"Trust people you've never worked with" - A social network visualization of teamwork, cohesion, social support, and mental health in NHS Covid personnel

Background

The unprecedented rapid re-deployment of healthcare workers from different care pathways into newly created and fluid COVID-19 teams provides a unique opportunity to examine the interaction of many of the established non-technical factors for successful delivery of clinical care and teamwork in healthcare settings. This research paper therefore aims to address these gaps by qualitatively exploring the impact of COVID work throughout the pandemic on permanent and deployed personnel's experiences, their ability to effectively work together, and the effect of social dynamics (e.g., cohesion, social support) on teamwork and mental health.

Methods

Seventy-five interviews were conducted across the UK between March and December 2021 during wave 2 and 3 of COVID-19 with 75 healthcare workers who were either permanent staff on Intensive Care/High Dependency Units used as COVID wards, had been rapidly deployed to such a ward, or had managed such wards. Work Life Balance was measured using the WLB Scale. Interview transcripts were qualitatively coded and thematic codes were compared using network graph modeling.

Results

Using thematic network analysis, four overarching thematic clusters were found, (1) teamwork, (2) organizational support and management, (3) cohesion and social support, and (4) psychological strain. The study has three main findings. First, the importance of social factors for teamwork and mental health, whereby team identity may influence perceptions of preparedness, collaboration and communication, and impact on the collective appraisal of stressful events and work stressors. Secondly, it demonstrates the positive and negative impact of professional roles and skills on the development of teamwork and team identity. Lastly the study identifies the more pronounced negative impact of COVID work on deployed personnel's workload, mental health, and career intentions, exacerbated by reduced levels of social support during, and after, their deployment.

Conclusion

The thematic network analysis was able to highlight that many of the traditional factors associated with the successful delivery of patient care were impeded by pandemic constraints, markedly influencing personnel's ability to work together and cope with pandemic work stressors. In this environment teamwork, delivery of care and staff well-being appear to depend on relational and organizational context, social group membership, and psycho-social skills related to managing team identity. While results hold lessons for personnel selection, training, co-location, and organizational support during and after a pandemic, further research is needed into the differential impact of pandemic deployment on HCWs mental health and teamwork.

Preventing and Mitigating Inter-Professional Conflict Among Healthcare Professionals in Nigeria

Introduction

The primary obligation of healthcare professionals is the well-being of patients. Inter-professional conflict can prevent the achievement of this goal, thereby potentially putting patients in peril. This study aimed at articulating contextual strategies to mitigate and prevent inter-professional conflict among healthcare workers in Nigeria.

Methods

A cross sectional study was undertaken in various health facilities in Nigeria. Questionnaires were administered to healthcare professionals. Completed questionnaires were analysed using Statistical Package for Social Sciences. Descriptive and inferential statistical analyses were undertaken.

Results

A total of 2207 valid responses were included for analysis. Findings revealed that almost all the respondents (92.9%) indicated that the Ministry of Health has a key role in resolving conflict in the healthcare sector. Close to three quarters (70.4%) of the study participants disagreed that leadership of hospitals and health agencies be limited to a particular profession. Almost all the participants (90.15%) indicated that cognate administrative expertise and experience are critical for leadership. A strong majority of the sample (93.5%) opined that reforms are required in the leadership selection process of hospital and other healthcare agencies.

Conclusion

Due to the criticality of this issue to patients' access to healthcare, findings from this study can underpin a proactive evidence based strategy that can comprehensively address inter-professional conflict among healthcare workers in Nigeria.

Understanding the Nature and Sources of Conflict Among Healthcare Professionals in Nigeria: A Qualitative Study

Introduction

Inter-professional conflict in the Nigerian health sector is a concept that is as old as modern medical practice and has resulted in disruption of health care delivery, with the overall impact bearing down on patients.

Purpose

This study aimed to provide an in-depth understanding and a clearer insight into the causes of conflict in the Nigerian health sector.

Methods

A qualitative strategy was employed using a semi-structured interview approach. Data were obtained from health practitioners from diverse backgrounds in various healthcare facilities.

