Interprofessional Care Delivery Research Articles

Advancing the Art and Science of Professional Nursing Practice With the Virtually Integrated CareSM Model.

The purpose of this article is to share the transformative vision of 2 nurse executives and how this vision paved the way for the development of a revolutionary model that changed care delivery. The CommonSpirit Health Virtually Integrated Care Team operationalized the vision by leveraging technology to develop a team-based care model that seamlessly integrates a virtual nurse as part of the care team. This article will discuss the spark that created the impetus for the creation of this metamorphic, interprofessional care delivery model and how this model unburdens the workload of the nurses to idealize the art and science of professional nursing practice.

Interprofessional care in a retirement and assisted living community: the complexity of teamwork

ABSTRACT Teamwork is an aspiration in the delivery of interprofessional care to older adults, but how does it play out in residential settings that combine independent living, assisted living, and skilled nursing care? This study investigated teamwork as an organic part of a retirement and assisted living community immersed in mission-driven care. Drawing on 44 in-depth interviews, 62 meeting observations, and five years of immersion in the setting by the first author, we explored the complex dynamics of teamwork. Our overarching findings showed that co-location aided by physical design and a mission-driven investment in care may not be sufficient to effect teamwork in a complex care environment, and that the organizational context was potentially damaging to teamwork. Our study highlights opportunities to improve teamwork and interprofessional collaboration in organizational settings that combine the provision of health and social care. Increasing expectations for teamwork outcomes may prove essential as retirement and assisted living care settings offer supportive and therapeutic environments for older adults who move between different levels of care.

Implementation, mechanisms of change and contextual factors of a complex intervention to improve interprofessional collaboration and the quality of medical care for nursing home residents: study protocol of the process evaluation of the interprof ACT intervention package

BackgroundTo improve interprofessional collaboration between registered nurses (RNs) and general practitioners (GPs) for nursing home residents (NHRs), the interprof ACT intervention package was developed. This complex intervention includes six components (e.g., shared goal setting, standardized procedures for GPs’ nursing home visits) that can be locally adapted. The cluster-randomized interprof ACT trial evaluates the effects of this intervention on the cumulative incidence of hospital admissions (primary outcome) and secondary outcomes (e.g., length of hospital stays, utilization of emergency care services, and quality of life) within 12 months. It also includes a process evaluation which is subject of this protocol. The objectives of this evaluation are to assess the implementation of the interprof ACT intervention package and downstream effects on nurse–physician collaboration as well as preconditions and prospects for successive implementation into routine care.MethodsThis study uses a mixed methods triangulation design involving all 34 participating nursing homes (clusters). The quantitative part comprises paper-based surveys among RNs, GPs, NHRs, and nursing home directors at baseline and 12 months. In the intervention group (17 clusters), data on the implementation of preplanned implementation strategies (training and supervision of nominated IPAVs, interprofessional kick-off meetings) and local implementation activities will be recorded. Major outcome domains are the dose, reach and fidelity of the implementation of the intervention package, changes in interprofessional collaboration, and contextual factors. The qualitative part will be conducted in a subsample of 8 nursing homes (4 per study group) and includes repeated non-participating observations and semistructured interviews on the interaction between involved health professionals and their work processes. Quantitative and qualitative data will be descriptively analyzed and then triangulated by means of joint displays and mixed methods informed regression models.DiscussionBy integrating a variety of qualitative and quantitative data sources, this process evaluation will allow comprehensive assessment of the implementation of the interprof ACT intervention package, the changes induced in interprofessional collaboration, and the influence of contextual factors. These data will reveal expected and unexpected changes in the procedures of interprofessional care delivery and thus facilitate accurate conclusions for the further design of routine care services for NHRs.Trial registrationClinicalTrials.gov NCT03426475. Registered on 07/02/2018.

