Non-medical Health Professionals Research Articles

Implementing a digital platform for patient navigation: Experience of a Brazilian oncology network.

560 Background: Cancer treatment involves the use of long-term therapies, mostly oral, and new drug developments are improving patients’ survival, bringing hope, but also more complexity to care delivered. Trials using digital platforms for patient remote monitoring demonstrated increased survival and patient satisfaction, but demands a great effort in implementation and multidisciplinary team engagement. Oncoclínicas Group is a large multidisciplinary private oncology network present in 35 Brazilian cities with 133 units that have specialists in the areas of oncology, radiotherapy, hematology and bone marrow transplantation, multidisciplinary teams, complementary care and the most advanced in integrated assistance and individualized treatment. Here we describe our experience in developing and implementing the platform OC por Você. Methods: In July 2022, Oncoclinicas Group partnered with Meu Médico startup to develop an EHR-integrated platform that was adherent to Oncoclínicas safety needs. The agile development process incorporated user-centered design principles that required engagement from patients, clinicians, and health care systems. Defined features: a chat center specifically designed for the patient and multidisciplinary team with decision tree for patients specifics needs; embedded telemedicine; digital prescription; sending images or documents; view of the patient chart, health professionals agenda, pathology test results; access to treatment protocols for each cancer type. In January 2023 a first wave was planned, implementing in three sites. From April through June 2023, seven waves of implementation were planned. The Oncoclínicas Digital Team trained all health professionals before launch, and educational videos and digital cards were developed for both health professionals and patients. Results: From January through April 2023, 149 users downloaded the mobile platform. There were 11 doctors, 44 non-medical health professionals and 94 patients. A total of 199 chats were initiated, with 3409 messages exchanged and 20 teleconsultations. From April through June 2023, the platform was implemented in a total of 21 units, 10 cites, where 990 users downloaded the mobile platform. There were 173 doctors, 318 non-medical health professionals and 499 patients. A total of 870 chats were initiated, with messages exchanged and 224 teleconsultations. Until December 2025 other waves of implementation will happen to complete the full implementation process. Conclusions: Implementing a digital mobile platform for cancer patient care is feasible in a private oncology practice network in Brazil. Several pitfalls were identified, especially the need for constant engagement with the care provider team. Systems of this nature should be encouraged in order to keep the communication channel open to patients and families, improving the care to be rendered.

Long-term sleep apnea CPAP via tracheostomy in children with tracheomalacia: 20-year experience.

Children with severe tracheobronchomalacia may need placements of tracheostomies and long-term mechanical ventilation. Due to financial constraints, continuous positive airway pressure (CPAP) machines commonly used to treat obstructive sleep apnea in adults have been utilized to deliver positive distending pressure to such children at our institution for more than 20 years with favorable outcomes. We, therefore, reported our experience with 15 children using this machine. This is a retrospective study during 2001-2021. Fifteen children, 9 boys, aged ranged 3 months-5.6 years, were discharged home with CPAP via tracheostomies. All had co-morbidities including gastroesophageal reflux (n = 9, 60%), neuromuscular disorders (n = 6, 40%), genetic abnormalities (n = 6, 40%), cardiac diseases (n = 4, 27%) and chronic lungs (n = 3, 20%). Eight (53%) children were aged less than 1 year old. The smallest child was aged 3 months old, weighing 4.9 kg. All caregivers were relatives and non-medical health professionals. The 1-month and 1-year readmission rates were 13% and 66% respectively. No factor-associated unfavorable outcomes were statistically identified. No complications related to CPAP malfunction were found. Five (33%) were weaned off CPAP, and 3 died (2 from sepsis and 1 from a sudden unknown cause). We first reported the use of sleep apnea CPAP via tracheostomy in children with severe tracheomalacia. In limited-resource countries, this simple device may be another option for long-term invasive ventilatory support. The CPAP use in children with tracheobronchomalacia requires adequately trained caregivers.

A Qualitative Investigation on COVID-19 Vaccine Hesitancy in Neurodivergent Communities.