Results

The phenomenon of conflict was reported as a long existent and trans-generational strain on inter-professional relationships occurring in all sectors of health practice, primarily between the physicians and other health care professionals. Inter-professional conflict was reported to emanate primarily from lapses in leadership, remuneration structure, role description, communication and emotional intelligence. This has affected the effectiveness of the Nigerian healthcare system and has contributed to hindrance in the provision of high-quality care in the country.

Conclusion

Evidence from this study can help in developing contextual policy in addressing inter-professional conflict in the health sector, and this will consequently improve health care delivery in the country.

Nurse-Physician Inter-Professional Collaboration and Associated Factors at Public Hospitals in Dessie City, Amhara, Northeastern Ethiopia, 2021

Introduction

Nurse–physician collaboration is an integral part of quality improvement in health care. Collaboration enables individuals to work together to achieve defined and common health purposes. There is limited evidence related to nurse–physician inter-professional collaboration and its associated factors in Ethiopia, particularly in Dessie city public hospitals.

Objective

To assess nurse–physician inter-professional collaboration and associated factors at public hospitals in Dessie city, Ethiopia, 2021.

Methods

An institutional-based cross-sectional study was conducted among nurses and physicians at public hospitals in Dessie city. A self-administered questionnaire was used for data collection. Stratified simple random sampling techniques were used to select study participants proportional to the sample size allocation. The final sample size was 260 and allocated proportionally to Dessie Comprehensive Specialized Hospital and Boru Meda General Hospital. The data were entered and analyzed using EPI-data version 4.6 and SPSS version 26 software respectively. During analysis, p-values less than 0.25 in binary logistic regression were entered into multivariable logistic regression. Finally, p-values less than 0.05 in multi-variable logistic regression were considered statically significant.

Results

The mean score for inter-professional collaboration was 97.40 ± 19.6SD. In this study, inter-professional collaboration among nurses and physicians was 44.2%. This study showed that favorable attitude [AOR=3.205; CI: 1.781–5.766], respondents working in the gynecological department [AOR=0.210; CI: 0.052–0.849], satisfied organizational support [AOR=2.062; CI: 1.140–3.729] and urban residents [AOR=3.996; CI: 1.069–14.931] were factors associated with nurse–physician inter-professional collaboration.

Conclusion

In this study, nurse–physician inter-professional collaboration was low. Training on the importance of health teamwork, timely monitoring and evaluation of organizational support, and professional empowerment towards a favorable attitude of nurse–physician inter-professional collaboration shall be provided at hospital levels. Routine assessment and timely intervention of the gynecological department for nurse–physician inter-professional collaboration shall be done at hospital levels. Moreover, both quantitative and qualitative research shall be performed for future research.

Assessing the Delivery of Coordinated Care to Patients with Advanced Chronic Kidney Disease in Ontario, Canada: A Survey of Patients and Healthcare Professionals

Introduction:

Patients with advanced Chronic Kidney Disease (CKD) have complex health needs, and thus require care that is coordinated across professionals and organizations. This study aimed to describe the extent of coordinated care delivery for patients with advanced CKD from the perspectives of both patients and healthcare professionals.

Methods:

The Coordination Scale of the Patient Assessment of Chronic Illness Care (PACIC-26) survey was administered to a random sample of 14,257 patients on maintenance dialysis or receiving care in end-stage kidney disease preparation clinics in Ontario, Canada. A five-item survey was administered to 596 multidisciplinary nephrology professionals.

Results:

Among the 1,925 patient respondents, 67% reported they had been referred to an allied health professional; 19% had been encouraged to attend programs in the community; and 34% had been told how their visits with other types of doctors helped their treatment (% reporting “always” or “most of the time”). Patient responses were significantly different by treatment modality/setting, but not by gender or geographic location of treatment facility. Among the 276 professional respondents, 37% reported their patients’ care was well-coordinated across settings; 56% reported participating in interdisciplinary care planning discussions; and 53% reported they are aware of appropriate home and community services to support their patients (% reporting “always” or “most of the time”).

Conclusion:

The results suggest that care for patients with advanced CKD in Ontario is not consistently coordinated. Healthcare professionals may enhance patient perceptions of coordinated care through explicit communication with patients about how the professionals they see and treatments or services they receive influence their overall health and well-being. At a systems level, there is a need to improve professional awareness of and linkages to home- and community-based services.

