Integration of systematic clinical interprofessional training in a student-faculty collaborative primary care practice

The changing healthcare environment and movement toward team-based care are contemporary challenges confronting health professional education. The primary care workforce must be prepared with recent national interprofessional competencies to practice and lead in this changing environment. From 2012 to 2014, the weekly Beth Israel Deaconess Crimson Care Collaborative Student-Faculty Practice collaborated with Northeastern University to develop, implement and evaluate an innovative model that incorporated interprofessional education into primary care practice with the goal of improving student understanding of, and ability to deliver quality, team-based care. In the monthly interprofessional clinic, an educational curriculum empowered students with evidence-based, team-based care principles. Integration of nursing, pharmacy, medicine, and masters of public health students and faculty into direct patient care, provided the opportunity to practice skills. The TeamSTEPPS® Teamwork Attitudes Questionnaire was administered pre- and post-intervention to assess its perceived impact. Seventeen students completed the post-intervention survey. Survey data indicated very positive attitudes towards team-based care at baseline. Significant improvements were reported in attitudes towards situation monitoring, limiting personal conflict, administration support and communication. However, small, but statistically significant declines were seen on one team structure and two communication items. Our program provides further evidence for the use of interprofessional training in primary care.     

A review of instruments to measure interprofessional team-based primary care

Interprofessional team-based care is increasingly regarded as an important feature of delivery systems redesigned to provide more efficient and higher quality care, including primary care. Measurement of the functioning of such teams might enable improvement of team effectiveness and could facilitate research on team-based primary care. Our aims were to develop a conceptual framework of high-functioning primary care teams to identify and review instruments that measure the constructs identified in the framework, and to create a searchable, web-based atlas of such instruments (available at: http://primarycaremeasures.ahrq.gov/team-based-care/). Our conceptual framework was developed from existing frameworks, the teamwork literature, and expert input. The framework is based on an Input-Mediator-Output model and includes 12 constructs to which we mapped both instruments as a whole, and individual instrument items. Instruments were also reviewed for relevance to measuring team-based care, and characterized. Instruments were identified from peer-reviewed and grey literature, measure databases, and expert input. From nearly 200 instruments initially identified, we found 48 to be relevant to measuring team-based primary care. The majority of instruments were surveys (n = 44), and the remainder (n = 4) were observational checklists. Most instruments had been developed/tested in healthcare settings (n = 30) and addressed multiple constructs, most commonly communication (n = 42), heedful interrelating (n = 42), respectful interactions (n = 40), and shared explicit goals (n = 37). The majority of instruments had some reliability testing (n = 39) and over half included validity testing (n = 29). Currently available instruments offer promise to researchers and practitioners to assess teams’ performance, but additional work is needed to adapt these instruments for primary care settings.     

Interprofessional training and team function in patient-centred medical home: Findings from a mixed method study of interdisciplinary provider perspectives

ABSTRACT

Transitioning from profession-specific to interprofessional (IP) models of care requires major change. The Veterans Assessment and Improvement Laboratory (VAIL), is an initiative based in the United States that supports and evaluates the Veterans Health Administration’s (VAs) transition of its primary care practices to an IP team based patient-centred medical home (PCMH) care model. We postulated that modifiable primary care practice organizational climate factors impact PCMH implementation. VAIL administered a survey to 322 IP team members in primary care practices in one VA administrative region during early implementation of the PCMH and interviewed 79 representative team members. We used convergent mixed methods to study modifiable organizational climate factors in relationship to IP team functioning. We found that leadership support and job satisfaction were significantly positively associated with team functioning. We saw no association between team functioning and either role readiness or team training. Qualitative interview data confirmed survey findings and explained why the association with IP team training might be absent. In conclusion, our findings demonstrate the importance of leadership support and individual job satisfaction in producing highly functioning PCMH teams. Based on qualitative findings, we hypothesize interprofessional training is important, however, inconsistencies in IP training delivery compromise its potential benefit. Future implementation efforts should improve standardization of training process and train team members together. Interprofessional leadership coordination of interprofessional training is warranted.     

