Interprofessional Health Care Providers Research Articles

ECHO Care of the Elderly: Innovative Learning to Build Capacity in Long-term Care.

BackgroundOlder adults are entering long-term care (LTC) homes with more complex care needs than in previous decades, resulting in demands on point-of-care staff to provide additional and specialty services. This study evaluated whether Project ECHO® (Extension for Community Healthcare Outcomes) Care of the Elderly Long-Term Care (COE-LTC)—a case-based online education program—is an effective capacity-building program among interprofessional health-care teams caring for LTC residents.MethodsA mixed-method, pre-and-post study comprised of satisfaction, knowledge, and self-efficacy surveys and exploration of experience via semi-structured interviews. Participants were interprofessional health-care providers from LTC homes across Ontario.ResultsFrom January–March 2019, 69 providers, nurses/nurse practitioners (42.0%), administrators (26.1%), physicians (24.6%), and allied health professionals (7.3%) participated in 10 weekly, 60-minute online sessions. Overall, weekly session and post-ECHO satisfaction were high across all domains. Both knowledge scores and self-efficacy ratings increased post-ECHO, 3.9% (p = .02) and 9.7 points (p < .001), respectively. Interview findings highlighted participants’ appreciation of access to specialists, recognition of educational needs specific to LTC, and reduction of professional isolation.ConclusionWe demonstrated that ECHO COE-LTC can be a successful capacity-building educational model for interprofessional health-care providers in LTC, and may alleviate pressures on the health system in delivering care for residents.

Using Grounded Theory to Inform the Human-Centered Design of Digital Health in Geriatric Palliative Care

ContextDigital health offers innovative mechanisms to engage in palliative care, yet digital systems are typically designed for individual users, rather than integrating the patient's caregiving “social convoy” (i.e., family members, friends, neighbors, formal caregiving supports) to maximize benefit. As older adults with serious illness increasingly rely on the support of others, there is a need to foster effective integration of the social convoy in digitally supported palliative care. ObjectivesConduct a qualitative study examining patient, social convoy, and health care provider perspectives on digital health for palliative care to inform the design of future digital solutions for older adults with serious illness and their social convoy. MethodsGrounded theory approach using semi-structured interviews (N = 81) with interprofessional health care providers, older adults with serious illness, and their social convoy participants at home, clinic, or Zoom. Interviews were conducted using question guides relevant to the participant group and audio-recorded for verbatim transcription. Two coders lead the inductive analysis using open and axial coding. ResultsThematic results aligned with the human-centered design framework, which is a participatory approach to the design process that incorporates multiple user stakeholders to develop health solutions. The human-centered design process and corresponding theme included the following: 1) Empathy: Patient, Caregiver, and Provider Experience reports participants' experience with managing serious illness, caregiving, social support, and technology use. 2) Define: Reactions to Evidence-Based Care Concepts and Barriers illustrates participants' perspectives on the domains of palliative care ranging from symptom management to psychosocial-spiritual care. 3) Ideation: Desired Features reports participant recommendations for designing digital health tools for palliative care domains. ConclusionDigital health provides an opportunity to expand the reach of geriatric palliative care interventions. This paper documents human-centered preferences of geriatric palliative care digital health to ensure technologies are relevant and meaningful to health care providers, patients, and the caregiving social convoy.