Perceptions of ambulance nurses on their knowledge and competence when assessing psychiatric mental illness

AIMS AND OBJECTIVES

To obtain the current perception of the knowledge and competence of pre-hospital emergency specialist nurses (ambulance) in attending patients with psychiatric symptoms.

BACKGROUND

Psychiatric illnesses have increased throughout the population. Consequently, pre-hospital emergency services frequently attend individuals with suspected or known mental illnesses.

DESIGN

We employed a set of quantitative and qualitative methods to gain a deeper understanding of ambulance nurses' self-evaluated knowledge.

METHODS

Seven ambulance nurses received and completed a survey questionnaire prior commencing employment in November 2019. Then, we conducted interviews to explore ambulance nurses' perceptions of their own knowledge and competence when attending individuals with mental disorders. The surveys were analysed with descriptive statistics, followed by content analysis.

RESULTS

Three topics emerged: the encounter of patients with mental illness; the awareness of lacking knowledge about mental illnesses; and the expectations for future Prehospital Emergency Psychiatric Response Teams. Although ambulance nurses already possessed basic knowledge regarding psychiatric illnesses, it was insufficient, based on their perception of appropriate care. Ambulance nurses considered that combining pre-hospital and psychiatric expertise in the pre-hospital emergency unit would increase their in-depth knowledge about various psychiatric illnesses, the treatment options and the alternatives regarding where to deliver patients for continued care.

Chimeric Antigen Receptor, Teamwork, Education, Assessment, and Management (CAR-TEAM): A Simulation-Based Inter-professional Education (IPE) Intervention for Management of CAR Toxicities

Chimeric antigen receptor (CAR) therapies such as tisagenlecleucel, indicated for children and young adults with relapsed and/or refractory CD19⁺ acute lymphoblastic leukemia (ALL), have been associated with striking treatment outcomes and overall survival. Yet, they are also associated with unique and potentially life-threatening complications. Cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity (ICANS) are generally reversible complications of CAR therapies, but many patients may require critical care support especially if they are not promptly recognized and appropriately managed by frontline healthcare staff. As CAR therapies become more widely available, it is important that inter-professional staff members be aware of general principles regarding diagnosis and management. We hypothesized that an inter-professional education (IPE) simulation-based education intervention (CAR-TEAM) would improve knowledge base and confidence regarding complications of CAR therapies among inter-professional staff. Here, we demonstrate that following CAR-TEAM training, >90% of participants demonstrated knowledge proficiency and confidence in the IPE content area. CAR-TEAM training may serve as an important tool to establish initial and continued competency among sites introducing CAR therapies.

Post-intensive care syndrome in a cohort of infants & young children receiving integrated care via a pediatric critical care & neurotrauma recovery program: A pilot investigation

OBJECTIVE

Children treated in the pediatric intensive care unit (PICU) often face difficulties with long-term morbidities associated with neurologic injuries and lifesaving PICU interventions termed Post-Intensive Care Syndrome (PICS). In an effort to identify and address critical issues related to PICS, we developed an integrated model of care whereby children and families participate in follow-up clinics with a neuropsychologist and a critical care physician. To demonstrate preliminary impact, we present pilot findings on the early identification and treatment of PICS in a cohort of infants and young children in our program through a combination of multi-professional direct assessment and parent proxy questionnaires.

METHOD

Thirty-three infants and children, ages 3-72 months, participated in our initial follow-up clinic where issues related to physical health/recovery, development/cognition, mood/behavior, and quality of life were screened 1-3 months after discharge from the PICU.

RESULTS

In comparison to pre-hospitalization functioning, direct assessment revealed new neurological concerns identified by the critical care physician in 33.3% of participants and new neurocognitive concerns identified by the neuropsychologist in 36.4% of participants. Caregiver reported measures showed significant issues with patient cognitive functioning, emotional functioning, sleep, and impact on the family. Participants and families experienced significant difficulties related to changes in functioning and disability. Parents/caregivers and clinicians demonstrated agreement on functioning across a variety of indicators; however, important divergence in assessments were also found highlighting the importance of multiple assessments and perspectives.