An environmental scan of an aged care workplace using the PARiHS model: assessing preparedness for change

Aim The environmental scan aimed to deepen our understanding of the aged care work culture and to ascertain the readiness of the workers to advance towards team-based quality care provision. Background The workplace context was a high-care unit within a large residential aged care facility. Methods We used the Promoting Action on Research Implementation in Health Services (PARiHS) framework to assess workplace readiness via interviews, individual surveys and observation of practice. Results A profile of current culture emerged as mutually supportive and task focused, but at the same time lacking corporate team features of shared decision-making and feedback for practice improvement. However, latent within the frontline leaders and personal care staff, there was evidence of some embedded knowledge and capacity for corporate team performance. Conclusions This study has validated an evidence-based method for conducting environmental scanning in aged care, recommended before any major change is introduced. Implications for nursing management Environmental scanning helps gauge workforce capacity and limitations; this information can enable managers to capitalize on identified cultural strengths to fortify change and avoid pitfalls of personal and collective vulnerabilities.     

Innovative approaches to interprofessional care at the University of Pittsburgh Medical Center

Abstract

The enactment of the Affordable Care Act expands coverage to millions of uninsured Americans and creates a new workforce landscape. Interprofessional Collaborative Practice (ICP) is no longer a choice but a necessity. In this paper, we describe four innovative approaches to interprofessional practice at the University of Pittsburgh Medical Center. These models demonstrate innovative applications of ICP to inpatient and outpatient care, relying on non-physician providers, training programs, and technology to deliver more appropriate care to specific patient groups. We also discuss the ongoing evaluation plans to assess the effects of these interprofessional practices on patient health, quality of care, and healthcare costs. We conclude that successful implementation of interprofessional teams involves more than just a reassignment of tasks, but also depends on structuring the environment and workflow in a way that facilitates team-based care.     

Practice What You Preach: Developing Person-Centred Culture in Inpatient Mental Health Settings through Strengths-Based,Transformational Leadership

The experience of nursing staff and consumers in inpatient mental health wards is often reported as being negative. Efforts to improve culture and practice have had limited success, with ineffective leadership, staff resistance, and unresponsive organisational culture identified as common barriers to change. Practice development has been promoted as an approach to developing person-centred culture that enables professional development through participation, learning and empowerment. For person-centred practice to flourish, organisational leadership at all levels must reflect the same principles. In preparation for the opening of a new integrated mental health service, an inpatient mental health team participated in a practice development project. An action research approach was used to facilitate a series of “away days,” initially with the nursing team and then other members of the multidisciplinary team (MDT). Transformational leadership principles were adopted in the facilitation of team activities underpinned by strengths and solution-focused practices. Evaluation of the project by staff members was very positive and there was a high level of participation in practice development activities. The project resulted in the creation of a development plan for the ward, which prioritised five key themes: person-centred care, personal recovery, strengths-based principles, and evidence-based and values-based care. The project outcomes highlight the importance of leadership, which parallels the ideals promoted for clinical practice.     

Knowledge workers and knowledge-intense organizations, Part 2: Designing and managing for productivity.

Our economy is shifting from a hard goods and material products base to one in which knowledge is the primary mode of production. Organizations are experimenting with designs that support knowledge work by clustering individuals with different but complementary skills in focused teams. The goal is to increase applied knowledge that furthers the organization's strategic intent. The team-based knowledge work model holds promise for healthcare organizations that are under pressure to use knowledge to improve clinical care, integrate care across disciplines and settings, and accept accountability for costs. However, the shift from the traditional bureaucratic model to the flexible team-based design mandates changes in the design of the organization, the role of leadership, and the attributes of the teams and team members. In Part 2 of this three-part series, the authors explore the necessary design changes and the new roles for leadership, teams, and their members. Additionally, implications for healthcare clinicians, particularly nurses, are discussed.     

Interprofessional dietary assessment practices in primary care: A mixed-methods study

Patients in primary care (PC) are often counselled on diet, and assessment of current food intake is a necessary prerequisite for individualized nutrition care. This sequential mixed-methods study explored current diet assessment (DA) practices in team-based PC in Ontario, Canada, with interdisciplinary focus groups (FGs) followed by a web-based survey. Eleven FGs (n = 50) discussed key patient groups and health conditions requiring DA, as well as facilitators and barriers to accurate DA. Interpretative analysis revealed three themes: DA as a common activity that differed by health profession, communication of DA results within the team, and nutrition care as a collaborative team activity. A total of 191 providers from 73 Family Health Teams completed the web-based survey, and confirmed that many providers are frequently doing DA and that methods vary by discipline. Most providers conducted DAs every day or almost every day. As expected, dietitians used more formal and detailed methods to assess diet than other disciplines, who were more likely to ask a few pointed questions. These baseline data provide information on the range of current DA practices in team-based PC that can inform development of new, more accurate approaches that may improve counselling effectiveness.     