AN EXPLORATION OF HOME CARE NURSES’ EXPERIENCES IN DEPRESCRIBING OF MEDICATIONS FOR OLDER ADULTS IN THE COMMUNITY

The aim of this study is to explore the barriers and enablers of deprescribing from the perspectives of home care nurses, as well as to conduct a scalability assessment of an educational plan to address the learning needs of home care nurses about deprescribing. This study employed an exploratory qualitative descriptive research design, using scalability assessment from two focus groups with a total of eleven home care nurses in Ontario, Canada. Thematic analysis was used to derive themes about home care nurse’s perspectives about barriers and enablers of deprescribing, as well as learning needs in relation to deprescribing approaches. Home care nurse’s identified challenges for managing polypharmacy in older adults in home care settings, including a lack of open communication and inconsistent medication reconciliation practices. Additionally, inadequate partnership and ineffective collaboration between inter-professional healthcare providers were identified as major barriers to safe deprescribing. Further, home care nurses highlighted the importance of raising awareness about deprescribing in the community, and they emphasized the need for a consistent and standardized approach in educating healthcare providers, informal caregivers, and older adults about the best practices of safe deprescribing. Nurses in home care play a vital role in medication management and, therefore, educational programs must be developed to support their awareness and understanding of deprescribing. Study findings highlighted the need for the future improvement of existing programs about safer medication management through the development of a supportive and collaborative relationship among the home care team, frail older adults and their informal caregivers.

Partnerships for improving dementia care in primary care: Extending access to primary care‐based memory clinics in Ontario, Canada

In Ontario, Canada, the Primary Care Collaborative Memory Clinic (PCCMC) model of dementia care provides a team-based assessment and management service that has demonstrated increased capacity for dementia care at the primary care level. PCCMCs are established following completion of a multi-faceted memory clinic training programme. Evidence of the success of this care model has been demonstrated primarily in practice settings with integrated interprofessional healthcare providers (HCPs). Desire to implement PCCMCs in less-resourced family practice settings without integrated interprofessional HCPs has resulted in partnerships with community agencies and services to create the multifaceted teams needed for this care model. The purpose of this study was to describe the key lessons learned in the development and implementation of 18 PCCMCs in primary care practice models without integrated interprofessional HCPs. Mixed methods included tracking of clinic referrals, pre- (N=122) and post- (N=71) training surveys to assess practice changes and factors facilitating and challenging clinic implementation. Interviews were conducted with 40 team members to identify key lessons learned. Key enablers were access to training, organisational/ management and care provider support, availability of infrastructure supports and clinic coordination. Data were collected between January 2012 and January 2017. PCCMCs were challenged by a lack of sustainable funding, inadequate infrastructure support, competing priorities, maintaining adequate communication among team members, and coordinating multiple schedules. Suggestions to support longer term sustainability were identified, many addressing identified challenges such as securing sustainable funding, and ensuring partners understand the importance of their role and succession planning. This study demonstrated that by establishing community partnerships and leveraging existing community resources, the PCCMC model is generalisable to multiple family practice settings including those without integrated interprofessional staff. Lessons learned can inform the development of interventions for complex chronic conditions requiring interprofessional support in primary care.

Exploration of home care nurse’s experiences in deprescribing of medications: a qualitative descriptive study

ObjectivesThe aim of this study is to explore the barriers and enablers of deprescribing from the perspectives of home care nurses, as well as to conduct a scalability assessment of...

Implementing an Inpatient Acupuncture Service for Pain and Symptom Management: Identifying Opportunities and Challenges.

Objective: To explore an interprofessional group of health care providers' perspectives on the facilitators and barriers to implementation of an inpatient acupuncture service for pain and symptom management. Design: Qualitative. Setting: An urban, academic, tertiary care health system. Subjects: Key interprofessional health care providers, including physicians, nurses, and administrators. Methods/interventions: We used interviews and focus group with questions guided by the Promoting Action on Research Implementation in Health Services framework to explore three domains of implementation-evidence, context, and facilitation. Data were analyzed using content analysis. Results: Thirty health professionals participated in 11 interviews and 1 focus group. We identified 12 codes or topics, grouped into 3 categories: (1) facilitators to implementation, (2) barriers to implementation, and (3) strategies to promote successful implementation. Health professionals' awareness of acupuncture was high, and the positive support was based on beliefs that acupuncture fills a biomedical gap in treatment and adds institutional value by enhancing the reputation of the health system. Many thought that to provide comprehensive care, acupuncture should be available to inpatients, but opinions varied on the appropriateness and timing of acupuncture in patients' disease or care trajectory. Concerns about inconsistencies in insurance coverage and resulting expenses patients may incur were noted. Strategies to overcome implementation challenges included ensuring buy-in, setting appropriate expectations of the benefits of acupuncture, and educating patients and providers. Conclusions: Our study finds clear support for acupuncture. These strong endorsements were the foundation of facilitating factors that can guide implementation of acupuncture in the inpatient setting. Although we also identified potential barriers to implementation that must be addressed, we also report a number of actionable steps to operationalize evidence-based acupuncture to patients who are inpatients.

