Do multidisciplinary integrated care pathways improve interprofessional collaboration?

This paper reports on the evaluation stage of an action research project on interprofessional collaboration in discharge planning. Findings from interviews with health care professionals working in the acute sector had revealed concerns about discharge planning and multidisciplinary teamwork. In the United Kingdom the National Health Service (NHS) Plan has reinforced the need for an integrated approach to health care. Effective health care integration requires effective communication, teamwork and the commitment to deliver integrated care. Integrated documentation is a key strategy for enhancing interprofessional collaboration and reducing the isolation of professionals, and has been successfully implemented in a range of health care settings. Presented with the concerns about the collaborative process in discharge planning, an action research strategy was chosen to bring about change in an orthopaedic ward in one London teaching hospital. This paper will evaluate the implementation of an integrated care pathway with fractured neck of femurs in one London teaching hospital. Care pathways facilitate the management of defined patient groups using interdisciplinary plans of care. The emphasis will be on understanding whether integrated care pathways enhance and develop interprofessional collaboration and enable effective information access and flow across the professions and the organization. The criteria for evaluation, forming the hypotheses of the study, were that interprofessional nonverbal and verbal communication would be enhanced and that interprofesisonal collaboration would increase. Methods of evaluation used were: (i) stakeholder interviews, (ii) interprofessional audit and (iii) analysis of the variances from the integrated care pathway. The evaluation revealed that although integrated care pathways led to improved outcomes for the health care trust there was little evidence to suggest that interprofessional relationships and communication were enhanced. Furthermore, key factors in discharge delays appeared to be organizational rather than professional.     

Risks with older adults in acute care settings: UK occupational therapists' and physiotherapists' perceptions of risks associated with discharge and professional practice

Internationally, there is evidence that hospital discharge to home for older adults is a complex and challenging process that is dependent upon multidisciplinary team working. At the centre of the discharge process is the management of risk, which involves occupational therapists and other healthcare professionals managing perceived dangers and determining why some dangers are seen as presenting risks while others are not. This study did not aim to explore interprofessional differences but to ascertain a greater understanding of professionals' perceptions of risk in acute care settings. This qualitative study utilised 12 semi-structured interviews with seven occupational therapists and five physiotherapists in the United Kingdom (UK). During the interview, therapists were asked to read and answer questions on a validated vignette. The interview data were subjected to thematic content analysis and the vignettes to template analysis. Our research is one of the first studies to explore therapists' perceptions of risk with older adults in acute care settings. Our study has highlighted that perception of risk does have an impact on discharge decision-making and location. Therapists used negative terminology to refer to patients who wanted to take risks, which could be a reflection of the therapists' anxiety. Mental capacity, and patients' functioning and safety were key factors in risk decision-making with older adults. Our research has highlighted the potential value of multidisciplinary working to manage risk situations and the need for reflection and discussion regarding how persons who do not have capacity wishes are managed within acute care settings. There is a need to develop an interprofessional care pathway to guide clinicians through the risk decision-making process which needs to ensure that the client's opinions and wishes are taken into account throughout.     

Components of a proper hospital discharge for elders

SIGNIFICANCE: Effective discharge planning is a vital link in continuity of care for elders. Previous studies identify problems with planning for elders' discharge from the hospital and problems elders encounter managing care post-discharge. However, little attention has been given to identifying effective discharge planning processes. Explicating the components of effective discharge planning is critical to replicate the process in other health care settings and predict post-discharge outcomes. PURPOSE: The purpose of this study was to identify the components of effective discharge planning for elders and factors that impede planning. METHODS: Ethical approvals were obtained from the University and National Health Service (NHS) Trust. Qualitative methods were used and data were collected from two wards in a 78-bed geriatric rehabilitation hospital that was part of a National Health Service Trust serving Southwest London. Data included semi-structured interviews and documents related to discharge planning, care delivery, and community resources. A total of 24 semi-structured interviews were conducted with health care professionals who were part of the hospital's multidisciplinary team, those affiliated with the Community Trust that provided aftercare, elders, and family carers. RESULTS: Participants consistently used the term "proper discharge" when referring to effective discharge planning. The multidisciplinary team comprised a vital context for a proper discharge. The findings indicated that three circles of communication were central in a four stage discharge process. Different circles of communication were key at different stages. CONCLUSIONS: The findings provide insights for educating nurses about effective planning practices and examining the global significance of impediments to a proper hospital discharge.     