Health Communication and Inter-professional Care in Context of Multimorbidity Management: Assessment of Health Professional Curricular Focus in India

To meet the long term care demands of chronic diseases as well as multimorbidity, healthcare providers from different disciplines need to work collaboratively in practice. This requires healthcare providers to be appropriately trained on delivery of inter-professional care (IPC) and health communication aspects during formative professional years. In this study, we have looked at the prevailing undergraduate and postgraduate healthcare professional curricula to understand the focus on health communication and on IPC for the delivery of multidisciplinary care for multimorbidity management. We observe that while there are exclusive courses on health communication being delivered at different levels, the focus on IPC is still in stages of infancy. The IPC component is just beginning to be woven into the health professional curricula through elements like competency-based curriculum, rotational posting, inter-departmental engagements. At the same time, the need to put curricular attention on multimorbidity is also highlighted here. There remains wider scope for strengthening learning on health communication and IPC among different disciplines within the curricula in the context of multimorbidity. We expect our findings to provide key inputs to academic planners and policy makers towards the introduction of adequate curricular components for addressing multimorbidity along with necessary prescriptions for health communication and IPC in India.

Infusing geriatrics expertise in health professions education through interprofessional faculty development

ABSTRACT As the population of older adults continues to grow, the need for health care professionals trained in the delivery of interprofessional care for older adult patients is critical. The purpose of this paper is to detail the outcomes of an interprofessional, geriatrics training program for healthcare professionals with a faculty appointment. Specifically, we gathered outcomes at four levels: reactions/satisfaction, learning, behavioral, and organizational. Our findings suggest that programs structured like the Faculty Development Program (FDP) have the potential to increase the amount of geriatrics content introduced in already existing health professions curricula, as well as to offer faculty needed training in how to provide their students with interprofessional learning experiences.

A multilevel study of patient-centered care perceptions in mental health teams

BackgroundThe successful combination of interprofessional collaboration in multidisciplinary teams with patient-centered care is necessary when it comes to delivering complex mental health services. Yet collaboration is challenging and patient-centered care is intricate to manage. This study examines correlates of patient-centered care such as team adaptivity and proactivity, collaboration, belief in interprofessional collaboration and informational role self-efficacy in multidisciplinary mental health teams.MethodA cross-sectional multilevel survey design was used, based on self-administered bilingual validated questionnaires. Participants (N=314) were mental health professionals and managers working in public primary care or specialized mental health services, in inpatient or outpatient settings.ResultsThis study showed that belief in interprofessional collaboration’s relationship with patient-centered perceptions is increased in teams with high collaboration. Collaboration is also found as a mediator, representing a process by which team adaptive and proactive behaviors are transformed into positive patient-centered perceptions.ConclusionsOur results were in line with recent studies on team processes establishing that collaboration is a key component in multilevel examinations of predictors of patient-centered care. In terms of practice, our study showed that multidisciplinary teams should know that working hard on collaboration is an answer to the complexity of patient-centered care. Collaboration is related to the teams’ ability to respond to its challenges. It is also related to individuals’ beliefs central to the delivery of interprofessional care.

Examining Interprofessional teams structures and processes in the implementation of a primary care intervention (Health TAPESTRY) for older adults using normalization process theory

BackgroundMany countries are engaged in primary care reforms to support older adults who are living longer in the community. Health Teams Advancing Patient Experience: Strengthening Quality [Health TAPESTRY] is a primary care intervention aimed at supporting older adults that involves trained volunteers, interprofessional teams, technology, and system navigation. This paper examines implementation of Health TAPESTRY in relation to interprofessional teamwork including volunteers.MethodsThis study applied Normalization Process Theory (NPT) and used a descriptive qualitative approach [1] embedded in a mixed-methods, pragmatic randomized controlled trial. It was situated in two primary care practice sites in a large urban setting in Ontario, Canada. Focus groups and interviews were conducted with primary care providers, clinical managers, administrative assistants, volunteers, and a volunteer coordinator. Data was collected at 4 months (June–July 2015) and 12 months (February–March 2016) after intervention start-up. Patients were interviewed at the end of the six-month intervention. Field notes were taken at weekly huddle meetings.ResultsOverall, 84 participants were included in 17 focus groups and 13 interviews; 24 field notes were collected. Themes were organized under four NPT constructs of implementation: 1) Coherence- (making sense/understanding of the program’s purpose/value) generating comprehensive assessments of older adults; strengthening health promotion, disease prevention, and self-management; enhancing patient-focused care; strengthening interprofessional care delivery; improving coordination of health and community services. 2) Cognitive Participation- (enrolment/buy-in) tackling new ways of working; attaining role clarity. 3) Collective Action- (enactment/operationalizing) changing team processes; reconfiguring resources. 4) Reflective Monitoring- (appraisal) improving teamwork and collaboration; reconfiguring roles and processes.ConclusionsThis study contributes key strategies for effective implementation of interventions involving interprofessional primary care teams. Findings indicate that regular communication among all team members, the development of procedures and/or protocols to support team processes, and ongoing review and feedback are critical to implementation of innovations involving primary care teams.Trial registrationClinicalTrials.gov, no. NCT02283723 November 5, 2014. Prospectively registered.

