More than one dollop of cortex: patients' experiences of interprofessional care at an urban family health centre

While Canada's government has called for collaborative patient-centered care, there is a paucity of research on patients' perspectives of such interprofessional care. This qualitative study conducted at an urban health centre begins to address our knowledge gap through semi-structured interviews and narrative analysis strategies. Findings indicate that "good care" is interprofessional care in the sense that patients perceive it as based in a strong patient-professional relationship that facilitates access to and communication amongst health professionals. Patients affirmed a frequent refrain of family physicians that the most valued characteristics of a health care team are the three "A's": availability, affability and ability. While on several dimensions, the delivery of care was rooted in a patient-centered model, professionals, at points, struggled to find common ground with patients and initiated interprofessional care as a strategy for grappling with this conflict.     

Up a river! Interprofessional education and the Canadian healthcare professional of the future

The benefits of an interprofessional approach to patient care are becoming well known and the adoption of these ideas for collaboration by future healthcare professionals will be influenced by positive exposures during pre-licensure education. Although much work has been done, the establishment of interprofessional education in health care programs is still in the developmental phase in many centers. But the need for such education is obvious and urgent. Once these new professionals enter into practice, they will be expected to function as members of interprofessional teams. Therefore, they should be equipped with the skills they will need to function effectively on a team. The future of the healthcare system relies on the education of tomorrow's professionals. When we finally train healthcare professionals to perform as part of a team, “paddling in harmony”, we will be able to steer toward our goal of an efficient, sustainable and safe health care system. If we do not learn to work together, we will continue to go in circles.     

Designing an interprofessional training program for shared decision making

For implementation of patient-centered treatment in interprofessional health care units, such as rehabilitation teams, external participation (interaction between patient and health care professionals) and internal participation (communication, coordination and cooperation in the interprofessional team) need to be considered. The aim of this study is to identify the preferences of patients and health care professionals concerning internal and external participation in rehabilitation clinics, in order to develop an interprofessional shared decision-making (SDM) training program for health care professionals to enhance both types of participation. Therefore, a cross-sectional mixed-methods study was implemented in four rehabilitation clinics. The study consists of two parts: focus groups with patients and a survey of experts (senior health care professionals from medicine, psychotherapy, physical therapy and nursing). More time, more respect from the health care professionals and the desire for more participation in decision-making processes were mentioned most frequently by patients (n = 36) in the focus groups. The health care professionals (n = 32) saw most deficits in internal participation, e.g. management of feedback, talking with difficult team members and moderate conflict discussion. The results of both assessments have been used to develop an interprofessional SDM training program for implementing internal and external participation in interprofessional teams in medical rehabilitation.     

Transforming Preprofessional Health Education Through Relationship-Centered Care and Narrative Medicine

Issue: The Institute of Medicine identified health care education reform as a key to improving the error prone, costly, and unsatisfying U.S. health care system. It called for health care education that no longer focuses exclusively on the mastery of technical skills but teaches students the human dimensions of care and develops their ability to collaborate with patients and colleagues to alleviate suffering and improve health. When should this educational reform begin, by what frameworks should it be guided, and which methods should it employ are important questions to explore. Evidence: There is increasing evidence that practitioners' relational skills, such as empathy and reflection, improve patients' health outcomes. Efforts to shift education toward patient-centered care in interprofessional teams have been made at the professional level, most notably in medical schools. However, reform must begin at the preprofessional level, to start cultivation of the habits that support humane care as early as possible and protect against empathic decline and the development of counterproductive attitudes to collaboration. The conceptual basis for reform is offered by relationship-centered care (RCC), a framework that goes beyond patient-centered care and interprofessional teamwork to focus on the reciprocal human interactions at the micro, mezzo, and macro levels of care. RCC identifies practitioners' relationships with patients, colleagues, community, and self as the critical interpersonal dimensions of healthcare and describes a foundation of values, knowledge, and skills required for teaching each dimension. The teaching of these foundations can be facilitated with techniques from narrative medicine, a compatible care model that conceptualizes health care as a context in which humans exchange stories and thus require narrative competence. Implications: We suggest beginning the educational reform at the preprofessional level with the implementation of a formal curriculum based on the 4 RCC dimensions with students expected to gain beginner levels of competency on these dimensions in addition to evidence-based principles of health sciences. This requires interprofessional collaboration among health professions, social science, and liberal arts faculty and training of health professions faculty in narrative medicine. Next, we suggest engaging in incremental change in the organizational culture with professional development and team-building activities. Although we need systematic research on the efficacy of the components of the transformation, their impact on students' learning, and their costs, it is important to engage in efforts to prepare professionals who are able to respond to the complex health needs of individuals and society in the 21st century.     

