Interprofessional communication failures in acute care chains: How can we identify the causes?

Beyond empathy training for practitioners: Cultivating empathic healthcare systems and leadership

Empathic care benefits patients and practitioners, and empathy training for practitioners can enhance empathy. However, practitioners do not operate in a vacuum. For empathy to thrive, healthcare consultations must be situated in a nurturing milieu, guided by empathic, compassionate leaders. Empathy will be suppressed, or even reversed if practitioners are burned out and working in an unpleasant, under-resourced environment with increasingly poorly served and dissatisfied patients. Efforts to enhance empathy must therefore go beyond training practitioners to address system-level factors that foster empathy. These include patient education, cultivating empathic leadership, customer service training for reception staff, valuing cleaning and all ancillary staff, creating healing spaces, and using appropriate, efficiency saving technology to reduce the administrative burden on healthcare practitioners. We divide these elements into environmental factors, organisational factors, job factors, and individual characteristics.

"It is great what we have learned from each other!" - Bedside teaching in interprofessional small groups using the example of Parkinson's disease

Background

While patient care often involves interprofessional collaboration, interprofessional teaching formats with participants from medical and physiotherapy fields are still rare. Furthermore, interprofessional education often takes place as separate courses and is not integrated into the clinical curriculum. Therefore, the goal of this project was to develop and implement interprofessional content into bedside teaching.

Course development

The clinical subject of the course was "Parkinson's disease", as this condition allowed for the exemplary demonstration of interprofessional teamwork and different competencies. Through interprofessional bedside teaching and a specific clinical context, interprofessionalism was intended to be integrated and experienced as natural part of clinical practice. The bedside teaching was complemented with work in break-out groups and a lecture.

Evaluation

The course was first conducted in the winter semester 2021/22. Participants were medical and physiotherapy students. Teaching teams were also interprofessional. A concurrent evaluation was carried out using the University of the West of England Interprofessional Questionnaire (UWE-IP) before and after course participation. UWE-IP scores in all sub-scales indicated a positive attitude, except for the "Interprofessional Learning" scale among physiotherapy students, which reflected a neutral attitude. Significant group differences were observed in the same scale at the pre-course time point between medical and physiotherapy students (p<0.01) and among medical students before and after course participation (p=0.02).

Conclusion

The course proved to be well-suited for integrating interprofessional content into clinical education and can serve as a model for future teaching units. The evaluation reflected a positive attitude toward interprofessional learning.

How and why might interprofessional patient- and family-centered rounds improve outcomes among healthcare teams and hospitalized patients? A conceptual framework informed by scoping and narrative literature review methods

Poor communication within healthcare contributes to inefficiencies, medical errors, conflict, and other adverse outcomes. A promising model to improve outcomes resulting from poor communication in the inpatient hospital setting is Interprofessional Patient- and Family-Centered rounds (IPFCR). IPFCR brings two or more health professions together with hospitalized patients and families as part of a consistent, team-based routine to share information and collaboratively arrive at a daily plan of care. A growing body of literature focuses on implementation and outcomes of IPFCR to improve healthcare quality and team and patient outcomes. Most studies report positive changes following IPFCR implementation. However, conceptual frameworks and theoretical models are lacking in the IPFCR literature and represent a major gap that needs to be addressed to move this field forward. The purpose of this two-part review is to propose a conceptual framework of how IPFCR works. The goal is to articulate a framework that can be tested in subsequent research studies. Published IPFCR literature and relevant theories and frameworks were examined and synthesized to explore how IPFCR works, to situate IPFCR in relation to existing models and frameworks, and to postulate core components and underlying causal mechanisms. A preliminary, context-specific, conceptual framework is proposed illustrating interrelationships between four core components of IPFCR (interprofessional approach, intentional patient and family engagement, rounding structure, shared development of a daily care plan), improvements in communication, and better outcomes.