CONCLUSIONS

New PICS morbidities are common in the early phase of recovery after discharge in infants, young children and their families. Results demonstrate the benefits and need for timely PICU follow-up care that involves collaboration/integration of physicians, neuropsychologists, and families to identify and treat PICS issues.

Educational Targets to Reduce Medication Errors by General Surgery Residents

OBJECTIVE

Hospitalized patients are exposed to more than 1 medication error per day, but there are limited data concerning the factors associated with medication order errors made by general surgery residents. The objective of this study was to identify patterns in medication order errors amongst general surgery residents, which may provide educational targets to reduce medication errors by this population of providers.

DESIGN

This study used a retrospective cohort design to review inpatient medication orders placed via a computerized physician order entry system by general surgery residents at a single academic medical center from July 2011 to February 2018.

SETTING

A single large academic medical center located in the Midwest, United States.

PARTICIPANTS

General surgery residents completing residency between July 2011 and February 2018 and their respective inpatient medication orders.

RESULTS

Of 571,811 included medication orders placed by 169 unique general surgery residents, 4.2% (n = 24,177) triggered pharmacist intervention, and 11 (0.001%) resulted in significant near-miss events. Of orders requiring pharmacist intervention, most were either duplicate therapies (n = 8703, 36.1%) or errors in renal dosing (n = 7576, 31.3%). Error rates were higher within pharmaceutical classes ordered less frequently, with the notable exception of antimicrobials and anticoagulants, which accounted for 20.1% (n = 5280) and 13.5% (n = 3270) of all order errors, respectively. In a multivariable model, errors were more likely to occur in the intensive care unit versus other units (OR = 1.21, 95%CI = 1.14-1.29) and in August versus other months (OR = 1.09, 95%CI = 1.01-1.17), but were independent of other resident and order characteristics.

CONCLUSIONS

This study identified that resident medication order errors are common and are associated with specific therapeutic classes, the beginning of academic years, and intensive care unit patients. These findings represent potential targets for educational interventions and highlight the role of interdisciplinary teams in providing quality surgical care.

Team Functioning And Beliefs About Team Effectiveness In Inter-Professional Teams: Questionnaire Development And Validation

Purpose

Few validated instruments are available to measure team functioning in acute and primary care teams. To address this, we developed a questionnaire measuring healthcare provider perceptions of team effectiveness (Provider-PTE) and assessed its psychometric properties.

Patients and methods

Empirical evidence and a conceptual model were used for item generation. The 41-item self-completed questionnaire was developed. A cross-sectional survey of healthcare providers (n=283) across a range of settings was performed. Psychometric properties were assessed for French and English language questionnaires using Cronbach alpha (α) for reliability, the feedback form for face validity, expert opinion for content validity, and the known-group technique for construct validity. Responsiveness was examined by comparing scores in high and low functioning teams.

Results

The mean time needed to complete the questionnaire was less than 9 mins. Respondents were typically female (84%), and employed full time (80%) in urban settings (82%). Cronbach α values were as follows: Team Processes = 0.88; PTE-Overall = 0.91; Outcomes = 0.72. Significant differences were found by professional group (p = 0.017), length of time in the team (p = 0.025), and presence of nurse practitioners. Responses to Outcomes varied by employment status (p = 0.017). Differences were identified in high and low functioning teams (p<0.001). Feedback indicated that two questions related to team meetings needed to be added.

Conclusion

The study produced evidence of validity for English and French language Provider-PTE questionnaires. The revised 43-item instrument represents an important contribution by providing a validated questionnaire to measure team functioning across a range of settings that is consistent with a conceptual framework.

Inter-professional education and primary care: EFPC position paper

Inter-professional education (IPE) can support professionals in developing their ability to work collaboratively. This position paper from the European Forum for Primary Care considers the design and implementation of IPE within primary care. This paper is based on workshops and is an evidence review of good practice. Enablers of IPE programmes are involving patients in the design and delivery, providing a holistic focus, focussing on practical actions, deploying multi-modal learning formats and activities, including more than two professions, evaluating formative and summative aspects, and encouraging team-based working. Guidance for the successful implementation of IPE is set out with examples from qualifying and continuing professional development programmes.