Development and initial validation of the interprofessional team learning profiling questionnaire

Informal workplace interprofessional learning occurs as health professionals interact with each other as part of everyday work practice. Participation in interprofessional team meetings is a practical way to foster learning. However, a gap exists in the availability of a reliable and valid instrument that adequately captures the nuances of informal workplace interprofessional learning in this setting. The purpose of this study was to develop a questionnaire to measure the different components of interprofessional learning that contribute to the quality of interprofessional learning within the interprofessional team meeting. Questionnaire items were developed from a review of the literature and interviews with health professionals. Exploratory factor analysis was used to determine the underlying factor structure. Two hundred and eighty-five health professionals completed a 98-item questionnaire. After elimination of unreliable items, the remaining items (n = 41) loaded onto four factors named personal and professional capacity; turning words into action—“walk the talk”; the rhetoric of interprofessional learning—“talk the talk”; and inclusiveness. Internal consistency was high for all sub-scales (Cronbach’s alpha 0.91, 0.87, 0.83, and 0.83, respectively). Content, construct, and concurrent validity were assessed. The instrument developed in this study indicated consistency and robust psychometric properties. Future studies that further test the psychometric properties of the questionnaire will help to establish the usefulness of this measure in establishing evidence for the perceived effectiveness of interprofessional learning in a healthcare setting.     

Development of the Nurses’ Care Coordination Competency Scale for mechanically ventilated patients in critical care settings in Japan: Part 2 Validation of the scale

ObjectivesTo confirm the validity and reliability of the nurses' care coordination competency draft scale for mechanically ventilated patients in Japan.Design/MethodIn this cross sectional observational study, a draft scale measuring care coordination was distributed to 2189 nurses from 73 intensive care units in Japan from February–March 2016. Based on the valid 887 responses, we examined construct validity including structural validity (exploratory and confirmatory factor analysis), convergent and discriminant validity and internal consistency reliability.Settings73 Intensive care units.ResultsExploratory factor analyses yielded four factors with 22 items: 1) promoting team cohesion, 2) understanding care coordination needs, 3) aggregating and disseminating information, 4) devising and clearly articulating the care vision. The four-factor model was confirmed using a confirmatory factor analysis (confirmatory fit index = 0.942, root mean square error of approximation = 0.062). Scale scores positively correlated with team leadership and clearly identified and discriminated nurses’ attributes. Cronbach’s alpha coefficient for each subscale was between 0.812 and 0.890, and 0.947 for the total scale.ConclusionsThe Nurses’ Care Coordination Competency Scale with four factors and 22 items had sufficient validity and reliability. The scale could make care coordination visible in nursing practice. Future research on the relationship between this scale and patient outcomes is needed.     

Conceptualizing Interprofessional Teams as Multi-Team Systems—Implications for Assessment and Training

