalie Gauthier
- Nursing and Physical Health Directorate, Centre intégré universitaire de santé et de services sociaux de La Capitale-Nationale, Québec, Québec, Canada
| | - Marie-Dominique Beaulieu
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
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Iriarte-Roteta A, Lopez-Dicastillo O, Mujika A, Ruiz-Zaldibar C, Hernantes N, Bermejo-Martins E, Pumar-Méndez MJ. Nurses' role in health promotion and prevention: A critical interpretive synthesis. J Clin Nurs 2020; 29:3937-3949. [PMID: 32757432 DOI: 10.1111/jocn.15441] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 07/30/2020] [Accepted: 07/31/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Role confusion is hampering the development of nurses' capacity for health promotion and prevention. Addressing this requires discussion to reach agreement among nurses, managers, co-workers, professional associations, academics and organisations about the nursing activities in this field. Forming a sound basis for this discussion is essential. AIMS AND OBJECTIVES To provide a description of the state of nursing health promotion and prevention practice expressed in terms of activities classifiable under the Ottawa Charter and to reveal the misalignments between this portrayal and the ideal one proposed by the Ottawa Charter. METHODS A critical interpretive synthesis was conducted between December 2018 and May 2019. The PubMed, CINAHL, Scopus, PsychINFO, Web of Science and Dialnet databases were searched. Sixty-two papers were identified. The relevant data were extracted using a pro-forma, and the reviewers performed an integrative synthesis. The ENTREQ reporting guidelines were used for this review. RESULTS Thirty synthetic constructs were developed into the following synthesising arguments: (a) addressing individuals' lifestyles versus developing their personal skills; (b) focusing on environmental hazards versus creating supportive environments; (c) action on families versus strengthening communities; (d) promoting community partnerships versus strengthening community action; and (e) influencing policies versus building healthy public policy. CONCLUSIONS There are notable misalignments between nurses' current practice in health promotion and prevention and the Ottawa Charter's actions and strategies. This may be explained by the nurses' lack of understanding of health promotion and prevention and political will, research methodological flaws, the predominance of a biomedical perspective within organisations and the lack of organisational prioritisation for health promotion and prevention.
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Affiliation(s)
| | - Olga Lopez-Dicastillo
- Department of Community, Maternity and Pediatric Nursing, School of Nursing, University of Navarra, Navarra, Spain.,IdiSNA, Navarra Institute for Health Research, Navarra, Spain
| | - Agurtzane Mujika
- Department of Community, Maternity and Pediatric Nursing, School of Nursing, University of Navarra, Navarra, Spain.,IdiSNA, Navarra Institute for Health Research, Navarra, Spain
| | | | - Naia Hernantes
- Department of Community, Maternity and Pediatric Nursing, School of Nursing, University of Navarra, Navarra, Spain
| | - Elena Bermejo-Martins
- Department of Community, Maternity and Pediatric Nursing, School of Nursing, University of Navarra, Navarra, Spain
| | - María J Pumar-Méndez
- Department of Community, Maternity and Pediatric Nursing, School of Nursing, University of Navarra, Navarra, Spain.,IdiSNA, Navarra Institute for Health Research, Navarra, Spain
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Sibbald S, Schouten K, Sedig K, Maskell R, Licskai C. Key characteristics and critical junctures for successful Interprofessional networks in healthcare - a case study. BMC Health Serv Res 2020; 20:700. [PMID: 32727464 PMCID: PMC7391486 DOI: 10.1186/s12913-020-05565-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 07/21/2020] [Indexed: 12/02/2022] Open
Abstract
Background The use of networks in healthcare has been steadily increasing over the past decade. Healthcare networks reduce fragmented care, support coordination amongst providers and patients, improve health system efficiencies, support better patient care and improve overall satisfaction of both patients and healthcare professionals. There has been little research to date on the implementation, development and use of small localized networks. This paper describes lessons learned from a successful small localized primary care network in Southwestern Ontario that developed and implemented a regional respiratory care program (The ARGI Respiratory Health Program - ARGI is a not-for-profit corporation leading the implementation and evaluation of a respiratory health program. Respiratory therapists (who have a certified respiratory educators designation), care for patients from all seven of the network’s FHTs. Patients rostered within the network of FHTs that have been diagnosed with a chronic respiratory disease are referred by their family physicians to the program. The RTs are integrated into the FHTs, and work in a triad along with patients and providers to educate and empower patients in self-management techniques, create exacerbation action plans, and act as a liaison between the patient’s care providers. ARGI uses an eTool designed specifically for use by the network to assist care delivery, choosing education topics, and outcome tracking. RTs are hired by ARGI and are contracted to the participating FHTs in the network.). Methods This study used an exploratory case study approach. Data from four participant groups was collected using focus groups, observations, interviews and document analysis to develop a rich understanding of the multiple perspectives associated with the network. Results This network’s success can be described by four characteristics (growth mindset and quality improvement focus; clear team roles that are strengths-based; shared leadership, shared success; and transparent communication); and five critical junctures (acknowledge a shared need; create a common vision that is flexible and adaptable depending on the context; facilitate empowerment; receive external validation; and demonstrate the impacts and success of their work). Conclusions Networks are used in healthcare to act as integrative, interdisciplinary tools to connect individuals with the aim of improving processes and outcomes. We have identified four general lessons to be learned from a successful small and localized network: importance of clear, flexible, and strengths-based roles; need for shared goals and vision; value of team support and empowerment; and commitment to feedback and evaluations. Insight from this study can be used to support the development and successful implementation of other similar locally developed networks.