Development of individual competencies and team performance in interprofessional ward rounds: results of a study with multimodal observations at the Heidelberg Interprofessional Training Ward

Introduction

Interprofessional training wards (IPTW) aim to improve undergraduates' interprofessional collaborative practice of care. Little is known about the effects of the different team tasks on IPTW as measured by external assessment. In Heidelberg, Germany, four nursing and four medical undergraduates (= one cohort) care for up to six patients undergoing general surgery during a four-week placement. They learn both professionally and interprofessionally, working largely on their own responsibility under the supervision of the medical and nursing learning facilitators. Interprofessional ward rounds are a central component of developing individual competencies and team performance. The aim of this study was to evaluate individual competencies and team performance shown in ward rounds.

Methods

Observations took place in four cohorts of four nursing and four medical undergraduates each. Undergraduates in one cohort were divided into two teams, which rotated in morning and afternoon shifts. Team 1 was on morning shift during the first (t0) and third (t1) weeks of the IPTW placement, and Team 2 was on morning shift during the second (t0) and fourth (t1) weeks. Within each team, a tandem of one nursing and one medical undergraduate cared for a patient room with three patients. Ward round observations took place with each team and tandem at t0 and t1 using the IP-VITA instrument for individual competencies (16 items) and team performance (11 items). Four hypotheses were formulated for statistical testing with linear mixed models and correlations.

Results

A total of 16 nursing and medical undergraduates each were included. There were significant changes in mean values between t0 and t1 in individual competencies (Hypothesis 1). They were statistically significant for all three sum scores: "Roles and Responsibilities", Patient-Centeredness", and "Leadership". In terms of team performance (Hypothesis 2), there was a statistically significant change in mean values in the sum score "Roles and Responsibilities" and positive trends in the sum scores "Patient-Centeredness" and "Decision-Making/Collaborative Clinical Reasoning". Analysis of differences in the development of individual competencies in the groups of nursing and medical undergraduates (Hypothesis 3) showed more significant differences in the mean values of the two groups in t0 than in t1. There were significant correlations between individual competencies and team performance at both t0 and t1 (Hypothesis 4).

Discussion

The study has limitations due to the small sample and some sources of bias related to the external assessment by means of observation. Nevertheless, this study offers insights into interprofessional tasks on the IPTW from an external assessment. Results from quantitative and qualitative analysis of learners self-assessment are confirmed in terms of roles and responsibilities and patient-centeredness. It has been observed that medical undergraduates acquired and applied skills in collaborative clinic reasoning and decision-making, whereas nursing undergraduates acquired leadership skills. Within the study sample, only a small group of tandems remained constant over time. In team performance, the group of constant tandems tended to perform better than the group of random tandems. The aim of IPTW should be to prepare healthcare team members for the challenge of changing teams. Therefore, implications for IPTW implementation could be to develop learning support approaches that allow medical and nursing undergraduates to bring interprofessional competencies to team performance, independent of the tandem partner or team.

Measuring the determinants of implementation behavior in multiprofessional rehabilitation

BACKGROUND

The Determinants of Implementation Behavior Questionnaire (DIBQ) measures facilitators or barriers of healthcare professionals' implementation behaviors based on the current implementation research on practice and policy. The DIBQ covers 18 domains of the Theoretical Domains Framework and consists of 93 items. A previously tailored version (DIBQ-t) covering 10 domains and 28 items focuses on implementing best-practice low back pain care.

AIM

To tailor a shortened version of DIBQ to multiprofessional rehabilitation context with cross-cultural adaptation to Finnish language.

DESIGN

A two-round Delphi study.

SETTING

National-level online survey.

POPULATION

Purposively recruited experts in multiprofessional rehabilitation (N.=25).

METHODS

Cross-cultural translation of DIBQ to Finnish was followed by a two-round Delphi survey involving diverse experts in rehabilitation (physicians, physiotherapists, occupational therapists, psychologists, nursing scientists, social scientists). In total, 25 experts in Round 1, and 21 in Round 2 evaluated the importance of DIBQ items in changing professionals' implementation behavior by rating on a 5-point Likert Scale (1 = Strongly Disagree, 5 = Strongly Agree) of including each item in the final scale. Consensus to include an item was defined as a mean score of ≥4 by ≥75% of Delphi participants. Open comments were analyzed using inductive content analysis. Items with agreement of ≤74% were either directly excluded or reconsidered and modified depending on qualitative judgements, amended with experts' suggestions. After completing an analogous second-round, a comparison with DIBQ-t was performed. Lastly, the relevance of each item was indexed using content validity index on item-level (I-CVI) and scale-level (S-CVI/Ave).