SGEA 2015 CONFERENCE ABSTRACT (EDITED) Evaluating Interprofessional Teamwork During a Large-Scale Simulation Courtney West, Karen Landry, Anna Graham, and Lori Graham. Construct: This study investigated the multidimensional measurement of interprofessional (IPE) teamwork as part of large-scale simulation training. Background: Healthcare team function has a direct impact on patient safety and quality of care. However, IPE team training has not been the norm. Recognizing the importance of developing team-based collaborative care, our College of Nursing implemented an IPE simulation activity called Disaster Day and invited other professions to participate. The exercise consists of two sessions: one in the morning and another in the afternoon. The disaster scenario is announced just prior to each session, which consists of team building, a 90-minute simulation, and debriefing. Approximately 300 Nursing, Medicine, Pharmacy, Emergency Medical Technicians, and Radiology students and over 500 standardized and volunteer patients participated in the Disaster Day event. To improve student learning outcomes, we created 3 competency-based instruments to evaluate collaborative practice in multidimensional fashion during this exercise. Approach: A 20-item IPE Team Observation Instrument designed to assess interprofessional team's attainment of Interprofessional Education Collaborative (IPEC) competencies was completed by 20 faculty and staff observing the Disaster Day simulation. One hundred sixty-six standardized patients completed a 10-item Standardized Patient IPE Team Evaluation Instrument developed from the IPEC competencies and adapted items from the 2014 Henry et al. PIVOT Questionnaire. This instrument assessed the standardized or volunteer patient's perception of the team's collaborative performance. A 29-item IPE Team's Perception of Collaborative Care Questionnaire, also created from the IPEC competencies and divided into 5 categories of Values/Ethics, Roles and Responsibilities, Communication, Teamwork, and Self-Evaluation, was completed by 188 students including 99 from Nursing, 43 from Medicine, 6 from Pharmacy, and 40 participants who belonged to more than one component, were students at another institution, or did not indicate their institution. The team instrument was designed to assess each team member's perception of how well the team and him- or herself met the competencies. Five of the items on the team perceptions questionnaire mirrored items on the standardized patient evaluation: demonstrated leadership practices that led to effective teamwork, discussed care and decisions about that care with patient, described roles and responsibilities clearly, worked well together to coordinate care, and good/effective communication. Results: Internal consistency reliability of the IPE Team Observation Instrument was 0.80. In 18 of the 20 items, more than 50% of observers indicated the item was demonstrated. Of those, 6 of the items were observed by 50% to 75% of the observers, and the remaining 12 were observed by more than 80% of the observers. Internal consistency reliability of the IPE Team's Perception of Collaborative Care Instrument was 0.95. The mean response score—1 (strongly disagree) to 4 (strongly agree)—was calculated for each section of the instrument. The overall mean score was 3.57 (SD = .11). Internal consistency reliability of the Standardized Patient IPE Team Evaluation Instrument was 0.87. The overall mean score was 3.28 (SD = .17). The ratings for the 5 items shared by the standardized patient and team perception instruments were compared using independent sample t tests. Statistically significant differences (p < .05) were present in each case, with the students rating themselves higher on average than the standardized patients did (mean differences between 0.2 and 0.6 on a scale of 1–4). Conclusions: Multidimensional, competency-based instruments appear to provide a robust view of IPE teamwork; however, challenges remain. Due to the large scale of the simulation exercise, observation-based assessment did not function as well as self- and standardized patient-based assessment. To promote greater variation in observer assessments during future Disaster Day simulations, we plan to adjust the rating scale from “not observed,” “observed,” and “not applicable” to a 4-point scale and reexamine interrater reliability.     

Measuring interdisciplinary team performance in a long-term care setting

OBJECTIVES: The objectives of this study were to test the reliability and the validity of a survey instrument for assessing interdisciplinary team performance in long-term care settings and to measure team performance in the Program of All-Inclusive Care for the Elderly (PACE). RESEARCH DESIGN AND METHODS: The analysis is based on 1220 surveys completed by team members of 26 PACE programs. Cronbach's alphas, analysis of variance, and regression models were used to assess the reliability and the validity of the instrument. Multivariate regression analysis was used to examine factors associated with team performance in PACE. RESULTS: Cronbach's alphas ranging from 0.76 to 0.89 demonstrate good-to-high reliability for all domains of the team process and performance (effectiveness). Construct validity is demonstrated through the results of the regression analysis showing that leadership, communication, coordination, and conflict management are positive and significant (P <0.001) predictors of team cohesion and team effectiveness. The data also support the appropriateness of aggregating individual-level responses to the unit level. Perceived team effectiveness significantly (P <0.05) increases with: age of the respondents; longer length of the team's professional work experience; shorter duration of the team's PACE experience; more ethnically diverse composition of the team; greater ethnic concordance between team members and the participants; and greater perceived resource availability. CONCLUSIONS: Several of the factors influencing team effectiveness in PACE are potentially modifiable and, therefore, could offer insights for improving team practice.     