The dislocation of medical dominance: making space for interprofessional care

Abstract

The historical transition of modern medicine from an autonomous profession to a team-based interprofessional practice can be described in terms of space rather than time, with “place” as the unit of analysis. Imagining modern medicine spatially was instigated by Foucault, who described medical dominance as a territorializing of both individual body spaces and public spaces – the former through the diagnostic medical gaze, the latter in a gaze of health surveillance. However, much has happened since Foucault’s (1963) analysis. The diagnostic gaze has been dispersed to develop a collaborative gaze including patients and healthcare professionals; political interests have appropriated the public health gaze; and the medical profession is subject to democratic processes of accountability. Medicine has lost its territorial imperative as new “liquid” and “nomadic” work practices emerge, making space for interprofessional care. Such dislocation of medical dominance and its multiple relocations are poorly theorised. Deleuze and Guattari distinguish between “striated” and “smooth” spaces. Striated space is associated with hierarchies and boundaries, where smooth space includes boundary crossing and democratic collaboration. Smooth or liminal spaces in hospitals, such as corridors, can paradoxically act as catalysts for collaboration or assembly democracy, affording opportunities for improvised interprofessional encounters. Such encounters can act as an antidote to planned protocols or imperatives for interprofessional collaboration.     

An interprofessional course in bioethics: Training for real-world dilemmas

Future health professionals are often educated with other students of their same discipline when, in practice, they will be working with professionals from other backgrounds to provide care for the patient. Complex issues of ethical concern are common to health professionals due to modern technology. This paper describes the evolution of an interprofessional bioethics course that had a unique combination of students and faculty. Innovative teaching methods were utilized and continuously refined based on student evaluations. Students commonly cited the interprofessional interactions as the most enjoyable part of the learning experience. Establishing a patient-centered focus and an appreciation of the contributions of other disciplines, students learned how to apply ethical decision-making to real cases. At the conclusion of the course, students reported improved attitudes toward interprofessional teamwork. This course format and teaching techniques may be applied at other universities looking for linkages to encourage consistent interprofessional collaboration across disciplines.     

Examining “success” in post-hip fracture care transitions: A strengths-based approach

Transitions between health care settings are a high-risk period for care quality and patient safety (; ), particularly for older patients – such as those with hip fracture – who have complex needs and may undergo multiple care transitions. We sought to understand the key elements of “success” in care transition. Using a strengths-based perspective (; ), we focused on interprofessional health care providers' perspectives of what constitutes a “good” care transition for elderly hip fracture patients. As part of a larger ethnographic field study, semi-structured interviews were conducted with 17 health providers across a number of disciplines employed across the continuum of post-hip fracture management in British Columbia, Canada. We found two hallmarks of “success” in care transitions: a focus on process – information gathering and communication, and a focus on outcomes – autonomy and care pathways. Strategies for promoting and improving success, such as using practitioner-driven ground-up solutions to address challenges in care transitions, are highlighted.     

