An interprofessional collaborative practice approach to transform heart failure care: An overview

Interprofessional collaborative practice (IPCP) approaches to health care are increasingly recognized as necessary to achieve the Triple Aim—improved health of the population, improved patient care experience, and improved affordability of care. This paper introduces and provides an overview of an interprofessional intervention to improve a healthcare team, healthcare system, and patient outcomes for hospitalized patients with heart failure. In this paper, we describe the overall project resulting from a workforce training grant and the proposed series of future papers resulting from the interprofessional intervention. Collectively, these papers will describe the results of a unique IPCP approach on team, system, and patient outcomes as well as describe and compare organizational and leadership traits that affect collaborative practice. Our hope is that the intervention approaches, evaluation results, and lessons learned described in these papers will help further the efforts to spread IPCP approaches to transforming health care.     

医护协作型心衰护理门诊的建立及管理

通过开设心衰专病医护协作性护理门诊、规范诊疗护理流程,为心衰患者提供更有效快捷的医疗护理服务,保持护理的延续性和持久性。通过选拔及培训护理专家、完善心衰护理门诊医护协作配置、明确专科护理门诊工作流程和内容建立医护协作型心衰护理门诊;对心衰护理门诊的运作进行质量控制等管理。自医护协作型心衰护理门诊开诊以来,共接诊1910人次。开展医护协作型心衰护理门诊,制定了心衰护理门诊规范标准,规范心衰管理工作,并为专科护士提供了职业发展平台。     

The role of interprofessional collaboration for intimate partner violence in psychiatric care: A research and development project

In Finland, policy requirements have demanded providers to work collaboratively together with regard to intimate partner violence (IPV). This research and development project seeks to identify efficient tools for stopping IPV. The project included staff training to recognize and respond to IPV, the development of a research-based guideline for use in the care situations of victims and perpetrators and the integration of the guideline into practices and staff development. Networking was developed during the project through interprofessional and multiagency collaboration, whereas appraisal information was collected at different stages of the process. This paper focuses on the issues of interprofessional collaboration, and uses psychiatric care as an example. There is some evidence that interprofessional interventions reduce the cost of patient care and improve the quality of IPV services. That is why it is important to discuss these issues and solve possible problems arising in interprofessional patient care.     

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

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

Effectiveness of an interprofessional education model based on the transtheoretical model of behaviour change to improve interprofessional collaboration

This study aimed to assess the effectiveness of an interprofessional education model (IPE) based on the transtheoretical model to improve the participants’ interprofessional collaborative practice. The study was conducted in Iran using a controlled before-and-after study design. The participants (n = 91) were the residents of emergency medicine and nurses of the emergency units from two teaching hospitals affiliated to Iran University of Medical Sciences. The participants in the intervention group (n = 40) were 22 residents and 18 nurses. The control group (n = 51) consisted of 20 residents and 31 nurses. The participants were classified based on their stage of readiness to change. The interventions were two-day workshops for each stage (i.e., attitude and intention). We used the Interprofessional Collaborator Assessment Rubric (ICAR) to assess the effectiveness of the developed model. The interprofessional collaboration of the participants in the intervention and control groups was assessed at four time points before and after the intervention in the real emergency unit environment. Student’s t-test and repeated measures analysis of variance (RM-ANOVA) were used to analyse the data. We used partial eta-squared (η²) for effect size calculations. The mean values of ICAR scores in the intervention and control groups were 95.63 ± 19.14 and 89.19 ± 16.11 before the intervention. The mean values of ICAR scores at 3 months after the intervention were 99.82 ± 22.32 and 88.29 ± 16.87 in the intervention and control groups, respectively. After 6 months, the mean values of ICAR scores of the intervention and control groups were 98.6 ± 23.40 and 87.98 ± 16.01, respectively. The results showed that the intervention had a medium educational effect size (partial η² = 0.06) on performance of the participants. Our results showed that an IPE model that is tailored to the learners’ stage of readiness to change improves interprofessional collaboration in the participants. The developed model could be applied for improving interprofessional collaborative performance in other IPE programmes.     

Adherence to clinical guidelines in heart failure (HF) outpatients: Impact of an interprofessional HF team on evidence-based medication use

Abstract

Clinical systolic heart failure (HF) guidelines specify recommendations for ACE inhibitors (ACEI), angiotensin receptor blockers (ARB), and beta blockers according to doses used in clinical trials. However, many HF patients remain suboptimally treated. We sought to determine which provider type, between an interprofessional HF team, non-HF cardiologists, and primary care physicians (PCP), most optimally manages HF medications and doses. A retrospective chart review was performed on adult patients at an academic county hospital with an ejection fraction ≤40% and a diagnosis of HF, seen by a single provider type (HF team, cardiologist, or PCP) at least twice within a 12-month period. Utilization rates of any ACEI/ARB and any beta blocker were robust across provider types, though evidence-based ACEI/ARB and beta blocker were greatest from the HF team. Doses of evidence-based therapies dropped markedly in the non-HF team groups. The percent of patients prescribed optimal doses of an evidence-based ACEI/ARB AND beta blocker was 69%, 33%, and 25% for the HF team, cardiologists and PCPs, respectively (p?<?0.0167). Patients followed by the HF team were more frequently prescribed evidence-based medications at optimal doses. This supports using specialized interprofessional HF teams to attain greater adherence to evidence-based recommendations in treating systolic HF.     

