Interprofessional team debriefings with or without an instructor after a simulated crisis scenario: An exploratory case study

The value of debriefing after an interprofessional simulated crisis is widely recognised; however, little is known about the content of debriefings and topics that prompt reflection. This study aimed to describe the content and topics that facilitate reflection among learners in two types of interprofessional team debriefings (with or without an instructor) following simulated practice. Interprofessional operating room (OR) teams (one anaesthesia trainee, one surgical trainee, and one staff circulating OR nurse) managed a simulated crisis scenario and were randomised to one of two debriefing groups. Within-team groups used low-level facilitation (i.e., no instructor but a one-page debriefing form based on the Ottawa Global Rating Scale). The instructor-led group used high-level facilitation (i.e., gold standard instructor-led debriefing). All debriefings were recorded, transcribed, and thematically analysed using the inductive qualitative methodology. Thirty-seven interprofessional team-debriefing sessions were included in the analysis. Regardless of group allocation (within-team or instructor-led), the debriefings centred on targeted crisis resource management (CRM) content (i.e., communication, leadership, situation awareness, roles, and responsibilities). In both types of debriefings, three themes emerged as topics for entry points into reflection: (1) the process of the debriefing itself, (2) experience of the simulation model, including simulation fidelity, and (3) perceived performance, including the assessment of CRM. Either with or without an instructor, interprofessional teams focused their debriefing discussion on targeted CRM content. We report topics that allowed learners to enter reflection. This is important for understanding how to maximise learning opportunities when creating education activities for healthcare providers that work in interprofessional settings.     

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.     

Implementation of an interprofessional communication and collaboration intervention to improve care capacity for heart failure management in long-term care

Heart failure affects up to 20% of nursing home residents and is associated with high morbidity, mortality, and transfers to acute care. A major barrier to heart failure management in nursing home settings is limited interprofessional communication. Guideline-based heart failure management programs in nursing homes can reduce hospitalisation rates, though sustainability is limited when interprofessional communication is not addressed. A pilot intervention, ‘Enhancing Knowledge and Interprofessional Care for Heart Failure’, was implemented on two units in two conveniently selected nursing homes to optimise interprofessional care processes amongst the care team. A core heart team was established, and participants received tailored education focused on heart failure management principles and communication processes, as well as weekly mentoring. Our previous work provided evidence for this intervention’s acceptability and implementation fidelity. This paper focuses on the preliminary impact of the intervention on staff heart failure knowledge, communication, and interprofessional collaboration. To determine the initial impact of the intervention on selected staff outcomes, we employed a qualitative design, using a social constructivist interpretive framework. Findings indicated a perceived increase in team engagement, interprofessional collaboration, communication, knowledge about heart failure, and improved clinical outcomes. Individual interviews with staff revealed innovative ways to enhance communication, supporting one another with knowledge and engagement in collaborative practices with residents and families. Engaging teams, through the establishment of core heart teams, was successful to develop interprofessional communication processes for heart failure management. Further steps to be undertaken include assessing the sustainability and effectiveness of this approach with a larger sample.     

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.     

Rapid response systems and collective (in)competence: An exploratory analysis of intraprofessional and interprofessional activation factors

Abstract

The rapid response system (RRS) is a patient safety initiative instituted to enable healthcare professionals to promptly access help when a patient’s status deteriorates. Despite patients meeting the criteria, up to one-third of the RRS cases that should be activated are not called, constituting a “missed RRS call”. Using a case study approach, 10 focus groups of senior and junior nurses and physicians across four hospitals in Australia were conducted to gain greater insight into the social, professional and cultural factors that mediate the usage of the RRS. Participants’ experiences with the RRS were explored from an interprofessional and collective competence perspective. Health professionals’ reasons for not activating the RRS included: distinct intraprofessional clinical decision-making pathways; a highly hierarchical pathway in nursing, and a more autonomous pathway in medicine; and interprofessional communication barriers between nursing and medicine when deciding to make and actually making a RRS call. Participants also characterized the RRS as a work-around tool that is utilized when health professionals encounter problematic interprofessional communication. The results can be conceptualized as a form of collective incompetence that have important implications for the design and implementation of interprofessional patient safety initiatives, such as the RRS.     

Review article: Crisis resource management in emergency medicine

Effective team management is a core element of expert practice in emergency medicine. Thus far, training in emergency medicine has focussed predominantly on proficiency in medical and technical skills, with emergency physicians acquiring these ‘non‐technical’ skills in an ad hoc manner or by trial and error with varying levels of success. This paper describes a set of behaviours that, when practised in conjunction with medical and technical expertise, can reduce the incidence of clinical error and contribute to effective teamwork and the smooth running of an ED. Teaching and practice of these behaviours is now a core element of training and skills maintenance in other high‐risk areas, such as aviation, and is becoming part of the routine training for anaesthetists. They address areas, such as communication, leadership, knowledge of environment, anticipation and planning, obtaining timely assistance, attention allocation and workload distribution. We outline the application of these behaviours in the speciality of emergency medicine, and suggest that the teaching and practice of crisis resource management principles should become part of the curriculum for training and credentialing of emergency medicine specialists.     