An interprofessional collaboration of care to improve clinical outcomes for patients with diabetes

This project addressed interprofessional team-based care to improve management and outcomes of complex patients with diabetes. A collaborative model between Family Medicine and Nursing was developed to determine if having nursing students as case managers would improve the quality of care. From 2015-2016, patients with diabetes at greatest risk for poor outcomes (N = 58) received an intervention from senior nursing students (N = 6) at a Family Practice Center. Nursing students shared responsibilities with physicians, medical students, and medical assistants to deliver high quality care. For the intervention, nursing students reviewed charts, called patients for follow-up visits, and facilitated patients' adherence to providers' recommendations. Students also conducted group education sessions on nutrition, medication adherence, obesity, and exercise for patients. The control group included 61 randomly selected patients with diabetes who did not receive the intervention during the same period of time. Compared to the control group, the intervention group showed significantly improved outcomes in HgA1C levels (66% vs. 40.8%; p = .009), blood pressure control (61.1% vs. 36.8%; p = .009), and urine microalbumin test completion (87.5% vs. 48.3%; p<  .0001). Outpatient practices offer an optimal opportunity for nursing students to practice case management. This team-based care approach suggests better outcomes for patients with diabetes.

A Qualitative Study Exploring the Role of Pharmacists in Medical Student Training for the Prescribing Safety Assessment

Five years after the introduction of the Prescribing Safety Assessment (PSA) in the UK, the role pharmacists play to help prepare medical students for this challenge is uncertain. Our study explored pharmacists’ perceptions about their role in undergraduate medical training for the Prescribing Safety Assessment (PSA). One hundred and seventy-nine prospective participants from UK hospitals and education and training boards were emailed an interview schedule aimed at ascertaining their current involvement in undergraduate medical education, particularly the preparation for PSA. Responses received via email were thematically-analysed. A total of 27 hospital pharmacists and 3 pharmacists from local education and training boards participated in the interviews. Pharmacists were positive about their involvement in medical student training, recognising the added value they could provide in prescribing practice. However, respondents expressed concerns regarding resource availability and the need for formal educational practice mentoring. Despite a low response rate (17%), this research highlights the potential value of pharmacists’ input into medical education and the need for a discussion on strategies to expand this role to maximise the benefits from having a pharmacist skill mix when teaching safe prescribing.

Barriers and facilitators to medication adherence: a qualitative study with general practitioners

BACKGROUND

General practitioners (GPs) manage the drug therapies of people with chronic diseases, and poor adherence to medication remains a major challenge.

OBJECTIVE

This qualitative study examined GPs' insights into non-adherence and ways of overcoming this problem.

METHODS

We ran four focus groups comprising 16 GPs at the Kirkkonummi Health Centre (Southern Finland). Interviews were audiotaped, transcribed verbatim and analysed by inductive content analysis.

MAIN RESULTS

The two main themes in the discussions with the GPs were non-adherence in the care of chronic disease and increased need for medicine information. The medication management challenges identified were related to: patient-specific factors, the healthcare system, characteristics of drug therapies and the function and role of healthcare professionals as a team. To improve the situation, the GPs offered a number of solutions: improved coordination of care, better patient education and IT systems as well as enhanced interprofessional involvement in the follow-up of patients.

DISCUSSION AND CONCLUSIONS

With an ageing population, the GPs were increasingly confronted with non-adherence in the care of chronic diseases. They had mostly a positive attitude towards organising care in a more interprofessional manner. To support medication adherence and self-management, the GPs appreciated pharmacists' assistance especially with patients with polypharmacy and chronic diseases.

International quality improvement initiatives

Across the globe, the implementation of quality improvement science and collaborative learning has positively affected the care and outcomes for children born with CHD. These efforts have advanced the collective expertise and performance of inter-professional healthcare teams. In this review, we highlight selected quality improvement initiatives and strategies impacting the field of cardiovascular care and describe implications for future practice and research. The continued leveraging of technology, commitment to data transparency, focus on team-based practice, and recognition of cultural norms and preferences ensure the success of sustainable models of global collaboration.