Vaccine hesitancy is a major barrier to vaccination, hindering the success of vaccine efforts and thereby increasing public health risk to viral diseases, including COVID-19. Neurodivergent (ND) individuals, including individuals with an intellectual and/or developmental disability, have demonstrated a heightened risk of hospitalization and death due to COVID-19, highlighting the need for further research specifically on ND communities. We conducted a qualitative analysis using in-depth interviews with medical professionals, non-medical health professionals and communicators, and ND individuals or their caregivers. Using a thematic coding analysis methodology, trained coders identified major themes according to 24 distinct codes spanning across the categories of (1) barriers to vaccination; (2) facilitators to vaccination; and (3) suggestions for improving vaccine confidence. Qualitative findings identify misinformation, perception of vaccine risk, sensory sensitivities, and structural hardship as the most significant barriers to COVID-19 vaccination. We highlight the importance of accommodations to vaccination for the ND community alongside coordinated efforts by healthcare leaders to direct their communities to accurate sources of medical information. This work will inform the direction of future research on vaccine hesitancy, and the development of programs specific to the ND community's access to vaccines.

Interprofissionalidade e terapia ocupacional: percepção dos participantes do Programa de Aprimoramento Profissional em um serviço de reabilitação

Abstract The “Prof. Gabriel O. S. Porto” Center for Studies and Research in Rehabilitation (CEPRE) participated in the Professional Improvement Program (PAP) for non-medical health professionals from 1994 to 2019. This study aimed to understand and assess the occurrence of interprofessionality and the role of occupational therapy among the PAP participants working at CEPRE. This descriptive, qualitative research involved 18 interns from the areas of speech therapy, education, psychology, social service, and occupational therapy who joined PAP at CEPRE in 2018. Data were collected through semi-structured interviews that included both closed and open questions addressing experiences and insights during PAP. These interviews were audio recorded and later transcribed. The data were assessed by content analysis. The results showed that professional improvement positively influenced knowledge about other areas, especially occupational therapy, which was facilitated through interdisciplinary classes. The content analysis revealed that shared moments were important for the occurrence of patient-centered interprofessional practice with a focus on comprehensiveness, and that this space further strengthened the overall work.

The attitudes of mental health professionals on the employability of people with mental illness: A different view limiting employment rehabilitation.

ObjectivesMental health professionals are becoming increasingly involved in the process of employment rehabilitation of persons with psychiatric disabilities. However, few studies address the attitudes of these professionals toward the employability of those with mental illness. The aim of this research was to identify differences in the attitudes of medical and non‐medical mental health professionals, as well as to detect any association between attitude scores and the type of professional.MethodsA sample of 140 employees from public and third sector mental health organizations answered a questionnaire using a scale measuring their attitudes and views on the employability of people with psychiatric disabilities. The psychometric characteristics of the scale are provided together with the variations detected in the professionals’ attitudes.ResultsThis research shows that significant differences in the attitudes between medical and non‐medical mental health employees exist and that there is a need for the implementation of educational programs that may help to improve the attitudes of medical professionals toward the employability of people with mental illness.ConclusionThis research indicates the importance of improving the professionals’ attitudes to support people attempting to return to work.

Knowledge and attitudes regarding mental illness among nonpsychiatric physicians working in public hospitals in the Eastern province of Rwanda

INTRODUCTION: The occurrence of mental illness has been common throughout the world and the care for mental health disorders has been a growing public health concern. Unfortunately, the treatment gap is huge between high-income countries (HICs) and low-income countries (LICs) and is particularly inadequate among non-specialist mental health professionals. The aim was to assess the existing knowledge and attitudes regarding mental illness among medical doctors working in public hospitalsMETHODS: A quantitative cross-sectional study was conducted in public hospitals in the Eastern Province of Rwanda. The study enrolled medical doctors working as clinicians. A self-completed questionnaire was used to assess their knowledge and attitudes regarding mental illness.RESULTS: Most of the participants reported having sufficient knowledge 81.90 %) and a positive attitude (87.40%). The study also found a strong correlation between knowledge and attitudes (P= 0.000). Age and specialist years of experience have been found to have the most significant correlation with attitude (P = 0.048), (P= 0.023) as well as with knowledge level since respective P-values are (P = 0.006) and (P = 0.003).CONCLUSION: Globally, physicians assessed reported to have enough knowledge and positive attitudes regarding mental illness. However, further studies targeting non-medical health professionals are still needed to identify the broader picture of mental health literacy.