Experiences in disaster-related mental health relief work: An exploratory model for the interprofessional training of psychological relief workers

The purpose of this study was to begin to generate an exploratory model of the disaster-related mental health education process associated with the training experiences of psychological relief workers active during the Sichuan earthquake in China. The data consisted of semi-structured interviews with 20 psychological relief workers from four different professions (social workers, psychiatric nurses, psychiatrists, and counsellors) regarding their experiences in training and ideas for improvement. The model explains the need to use a people-centred community interprofessional education approach, which focuses on role-modelling of the trainer, caring for relief workers, paying attention to the needs of the trainee, and building systematic interprofessional education strategies. The proposed model identifies areas for the comprehensive training of relief workers and aims to address the importance of people-centred mental health service provisions, ensure intentional and strategic training of relief workers using interprofessional concepts and strategies, and use culturally attuned and community-informed strategies in mental health training practices.     

Partnership to promote interprofessional education and practice for population and public health informatics: A case study

Abstract

Team-based healthcare delivery models, which emphasize care coordination, patient engagement, and utilization of health information technology, are emerging. To achieve these models, expertise in interprofessional education, collaborative practice across professions, and informatics is essential. This case study from informatics programs in the Academic Health Center (AHC) at the University of Minnesota and the Office of Health Information Technology (OHIT) at the Minnesota Department of Health presents an academic–practice partnership, which focuses on both interprofessionalism and informatics. Outcomes include the Minnesota Framework for Interprofessional Biomedical Health Informatics, comprising collaborative curriculum development, teaching and research, practicums to promote competencies, service to advance biomedical health informatics, and collaborative environments to facilitate a learning health system. Details on these Framework categories are presented. Partnership success is due to interprofessional connections created with emphasis on informatics and to committed leadership across partners. A limitation of this collaboration is the need for formal agreements outlining resources and roles, which are vital for sustainability. This partnership addresses a recommendation on the future of interprofessionalism: that both education and practice sectors be attuned to each other’s expectations and evolving trends. Success strategies and lessons learned from collaborations, such as that of the AHC-OHIT that promote both interprofessionalism and informatics, need to be shared.     

An intervention to improve interprofessional collaboration and communications: A comparative qualitative study

Interprofessional communication and collaboration are promoted by policymakers as fundamental building blocks for improving patient safety and meeting the demands of increasingly complex care. This paper reports qualitative findings of an interprofessional intervention designed to improve communication and collaboration between different professions in general internal medicine (GIM) hospital wards in Canada. The intervention promoted self-introduction by role and profession to a collaborating colleague in relation to the shared patient, a question or communication regarding the patient, to be followed by an explicit request for feedback from the partner professional. Implementation and uptake of the intervention were evaluated using qualitative methods, including 90 hours of ethnographic observations and interviews collected in both intervention and comparison wards. Documentary data were also collected and analysed. Fieldnotes and interviews were transcribed and analysed thematically. Our findings suggested that the intervention did not produce the anticipated changes in communication and collaboration between health professionals, and allowed us to identify barriers to the implementation of effective collaboration interventions. Despite initially offering verbal support, senior physicians, nurses, and allied health professionals minimally explained the intervention to their junior colleagues and rarely role-modelled or reiterated support for it. Professional resistances as well as the fast paced, interruptive environment reduced opportunities or incentive to enhance restrictive interprofessional relationships. In a healthcare setting where face-to-face spontaneous interprofessional communication is not hostile but is rare and impersonal, the perceived benefits of improvement are insufficient to implement simple and potentially beneficial communication changes, in the face of habit, and absence of continued senior clinician and management support.     

Knowledge translation: An interprofessional approach to integrating a pain consult team within an acute care unit

Management of pain in the frail elderly presents many challenges in both assessment and treatment, due to the presence of multiple co-morbidities, polypharmacy, and cognitive impairment. At Baycrest Health Sciences, a geriatric care centre, pain in its acute care unit had been managed through consultations with the pain team on a case-by-case basis. In an intervention informed by knowledge translation (KT), the pain specialists integrated within the social network of the acute care team for 6 months to disseminate their expertise. A survey was administered to staff on the unit before and after the intervention of the pain team to understand staff perceptions of pain management. Pre- and post-comparisons of the survey responses were analysed by using t-tests. This study provided some evidence for the success of this interprofessional education initiative through changes in staff confidence with respect to pain management. It also showed that embedding the pain team into the acute care team supported the KT process as an effective method of interprofessional team building. Incorporating the pain team into the acute care unit to provide training and ongoing decision support was a feasible strategy for KT and could be replicated in other clinical settings.     