Practice Report / Bericht aus der Praxis: Tutor training for a peer-assisted interprofessional communication seminar: A work in progress

A novel peer-led communication seminar for medical students and for students of the Interprofessional Health Care B.Sc. degree programme at the Medical Faculty of Heidelberg is currently being developed to address the increasing need for interprofessional collaborative competencies in health care professionals. The core elements of this course include role plays in interprofessional communication situations, patient-centred professional practice, and reflections on underlying attitudes. Each seminar will be conducted by a team of two senior students from both undergraduate programmes, practising their new roles as interprofessional tutors and, at the same time, serving as competent role models for interprofessional collaboration. To provide tutors with the necessary didactic preparation, an interprofessional tutor training was developed and implemented. It was positively evaluated and well accepted by participants. The seminar and tutor training concept presented in this paper aims to foster (inter-)professional ethics and communication competency development in medical students.

Ethics in the interface between multidisciplinary teams: a narrative in stages for inter-professional education

An ethically problematic clinical case is used to illustrate the potential importance of understanding clinical ethics in an interdisciplinary context. Whilst much has been written on ethics education for multidisciplinary and interdisciplinary teams, we argue that it is important that both healthcare professions and healthcare teams are able to look outside their own disciplinary ethos and sometimes outside their formal teams when considering the ramifications of an ethical issue. A complex (fictional but based on the authors’ pooled experiences) case involving the delivery of a new-born from a mother with HIV is used to illustrate this, because multiple clinical teams will be involved at different times and in parallel with one another.

Report on Proceedings of the Eighth Annual European CME Forum, Manchester, UK, November 2015

Delegates from Europe, Asia, and North America attended the Eighth European CME Forum in Manchester, UK, on 12 and 13 November 2015. A new format that included three separate workshop tracks was introduced. The workshops focused on standards and accreditation, education and partnerships, funding and practice in CME/CPD. Discussion and interactive sessions on accreditation issues, inter-professional education, backwards planning, and patient engagement were among the topics addressed.

Facilitated conversations were conducted with European leaders in the medical profession and a representative from a European commercial supporters’ organisation. Panel discussions on current and future trends and the views of local junior doctors representing the learner community were also conducted.

Teaching Tip: Developing an Intercollegiate Twitter Forum to Improve Student Exam Study and Digital Professionalism

#VetFinals has been developed as a novel online Twitter teaching event designed to support intercollegiate veterinary teaching using social media. Previous studies in other fields have suggested that Twitter use within universities may have benefits for undergraduate education. This "teaching tip" paper describes a project using Twitter to host online exam study sessions. The project has been a highly successful collaborative effort between the Royal Veterinary College and Nottingham Veterinary School in the UK. Over 4 years, the #VetFinals project has developed into a long-term, self-sustaining enterprise. This initiative provides a semi-structured means for student exam preparation with direct real-time input from a faculty member. It also creates a network of peers both horizontally across institutions and vertically throughout year groups. Based on similar initiatives in other disciplines, an anticipated outcome of this project was to contribute to student online professionalism. This could help address the veterinary community's recently highlighted problems with professional conduct and appropriate use of social media. Analysis of the success of this endeavor will be available in a future publication.

Using Focus Groups to Validate a Pharmacy Vaccination Training Program

Introduction: Focus group methodology is commonly used to quickly collate, integrated views from a variety of different stakeholders. This paper provides an example of how focus groups can be employed to collate expert opinion informing amendments on a newly developed training program for integration into undergraduate pharmacy curricula. Materials and methods: Four focus groups were conducted, across three continents, to determine the appropriateness and reliability of a developed vaccination training program with nested injection skills training. All focus groups were comprised of legitimate experts in the field of vaccination, medicine and/or pharmacy. Results: Themes that emerged across focus groups informed amendments giving rise to a validated version of a training program. Discussion: The rigorous validation of the vaccination training program offers generalizable lessons to inform the design and validation of future training programs intended for the health sector and or pharmacy curricula. Using the knowledge and experience of focus group participants fostered collaborative problem solving and validation of material and concept development. The group dynamics of a focus group allowed synthesis of feedback in an inter-professional manner. Conclusions: This paper provides a demonstration of how focus groups can be structured and used by health researchers to validate a newly developed training program.