RESULTS

After Round 1, 17 items were included and 48 excluded by consensus whereas 28 items were reconsidered, and 20 items added for Round 2. The open comments were categorized as: 1) "modifying"; 2) "supportive"; and 3) "critical". After Round 2, consensus was reached regarding all items, to include 21 items. After comparison with DIBQ-t, the final multiprofessional DIBQ (DIBQ-mp) covers 11 TDF domains and 21 items with I-CVIs of ≥0.78 and S-CVI/Ave of 0.93.

CONCLUSIONS

A Delphi study condensed a DIBQ-mp with excellent content validity for multiprofessional rehabilitation context.

CLINICAL REHABILITATION IMPACT

A potential tool for evaluating determinants in implementing evidence-based multiprofessional rehabilitation interventions.

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

BACKGROUND

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

METHOD

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

RESULTS

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

DISCUSSION

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

[Patient handover from anaesthesia to postanaesthesia unit: An analysis of the current situation in three Swiss hospitals]

Patient handover from anaesthesia to postanaesthesia unit: An analysis of the current situation in three Swiss hospitals Abstract: Background: Patient handovers carry a risk of inadequate or missing communication of important information that can jeopardize patient safety. To increase patient safety, protocols for processes and contents of a structured patient handover were created. Aim: To assess the current status of patient handovers from anaesthesia staff to recovery room nurses. Method: After a literature search an observation protocol for patient handovers according to the SBAR concept (von Dossow & Zwißler, 2016) was developed. Using this checklist, non-participant observations were conducted in three Swiss hospitals and evaluated with statistical analysis. Results: A total of 98 observations were made. The report receiving person felt integrated into the handover and received the necessary information. Deficiencies in patient identification and a joint control of lines after surgical interventions could be identified. The subjectively rated quality of patient handover did not differ between the three hospitals (X²(2)=,927, p=,629) and also not according to the time of day (X²(2)=3,604, p=,216). There was also no difference between the subjective quality of the handover and the delivering professional group (X²(3)=4,507, p=,212). Conclusions: The subjective quality of patient handover did not differ between the three hospitals. However, the patient handover protocols need to be adapted to ensure that patient identification and a joint assessment including control of lines and drains are performed.

Exploring Norwegian prison frontline workers' perceptions of inter professional collaboration - a pilot study

PURPOSE

Interprofessional collaboration is necessary for handling the complex psychosocial needs of prisoners. This collaboration must be addressed to avoid high recidivism rates and the human and societal costs linked to them. Challenges are exacerbated by a linear approach to handling prisoners' problems, silo working between welfare agencies and professional boundaries between frontline workers. There are few adequate theoretical frameworks and tools to address these challenges in the prison context. The purpose of this study is to explore the perceptions that frontline staff working in Norwegian prison facilities have regarding interprofessional collaboration in providing mental health services for prisoners.

DESIGN/METHODOLOGY/APPROACH

This study had a non-experimental, cross-sectional design to explore perceptions of interprofessional collaboration in a prison context. Descriptive and multifactorial analyses (exploratory factor analysis and confirmatory factor analysis) were used to explore the data.

FINDINGS

The analysis showed that three factors, communication, organizational culture and domain, explained 95% of the variance. Results are discussed using relational coordination, as well as the conceptual PINCOM model, as a theoretical framework.

ORIGINALITY/VALUE

Few studies explicitly explore collaboration between professionals in mental health and prison services despite its being a prerequisite to achieving sufficient services for prisoners. To our knowledge, this current study is one of the first in Norway to explore collaboration in a prison context by analysing quantitative data and focusing on frontline workers perception of the phenomenon.