Attitudes towards interprofessional collaboration among primary care physicians and nurses in Singapore

Interprofessional collaboration (IPC) has been shown to improve patient outcomes, cost efficiency, and health professional satisfaction, and enhance healthy workplaces. We determined the attitudes of primary care physicians and nurses towards IPC and factors facilitating IPC using a cross-sectional study design in Singapore. A self-administered anonymous questionnaire, based on the Jefferson Scale of Attitudes toward Physician-Nurse Collaboration (JSAPNC), was distributed to primary healthcare physicians and nurses working in National Healthcare Group Polyclinics (N = 455). We found that the mean JSAPNC score for physicians was poorer than that for nurses (50.39 [SD = 4.67] vs. 51.61 [SD = 4.19], respectively, mean difference, MD = 1.22, CI = 0.35–2.09, p = .006). Nurses with advanced education had better mean JSAPNC score than nurses with basic education (52.28 [SD = 4.22] vs. 51.12 [SD = 4.11], respectively, MD = 1.16, CI = 0.12–2.20, p = .029). Male participants had poorer mean JSAPNC score compared to females (50.27 [SD = 5.02] vs. 51.38 [SD = 4.22], respectively MD = 1.11, CI = 0.07–2.14, p = .036). With regression analysis, only educational qualification among nurses was independently and positively associated with JSAPNC scores (p = .018). In conclusion, primary care nurses in Singapore had more positive attitudes towards IPC than physicians. Among nurses, those with advanced education had more positive attitudes than those with basic education. Greater emphasis on IPC education in training of physicians and nurses could help improve attitudes further.     

Cognitive Aids for Role Definition (CARD) to improve interprofessional team crisis resource management: An exploratory study

This study aimed to assess the perceived value of the Cognitive Aids for Role Definition (CARD) protocol for simulated intraoperative cardiac arrests. Sixteen interprofessional operating room teams completed three consecutive simulated intraoperative cardiac arrest scenarios: current standard, no CARD; CARD, no CARD teaching; and CARD, didactic teaching. Each team participated in a focus group interview immediately following the third scenario; data were transcribed verbatim and qualitatively analysed. After 6 months, participants formed eight new teams randomised to two groups (CARD or no CARD) and completed a retention intraoperative cardiac arrest simulation scenario. All simulation sessions were video recorded and expert raters assessed team performance. Qualitative analysis of the 16 focus group interviews revealed 3 thematic dimensions: role definition in crisis management; logistical issues; and the “real life” applicability of CARD. Members of the interprofessional team perceived CARD very positively. Exploratory quantitative analysis found no significant differences in team performance with or without CARD (p > 0.05). In conclusion, qualitative data suggest that the CARD protocol clarifies roles and team coordination during interprofessional crisis management and has the potential to improve the team performance. The concept of a self-organising team with defined roles is promising for patient safety.     

Designing and evaluating an effective theory-based continuing interprofessional education program to improve sepsis care by enhancing healthcare team collaboration

Informed consent is a reflection of patients' autonomy in health decision-making. The main responsibility lies with the doctor. In practice, the nurses' contributions matter as well. This paper presents a case study that explored physicians' perceptions of the existing informed consent process, their suggestions for improvement and their views on the nurses' roles in this process. A two-phase approach was conducted. First, six physicians with different expertise were interviewed. Second, after attending presentations about informed consent and physician–patient relationship principles, 32 physicians were asked to complete an open-ended questionnaire. Data were analyzed by two independent coders and emerging themes were compared. The results of the questionnaires and the interviews were triangulated. Of 32 physicians attending the presentations, 24 (75%) completed the questionnaire. The results indicate that physicians perceive patients, physicians and the hospital as main factors influencing the process of informed consent. Physicians' misinterpretation of informed consent principles, (mis)perceptions regarding patients and their family, and deficient hospital policy and support challenge the informed consent process. Physicians value nurses' roles, provided nurses have sufficient clinical knowledge, sound comprehension of informed consent principles and effective communication skills.     