“So You Are Running Between”—A Qualitative Study of Nurses' Involvement With Diagnostic Imaging in South Africa

Nurses caring for patients in radiology departments are a relatively recent phenomenon. Only a few fragmented studies appear in the literature on the interprofessional nursing domain in these departments. This article attempts to give a more holistic picture of nurses' experiences of patient care related to diagnostic imaging and interprofessional interactions and relations with radiographers and radiologists. Focus groups were held, among others, with nurses at a district hospital and an adjacent academic hospital in South Africa. Participants were questioned about their experiences regarding referrals for diagnostic imaging, their professional roles, views on the roles of other professions, multidisciplinary interaction, and radiation awareness. Three main themes emerged, namely (1) patient care and communication include the subthemes of “being there” for patients and communicating with them; (2) scope of professional practice is divided into activities around the request form, preparation for diagnostic imaging, and further education needs; (3) interprofessional interactions relate to hierarchical and power relations and interprofessional communication and conflict. The study illustrates the collaborative and mediating roles of nurses at various points in the health system, from referral of patients for diagnostic imaging investigations to discharge from the health care facility. More studies are needed on interprofessional relations among radiographers, radiologists, and nurses, and nurses' ability to make appropriate judgments with regard to the completion and interpretation of request forms and preparing patients for specialized investigations.     

Interprofessional 30-day readmission review novel curriculum

ABSTRACT

Planning and coordination among health-care professionals decrease readmission rates, yet workers have few opportunities to learn interprofessionally to improve transitions of care. An interprofessional readmission review curriculum engaged medical residents, pharmacy residents, nurse practitioner students, early-career nurses, and social work students in a critical analysis of readmissions. Learners (N = 98) participated in a 2 h, collaborative learning session to review health records from a patient readmitted within 30 days of discharge and determine plausible root causes for readmissions. A 5-item post-session survey completed by 83 (85%) evaluated knowledge and perceived competencies in transitions of care before and after participation. Significant improvements (p < .001) occurred in ratings for all five items. Two open-ended questions captured learners’ perceptions of understanding and appreciating the roles of other disciplines in the discharge process and importance of interprofessional communication. Several themes emerged including understanding gaps in the discharge process, improving interprofessional collaboration and communication, and paying more attention to discharge documentation. This innovative program helped build essential skills to ensure safe discharges by introducing learners to interprofessional perspectives in analyzing root causes for readmissions, strategies to improve discharge planning, and the value of team-based care.     

Bedside nurses’ roles in discharge collaboration in general internal medicine: Disconnected,disempowered and devalued?

Collaboration among nurses and other healthcare professionals is needed for effective hospital discharge planning. However, interprofessional interactions and practices related to discharge vary within and across hospitals. These interactions are influenced by the ways in which healthcare professionals’ roles are being shaped by hospital discharge priorities. This study explored the experience of bedside nurses’ interprofessional collaboration in relation to discharge in a general medicine unit. An ethnographic approach was employed to obtain an in‐depth insight into the perceptions and practices of nurses and other healthcare professionals regarding collaborative practices around discharge. Sixty‐five hours of observations was undertaken, and 23 interviews were conducted with nurses and other healthcare professionals. According to our results, bedside nurses had limited engagement in interprofessional collaboration and discharge planning. This was apparent by bedside nurses’ absence from morning rounds, one‐way flow of information from rounds to the bedside nurses following rounds, and limited opportunities for interaction with other healthcare professionals and decision‐making during the day. The disconnection, disempowerment and devaluing of bedside nurses in patient discharge planning has implications for quality of care and nursing work. Study findings are positioned within previous work on nurse–physician interactions and the current context of nursing care.     