Clinical outcomes of patients treated on the Heidelberg interprofessional training ward vs. care on a conventional surgical ward: A retrospective cohort study

Interprofessional training wards (IPTW) are a form of interprofessional education enabling trainees of different healthcare professions to work together in teams. Concerns about patient safety are a major barrier to the implementation of IPTWs. The objective of this retrospective study was to analyze patient relevant clinical outcomes on Germany's first IPTW (Heidelberger Interprofessionelle Ausbildungsstation; HIPSTA) in the Department of Surgery at University Hospital Heidelberg in comparison to a conventional surgical ward (CSW). The setting is a large tertiary care center with a focus on major oncological surgery. The endpoints were postoperative complications according to the Dindo-Clavien Classification and a set of patient-safety outcomes. In total, 232 patients treated on HIPSTA were retrospectively compared with 465 patients on a CSW. Baseline characteristics were comparable between groups. No significant difference between rate or severity of overall postoperative complications was observed. In-hospital mortality did not significantly differ between groups. However, the mean length of hospital stay was significantly shorter on HIPSTA. Furthermore, HIPSTA patients had less frequent reoperations. Patient safety in surgical IPTW was not compromised in comparison to a CSW, and there were some areas where significantly better outcomes were identified.

The NUPHAC-EU Framework for Nurses' Role in Interprofessional Pharmaceutical Care: Cross-Sectional Evaluation in Europe

Clear role descriptions promote the quality of interprofessional collaboration. Currently, it is unclear to what extent healthcare professionals consider pharmaceutical care (PC) activities to be nurses’ responsibility in order to obtain best care quality. This study aimed to create and evaluate a framework describing potential nursing tasks in PC and to investigate nurses’ level of responsibility. A framework of PC tasks and contextual factors was developed based on literature review and previous DeMoPhaC project results. Tasks and context were cross-sectionally evaluated using an online survey in 14 European countries. A total of 923 nurses, 240 physicians and 199 pharmacists responded. The majority would consider nurses responsible for tasks within: medication self-management (86–97%), patient education (85–96%), medication safety (83–95%), monitoring adherence (82–97%), care coordination (82–95%), and drug monitoring (78–96%). The most prevalent level of responsibility was ‘with shared responsibility’. Prescription management tasks were considered to be nurses’ responsibility by 48–81% of the professionals. All contextual factors were indicated as being relevant for nurses’ role in PC by at least 74% of the participants. No task nor contextual factor was removed from the framework after evaluation. This framework can be used to enable healthcare professionals to openly discuss allocation of specific (shared) responsibilities and tasks.

Nurse/Resident Reciprocal Shadowing to Improve Interprofessional Communication

OBJECTIVES

Poor communication is a major contributor to sentinel events in hospitals. Suboptimal communication between physicians and nurses may be due to poor understanding of team members' roles. We sought to evaluate the impact of a shadowing experience on nurse-resident interprofessional collaboration, bidirectional communication, and role perceptions.

METHODS

This mixed-methods study took place at 2 large academic children's hospitals with pediatric residency programs during the 2018-2019 academic year. First-year residents and nurses participated in a reciprocal, structured 4-hour shadowing experience. Participants were surveyed before, immediately after, and 6 months after their shadowing experience by using an anonymous web-based platform containing the 20-item Interprofessional Collaborative Competency Attainment Survey, as well as open-ended qualitative questions. Quantitative data were analyzed via linear mixed models. Qualitative data were thematically analyzed.

RESULTS

Participants included 33 nurses and 53 residents from the 2 study sites. The immediate postshadowing survey results revealed statistically significant improvements in 12 Interprofessional Collaborative Competency Attainment Survey question responses for nurses and 19 for residents (P ≤ .01). Subsequently, 6 questions for nurses and 17 for residents revealed sustained improvements 6 months after the intervention. Qualitative analysis identified 5 major themes related to optimal nurse-resident engagement: effective communication, collaboration, role understanding, team process, and patient-centered.