Wound management: Investigating the interprofessional decision-making process.

Our aim is to develop a robust socio-geographical transferable theory outlining the basic social process used by members of an interprofessional health care team when making decisions around wound care management. Using a qualitative multigrounded theory approach, three focus groups were held at the Royal Victoria Regional Health Centre in Barrie, Ontario, Canada, comprised of 13 clinicians who participate in wound care decision-making. Data were analysed using an approach developed for multigrounded theory. A Critical Realist theoretical lens was applied to data analysis in the development of conclusions. Ten categories were identified before thematic saturation. Category interactions developed a perceived basic social process outlining how interprofessional clinicians determine how they approach wound care decisions: patient factors, scope of practice, equipment and supplies, internal clinician factors, knowledge and education, interprofessional team, assessment, wound care specialist consultation, and care plan, as well as documentation and communication. Understanding how wound care decision-making is determined by interprofessional health care providers will assist clinical leaders and policy makers in creating a foundation for determining resource allocation, allowing clinicians to use evidence-based practice to improve patient and clinician satisfaction, wound healing time, decrease costs, and prevent wound recurrence.

An International Interprofessional Study of Mental Models and Factors Delaying Neuroimaging of Critically Head-Injured Children Presenting to Emergency Departments.

Thousands of head-injured children are cared for by interprofessional teams in emergency departments every day. Teams must balance performing time-consuming interventions with safe transport for neuroimaging. This study aims to describe and compare providers' perspectives on the transfer of head-injured children to neuroimaging and factors contributing to delays. Participants were interprofessional health care providers involved in the care of head-injured children at sites in the United Kingdom, the United States, and New Zealand. They first viewed a 3-minute video of a child with a severe head injury presenting to their resuscitation bay. Next, they were presented with 5 physiologically different simulated scenarios and asked to report whether interventions were required before transporting each patient to neuroimaging. Then, they reported team and system factors contributing to delays in neuroimaging. Two hundred forty of 296 providers completed the intervention. The percentage of providers reporting that they would directly transport to neuroimaging without intervention was 89% for "stable," 49% for "Cushing's triad," 26% for "hypoxic," 25% for "tachycardic," and 5% for "extremis." There were differences noted in responses by profession for the hypoxia and tachycardia cases. No differences were noted between trainees and attending physicians for any cases. The most frequent factors reported as delaying neuroimaging were team decision making and waiting for equipment, medications, and scanner availability. There is variability in providers' perspectives on the interventions required before transporting severely head-injured patients for imaging. Diverse team and system factors contribute to delays in imaging.

EDUCATING HOME CARE NURSES ABOUT DEPRESCRIBING APPROACHES TO PROMOTE ACTIVE LIVING OF FRAIL OLDER ADULTS AT HOME

Deprescribing is considered to be an essential part of the prescribing process where healthcare providers carefully assess the need for backing off when medication dosages are too high, or stopping medications that are no longer needed on an ongoing basis. One important role of nurses in homecare is medication management, and therefore educational training must be developed to support homecare nurses in the development of their awareness and understanding of de-prescribing approaches to help enable the opportunities for active and independent living of the frail elders at home. This study used qualitative exploratory research design, consisting of two focus group interviews with eleven homecare nurses in Ontario, Canada. Content analysis method was used for data analysis process. The findings of the study illustrate that there is a need for undertaking deprescribing approach from homecare nurse’s perspective. Nurses indicated that lack of communication, education, and collaboration among inter-professional healthcare providers act as major barrier to practice safe deprescribing approaches. Furthermore, participants have acknowledged that there is a need for basic education of deprescribing for healthcare providers, informal caregivers, and older adults. The outcome of this project includes the development of innovative training tools that help support homecare nurses in identifying at risk older adults who are vulnerable in maintaining their independence in ADL and IADL due to polypharmacy. Our research will help lead to the future development of programs about safer medication management which will foster a supportive and collaborative relationship between the homecare team, frail elders and their informal caregivers.