An examination of students’ perceptions of their interprofessional placements in residential aged care

ABSTRACT

It is essential that health professionals are trained to provide optimal care for our ageing population. Key to this is a positive attitude to older adults along with the ability to work in teams and provide interprofessional care. There is limited evidence on the impact an interprofessional education (IPE) placement in a residential aged care facility (RACF) has on students. In 2015 in Western Australia, 51 students (30% male, median age 23 years), from seven professions, undertook a placement between 2 and 13 weeks in length at 1 RACF. Pre- and post-placement measurements of attitudes to the elderly were collected using the Ageing Semantic Differential (ASD) questionnaire and level of readiness for interprofessional learning with the Readiness for Interprofessional Learning Scale (RIPLS). A total of 47 students completed matched ASD and RIPLS surveys. The mean total score on the ASD survey decreased significantly from pre- to post-placement from 116.0 to 108.9 (p = 0.033), indicating attitudes became increasingly positive towards older adults. Significant differences post-placement were seen indicating better readiness for interprofessional learning, for two out of four subscales on the RIPLS, namely “teamwork & collaboration” (42.1–44.0; (p = 0.000)) and “positive professional identity” (18.2–19.3 (p = 0.001)). The degree of change is similar to findings from other settings. The results support IPE-focussed student placements within RACF positively influence student’s attitudes towards the older adult as well as increase student’s readiness for interprofessional learning, confirming RACF are valuable places for training health professionals.     

Family health teams: A new Canadian interprofessional initiative

Interprofessional learning (IPL) and interprofessional practice (IPP) are strategies for healthcare services' striving to improve patient care. While health professionals are enacting IPL and IPP, the capacity to understand and comprehensively map IPL and IPP activities has remained elusive. Additionally, understanding and accounting for the impact of organizational context and culture on IPL and IPP requires attention. This paper presents the “interprofessional praxis audit framework” (IPAF), which is a unique tool to address these two issues. The IPAF comprises five components: context, culture, conduct, attitudes and information. Conjoined, the components facilitate examination of an organization's enactment of IPL and IPP. Utilized within an action research methodology, the IPAF enables a synchronized inspection, whereby similarities and differences of the components are considered simultaneously, and the knowledge developed is used to promote change projects to improve patient care.     

The spiritual and pastoral dimensions of care in interprofessional contexts

Spiritual issues encompass what is most meaningful and central in human existence. During times of illness, crisis or transition spiritual issues are likely to come to the fore of human awareness for both patients and professionals. All health care professionals need to include the spiritual dimension in assessment and treatment of patients. Professionals in different disciplines have distinct contributions to make in the way they use the lens and language of their training to assess religious and spiritual issues of patients. Therefore, interprofessional dialogue and collaboration is important in understanding each other's perspective on the spiritual dimensions of care. In this article the spiritual dimensions of care are explored. The differences between pastoral, medical and nursing approaches to spiritual care are demonstrated through case examples. Guidelines for assessment of religion and spiritual information useful to health care professionals across interprofessional boundaries are presented.     

Meanings and perceptions of patient-centeredness in social work,nursing and medicine: A comparative study

Answering patients' evolving, more complex needs has been recognized as a main incentive for the development of interprofessional care. Thus, it is not surprising that patient-centered practice (PCP) has been adopted as a major outcome for interprofessional education. Nevertheless, little research has focused on how PCP is perceived across the professions. This study aimed to address this issue by adopting a phenomenological approach and interviewing three groups of professionals: social workers (n = 10), nurses (n = 10) and physicians (n = 8). All the participants worked in the same department (the General Internal Medicine department of a university affiliated hospital). Although the participants agreed on a core meaning of PCP as identifying, understanding and answering patients' needs, they used many dimensions to define PCP. Overall, the participants expressed value for PCP as a philosophy of care, but there was the sense of a hierarchy of patient-centeredness across the professions, in which both social work and nursing regarded themselves as more patient-centered than others. On their side, physicians seemed inclined to accept their lower position in this hierarchy. Gieryn's concept of boundary work is employed to help illuminate the nature of PCP within an interprofessional context.     