Grassroots to Global: The Future of Nursing Leadership.

The 2018 International Nursing Administration Research Conference, Grassroots to Global, was held in Atlanta, Georgia, with attendees from 38 US states, Canada, and China. Presenters discussed the need for nurse leaders to be prepared to partner with those inside and outside of healthcare to create innovative, interprofessional care delivery models; advocate for advancements in technology to address healthcare access shortages; and lead new areas of research that can drive policy change to support nurse leaders in long-term care and the essential role of the nurse manager in creating optimal practice environments for quality outcomes. This article will report on these important insights.

Practicing interprofessional communication competencies with health profession learners in a palliative care virtual simulation: A curricular short report

Abstract This 6-week learning activity used an online virtual reality environment through Second Life® to advance interprofessional education with a convenience sample of undergraduate and graduate health professions learners through a simulated palliative and end-of-life care conference. The activity was implemented in four phases: scheduling, pre-learning, virtual simulation engagement, and a guided reflection discussion for closure. Four learning objectives guided the activity and addressed learner ability to: critique individual team communication performance using selected sections of the Interprofessional Collaborator Assessment Rubric (ICAR)1, demonstrate at least two specific communication skills while participating in the activity, share a list of the patient/family goals for end-of-life care, and propose at least three different strategies that could be used in their future practice to facilitate effective interprofessional care delivery. Faculty used a grading rubric to assess learner achievement of the four learning objectives. A mixed methods approach evaluated the effectiveness of the activity and effect on self-reported learner attitudes and future practice. This educational resource was an effective, accessible, and low-risk learning modality for advancing interprofessional competencies in education for practice. Teaching strategies that emphasize situated learning and reflective learning support interprofessional competency development. Use of virtual reality technologies engages learners in realistic scenarios in a safe environment free from the risk of harm to patients and families, allowing small groups of learners to meet synchronously online, and providing an alternative to face-to-face synchronous scheduling of multiple health professions disciplines, thus reducing strain on program budgets and scheduling logistics. Materials are shared and may be adapted to prepare learners for other contexts of practice.

Advancing Hospice and Palliative Care Social Work Leadership in Interprofessional Education and Practice

ABSTRACTThe importance of interprofessional collaboration in achieving high quality outcomes, improving patient quality of life, and decreasing costs has been growing significantly in health care. Palliative care has been viewed as an exemplary model of interprofessional care delivery, yet best practices in both interprofessional education (IPE) and interprofessional practice (IPP) in the field are still developing. So, too, is the leadership of hospice and palliative care social workers within IPE and IPP. Generating evidence regarding best practices that can prepare social work professionals for collaborative practice is essential. Lessons learned from practice experiences of social workers working in hospice and palliative care can inform educational efforts of all professionals. The emergence of interprofessional education and competencies is a development that is relevant to social work practice in this field. Opportunities for hospice and palliative social workers to demonstrate leadership in IPE and IPP are presented in this article.