Systems thinking and incivility in nursing practice: An integrative review.

There is a critical need for nurses and interprofessional healthcare providers to implement systems thinking (ST) across international borders, addressing incivility and its perilous effects on patient quality and safety. An estimated one million patients die in hospitals worldwide due to avoidable patient-related errors. Establishing safe and civil workplaces using ST is paramount to promoting clear, level-headed thinking from which patient-centered nursing actions can impact health systems. The purpose of the paper is to answer the research question, What ST evidence fosters the effect of workplace civility in practice settings? Whittemore and Knafl's integrative review method guided this study. The quality of articles was determined using Chu etal.'s Mixed Methods Assessment Tool. Thirty-eight studies were reviewed. Themes emerged describing antecedents and consequences of incivility as embedded within complex systems, suggesting improvements for civility and systems/ST in nursing practice. This integrative review provides information about worldwide incivility in nursing practice from a systems perspective. Several models are offered as a means of promoting civility in nursing practice to improve patient quality and safety. Further study is needed regarding incivility and resultant effects on patient quality and safety.

Do not confuse multidisciplinary task management in nursing homes with interprofessional care!

In usual care the perceived interactions between professionals are called collaboration. Obviously physicians and all healthcare professionals do not work interprofessionally according to definitions from the literature. This study provided evidence of the awareness that interprofessional collaboration in usual care is situational and fragmentary organised.

Healthcare Provider Perceptions of Causes and Consequences of ICU Capacity Strain in a Large Publicly Funded Integrated Health Region: A Qualitative Study.

Discrepancy in the supply-demand relationship for critical care services precipitates a strain on ICU capacity. Strain can lead to suboptimal quality of care and burnout among providers and contribute to inefficient health resource utilization. We engaged interprofessional healthcare providers to explore their perceptions of the sources, impact, and strategies to manage capacity strain. Qualitative study using a conventional thematic analysis. Nine ICUs across Alberta, Canada. Nineteen focus groups (n = 122 participants). None. Participants' perspectives on strain on ICU capacity and its perceived impact on providers, families, and patient care were explored. Participants defined "capacity strain" as a discrepancy between the availability of ICU beds, providers, and ICU resources (supply) and the need to admit and provide care for critically ill patients (demand). Four interrelated themes of contributors to strain were characterized (each with subthemes): patient/family related, provider related, resource related, and health system related. Patient/family-related subthemes were "increasing patient complexity/acuity," along with patient-provider communication issues ("paucity of advance care planning and goals-of-care designation," "mismatches between patient/family and provider expectations," and "timeliness of end-of-life care planning"). Provider-related factor subthemes were nursing workforce related ("nurse attrition," "inexperienced workforce," "limited mentoring opportunities," and "high patient-to-nurse ratios") and physician related ("frequent turnover/handover" and "variations in care plan"). Resource-related subthemes were "reduced service capability after hours" and "physical bed shortages." Health system-related subthemes were "variable ICU utilization," "preferential "bed" priority for other services," and "high ward bed occupancy." Participants perceived that strain had negative implications for patients ("reduced quality and safety of care" and "disrupted opportunities for patient- and family-centered care"), providers ("increased workload," "moral distress," and "burnout"), and the health system ("unnecessary, excessive, and inefficient resource utilization"). Engagement with frontline critical care providers is essential for understanding their experiences and perspectives regarding strained capacity and for the development of sustainable strategies for improvement.

Explaining Student Interest and Confidence in Providing Care for Older Adults: The Role of Demographics and Life Experiences.

America's aging population needs interprofessional health care providers committed to providing high-quality, patient-centered care. Considering the often negative attitudes held by health care students about older adults and the impact that can have on their care, it is important to explore factors that influence student attitudes and desire to provide geriatric care. Five hundred seventy-two students pursuing nursing, physical therapy, athletic training, dietetics, and social work degrees were surveyed. Students reported demographic factors, amount of contact with older adults, how rewarding that contact had been, and confidence and interest in working with older adults. Higher levels of confidence were associated with gender, studying nursing or physical therapy, and being older. Overall, confidence and interest were positively correlated with (a) positive attitudes toward aging, (b) contact frequency, and (c) quality experiences with older adults. Therefore, confident students with an interest in working with the geriatric population upon graduation have more exposure and more rewarding experiences with older adults before entering their program. [Journal of Gerontological Nursing, 43(3), 13-18.].