Developing health and social care planning in collaboration

Abstract

Collaboration between different professions in community care for older people is often both difficult and complex. In this project, a participatory action research (PAR) was conducted in order to support the professions involved in the care for older people to develop individualized health and social care plans. Cases from daily work were discussed in different professional groups over a period of one year. A key finding was that lack of knowledge regarding the other professions' field of expertise and their underlying professional culture and values was a barrier in their collaboration. However, as the continuous reflective dialogue process progressed, the participants began to reflect more about the importance of collaboration as a prerequisite to achieve the best possible care for the recipient. This process of reflection led to the often complex needs of the care recipients being given a more central position and thus care plans being better tailored to each person's needs.     

Linking integrative medicine with interprofessional education and care initiatives: Challenges and opportunities for interprofessional collaboration

Although the fields of interprofessional education and collaboration (IPE/IPC) and integrative medicine (IM) are both recognised and clearly advancing as of late, a curious paradox exists: IPE/IPC and IM are both concerned with communicating about and attempting to resolve differences between healthcare professions with the fundamental goal of improving patient outcomes, yet they have remained quite distinct fields of research. This disconnect could be due to the fact that one field deals with integration within the general paradigm of biomedicine (IPE/IPC), while the other addresses integration across paradigms (IM). It is an opportune time for a critical comparison between the two. First, the main themes of IM are summarised as they are reflected in the IM literature. Second, a comparative analysis is presented focusing on the significant similarities and differences between IPE/IPC and IM. The final section addresses the question: What key learning areas from IM could benefit and enhance IPE/IPC?     

Exploring the nature of interprofessional collaboration and family member involvement in an intensive care context

Abstract

Little is known about the nature of interprofessional collaboration on intensive care units (ICUs), despite its recognition as a key component of patient safety and quality improvement initiatives. This comparative ethnographic study addresses this gap in knowledge and explores the different factors that influence collaborative work in the ICU. It aims to develop an empirically grounded team diagnostic tool, and associated interventions to strengthen team-based care and patient family involvement. This iterative study is comprised of three phases: a scoping review, a multi-site ethnographic study in eight ICUs over 2 years; and the development of a diagnostic tool and associated interprofessional intervention-development. This study’s multi-site design and the richness and breadth of its data maximize its potential to improve clinical outcomes through an enhanced understanding of interprofessional dynamics and how patient family members in ICU settings are best included in care processes. Our research dissemination strategy, as well as the diagnostic tool and associated educational interventions developed from this study will help transfer the study’s findings to other settings.     

The use of virtual communities of practice to improve interprofessional collaboration and education: findings from an integrated review

The recent growth in online technology has led to a rapid increase in the sharing of health related information globally. Health and social care professionals are now using a wide range of virtual communities of practice (VCoPs) for learning, support, continuing professional education, knowledge management and information sharing. In this article, we report the findings from a review of the literature that explored the use of VCoPs by health and social care professionals to determine their potential for interprofessional education and collaboration. We employed integrated review methods to search and identify relevant VCoP articles. We undertook searches of PubMed and Google Scholar from 2000, which after screening, resulted in the inclusion of 19 articles. A thematic analysis generated the following key issues related to the use of VCoPs: ‘definitions and approaches’, ‘technological infrastructure’, ‘reported benefits’, ‘participation issues’, ‘trust and privacy and ‘technical ability’. Based on the findings from this review, there is some evidence that VCoPs can offer an informal method of professional and interprofessional development for clinicians, and can decrease social and professional isolation. However, for VCoPs to be successful, issues of privacy, trust, encouragement and technology need to be addressed.     

A review of instruments to measure interprofessional collaboration for chronic disease management for community-living older adults

It is acknowledged internationally that chronic disease management (CDM) for community-living older adults (CLOA) is an increasingly complex process. CDM for older adults, who are often living with multiple chronic conditions, requires coordination of various health and social services. Coordination is enabled through interprofessional collaboration (IPC) among individual providers, community organizations, and health sectors. Measuring IPC is complicated given there are multiple conceptualisations and measures of IPC. A literature review of several healthcare, psychological, and social science electronic databases was conducted to locate instruments that measure IPC at the team level and have published evidence of their reliability and validity. Five instruments met the criteria and were critically reviewed to determine their strengths and limitations as they relate to CDM for CLOA. A comparison of the characteristics, psychometric properties, and overall concordance of each instrument with salient attributes of IPC found the Collaborative Practice Assessment Tool to be the most appropriate instrument for measuring IPC for CDM in CLOA.     