Interprofessional education for personalized medicine through technology-based learning

The delivery of personalized medicine utilizing genetic and genomic technologies is anticipated to involve many medical specialties. Interprofessional education will be key to the delivery of personalized medicine in order to reduce disjointed or uncoordinated clinical care, and optimize effective communication to promote patient understanding and engagement regarding the use of or need for these services. While several health professional organizations have endorsed and/or developed core competencies for genetics and genomics, the lack of interprofessional guidelines and training may hamper the delivery of coordinated personalized medicine. In this perspective, we consider the potential for interprofessional education and training using technology-based approaches, such as virtual simulation and gaming, compared with traditional educational approaches.

Nutrition competencies in health professionals' education and training: a new paradigm

Most health care professionals are not adequately trained to address diet and nutrition-related issues with their patients, thus missing important opportunities to ameliorate chronic diseases and improve outcomes in acute illness. In this symposium, the speakers reviewed the status of nutrition education for health care professionals in the United States, United Kingdom, and Australia. Nutrition education is not required for educating and training physicians in many countries. Nutrition education for the spectrum of health care professionals is uncoordinated, which runs contrary to the current theme of interprofessional education. The central role of competencies in guiding medical education was emphasized and the urgent need to establish competencies in nutrition-related patient care was presented. The importance of additional strategies to improve nutrition education of health care professionals was highlighted. Public health legislation such as the Patient Protection and Affordable Care Act recognizes the role of nutrition, however, to capitalize on this increasing momentum, health care professionals must be trained to deliver needed services. Thus, there is a pressing need to garner support from stakeholders to achieve this goal. Promoting a research agenda that provides outcome-based evidence on individual and public health levels is needed to improve and sustain effective interprofessional nutrition education.

Inter-professional practice: from veterinarian to the veterinary team

Animal health care is being delivered by an increasing number of professions and occupations. This article takes an inward look at the veterinary team, focusing on the day-to-day life of veterinarians and those with whom they work, such as veterinary technicians/nurses, physical therapists, and farriers. The evolution of the work of the veterinarian should be explored alongside the evolution of closely related occupations, as the current working practice of veterinarians is affected by the practice of these other occupations. An example is given of UK veterinary nurses (similar to veterinary technicians in North America) who are currently undergoing professionalization. Seminal implementations have included a register (2007), disciplinary procedures (2011), a declaration of professional responsibilities (2012), and required continuing professional development for registered veterinary nurses (RVNs). These implementations result in veterinary nurses who are now accountable for their actions. There are many potential benefits to good inter-professional practice for the practice itself, individual team members, clients, and patients, including better results produced by the whole team rather than the sum of the parts, financial benefits to using individuals in lower-paid occupations for shared roles, and greater client satisfaction regarding increased options for treatment. There are, however, many challenges to inter-professional working that center on the interlinked themes of hierarchy (power, status, and the understanding/appreciation of professional roles) and communication (lack of/poor). Inter-professional education (IPE) is suggested as a potential means to overcome these challenges; however, research into IPE exclusively related to the veterinary team is lacking.

Reframing the challenges to integrated care: a complex-adaptive systems perspective

INTRODUCTION

Despite over two decades of international experience and research on health systems integration, integrated care has not developed widely. We hypothesized that part of the problem may lie in how we conceptualize the integration process and the complex systems within which integrated care is enacted. This study aims to contribute to discourse regarding the relevance and utility of a complex-adaptive systems (CAS) perspective on integrated care.

METHODS

In the Canadian province of Ontario, government mandated the development of fourteen Local Health Integration Networks in 2006. Against the backdrop of these efforts to integrate care, we collected focus group data from a diverse sample of healthcare professionals in the Greater Toronto Area using convenience and snowball sampling. A semi-structured interview guide was used to elicit participant views and experiences of health systems integration. We use a CAS framework to describe and analyze the data, and to assess the theoretical fit of a CAS perspective with the dominant themes in participant responses.

RESULTS

Our findings indicate that integration is challenged by system complexity, weak ties and poor alignment among professionals and organizations, a lack of funding incentives to support collaborative work, and a bureaucratic environment based on a command and control approach to management. Using a CAS framework, we identified several characteristics of CAS in our data, including diverse, interdependent and semi-autonomous actors; embedded co-evolutionary systems; emergent behaviours and non-linearity; and self-organizing capacity.