Confiabilidad interevaluador de la medición de la excursión diafragmática y fracción de engrosamiento diafragmático mediante ultrasonografía en voluntarios sanos

Background and objectiveTo determine the inter-rater reliability in the ultrasonographic (US) measurement of the diaphragmatic excursion (DE) and the diaphragm thickness fraction (DTF) performed by non-medical health professionals in healthy people. Participants and methodsProspective observational study in a third level hospital in Cali, Colombia. Measurements were made to 30 healthy volunteers chosen by convenience sampling, without a history of lung diseases, with ages between 18-60 years. A pilot test was previously carried out with 8 healthy volunteers. US measurements of DE, and DTF were based on previously published protocols. Each assessor independently observed several cycles of normal quiet breathing for 3minutes to establish a baseline. The Intraclass Correlation Index (ICC) was used to evaluate the inter-rater reliability in the measurements of DE and DTF, with 95% confidence intervals and a P<.05. ResultsSubstantial agreement was identified in the measurement of DE in the splenic and hepatic windows because the ICC was greater than 0.6 (P<.05). The measurement of the DTF in the hepatic window showed slight agreement in both 2D and M modes (P>.05). In the splenic window, the measurement of the DTF in the 2D mode was found to be moderate agreement and for the M mode a slight agreement was found (P>.05) ConclusionsThe diaphragmatic US constitutes a reproducible method with acceptable inter-rater reliability for the measurement of inspiratory/expiratory thickness, and with little reliability for the measurement of DTF.

Culture, cognisance, capacity and capability: The interrelationship of individual and organisational factors in developing a research hospital.

To share our experience of implementing a programme of interventions aimed at building research capacity and capability of nurses and allied health professionals in a specialist children's hospital. Clinicians at the forefront of care are well positioned to lead on research to improve outcomes and experiences of patients but some professional groups continue to be underrepresented. Inequities persist alongside robust national infrastructures to support Clinical Academic Careers for non-medical health professionals, further highlighting the need to address local infrastructure and leadership to successfully build research capacity. An evolving programme of inquiry and analysis was established in one organisation, this included targeted interventions to mitigate barriers and enable research capacity and capability. An all-staff survey was conducted in 2015 to understand the existing research culture. Interventions were put in place, evaluated through a second survey (2018), and focus group interviews with staff who had accessed interventions. Respondents demonstrated high levels of interest and commitment to research at the individual level which were not always harnessed at the organisational level. Inequities between professional groups existed in terms of training, time to undertake research and opportunities and outputs. Follow-up revealed continuing structural barriers at an organisational level, however at an individual level, interventions were reflected in >30 fellowship awards; major concerns were reported about sustaining these research ambitions. Success in building a research-active clinical workforce is multifactorial and all professional groups report increasing challenges to undertake research alongside clinical responsibilities. Individuals report concerns about the depth and pace of cultural change to sustain Clinical Academic Careers and build a truly organisation-wide research hospital ethos to benefit patients. The achievements of individual nurses and allied health professionals indicate that with supportive infrastructure, capacity, cognisance and capability are not insurmountable barriers for determined clinicians. We use the standards for reporting organisational case studies to report our findings (Rodgers et al., 2016 Health Services and Delivery Research, 4 and 1).

Comparison of accredited person and medical officer discharge decisions under the Mental Health Act of NSW: A cohort study of deliberate self-poisoning patients.

The Accredited Persons Programme was introduced in 2003. The relevant Mental Health Acts (NSW) authorised reviews by appropriately credentialed non-medical health professionals as part of the process of detaining and treating a person without consent: an authority previously held by medical officers. Evaluations of the Programme are needed. To compare discharge decisions for hospital-treated deliberate self-poisoning patients made by an Accredited Person and Medical Officers. For a 10-year cohort (2003-2012) of index hospital-treated deliberate self-poisoning admissions at the Calvary Mater Newcastle, we compared Accredited Person and Medical Officer discharge decisions from the general hospital. We specifically examined discharges to the psychiatric hospital under a Mental Health Act certificate (used as an index of the Accredited Person's use of the authority under the Accredited Persons Programme) compared to any other discharge destination. Unadjusted and adjusted logistic regression models and a propensity score analysis were used to explore the relationship between clinician type and discharge destination. There were 2237 index assessments (Accredited Person = 884; Medical Officer = 1443). One-quarter (27%) were referred for assessment under the Act at the psychiatric hospital, with the Accredited Person significantly more likely (32%) to require this compared to the Medical Officers (24%); Risk Difference: 8.3% (4.5 to 12.1). However, after adjusting for patient characteristics; Risk Difference: -3.0% (-5.9 to -0.1) and for propensity score, Risk Difference: -3.3% (-6.7 to 0.1), the Accredited Person and Medical Officer likelihood of discharging for an assessment under the Act was similar. The Accredited Person assessed more clinically complex patients than the Medical Officers. After adjusting for clinical complexity and propensity score, the likelihood of referral for involuntary psychiatric hospital care was similar for Accredited Person and Medical Officers. Our evaluation of the Accredited Person programme in the general hospital was favourable, and wider implementation and evaluation is warranted.