Repeated cross-sectional study of the longitudinal changes in attitudes toward interprofessional health care teams amongst undergraduate students

Abstract

The interprofessional education (IPE) program at Gunma University, Maebashi, Japan, uses a lecture style for first-year students and a training style for third-year students. To investigate the comprehensive implications of IPE, the change pattern of attitudes toward health care teams was examined longitudinally in pre-qualified students. The modified Attitudes Toward Health Care Teams Scale (mATHCTS) was used. The overall mean score of the mATHCTS improved significantly after the training-style IPE in their third year. Two individual items in the factor “quality of care delivery” decreased significantly during the first year. In contrast, two individual items in the factor “patient-centered care” increased significantly during the third year. These changes over time were confirmed by analyses using regression factor scores. There are at least two independent attitudes toward collaborative practice (CP) or IPE in response to IPE interventions: the attitude toward “value of IPE for health care providers” may response negatively to IPE in the early stages, and the attitude toward “value of IPE for health care receivers” positively in the later stages. These findings suggest that the continuation of mandatory IPE, which must be designed on the basis of students’ high expectations for IPE and CP on entry, may result in profound changes in attitudes amongst participating students.     

Clients as mediators of interprofessional collaboration in mental health services in Iran

Interprofessional collaboration (IPC) has long been identified as a way of providing optimal mental health services (MHS). It is important, therefore, to identify and facilitate factors driving IPC. This paper presents health professionals' experiences and perceptions regarding the clients' role as a driving factor for IPC in MHS in an Iranian context. Health professionals included nurses, physicians (general physicians and medical specialists), psychologists and consultants. Qualitative methods were employed in the form of in-depth individual interviews and focus groups to collect data from 24 professionals and 4 clients. Data analysis generated four key themes: “Clients as axis of IPC”, “Seamless services as a common incentive for IPC”, “Clients as a common interprofessional linkage” and “Clients as a driving force to achieve IPC”. From the professionals' perspective, it was found that clients had a mediating role in their collaborative relationships and practices. These findings are discussed in relation to the interprofessional literature. This paper goes on to argue that professionals need to be aware of and be trained about how to manage, as well as benefit from, the clients' fundamental role in IPC.     

Veteran Affairs Centers of Excellence in Primary Care Education: Transforming nurse practitioner education

To integrate health care professional learners into patient-centered primary care delivery models, the Department of Veterans Affairs has funded five Centers of Excellence in Primary Care Education (CoEPCEs). The main goal of the CoEPCEs is to develop and test innovative structural and curricular models that foster transformation of health care training from profession-specific “silos” to interprofessional, team-based educational and care delivery models in patient-centered primary care settings. CoEPCE implementation emphasizes four core curricular domains: shared decision making, sustained relationships, interprofessional collaboration, and performance improvement. The structural models allow interprofessional learners to have longitudinal learning experiences and sustained and continuous relationships with patients, faculty mentors, and peer learners. This article presents an overview of the innovative curricular models developed at each site, focusing on nurse practitioner (NP) education. Insights on transforming NP education in the practice setting and its impact on traditional NP educational models are offered. Preliminary outcomes and sustainment examples are also provided.     

“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 care review with medical residents: Lessons learned,tensions aired – A pilot study

Integrated interprofessional care teams are the focus of Canadian and American recommendations about the future of health care. Keeping with this, a family medicine teaching site developed an educational initiative to expose trainees to interprofessional care processes and learning (Interprofessional Care Review; IPC). A formative evaluation pilot study was completed using one-on-one interviews and a focus group (n?=?6) with family medicine residents. A semi-structured guide was utilized regarding: knowledge, skills and attitudes related to interprofessional care; their experience of the processes utilized in IPC. Data were analyzed using content analysis. Residents' perspectives on their learning revolved around four themes: changes to understanding and practice of interprofessional care; personal impact of IPC; learning about other health professionals; tension and challenges of IPC learning and clinical implementation. Residents valued the educational experience, but identified that faculty supervisors provided “mixed messages” in the value of collaborating with other health professionals. Implications regarding future educational and research opportunities are discussed.     