DISCUSSION AND CONCLUSION

One possible explanation for the lack of systems change towards integration is that we have failed to treat the healthcare system as complex-adaptive. The data suggest that future integration initiatives must be anchored in a CAS perspective, and focus on building the system's capacity to self-organize. We conclude that integrating care requires policies and management practices that promote system awareness, relationship-building and information-sharing, and that recognize change as an evolving learning process rather than a series of programmatic steps.

Clinical impact and evidence base for physiotherapy in treating childhood chronic pain

PURPOSE

As part of the special series on pain, our objectives are to describe the key features of chronic pain in children, present the rationale for interdisciplinary treatment, report a case study based on our biopsychosocial approach, and highlight the integral role of physiotherapy in reducing children's pain and improving function. We also evaluate the evidence base supporting physiotherapy for treating chronic neuropathic pain in children.

SUMMARY OF KEY POINTS

Chronic pain affects many children and adolescents. Certain challenging pain conditions begin primarily during adolescence and disproportionately affect girls and women. Children with these conditions require an interdisciplinary treatment programme that includes physiotherapy as well as medication and/or psychological intervention. Converging lines of evidence from cohort follow-up studies, retrospective chart reviews, and one randomized controlled trial support the effectiveness of physiotherapy within an interdisciplinary programme for treating children with chronic pain.

CONCLUSIONS

Evidence-based practice dictates that health care providers adopt clear guidelines for determining when treatments are effective and for identifying children for whom such treatments are most effective. Thus, additional well-designed trials are required to better identify the specific physiotherapy modalities that are most important in improving children's pain and function.

Collaborative working within UK NHS secondary care and across sectors for COPD and the impact of peer review: qualitative findings from the UK National COPD Resources and Outcomes Project

Introduction

We investigated the effects on collaborative work within the UK National Health Service (NHS) of an intervention for service quality improvement: informal, structured, reciprocated, multidisciplinary peer review with feedback and action plans. The setting was care for chronic obstructive pulmonary disease (COPD).

Theory and methods

We analysed semi-structured interviews with 43 hospital respiratory consultants, nurses and general managers at 24 intervention and 11 control sites, as part of a UK randomised controlled study, the National COPD Resources and Outcomes Project (NCROP), using Scott's conceptual framework for action (inter-organisational, intra-organisational, inter-professional and inter-individual). Three areas of care targeted by NCROP involved collaboration across primary and secondary care.

Results

Hospital respiratory department collaborations with commissioners and hospital managers varied. Analysis suggested that this is related to team responses to barriers. Clinicians in unsuccessful collaborations told ‘atrocity stories’ of organisational, structural and professional barriers to service improvement. The others removed barriers by working with government and commissioner agendas to ensure continued involvement in patients' care. Multidisciplinary peer review facilitated collaboration between participants, enabling them to meet, reconcile differences and exchange ideas across boundaries.

Conclusions

The data come from the first randomised controlled trial of organisational peer review, adding to research into UK health service collaborative work, which has had a more restricted focus on inter-professional relations. NCROP peer review may only modestly improve collaboration but these data suggest it might be more effective than top-down exhortations to change when collaboration both across and within organisations is required.

Engagement and action for health: the contribution of leaders' collaborative skills to partnership success

A multi-site evaluation (survey) of five Kellogg-funded Community Partnerships (CPs) in South Africa was undertaken to explore the relationship between leadership skills and a range of 30 operational, functional and organisational factors deemed critical to successful CPs. The CPs were collaborative academic-health service-community efforts aimed at health professions education reforms. The level of agreement to eleven dichotomous ('Yes/No') leadership skills items was used to compute two measures of members' appreciation of their CPs' leadership. The associations between these measures and 30 CPs factors were explored, and the partnership factors that leadership skills explained were assessed after controlling. Respondents who perceived the leadership of their CPs favourably had more positive ratings across 30 other partnership factors than those who rated leadership skills less favourably, and were more likely to report a positive cost/ benefit ratio. In addition, respondents who viewed their CPs' leadership positively also rated the operational understanding, the communication mechanisms, as well as the rules and procedures of the CPs more favourably. Leadership skills explained between 20% and 7% of the variance of 10 partnership factors. The influence of leaders' skills in effective health-focussed partnerships is much broader than previously conceptualised.