Doctors' assistants' views of case management to improve chronic heart failure care in general practice: a qualitative study

Title. Doctors’ assistants’ views of case management to improve chronic heart failure care in general practice: a qualitative study. Aim. This paper is a report of a study to explore the views, concerns and experiences of doctors’ assistants of case management for patients with chronic heart failure, while experiencing the new role of being a case manager within the Heidelberg Integrated Case Management trial. Background. Case management is being investigated as part of a randomised controlled trial aiming to improve care for patients with chronic systolic heart failure. In a complex, multifaceted intervention, trained doctors’ assistants (equivalent to a nursing role) adopted new tasks using standardised case management involving telephone monitoring, home visits and diagnostic screening. Method. In April 2007, 3 months after implementation of the intervention programme, 27 doctors’ assistants participated in four focus group interviews discussing their views on, and experiences of, case management. Thematic analysis of the data was undertaken. Findings. Participants believed that the most positive factors in case management were about interaction with patients, including opportunities for identifying disease and psychosocial problems. However, barriers included lack of time allocated to perform case management in addition to their normal role and poor cooperation within the practice team. According to the doctors’ assistants, the routine implementation of case management was acceptable, feasible and effective in improving the management of patients with chronic systolic heart failure. Conclusion. Case management enhanced the role of doctors’ assistants, leading to increased awareness of the perspective of patients with chronic disease. In the wider international primary care practice nursing context, the orchestrated delegation of tasks using specific case management may be a promising strategy for improving the quality of care of chronically ill patients and enabling patient self‐management.     

The correlation of standard heart failure assessment and palliative care questionnaires in a multidisciplinary heart failure clinic

Context

Heart failure (HF) is a leading cause of death and disability, and despite optimal care, patients may eventually require palliative care. Little is known about how palliative care questionnaires (the Edmonton Symptom Assessment Scale [ESAS] and the Palliative Performance Scale [PPS]) perform compared with HF assessment using the New York Heart Association (NYHA) functional class and the Kansas City Cardiomyopathy Questionnaire (KCCQ).

Objectives

To assess the utility of a palliative care questionnaire in patients with HF.

Methods

One hundred and five patients (mean age = 65 years, 76% male, mean ejection fraction = 28%) followed in an HF clinic were surveyed with the NYHA, PPS, ESAS, and KCCQ.

Results

The PPS and ESAS were each correlated to the NYHA class (P < 0.0001 for both) and the KCCQ score (PPS: R² = 0.57; ESAS: R² = −0.72; both P < 0.0001). There were 33 patients who either died (10 deaths) or were hospitalized (26 patients) for more than one year. In addition to age and gender, a higher (worse) ESAS score trended toward significance (P = 0.07) and a lower (worse) PPS was a significant (P = 0.04) predictor of all-cause hospitalization or death.

Conclusion

In a cohort of HF patients, we found a modest correlation with NYHA class and KCCQ assessment with the PPS and ESAS, two standard palliative care questionnaires. Given the difficulty in identifying patients with HF eligible for palliative or hospice care, these tools may be of use in clinical practice.     

A communication intervention for nursing staff in chronic care

Title.  A communication intervention for nursing staff in chronic care.
Aim.  The paper is a report of a study conducted to evaluate the effect of a brief, focused educational intervention on the quality of verbal interactions between nursing staff and patients in a chronic care facility.
Background.  Positive nurse–patient communication in chronic care is crucial to the quality of life and well-being of patients. Despite this, patients are dissatisfied with these interactions and nursing staff indicate the need for additional training.
Method.  A repeated-measures design was used to collect data between April 2003 and February 2004, by audiotaping verbal interactions between nursing staff and patients during morning care. Baseline data were analysed and an educational intervention was developed based on the results of the pretest. Five months after the educational intervention, interactions between the same nursing staff and patients were audiotaped. Twenty-seven randomly chosen patients and selected nursing staff participated in the study. Data were analysed using a qualitative comparative method, and a quantification technique was developed to compare the quality of the interactions before and after the intervention.
Findings.  Preintervention interactions were task-oriented, superficial and dominated by nursing staff. Results statistically significantly improved after the intervention was implemented. Nursing staff were less authoritative, used more solution-focused communication and interactions had a statistically significantly higher positive ratio.
Conclusion.  Brief interventions can change nursing staff's communication practice and they realized the importance of effective communication as a fundamental component to deliver patient-focused care.     

Becoming an interprofessional practitioner: factors promoting the application of pre-qualification learning to professional practice in maternity care

Abstract

Teamwork and collaboration have been recognized as essential competencies for health care providers in the field of maternity care. Health care policy and regulatory bodies have stressed the importance of Interprofessional Education (IPE) for learners in this field; however, there is little evidence of sustained application of pre-qualifying IPE to the realm of interprofessional collaboration (IPC) in practice following qualification. The aim of this research was to understand how newly qualified midwives applied their IPE training to professional practice. A purposive sample of midwifery students, educators, new midwives and Heads of Midwifery from four universities in the United Kingdom participated in semi-structured interviews, questionnaires and focus groups. Qualitative, grounded theory methodology was used to develop the emerging theory. Newly qualified midwives appeared better able to integrate their IPE training into practice when IPE occurred in a favourable learning environment that facilitated acquisition and application of IPE skills and that recognized the importance of shared partnership between the university and the clinical workplace.