A qualitative study of nurse practitioner promotion of interprofessional care across institutional settings: Perspectives from different healthcare professionals

ObjectiveInterprofessional care, an aim of institutional healthcare settings globally, promotes safe, cost-effective, quality care. How professionals act to enable interprofessional care has not been described. The nurse practitioner role, with its expertise in both medicine and nursing, is known to enhance collaboration and promote interprofessional care delivery. The objective of this study was to identify, from the healthcare professionals' perspective, nurse practitioner strategies used to enhance interprofessional care. MethodA hermeneutic phenomenology design was employed. Healthcare professionals from acute care hospitals and associated long-term care residences (n = 6) in one Canadian province were invited to participate. Individual interviews were held with healthcare professionals (n = 52) who regularly work with a nurse practitioner. The participants were asked to share experiences that held significance or value in promoting interprofessional care. ResultsFour valued role attributes were identified; consistent role presence, time to focus on the patient, effective communication, and respectful centrality. Identified strategies extending from the attributes included knowledge sharing, respectful negotiation, identifying patient issues, being open and transparent, listening to opinions, bridging professions, and working as the hub of the group. Multiple types of interprofessional relationships were perceived, with the hierarchical type as the most common. ConclusionsNurse practitioners in acute care hospital and long-term care settings have valued attributes that can promote interprofessional care. Effective strategies to promote interprofessional care emerge from these role attributes. However, the interprofessional relationship type perceived could enhance or impede the contribution of the strategies to interprofessional care promotion.

Prioritization of patients for comprehensive medication review by a clinical pharmacist in family medicine.

This pilot study describes and evaluates the clinical pharmacy priority (CP2) score. We hypothesize that patients with high CP2 scores are more likely to receive a medication recommendation after comprehensive medication review (CMR) than patients with lower scores. Prioritization of patients for CMR by a clinical pharmacist in family medicine could enhance the provision of interprofessional care within the patient-centered medical home. The CP2 score was developed collaboratively by the research team and is derived from 11 patient-specific factors extracted from the electronic health record. To evaluate the utility of the score, CMR was performed prospectively by a clinical pharmacist for patients with appointments between October 1 and December 31, 2012, at 2 University of Colorado family medicine clinics. CMR was performed for 1107 patient appointments. Of these, 101 were identified as having received a medication recommendation from the clinical pharmacist. For patients with a CP2 score of 0 to 2, 2 of 588 charts (0.3%) reviewed received a recommendation (level 1). The proportion increased to 37 of 358 (10.3%) for scores of 3 to 7 (level 2), 40 of 119 (33.6%) for scores of 8 to 10 (level 3), and 22 of 42 (52.4%) for scores of ≥11 (level 4). Compared with CP2 scores in level 1, patient appointments were more likely to receive a medication recommendation after CMR in level 2 (relative risk [RR], 30.4; 95% confidence interval [CI], 7.4-125.3), in level 3 (RR, 98.8; 95% CI, 24.2-403.3), and in level 4 (RR, 154; 95% CI, 37.5-632.8). Patients with higher CP2 scores were more likely to receive a medication recommendation after CMR by a clinical pharmacist than patients with lower scores. The CP2 score could be used by clinical pharmacists in family medicine to enhance the efficient and effective delivery of interprofessional care.

Interprofessional Care and Role of Team Leaders

Interprofessional care is an essential part of the health service delivery system. It helps to achieve improved care and to deliver the optimal and desired health outcomes by working together, sharing and learning skills. Health care organisation is a collective sum of many leaders and followers. Successful delivery of interprofessional care relies on the contribution of interprofessional care team leaders and health care professionals from all groups. The role of the interprofessional care team leader is vital to ensuring continuity and consistency of care and to mobilise and motivate health care professionals for the effective delivery of health services. Medical professionals usually lead interprofessional care teams. Interprofessional care leaders require various skills and competencies for the successful delivery of interprofessional care.

Delivering Interprofessional Care in Intensive Care: A Scoping Review of Ethnographic Studies

The sustained clinical and policy interest in the United States and worldwide in quality and safety activities initiated by the release of To Err Is Human has resulted in some high-profile successes and much disappointment. Despite the energy and good intentions poured into developing new protocols and redesigning technical systems, successes have been few and far between, leading some to argue that more attention should be given to the context of care. To examine the insights provided by qualitative studies of interprofessional care delivery in intensive care. A total of 532 article abstracts were reviewed. Of these, 24 met the inclusion criteria. Articles focused on the nurse-physician relationship, patient safety, patients' families and end-of-life care, and learning and cognition. The findings indicated the complexities and nuances of interprofessional life in intensive care and also that much needs to be learned about team processes. The fundamental insight that interprofessional interactions in intensive care do not happen in a historical, social, and technological vacuum must be brought to bear on future research in intensive care if patient safety and quality of care are to be improved.