Educating for leadership: a programme designed to build a responsive health care culture

paterson k., henderson a. & trivella a. (2010) Journal of Nursing Management 18 , 78–83
Educating for leadership: a programme designed to build a responsive health care culture
Aim  To describe a leadership programme that progressively builds nurses capacity from the commencement of their employment to assist with the development of 'others'. Such an approach ultimately contributes to the creation of a team responsive to changing health care needs.
Background  The literature supports the relationship between positive leadership attributes, good nursing care and patient outcomes. Despite this, nurses are not routinely encultured into effective leadership practices early in their career, but rather they are 'added on' at a later stage according to organizational need.
Key issues  The effective education of leadership practices in this programme is largely dependent on an inclusive and embedded approach to learning. This is achieved through targeting staff early, enhancing their responses to clinical interactions in a structured and supported approach, and challenging their beliefs about capacity to influence through leadership.
Conclusions  Clinical leadership education needs to directly link with clinical areas to engage staff at the commencement of employment, and support them through their career trajectory, so that a systematic pathway of professional development is fostered.
Implications for nursing management  Clearly delineated progressive pathways for leadership development are essential to encourage lifelong reflection and learning that directly impacts on health care quality.     

Empowering the Health and Well-Being of the Palliative Care Workforce: Evaluation of a Weekly Self-Care Checklist

BackgroundWorkplace interventions are needed to prevent burnout and support the well-being of the palliative care workforce.MeasuresWe conducted a survey of all palliative care clinical staff to evaluate the usefulness and feasibility of checklist items and the checklist itself. We collected demographics, perceptions of professional satisfaction and burnout, and qualitative feedback aimed at improving the checklist.InterventionWe implemented a 13-item self-care checklist, included in a handbook on palliative care carried in the laboratory coat of all clinical personnel, to remind them to care of their own well-being.OutcomesOf 39 personnel contacted, 32 (82%) responded. Most (20; 62%) found the checklist useful. Exercise was the most highly ranked item, whereas watching visual arts was the lowest ranked item.Conclusions/Lessons LearnedNumerous opportunities were identified to improve the checklist and facilitate achievement of checklist items. Survey data will be used in the next checklist version.     

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.     

E-learning and professional development--never too old to learn

A growing concern among healthcare professionals is the need to continually update knowledge and skills in order to enhance clinical practice. It is recognized that there are major concerns about recruitment and retention of staff within health care, and an increasing need for greater emphasis on valuing the existing workforce. This article contributes to the debate about the role of e-learning in conjunction with continuing professional development (CPD) and personal professional development. It describes how healthcare professionals utilized an innovative, self-managed, pick-up and put-down distance learning module delivered online or by CD-ROM. Staff enrolled on the module were encouraged to complete a questionnaire online or by post upon completion of each unit; to enhance validity, telephone interviews were also conducted with selected staff. Results indicate that participants showed some improvement in all categories, especially patient care where 90% of staff reported some improvement after completing the course. This particular method of teaching and learning was shown to be favoured by staff as a method of CPD, and thus has the potential to enhance patient care.     

Refining the measurement of physician job satisfaction: results from the Physician Worklife Survey. SGIM Career Satisfaction Study Group. Society of General Internal Medicine.

BACKGROUND: Physician job satisfaction has been linked to various patient care and health system outcomes. A survey instrument that concisely measures physicians' satisfaction with various job facets can help diverse stake-holders to better understand and manage these outcomes. OBJECTIVE: To document the development and validation of a multidimensional physician job satisfaction measure and separate global satisfaction measures. DESIGN: Self-administered questionnaire: Physician Worklife Survey (PWS). SUBJECTS: A pilot study employed a national American Medical Association Masterfile sample of US primary care physicians and random samples from four states. Responses (n = 835; 55% return rate) were randomly assigned to developmental (n = 560) or cross-validation (n = 275) samples. A national sample (n = 2,325; 52% response rate) of physicians was used in a subsequent validation study. RESULTS: A 38-item, 10-facet satisfaction measure resulting from factor and reliability analyses of 70 pilot items was further reduced to 36 items. Reliabilities of the 10 facets ranged from .65 to .77. Three scales measuring global job, career, and specialty satisfaction were also constructed with reliabilities from .84 to .88. Results supported face, content, convergent, and discriminant validity of the measures. CONCLUSIONS: Physician job satisfaction is a complex phenomenon that can be measured using the PWS.