How team working influences discharge planning from hospital: a study of four multi-disciplinary teams in an acute hospital in England

A research project was carried out to critically explore and analyse what factors in an interdisciplinary/multidisciplinary context inhibited or promoted decision-making for the discharge planning process for patients returning home from an acute hospital in London. This was done through observations, informal interviewing and focus groups held on two wards and with the supported discharge rehabilitation team. Data were analysed and a conceptual framework developed, highlighting the important factors namely: leadership, team working and communication, affected by behaviours, feelings and resources, including environmental as well as personnel resources. Further analysis of the data suggested that leadership, which acted as a nerve centre for pivoting information, orchestrating and representing the team, and ensuring good outcomes were all important for decision-making in discharge planning. Team working, based on sharing, agreeing responsibilities, roles and boundaries, developing trust, learning together were all important factors. The study showed that good team working and leadership are vital to the success of effective discharge planning, but these aspects are rarely investigated and few resources are targeted on improving them.     

Discharge Planning: Comparison of Patients'and Nurses'Perceptions of Patients Following Hospital Discharge

Planning for hospital discharge is an important component of nursing. Results are presented of a study to determine how well primary nurses predict the functional ability of their patients following discharge and to assess whether patients and nurses agree about their patients' understanding of the post-discharge treatment plan. Comparing nurses' predictions with patients' reports of functional status 2 months following discharge, we found that nurses consistently underestimate the functional ability of their patients. Comparing nurses' perceptions of their patients' understanding of their post-discharge treatment plan with patients' reports about their understanding, significant differences were found between nurses' perceptions and patients' reports. Nurses' perceptions were that patients were much more knowledgeable than their patients reported. These preliminary data suggest that hospital discharge planning is an area for further investigation and intervention. Nurses should explore new paradigms for patient education as lengths of hospital stay decrease and care shifts from acute care to community care.     

From students to professionals: Results of a longitudinal study of attitudes to pre-qualifying collaborative learning and working in health and social care in the United Kingdom

During a longitudinal evaluation of a pre-qualifying interprofessional curriculum, health and social care students completed questionnaires concerning communication and teamwork skills and interprofessional learning and working. Data were collected on entry to their educational programme, during the second year of study, at qualification and after 9–12 months' qualified practice. This paper presents results from practice data from 414 professionals; 275 were educated on the interprofessional curriculum, 139 on previous uniprofessional curricula. The former were more confident at qualification about their communicative skills, their interprofessional relationships and other professionals' interaction, and showed positive correlations between perceptions of their relevant skills and their interprofessional relationships. They were also more positive about their interprofessional relationships than practitioners educated on uniprofessional curricula. Age and previous experience of higher education influenced professionals' attitudes negatively: mature individuals may require more support when entering the workforce. Between qualification and practice, respondents from the interprofessional cohorts grew more critical of interprofessional education. However, experience of interprofessional education appears to produce and sustain positive attitudes towards collaborative working, suggesting that individuals' perceptions of their own educational experience are inadequate as an evaluative measure of interprofessional learning initiatives. This study reinforces the argument for including IPE in pre-qualifying curricula.     