Mental health literacy at the public health level in low and middle income countries: An exploratory mixed methods study in Vietnam.

PurposeMental health literacy (MHL) is key for mental health development, particularly in low-and-middle-income countries (LMIC) where mental health resources are limited. MHL development can be thought of as occurring at two levels: the individual person level (via direct contact, with specifically-targeted individuals), and the public health level (via indirect contact through public media, targeting the general public). Each approach has advantages and disadvantages.MethodsThe present mixed methods study assessed the status of and best approaches for development of mental health literacy in the Southeast Asian LMIC Vietnam. Because there has been relatively little discussion of MHL development at the public health level, this assessment focused on the public health level, although not exclusively. Because mental health professionals generally have the most in-depth understanding of their mental health system, study participants were 82 Vietnamese mental health professionals who completed a quantitative survey, with 48 participating in focus groups.ResultsMost of the professionals viewed MHL in Vietnam as low or very low, and that it was difficult or very difficult for the general public to find effective mental health services. Main barriers underlying these problems and more generally for developing MHL in Vietnam identified in the focus groups were: (a) misinformation in the media regarding mental health and mental illness; (b) lack of licensure for non-medical mental health professionals (e.g., psychologists; social workers); (c) lack of interest in mental health from upper-level leadership.ConclusionsTo the best of our knowledge, this is the first study assessing professionals’ perceptions regarding mental health literacy at both the public health and individual-person levels. Although sampling was restricted to Vietnamese professionals, results may provide initial preliminary guidance for other LMIC considering mental health literacy development at multiple levels.

Facilitating equal access to primary care for all: work experiences of health mediators in a primary health care model programme in Hungary

BackgroundA Primary Care Model Programme was implemented in Hungary between 2013 and 2017 in order to increase access of disadvantaged population groups to primary care and to offer new preventive services for all clients. In a country with single-handed practices, four group practices or GP clusters were created in the Programme. Six GPs comprised one cluster who together employed nonmedical health professionals and nonprofessional health mediators, the latter recruited from the serviced communities, many of them of Roma ethnicity. Health mediators were tasked by improving access of the local communities – including its vulnerable Roma members – to existing and new services. Health mediators were interviewed about their work experiences, motivation, and overall opinion as members of the clusters as part of the Programme evaluation.MethodsAs part of the Programme evaluation, structured interviews were conducted with all 40 health mediators employed at the time in the Programme. Interviews were transcribed and content analysis was carried out.ResultsThree themes emerged from the transcripts. The first focused on the health mediators’ personal characteristics such as motivation to join the Programme, the way their job increased their self-esteem, social status and health consciousness. Domains of the second theme of their work included importance of on-the-job training and of their insider knowledge of local communities, as well as their pride to have become members of the primary care team. The third theme covered overall functioning of the Programme of which they had mostly positive opinions, notwithstanding some criticism regarding procurement.ConclusionsHealth mediators had earlier worked in various European countries specifically to improve access of Roma ethnic groups to health services but the Hungarian Model Programme was globally the first in which health mediators as non-professional workers became equal members of the primary care team as employees. Their contribution and overwhelmingly positive experiences, along with their useful insights for improvement call for the establishment and funding of health mediator positions in primary care especially in areas with large numbers of disadvantaged Roma populations.

Attitude of Parents Towards Pediatric Care and Interprofessional Task-Sharing in Regions Distant Versus Close to Care Facilities: Results of a Standardized Survey

The aim of the study was to determine parents' views in regions distant to medical care (dtmc) vs. close to medical care (ctmc) on (1) the assessment of situation in pediatric care and (2) on delegation of medical tasks to qualified members of non-medical health professions. A self-developed questionnaire was sent to parents in kindergartens, who are either nearby (=close to the medical care provider, ctmc) or more than 20 km away from the nearest pediatric practice and a pediatrics department (=distant to the medical care provider, dtmc). The questions covered socio-demographic, pediatric-care-related aspects and attitudes to delegation of defined medical tasks to non-medical health professionals. Of the n=407 evaluable questionnaires (response rate: 18%), 49% came from parents in ctmc-kindergartens and 51% from parents in dtmc-kindergartens. Significant differences were found in the number of children living in the household (ctmc: 21% with 3 or more children vs. dtmc:13%; p-value 0,044), years of education of parents (ctmc: 50% had more than 10 years vs. dtmc: 39%; p-value 0.026), the number of visits to doctor (ctmc: 50% presented her child 4 or more times to a doctor in the last 12 months vs. dtmc: 32%; p-value <0.001) and the kind of medical doctor present (dtmc: in 51% a pediatrician vs. ctmc: 87%; p-value <0.001). The distance to the doctor was significantly different (p-value <0.001) and parents in dtmc-kindergartens perceived more often problems in pediatric health care (dtmc: 61% confirmed problems vs. ctmc: 47%; p-value 0.032). Dtmc-kindergarten-parents more often approved delegation for all of the defined and proposed medical tasks. The results show clear differences between the survey regions. To support pediatric care in regions distant to medical care facilities, innovative care concepts are needed. The positive attitude of the majority of parents on the subject of delegation forms a good basis for the development of concrete concepts and their practical testing in pilot projects.