Self-Administered Mind-Body Practices for Reducing Health Disparities: An Interprofessional Opinion and Call to Action.

Health disparities (HD) continue to persist in the United States which underscores the importance of using low-cost, accessible, evidence-based strategies that can improve health outcomes, especially for chronic conditions that are prevalent among underserved minority populations. Complementary/integrative health modalities, particularly self-administered mind-body practices (MBP), can be extremely useful in reducing HD because they are intrinsically patient-centered and they empower patients to actively engage in self-care of health and self-management of symptoms. Interprofessional healthcare providers and patients can engage in powerful partnerships that encompass self-administered MBP to improve health. This is a call to action for interprofessional researchers to engage in high-quality research regarding efficacy and cost-effectiveness of self-administered MBP, for practitioners to engage patients in self-administered MBP for health promotion, disease prevention, and symptom management, and for healthcare institutions to integrate self-administered MBP into conventional health practices to reduce HD in their communities.

Diabetes Management and Education in Older Adults: The Development of a National Consensus of Key Research Priorities.

Diabetes in older adults is increasing in its prevalence and complexity. To date, little research has been done to inform current diabetes management, including education and support, in older adults in Canada. The objective of this interactive national workshop was to develop key research priorities for future research related to diabetes in older adults. Workshop participants comprised interprofessional healthcare providers, decision makers and policy makers from across Canada. Approximately 30 individuals attended an interactive 2-day meeting that included expert presentations and group consensus building using an electronic meeting system as well as nominal group techniques. The results of the 2-day meeting found more than 50 ideas that were summarized into 5 overall themes, with 14 subquestions, reflecting areas such as 1) identifying relevant outcomes for patients, providers and decision makers; 2) diabetes prevention; 3) the impact of diabetes on older adults and informal caregivers; 4) risk assessment tools and 5) effective models of care across a variety of healthcare settings. To date, this workshop is the first of its kind and follows suit with other international working groups and associations. The research priorities developed through consensus from this workshop set forward a research agenda for diabetes in older adults in Canada.

Interprofessional Education: Oral Health and Mechanically Ventilated Critically Ill Adults

Abstract Introduction The PowerPoint presentation with audio and embedded video clips presents an overview of the relationship of oral health to overall systemic health in mechanically ventilated a...

Connection Versus Disconnection: Examining Culturally Competent Care in the Neonatal Intensive Care Unit

Culturally competent health care is of critical importance; however, it is presented as a frequent challenge in health care settings. This study explored cross-cultural care from the health care provider perspective within two tertiary level Neonatal Intensive Care Units (NICUs). Fifty eight inter-professional health care providers (HCP) participated in focus groups. Participants identified perceived care-related experiences of newly immigrated parents whose infant received care in the NICU as well as health care provider perspectives on delivering that care. Results identified core processes of “connection” and “disconnection,” which appeared to have a substantial bearing on NICU experience and interaction. Connection comprised congruity, synergy, and “fit,” and resulted in an enhanced relationship between the family and HCP. Disconnection, in contrast, entailed a lack of “fit” and in some cases, misunderstanding and/or conflict between the family and a member or members of the health care team. Connection and disconnection occurred at various junctures of NICU care. These junctures reflected interaction between the family and HCP at the bedside and/or at the level of the unit, hospital, or community at large. Implications for practice, policy, and research are discussed.