From students to professionals: results of a longitudinal study of attitudes to pre-qualifying collaborative learning and working in health and social care in the United Kingdom

During a longitudinal evaluation of a pre-qualifying interprofessional curriculum, health and social care students completed questionnaires concerning communication and teamwork skills and interprofessional learning and working. Data were collected on entry to their educational programme, during the second year of study, at qualification and after 9-12 months' qualified practice. This paper presents results from practice data from 414 professionals; 275 were educated on the interprofessional curriculum, 139 on previous uniprofessional curricula. The former were more confident at qualification about their communicative skills, their interprofessional relationships and other professionals' interaction, and showed positive correlations between perceptions of their relevant skills and their interprofessional relationships. They were also more positive about their interprofessional relationships than practitioners educated on uniprofessional curricula. Age and previous experience of higher education influenced professionals' attitudes negatively: mature individuals may require more support when entering the workforce. Between qualification and practice, respondents from the interprofessional cohorts grew more critical of interprofessional education. However, experience of interprofessional education appears to produce and sustain positive attitudes towards collaborative working, suggesting that individuals' perceptions of their own educational experience are inadequate as an evaluative measure of interprofessional learning initiatives. This study reinforces the argument for including IPE in pre-qualifying curricula.     

Communicating with families of patients in an acute hospital with advanced cancer: problems and strategies identified by nurses

After pain management, poor communication with health professionals creates the most distress for families of patients with cancer. Difficulties communicating with families also have been identified as potentially stressful for nurses. This is particularly the case for nurses working in acute care settings. However, little research has been undertaken to examine the specific problems and challenges confronting nurses who endeavor to communicate with families of patients with cancer in a hospital setting. The purpose of this study was to describe nurses' perceptions of communication issues, potential barriers, and strategies associated with nurse-family interactions in an acute cancer hospital setting. Focus groups were conducted with nurses from two cancer wards at an Australia hospital. Four distinct themes emerged. First, all nurses described communication difficulties they encountered when interacting with families. Second, team factors appeared to be a central determinant of the quality of nurse-family communication. Third, nurses described difficulties associated with the delivery of bad news and treatment plans that are not clearly defined for the patient. Finally, the effects of poor communication on nurses were notably and vividly described. In this report, recommendations for clinical practice and subsequent research are offered.     

A network model of communication in an interprofessional team of healthcare professionals: A cross-sectional study of a burn unit

Healthcare teams consist of individuals communicating with one another during patient care delivery. Coordination of multiple specialties is critical for patients with complex health conditions, and requires interprofessional and intraprofessional communication. We examined a communication network of 71 health professionals in four professional roles: physician, nurse, health management, and support personnel (dietitian, pharmacist, or social worker), or other health professionals (including physical, respiratory, and occupational therapists, and medical students) working in a burn unit. Data for this cross-sectional study were collected by surveying members of a healthcare team. Ties were defined by asking team members whom they discussed patient care matters with on the shift. We built an exponential random graph model to determine: (1) does professional role influence the likelihood of a tie; (2) are ties more likely between team members from different professions compared to between team members from the same profession; and (3) which professions are more likely to form interprofessional ties. Health management and support personnel ties were 94% interprofessional while ties among nurses were 60% interprofessional. Nurses and other health professionals were significantly less likely than physicians to form ties. Nurses were 1.64 times more likely to communicate with nurses than non-nurses (OR = 1.64, 95% CI: 1.01–2.66); there was no significant role homophily for physicians, other health professionals, or health management and support personnel. Understanding communication networks in healthcare teams is an early step in understanding how teams work together to provide care; future work should evaluate the types and quality of interactions between members of interprofessional healthcare teams.     

Patients'' rights and the admission and discharge process

This study examines what patients' admission to and discharge from hospital means for nurses in their relations with patients. The study focuses on the rights of patients and the rights and duties of nurses working in a general hospital and in the community. The 'information standard' is introduced, consisting of three conceptions: informed consent, informed referral and informed discharge. In-depth interviews have been conducted with patients (n = 11) and nurses (n = 22) to elucidate views on and personal experience of the admission and discharge process, in relation to the information standard. The interviews have been analysed by means of qualitative research methods. The results show that patients did not complain about the admission and discharge process, and that they were not informed about the information exchange between nurses working in hospital and in the community. In addition, community nurses were often not informed about a patient's admission to hospital. Nursing programmes for home care were arranged by community nurses and hospital nurses without co-ordination, resulting in unsuitable nursing care.