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Affiliation(s)
- Shannon Sibbald
- Faculty of Health Sciences, Western University, 1151 Richmond Street, London, Ontario, N6A 3K7, Canada. .,Schulich School of Medicine and Dentistry, Western University, 1151 Richmond Street, London, Ontario, N6A 3K7, Canada. .,Western Center for Public Health and Family Medicine, 1465 Richmond Street, London, Ontario, N6G 2M1, Canada.
| | - Karen Schouten
- Faculty of Health Sciences, Western University, 1151 Richmond Street, London, Ontario, N6A 3K7, Canada
| | - Kimia Sedig
- Faculty of Health Sciences, Western University, 1151 Richmond Street, London, Ontario, N6A 3K7, Canada
| | - Rachelle Maskell
- Faculty of Health Sciences, Western University, 1151 Richmond Street, London, Ontario, N6A 3K7, Canada
| | - Christopher Licskai
- Schulich School of Medicine and Dentistry, Western University, 1151 Richmond Street, London, Ontario, N6A 3K7, Canada
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Kilpatrick K, Paquette L, Jabbour M, Tchouaket E, Fernandez N, Al Hakim G, Landry V, Gauthier N, Beaulieu MD, Dubois CA. Systematic review of the characteristics of brief team interventions to clarify roles and improve functioning in healthcare teams. PLoS One 2020; 15:e0234416. [PMID: 32520943 PMCID: PMC7286504 DOI: 10.1371/journal.pone.0234416] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/25/2020] [Indexed: 11/18/2022] Open
Abstract
AIM Describe brief (less than half a day) interventions aimed at improving healthcare team functioning. METHODS A systematic review on brief team interventions aimed at role clarification and team functioning (PROSPERO Registration Number: CRD42018088922). Experimental or quasi-experimental studies were included. Database searches included CINAHL, Medline, EMBASE, PUBMED, Cochrane, RCT Registry-1990 to April 2020 and grey literature. Articles were screened independently by teams of two reviewers. Risk of bias was assessed. Data from the retained articles were extracted by one reviewer and checked by a second reviewer independently. A narrative synthesis was undertaken. RESULTS Searches yielded 1928 unique records. Final sample contained twenty papers describing 19 studies, published between 2009 and 2020. Studies described brief training interventions conducted in acute care in-patient settings and included a total of 6338 participants. Participants' socio-demographic information was not routinely reported. Studies met between two to six of the eight risk of bias criteria. Interventions included simulations for technical skills, structured communications and speaking up for non-technical skills and debriefing. Debriefing sessions generally lasted between five to 10 minutes. Debriefing sessions reflected key content areas but it was not always possible to determine the influence of the debriefing session on participants' learning because of the limited information reported. DISCUSSION Interest in short team interventions is recent. Single two-hour sessions appear to improve technical skills. Three to four 30- to 60-minute training sessions spread out over several weeks with structured facilitation and debriefing appear to improve non-technical skills. Monthly meetings appear to sustain change over time. CONCLUSION Short team interventions show promise to improve team functioning. Effectiveness of interventions in primary care and the inclusion of patients and families needs to be examined. Primary care teams are structured differently than teams in acute care and they may have different priorities.
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Affiliation(s)
- Kelley Kilpatrick
- Susan E. French Chair in Nursing Research and Innovative Practice, Ingram School of Nursing, Faculty of Medicine, McGill University, Montréal, Québec, Canada
- Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal-Hôpital Maisonneuve-Rosemont (CIUSSS-EMTL-HMR), Montréal, Québec, Canada
| | - Lysane Paquette
- Faculty of Nursing, Université de Montréal, Montréal, Québec, Canada
| | - Mira Jabbour
- Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal-Hôpital Maisonneuve-Rosemont (CIUSSS-EMTL-HMR), Montréal, Québec, Canada
| | - Eric Tchouaket
- Department of Nursing, Université du Québec en Outaouais, Saint-Jérôme, Québec, Canada
| | - Nicolas Fernandez
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Grace Al Hakim
- Clinical and Professional Development Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Véronique Landry
- Faculty of Nursing, Université de Montréal, Montréal, Québec, Canada
| | - Nathalie Gauthier
- Nursing and Physical Health Directorate, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, Québec, Canada
| | | | - Carl-Ardy Dubois
- Department of Management, Evaluation and Health Policy, School of Public Health, Université de Montréal, Montréal, Québec, Canada
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15
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Hu Y, Broome M. Interprofessional collaborative team development in china: A grounded theory study. J Nurs Manag 2019; 27:1075-1083. [PMID: 30951214 DOI: 10.1111/jonm.12775] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 03/02/2019] [Accepted: 03/31/2019] [Indexed: 11/28/2022]
Abstract
AIMS To generate a theory of interprofessional collaborative team development in China. BACKGROUND Interprofessional collaborative practice is an important approach to improve the patient-centred care. METHODS Theoretical sampling was used to recruit individuals who had collaboration experiences. They each participated in face-to-face interviews lasting 40-60 min. Major categories describing the team development process for collaboration were extracted according to the grounded theory methodology. FINDINGS The interprofessional collaborative team development was guided by a common purpose-"patient-centredness." Three stages involved in team development were identified: exploration, integration and continuous adjustment. Various strategies described for each stage are required to move successfully through the process. CONCLUSION Interprofessional team development is a dynamic process with three primary stages. The culture in which a teamworks is reflected in each stage of team development and collaboration. IMPLICATIONS FOR NURSING MANAGEMENT Understanding interprofessional collaborative team development and the strategies required will help nurse managers to better design interprofessional teamwork opportunities and provide necessary support to achieve the effective interprofessional collaborative practice.
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Affiliation(s)
- Yun Hu
- School of Nursing, Shanghai Jiao Tong University, Shanghai, China
| | - Marion Broome
- School of Nursing, Duke University, Durham, North Carolina
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