Evaluation of a student-led interprofessional innovative health promotion model for an underserved population with diabetes: A pilot project

Interprofessional education seeks to encourage different health professions to interact and learn together during their training process which will eventually lead to collaborative healthcare practices and improved care for patients. This study determined whether student understanding of diabetes management and the role of health professionals in diabetes care improved after the implementation of an interprofessional health promotion program. Sixty-three students from five health professions led six educational sessions concentrating on critical components of diabetes management. The longitudinal program covered topics within the Alphabet Strategy (A–G). Students were surveyed to determine their understanding of diabetes management. Data were gathered at the beginning of the study and its conclusion. Forty-seven students completed the program and the pre- and post-survey. There were significant improvements in students' knowledge of diabetes care, understanding of the roles of healthcare professionals and ability to work with other healthcare professionals. Nineteen patients completed the study. There were no significant differences in patients' diabetes knowledge, understanding of diabetes care and clinical outcomes. This study acknowledged the potential value of an interprofessional team approach to care. This innovative model could be applied to other practice settings and used for the management of other chronic diseases.     

Geriatric Care Boot Camp Series: Interprofessional education for a new training paradigm

Interprofessional education of health care professionals caring for older adults is critical to address the unique needs of geriatric patients. An interprofessional education program – the Geriatric Care Boot Camp Series (“Series”) – was designed for health care professionals to fill this education gap. The program consisted of three half-day, intensive boot camps conducted over a one-year period. A total of 112 learners participated; more than half were nurses. Data analysis revealed statistically significant increases following each boot camp in attendees’ reported knowledge about caring for older adults; statistically significant increases in comfort caring for older adults were also seen among participants in two boot camps. Attendees found the interprofessional nature of the program beneficial and said they would attend a similar program again. The Series is easily replicable, appealing to the target audience, and fulfills the need to better educate health care professionals on caring for older adults.     

Interprofessional care of people with multiple chronic conditions: An open-access resource for nursing educators

Nurses, nurse practitioners, and other healthcare professionals must be prepared to care for the growing population of patients with multiple chronic conditions, to promote patient engagement, patient self-management, and for interprofessional collaboration. Interprofessional Care of Individuals with Multiple Chronic Conditions is an open-access eLearning course designed to prepare students with these skills. The course features multimedia presentations, interactive exercises, and an immersive “day in the life of a patient-centered medical home” in which learners make decisions, receive feedback, and experience consequences in the context of real-world video scenarios. Three hundred thirty-four nurse practitioner students participated in the educational program. To evaluate the program, we conducted a paired-samples t-test to compare scores on pre and posttest evaluation surveys. There was a significant difference in the scores for applying the Chronic Care Model t (df) = 15.99; p < 0.001, coaching for self-management t (df) = 11.04; p < 0.001 and interprofessional collaboration t (df) = 3.86; p < 0.00. The majority of students were satisfied or very satisfied with the modules. Students found the immersive video scenarios to be the best feature of the course. The course is available to assist students in gaining the ability to care for patients with chronic illnesses within interprofessional practice settings.     

Team effectiveness in academic primary health care teams

Primary health care is undergoing significant organizational change, including the development of interdisciplinary health care teams. Understanding how teams function effectively in primary care will assist training programs in teaching effective interprofessional practices. This study aimed to explore the views of members of primary health care teams regarding what constitutes a team, team effectiveness and the factors that affect team effectiveness in primary care. Focus group consultations from six teams in the Department of Family Medicine at Queen's University were recorded and transcribed and qualitative analysis was used to identify themes. Twelve themes were identified that related to the impact of dual goals/obligations of education and clinical/patient practice on team relationships and learners; the challenges of determining team membership including nonattendance of allied health professionals except nurses; and facilitators and barriers to effective team function. This study provides insight into some of the challenges of developing effective primary care teams in an academic department of family medicine. Clear goals and attention to teamwork at all levels of collaboration is needed if effective interprofessional education is to be achieved. Future research should clarify how best to support the changes required for increasingly effective teamwork.