Using a conflict conceptual framework to describe challenges to coordinated patient care from the physicians' and pharmacists' perspective

In an effort to increase cost-effectiveness of health care and reduce overall costs, patient-centered medical homes have been proposed to spur fundamental changes in the way primary care is delivered. One of the chief principles that describe a patient-centered medical home is that care is organized across all elements of the broader health care system, including community pharmacies. To identify and describe challenges derived from a conflict management framework to a physician-pharmacist approach to coordinating patient care. A descriptive, exploratory, non-experimental study was conducted in Wisconsin (U.S. State) from June to December, 2011. Data were collected through two rounds of face-to-face interviews with physicians and community pharmacists. The first round involved one-on-one interviews with pharmacists and physicians. The second round brought pharmacist-physician dyads together in an open-ended interview exploring issues raised in the first round. Content analysis was guided by a conflict management conceptual framework using NVivo 10 qualitative software. A total of four major themes emerged from the conflict analysis of interviews that illustrate challenges to coordinated patient care: Scarce resources, technology design and usability, insurance constraints, and laws and policy governing patient care. The study findings indicate that both groups of health care professionals work within an environment of conflict and have to negotiate the challenges and strains that exist in the current health care system. Their need to work together, or interdependence, is primarily challenged by scarce resources and external interference. Efforts to coordinate patient care through teams of inter-professional health care providers will be more successful if they acknowledge the inherent conflict that exists. Efforts should be made to provide an infrastructure for interdependence and to support interpersonal communication.

The Many Faces of Moral Distress Among Clinicians: Introduction

This narrative symposium illuminates the problem of clinician moral distress. NIB editorial staff and narrative symposium editors, Cynda Rushton, PhD, RN, FAAN and Renee Boss, MD, MHS, developed a call for stories, which was sent to several list serves and posted on Narrative Inquiry in Bioethics' website. The request for personal stories from inter-professional healthcare providers asked them to: identify specific clinical situations that give rise to moral distress; discuss the sources of this distress; reflect on how they experienced moral distress-physically, psychologically, socially, or spiritually; assess how they managed their situations; and offer suggestions for avoiding future problems of a similar nature. Twelve stories are found in the print version of the journal and an additional eight supplemental stories are published online only through Project MUSE. The clinicians describe a wide range of experiences with patients, other clinicians, and their own professional and personal identities. Embedded in each of the narratives are deeply felt emotions that accompany their experiences of moral distress. Katherine Brown-Saltzman (a nurse), Alisa Carse (a philosopher), Zhanna Bagdasarov and Shane Connelly (industrial-organizational psychologists), and Nancy Berlinger (a bioethicist) provided commentaries.

Teambuilding across healthcare professions: The ELDER project

BackgroundThe key to ensuring quality care for older adults is a nursing workforce that collaborates across professions and provider levels (Wright M.C., Phillips-Bute, B.G., Petrusa, E.R., Griffin, K.L., Hobbs, G.W., & Taekman, J.M. (2008). Assessing teamwork in medical education and practice: Relating behavioural teamwork ratings and clinical performance. Med Teach, 29, 1-9). PurposeTo improve communication and teamwork among interprofessional health care providers (HCPs) by using innovative teambuilding activities over three years. MethodsParticipants: 97 multi-disciplinary HCPs from five long term or home care agencies in an underserved region of New England. Participants attended six interactive sessions focused on teambuilding skills through the use of role play, case studies, games, exercises and teambuilding strategies. The J. A. Hartford Foundation's (John A. Hartford Foundation. (2001). The John A. Hartford Foundation Geriatric Interdisciplinary Team Training (GITT) Program. Available at: http://www.nygec.org/index.cfm?section_id=26&sub_section_id=18&page_id=98) Geriatric Interdisciplinary Team Training (GITT) instrument and Interdisciplinary Teamwork IQ test were used to measure changes in knowledge and attitudes. ResultsT tests performed on matched pre/post GITT instruments (n=26) revealed no significant change, although scores improved slightly from pre: (71%) to post test (73.3%) (p=.39). Teamwork IQ scores also improved slightly though not significantly. Qualitative data gathered suggest that teambuilding exercises were helpful in practice and allowed for better understanding of other provider roles. ConclusionsRarely is a variety of health care disciplines invited to participate in educational opportunities together. The interprofessional small group methodology used is a replicable model with potential to overcome barriers in communication and teamwork skills.