CONCLUSIONS

The reciprocal shadowing experience was associated with an increase in participant understanding of contributions from all interprofessional team members. This improved awareness may improve patient care. Future work may be conducted to assess the impact of spread to different clinical areas and elucidate patient outcomes that may be associated with this intervention.

A Handoffs Software Led to Fewer Errors of Omission and Better Provider Satisfaction: A Randomized Control Trial

BACKGROUND

Computer-assisted communication is shown to prevent critical omissions ("errors") in the handoff process.

OBJECTIVE

The aim of the study was to study this effect and related provider satisfaction, using a standardized software.

METHODS

Fourteen internal medicine house officers staffed 6 days and 1 cross-covering teams were randomized to either the intervention group or control, employing usual handoff, so that handoff information was exchanged only between same-group subjects (daily, for 28 days).

RESULTS

In the intervention group, fewer omissions (among those studied) occurred intravenous access (17 versus 422, P < 0.001), code status (1 versus 158, P < 0.001), diet/nothing per mouth (28 versus 477, P < 0.001), and deep venous thrombosis prophylaxis (17 versus 284, P < 0.001); duration to compose handoff was similar; and physicians perceived less workload adjusted for patient census and provider characteristics (P = 0.004) as well as better handoff quality (P < 0.001) and clarity (P < 0.001).

CONCLUSIONS

The intervention was associated with fewer errors and superior provider satisfaction.

The viability of interprofessional entrustable professional activities

Interprofessional education (IPE) and entrustable professional activities (EPAs) represent two topics in health professions education that have attracted significant attention in recent years. IPE (when different health professionals learn with, from and about each other with the aim of optimal care) has an inherent focus on the collective. EPAs (units of professional practice that can be fully entrusted to a trainee, once he or she has demonstrated the necessary competence to execute this activity unsupervised) have a focus on the individual. Attempts to relate the two may cause friction and the question is: can they be reconciled? Are interprofessional EPAs or team-EPAs useful concepts and if so what should they look like? The authors argue that most work in modern healthcare involves interprofessional collaboration. Some EPAs have an inherent strong interprofessional nature, such as emergency teamwork, running multidisciplinary team meetings, and surgery. Other EPAs are less inherently dependent on interprofessional collaboration. The authors conclude that neither interprofessional team-EPAs (for which a team can or should be certified), nor IP-EPAs for individuals, as opposed to other EPAs, are viable concepts. However, the authors do not question that certifying health care professionals and entrusting trainees with most clinical tasks will require to ascertain their competence in interprofessional collaboration. This must be included when assessing learners for most EPAs and making entrustment decisions. This can help to strengthen interprofessional competence in the clinical workplace.

Patient involvement in interprofessional education: A qualitative study yielding recommendations on incorporating the patient's perspective

BACKGROUND

Patient involvement in interprofessional education (IPE) is a new approach in fostering person-centeredness and collaborative competencies in undergraduate students. We developed the Patient As a Person (PAP-)module to facilitate students in learning from experts by experience (EBEs) living with chronic conditions, in an interprofessional setting. This study aimed to explore the experiences of undergraduate students, EBEs and facilitators with the PAP-module and formulate recommendations on the design and organization of patient involvement in IPE.

METHODS

We collected data from students, EBEs and facilitators, through eight semi-structured focus group interviews and two individual interviews (N = 51). The interviews took place at Maastricht University, Zuyd University of Applied Sciences and Regional Training Center Leeuwenborgh. Conventional content analysis revealed key themes.

RESULTS

Students reported that learning from EBEs in an interprofessional setting yielded a more comprehensive approach and made them empathize with EBEs. Facilitators found it challenging to address multiple demands from students from different backgrounds and diverse EBEs. EBEs were motivated to improve the person-centredness of health care and welcomed a renewed sense of purpose.

CONCLUSIONS

This study yielded six recommendations: (a) students from various disciplines visit an EBE to foster a comprehensive approach, (b) groups of at least two students visit EBEs, (c) students may need aftercare for which facilitators should be receptive, (d) EBEs need clear instruction on their roles, (e) multiple EBEs in one session create diversity in perspectives and (f) training programmes and peer-to-peer sessions for facilitators help them to interact with diverse students and EBEs.