A Comprehensive Model to Build Improvement Capability in a Pediatric Academic Medical Center

Cincinnati Children’s Hospital Medical Center developed a comprehensive model to build quality improvement (QI) capability to support its goal to transform its delivery system through a series of training courses. Two online modules orient staff to basic concepts and terminology and prepare them to participate more effectively in QI teams. The basic program (Rapid Cycle Improvement Collaborative, RCIC) is focused on developing the capability to use basic QI tools and complete a narrow-scoped project in approximately 120 days. The Intermediate Improvement Science Series (I2S2) program is a leadership course focusing on improvement skills and developing a broader and deeper understanding of QI in the context of the organization and external environment. The Advanced Improvement Methods (AIM) course and Quality Scholars Program stimulate the use of more sophisticated methods and prepare Cincinnati Children’s Hospital Medical Center (CCHMC) and external faculty to undertake QI research. The Advanced Improvement Leadership Systems (AILS) sessions enable interprofessional care delivery system leadership teams to effectively lead a system of care, manage a portfolio of projects, and to deliver on CCHMC’s strategic plan. Implementing these programs has shown us that 1) a multilevel curricular approach to building improvement capability is pragmatic and effective, 2) an interprofessional learning environment is critical to shifting mental models, 3) repetition of project experience with coaching and feedback solidifies critical skills, knowledge and behaviors, and 4) focusing first on developing capable interprofessional improvement leaders, versus engaging in broad general QI training across the whole organization, is effective.

The future delivery of oncology care: Thoughts on the impact of quality improvement, personalized medicine, and integrating interprofessional collaboration.

19 Background: A significant thrust within recent innovation has been focused on improving the quality of diagnostics and system adherence to guidelines; equally important are attempts to improve patient-specific therapy plans, or personalized medicine. These two approaches—quality improvement and personalized medicine—have equally laudable goals toward improving cancer care and outcomes, yet have not been fully examined for their concomitant impacts, particularly among and within interprofessional teams, in which a mix of health care providers present varied foci within the oncology care delivery process. Methods: Twenty phone-based qualitative interviews were facilitated with community-based medical oncologists in active practice in July 2012. Transcripts of the interview sessions were examined through grounded qualitative analysis, and overall findings are presented. Results: Oncologists hold varied definitions of personalized medicine, yet share understanding of the central nature of the patient within personalized medicine care delivery. More varied are oncologists’ perceptions of the goals and value of implementation of quality improvement initiatives, which range from those focused on pragmatic concerns of the oncology clinic, such as patient flow, to the quality of clinical decision-making and outcomes. Oncologists value well-functioning and clearly defined roles within interprofessional teams within oncology practices, both among other clinicians and allied team members. However, functional and perceptional gaps remain in the practical application of quality improvement objectives within interprofessional teams and within the implementation of personalized oncology care delivery. Conclusions: This exploratory qualitative analysis approach provides grounded identification of practicing oncologists’ definitions of quality improvement, personalized medicine, interprofessional care delivery, and the practical interrelationships between these domains, enabling a framework for future research and quality initiatives.