Placing people in the same room is not enough: An interprofessional education intervention to improve collaborative knowledge of people with disabilities

This study evaluates a continuing interprofessional education (CIPE) intervention designed to improve the skills and knowledge related to managing people with disabilities (PWD) in the educational, healthcare, and social insurance systems, and to improve shared knowledge and promote inter-organisational collaboration. The intervention comprised both on-site and online courses where participants could design their own curriculum based on their perceived needs. A longitudinal survey study was conducted with questions about knowledge of other organisations’ work with PWD, knowledge concerning disability policies, competence in meeting PWD, shared values across organisations, and inter-organisational collaboration. Participants’ knowledge about disability, disability policy, and how other organisations work with PWD significantly increased after the intervention. Changes in shared values, attitude towards inter-organisational collaboration, or effects on actual collaboration could not be determined. The results suggest that CIPE interventions where participants are allowed to form customised curriculums may increase general knowledge about disability among professionals. Results on knowledge of and collaboration with other organisations were less conclusive, where this may be explained by an educational setting that included little interaction between course participants. To promote professional exchange and experiential learning activities, contextualized educational settings that place more focus on interaction between participants may be advised.     

From struggles to resource gains in interprofessional service networks: Key findings from a multiple case study

In interprofessional service networks, employees cross professional boundaries to collaborate with colleagues and clients with expertise and values different from their own. It can be a struggle to adopt shared work practices and deal with “multivoicedness.” At the same time, networks allow members to engage in meaningful service provision, gain a broader understanding of the service provided, and obtain social support. Intertwined network struggles and resource gains have received limited attention in the interprofessional care literature to date. The aim of the study was to investigate the learning potential of the co-existing struggles and resource gains. This article reports findings from two interprofessional networks. Interviews were conducted with 19 employees and thematically analysed. Three types of struggles and six types of resource gains of networking were identified. The struggles relate, first, to the assumptions of networking following similar practices to those in a home organisation; second, to the challenges of dealing with the multivoicedness of networking; and, third, to the experienced gap between the networking ideals and the reality of cooperation. At the same time, the network members experience gains in emotional resources (e.g., stronger sense of meaningfulness at work), cognitive resources (e.g., understanding the customer needs from alternative perspectives), and social resources (e.g., being able to rely on other professionals’ competence). Learning potential emerged from the dynamics between coexisting struggles and resource gains.     

Positive impact of crisis resource management training on no-flow time and team member verbalisations during simulated cardiopulmonary resuscitation: a randomised controlled trial

Objectives

To evaluate the impact of video-based interactive crisis resource management (CRM) training on no-flow time (NFT) and on proportions of team member verbalisations (TMV) during simulated cardiopulmonary resuscitation (CPR). Further, to investigate the link between team leader verbalisation accuracy and NFT.

Methods

The randomised controlled study was embedded in the obligatory advanced life support (ALS) course for final-year medical students. Students (176; 25.35 ± 1.03 years, 63% female) were alphabetically assigned to 44 four-person teams that were then randomly (computer-generated) assigned to either CRM intervention (n = 26), receiving interactive video-based CRM-training, or to control intervention (n = 18), receiving an additional ALS-training. Primary outcomes were NFT and proportions of TMV, which were subdivided into eight categories: four team leader verbalisations (TLV) with different accuracy levels and four follower verbalisation categories (FV). Measurements were made of all groups administering simulated adult CPR.

Results

NFT rates were significantly lower in the CRM-training group (31.4 ± 6.1% vs. 36.3 ± 6.6%, p = 0.014). Proportions of all TLV categories were higher in the CRM-training group (p < 0.001). Differences in FV were only found for one category (unsolicited information) (p = 0.012). The highest correlation with NFT was found for high accuracy TLV (direct orders) (p = 0.06).

Conclusions

The inclusion of CRM training in undergraduate medical education reduces NFT in simulated CPR and improves TLV proportions during simulated CPR. Further research will test how these results translate into clinical performance and patient outcome.     

Implementing a collaborative coaching intervention for professionals providing care to children and their families: An exploratory study

The growing complexity of healthcare requires family and interprofessional partnerships to deliver effective care. Interprofessional coaching can enhance family-centred practice and collaboration. The purpose of this study was to explore the acceptability and feasibility of collaborative coaching training to improve family centredness within acute paediatric rehabilitation. Using a participatory action design, service providers (SPs; n = 36) underwent a 6-month coaching programme involving coaching workshops, learning triads, and tailored sessions with a licensed coach. The feasibility and acceptability of coaching on SPs’ family interactions and care was explored. Measure of Processes of Care (MPOC) and MPOC-SP, a coaching skills questionnaire, and focus groups were used to evaluate the acceptability of coaching training. We found that structured coaching training was feasible and SPs reported significant improvements in their coaching skills; however, MPOC and MPOC-SP scores did not reveal significant differences. Qualitative themes indicated that clinicians are developing coaching competencies and applying these skills in clinical practice. Participants perceived that the coaching approach strengthened relationships amongst colleagues, and they valued the opportunity for interprofessional learning. Findings suggest that coaching offers promise as an approach to facilitate successful patient outcomes and improve processes of care. Preliminary findings indicate that interprofessional coaching training is acceptable, feasible, and can significantly improve SP coaching skills and improve team cohesion. Further research to study the effects of coaching on interprofessional care using validated outcome measures and to assess the impact on service delivery is recommended.