The association between nurse staffing levels and a failure to respond to patients with deranged physiology: A retrospective observational study in the UK

BACKGROUND

Responding to abnormalities in patients' vital signs is a fundamental aspect of nursing. However, failure to respond to patient deterioration is common and often leads to adverse patient outcomes. This study aimed to determine the association between Registered Nurse (RN) and Nursing Assistant (NA) staffing levels and the failure to respond promptly to patients' abnormal physiology.

METHODS

This retrospective, observational study used routinely collected patients' vital signs and administrative data, including nursing staffing, from 32 general wards of an acute hospital in England between April 2012 and March 2015. Mixed-effects binomial regression was used to model the relationship between nurse staffing, measured as 'Hours per Patient Day' (HPPD), and a composite primary outcome representing failure to respond for patients with National Early Warning Score (NEWS) values ≥ 6 and ≥ 7.

RESULTS

There were 189,123 NEWS values ≥ 6 and 114,504 NEWS values ≥ 7, affecting 28,098 patients. For patients with NEWS values ≥ 7, failure to respond was significantly associated with levels of RN HPPD ((IRR 0.98, 95% CI 0.96-0.99, p = 0.0001) but not NA HPPD (((IRR 0.99, 95%CI 0.96-1.01, p = 0.238). For patients with NEWS values ≥ 6, no such relationship existed.

CONCLUSIONS

RN, but not NA, staffing levels influence the rates of failure to respond for patients with the most abnormal vital signs (NEWS values ≥ 7). These findings offer a possible explanation for the increasingly reported association between low RN staffing and an increased risk of patient death during a hospital admission.

Lack of focus on nutrition and documentation in nursing homes, home care- and home nursing: the self-perceived views of the primary care workforce

Background

Malnutrition is a comprehensive challenge for the nursing home, home care- and home nursing sector. Nutritional care and the subsequent documentation are a common and multifaceted healthcare practice that requires that the healthcare professionals possess complex combinations of competencies in order to deliver high-quality care and treatment. The purpose of this study was to investigate how a varied group of healthcare professionals’ perceive their own competencies within nutrition and documentation and how organizational structures influence their daily work and the quality of care provided.

Methods

Two focus groups consisting of 14 healthcare professionals were conducted. The transcribed focus group interviews was analyzed using the qualitative content analysis approach.

Results

Six categories were identified: 1) Lack of uniform and systematic communication affect nutritional care practices 2) Experience-based knowledge among the primary workforce influences daily clinical decisions, 3) Different attitudes towards nutritional care lead to differences in the quality of care 4) Differences in organizational culture affect quality of care, 5) Lack of clear nutritional care responsibilities affect how daily care is performed and 6) Lack of clinical leadership and priorities makes nutritional care invisible.

Conclusions

The six categories revealed two explanatory themes: 1) Absent inter- and intra-professional collaboration and communication obstructs optimal clinical decision-making and 2) quality deterioration due to poorly-established nutritional care structure. Overall, the two themes explain that from the healthcare professionals’ point of view, a visible organization that allocates resources as well as prioritizing and articulating the need for daily nutritional care and documentation is a prerequisite for high-quality care and treatment. Furthermore, optimal clinical decision making among the healthcare professionals are compromised by imprecise and unclear language and terminology in the patients’ healthcare records and also a lack of clinical guidelines and standards for collaboration between different healthcare professionals working in nursing homes, home care or home nursing.

The findings of this study are beneficial to support organizations within these settings with strategies focusing on increasing nutritional care and documentation competencies among the healthcare professionals. Furthermore, the results advocate for the daily involvement and support of leaders and managers in articulating and structuring the importance of nutritional care and treatment and the subsequent documentation.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4450-1) contains supplementary material, which is available to authorized users.

Using Incident Reports to Assess Communication Failures and Patient Outcomes

INTRODUCTION

Communication failures pose a significant threat to the quality of care and safety of hospitalized patients. Yet little is known about the nature of communication failures. The aims of this study were to identify and describe types of communication failures in which nurses and physicians were involved and determine how different types of communication failures might affect patient outcomes.