The intersection of informatics and interprofessional collaboration

Institute of St Michael’sHospital, Toronto, Ontario, CanadaINTRODUCTIONAstheinterprofessionalfieldhasgrown,ithasbenefitedfromthe inclusion of perspectives byother academic fields such associology and economics (Reeves, 2010). Informatics isanother field that can play a role in enhancing interprofes-sional collaboration and care. This editorial explores how wecan establish synergies between the field of informatics andthe interprofessional field. We first provide some definingcharacteristics to help understand the nature of informatics.We also discuss the array of functional (and dysfunctional)uses when designing and implementing informatics inhealthcare.CHARACTERISTICS AND FUNCTIONAs a starting point we need to understand what informaticsis. First and foremost, informatics is more than justtechnology. Rather it is an interdisciplinary science thatincorporates fields such as information science, decisionscience and organizational theory. Although definitions vary,informatics involves the study of information and com-munication systems in healthcare and the application ofthese systems for decision-making and other tasks (Coiera,2003; Shortliffe & Blois, 2006). A key focus of informatics isthe development of solutions to address informationprocessing and communication issues. These solutionsinclude not only improved ways to collect data but alsoimprovedwaysto analyze and communicate data so it can beincorporated into care delivery. Although many informaticssolutions involve some aspect of technology, we should notassume that cutting-edge technology is necessary in allcircumstances.Associating informatics solely with technology is unfor-tunate and puts the emphasis on the tools (i.e. computers)rather than the collaborative processes and work undertakenas part of healthcare delivery (Musen, 2002). Coiera (1995)states that informatics is as much about computers ascardiology is about the stethoscope. A technology-centricperspective also implies that technology is always necessaryto solve informatics problems. Rather the use of technologyfor problem solving should be dependent upon the task athand. For example, the surgical safety checklist is aninformation management tool that lists the necessary tasksthat need to be completed pre- and post-surgery (Weiseret al., 2010). Although not a high technology tool, studieshave indicated it may be beneficial for enhancinginterprofessional communication and patient safety in anoperating room context (e.g. Haynes et al., 2009).USES AND ABUSES IN HEALTHCAREInformatics tools and applications have enhanced manyaspects of healthcare delivery. For example, Kuziemsky et al.(2012) described how informatics applications can providepatient, service delivery and administrative benefits inhospital and community settings. These benefits includedimproved administrative decision-making about resourcescheduling, the ability to provide patient-centered care andthelinkageofpatientrecordsover timetosupportcontinuityof care. The asynchronous and distributed nature ofcollaborative care delivery has benefited from informaticstools that facilitate communication and informationexchange across team members (Reddy, Gorman, &Bardram, 2011). Simulation tools and models have alsobeen found to be beneficial for supporting the delivery ofinterprofessional care (e.g. Wisborg, Ronning, Beck, &Brattebo, 2008).A key challenge for informatics is to ensure that itsresearch is relevant and meaningful for healthcare pro-fessionals. While well-designed health information technol-ogy (HIT) can enhance delivery, poorly designed systems

Developing midwifery and complementary medicine collaboration: The potential of interprofessional education?

A higher percentage of referrals to complementary and alternative medicine (CAM) by midwives can be linked to their affinity with CAM. However, midwifery education does not commonly include CAM as part of the curriculum leaving potential for misinformation and unsafe practice. An approach to CAM education which encourages collaboration between all care providers is needed to ensure safe, woman-centred maternity care. Whilst a number of models have been considered in health education they are not without their limitations when aiming to promote interprofessional collaboration. It is proposed through this paper that improved communication between midwives and qualified CAM practitioners may be developed through employing the interprofessional education model. This model develops attributes for collaborative practice and improves the delivery of interprofessional care. Achieving this collaboration is vital for safe, woman-centred care for the many pregnant women accessing CAM and conventional care for their pregnancy and birth.

Nurse practitioners in Ontario primary healthcare: Referral patterns and collaboration with other healthcare professionals

The purpose of this study is to examine referrals of nurse practitioners providing primary healthcare (PHC NPs) to better understand how PHC NPs collaborate with other healthcare professionals and contribute to interprofessional care. The analysis is based on the data from a survey of 378 PHC NPs registered in Ontario, Canada in 2008. Overall, 69% of PHC NPs made referrals to family physicians (FPs) and 67% of PHC NPs received referrals from FPs. Almost 50% of PHC NPs had bidirectional referrals between them and FPs. Eighty-nine percent of PHC NPs made referrals to specialist physicians. Bidirectional referrals between PHC NPs and social workers and mental health workers were common in family health teams and community health centers. Patterns of referrals (bidirectional, unidirectional and no referrals) between PHC NPs and FPs, social workers, mental and allied health workers in various practice settings indicate development of collaborative relationships between PHC NPs and other healthcare professionals and reflect the influence of practice models on delivery of interprofessional care. These findings are discussed in light of the development of NPs' role and integration of PHC NPs in the Ontario healthcare system. Implications for policy changes and future research are also suggested.