METHODS

Incident reports filed during fiscal year 2015-2016 at a Midwestern academic health care system (N = 16,165) were electronically filtered and manually reviewed to identify reports that described communication failures involving nurses and physicians (n = 161). Failures were categorized by type using two classification systems: contextual and conceptual. Thematic analysis was used to identify patient outcomes: actual or potential harm, patient dissatisfaction, delay in care, or no harm. Frequency of failure types and outcomes were assessed using descriptive statistics. Associations between failure type and patient outcomes were evaluated using Fisher's exact test.

RESULTS

Of the 211 identified contextual communication failures, errors of omission were the most common (27.0%). More than half of conceptual failures were transfer of information failures (58.4%), while 41.6% demonstrated a lack of shared understanding. Of the 179 identified outcomes, 38.0% were delays in care, 20.1% were physical harm, and 8.9% were dissatisfaction. There was no statistically significant association between failure type category and patient outcomes.

CONCLUSION

It was found that incident reports could identify specific types of communication failures and patient outcomes. This work provides a basis for future intervention development to prevent communication-related adverse events by tailoring interventions to specific types of failures.

Examining perceptions from in situ simulation-based training on interprofessional collaboration during crisis event management in post-anesthesia care

Due to the potentially life-threatening conditions and risk of severe complications, post-anesthesia care units (PACU) require prompt team interventions. Miscommunication among professionals during crisis event management may directly affect patient safety. Therefore, developing strategies to enhance interprofessional collaboration (IPC) among critical care teams should be prioritized. In situ simulation (ISS) can be valuable in improving patient safety because it allows the practice of care team dynamics within a real clinical environment. However, its impact on IPC has yet to be demonstrated. The aim of this study was to evaluate the effect of in situ simulation-based training on interprofessional collaboration and satisfaction toward co-workers during crisis event management in post-anesthesia care. A quasi-experimental study, pretest and post-test design with a paired control group was performed. A convenience sample (N = 69) was recruited from the healthcare professionals of the regular PACU team. The intervention group (N = 33) underwent a 6-hour ISS-based interprofessional training session. Three scenarios of deteriorating cases encountered in critical care settings were used, each followed by a debriefing period. The measured outcomes were evaluated by the Collaborative Work Questionnaire and the Satisfaction Towards Coworkers Questionnaire. Questionnaires were answered by the two groups before the intervention (T1), immediately after (T2) and six to eight weeks later (T3). We found that the change from baseline (T1) was different between the groups for global IPC (F = 3.88; p = 0.025) and for communication (F = 4.09; p = 0.021). Regarding global IPC, we observed a significant group effect from T1 to T2 (F = 5.65; p = 0.021) and from T1 to T3 (F = 5.34; p = 0.024). Furthermore, we observed a significant time effect for the experimental group (F = 4.06; p = 0.027). Regarding communication, we observed a significant group effect from T1 to T2 (F = 7.5; p = 0.001). In conclusion, ISS-based training had a slight impact on self-assessed IPC and communication during crisis event management in the PACU. The use of ISS should be promoted among critical care teams to enhance IPC and contribute to patient safety.

Heidelberger Interprofessionelle Ausbildungsstation (HIPSTA): a practice- and theory-guided approach to development and implementation of Germany's first interprofessional training ward

Background: Deficits in care and impaired patient-safety have been linked to inefficient interprofessional collaborative practice. Interprofessional training wards (IPTW) are an interprofessional educational intervention which aim to enable students and trainees from different health professions to work self-responsibly in order to manage the medical treatment and rehabilitation of real-life patients together as an interprofessional team. We aimed to develop and implement Germany´s first IPTW at the department of Surgery at Heidelberg University Hospital. Methods: The Kern cycle was used to develop an ITPW curriculum. Practical as well as theoretical considerations guided the design of the IPTW. Common project management tools including blueprinting and RASCI (Responsibility, Approval, Support, Consultation, Information) matrix were applied. Results: Since April 2017, 7 cohorts of students and trainees have had four-week long placements on HIPSTA. They run the IPTW in early and late shifts. Nursing and medical facilitators are supporting the IP team as needed. Learning objectives are operationalized as EPAs (entrustable professional activities) and interprofessional learning goals. Since initiation only minor modifications to the curriculum have been necessary and satisfaction of students/trainees, facilitators and patients is high. Conclusion: IPTWs can be established and run in the German health care system even in a complex clinical setting. The early involvement of all professions in a steering group seems to be key to success. Nursing and medical facilitators are of utmost importance for daily routine. The experiences outlined here could help others aiming to implement IPTWs at their sites. IPTWs might address a number of hitherto unaddressed educational needs. Trial registration: Not applicable.

Interprofessional collaboration to improve professional practice and healthcare outcomes

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The Patient Care Paradox: An Interprofessional Qualitative Study of Agitated Patient Care in the Emergency Department

OBJECTIVES

The emergency department (ED) has been recognized as a high-risk environment for workplace violence. Acutely agitated patients who perpetrate violence against healthcare workers represent a complex care challenge in the ED. Recommendations to improve safety are often based on expert opinion rather than empirical data. In this study we aim to describe the lived experience of staff members caring for this population to provide a broad perspective of ED patient violence. The findings of this study will contribute to the development of a comprehensive framework for ED agitated patient care that will guide safety interventions.

METHODS

We conducted uniprofessional focus groups and individual interviews using a phenomenologic approach with emergency medicine resident physicians, ED staff nurses, patient care technicians, and hospital police officers at an urban hospital in New York City. Audio recordings were transcribed and coded for thematic analysis using the constant comparison method.

RESULTS

We reached theoretical saturation with 31 interprofessional participants. Three broad themes emerged from our analysis: 1) ED healthcare workers provide high-quality care to a marginalized patient population that concurrently poses safety threats, creating a patient care paradox; 2) teamwork is critical to safely managing this population, but hierarchy and professional silos hinder coordinated care between healthcare professionals; and 3) environmental challenges and systems issues both in and outside the ED exacerbate threats to safety.

CONCLUSION

The experience of ED staff members while caring for agitated patients is complex and multidimensional. We identified issues that coalesced into four tiers of healthcare delivery at the individual, team, environment, and system levels. Future research is needed to determine applicability of our findings across institutions to build a comprehensive framework for ED agitated patient care.

Improving the governance of patient safety in emergency care: a systematic review of interventions

OBJECTIVES

To systematically review interventions that aim to improve the governance of patient safety within emergency care on effectiveness, reliability, validity and feasibility.

DESIGN

A systematic review of the literature.

METHODS

PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Database of Systematic Reviews and PsychInfo were searched for studies published between January 1990 and July 2014. We included studies evaluating interventions relevant for higher management to oversee and manage patient safety, in prehospital emergency medical service (EMS) organisations and hospital-based emergency departments (EDs). Two reviewers independently selected candidate studies, extracted data and assessed study quality. Studies were categorised according to study quality, setting, sample, intervention characteristics and findings.

RESULTS

Of the 18 included studies, 13 (72%) were non-experimental. Nine studies (50%) reported data on the reliability and/or validity of the intervention. Eight studies (44%) reported on the feasibility of the intervention. Only 4 studies (22%) reported statistically significant effects. The use of a simulation-based training programme and well-designed incident reporting systems led to a statistically significant improvement of safety knowledge and attitudes by ED staff and an increase of incident reports within EDs, respectively.

CONCLUSIONS

Characteristics of the interventions included in this review (eg, anonymous incident reporting and validation of incident reports by an independent party) could provide useful input for the design of an effective tool to govern patient safety in EMS organisations and EDs. However, executives cannot rely on a robust set of evidence-based and feasible tools to govern patient safety within their emergency care organisation and in the chain of emergency care. Established strategies from other high-risk sectors need to be evaluated in emergency care settings, using an experimental design with valid outcome measures to strengthen the evidence base.