Capturing the Real Impact of Clinical Academics in Practice

The Clinical Academic Careers Framework proposes an over-arching structure to develop the clinical academic workforce whose activities have patient benefit within a clear UK programme. Traditionally this has centred on professionals from medicine and dentistry, but in the last ten years has developed into a more inclusive career framework for non-medical health professions which includes Nurses, Midwives and Allied Health Professionals (NMAHPs) and Healthcare Scientists (HCSs) that provide NHS services. As such, it is reported that clinical academic NMAHPs and HCSs can contribute to the generation and translation of new knowledge to help improve outcomes and experiences for patients. In this article, we explore key issues relating to the impact of clinical academic NMAHPs and HCSs on clinical practice in a UK context, as well as some measurements of impact, including the value and limitations of currently used metrics (such as Key Performance Indicators, or KPIs). We report that measuring the learning in practice of this novel role will need to include smart metrics alongside a person-centred approach. We share four national case studies, all of which are drawn from clinical academic researchers from different UK settings to show the real variety and differences in roles. We argue that this is the key both to learning in practice about this role, and to witnessing the real differences clinical academics make.

Collaboration in healthcare delivery interprofessional

Interprofessional relations in health care have been examined through the frame of “clinical democracy”. Yet, traditional interpretations of democracy have assumed a zero-sum, competitive interpretation of power, leading to unelaborated invocations for health professionals to “collaborate” more or do “teamwork” better. The aim of this study was to understand the priorities that health professionals from different occupations have for individual patient care, and the opportunities they have to express those priorities, as a foundation for a more expansive democratic theory.The case setting was a mixed-method, pre-post, participatory research (PR) study examining the dynamics and levels of satisfaction of interprofessional information-sharing and decision-making on an acute aged care unit.Stage 1, pre-intervention, revealed that non-medical health professionals – nursing and, in particular, allied health professionals – lacked opportunities for input into decision-making for patient care. Following deliberative, public feedback of the findings to managers and health professionals, an intervention was negotiated to re-structure the weekly case conference and referral processes. Stage 2, the post-interventional findings showed an increase in perceptions of information-sharing, and participation in case conferences, as well as recognition of power differentials in interprofessional relations.In the public negotiation of increased prominence of particular roles and aligning role clarity with the needs of particular patients, the findings show that the notion of deliberative democracy characterizes the qualitative-cumulative, rather than merely quantitative-redistributive power among health professionals in different occupational roles. As a case of conscientization, deliberation engages practical interprofessional improvement simultaneously as educational empowerment.

General medical services by non-medical health professionals: a systematic quantitative review of economic evaluations in primary care.

Previous systematic reviews have found that nurses and pharmacists can provide equivalent, or higher, quality of care for some tasks performed by GPs in primary care. There is a lack of economic evidence for this substitution. To explore the costs and outcomes of role substitution between GPs and nurses, pharmacists, and allied health professionals in primary care. A systematic review of economic evaluations exploring role substitution of allied health professionals in primary care was conducted. Role substitution was defined as 'the substitution of work that was previously completed by a GP in the past and is now completed by a nurse or allied health professional'. The following databases were searched: Ovid MEDLINE, CINAHL, Cochrane Library, National Institute for Health and Care Excellence (NICE), and the Centre for Reviews and Dissemination. The review followed guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Six economic evaluations were identified. There was some limited evidence that nurse-led care for common minor health problems was cost-effective compared with GP care, and that nurse-led interventions for chronic fatigue syndrome and pharmacy-led services for the medicines management of coronary heart disease and chronic pain were not. In South Korea, community health practitioners delivered primary care services for half the cost of physicians. The review did not identify studies for other allied health professionals such as physiotherapists and occupational therapists. There is limited economic evidence for role substitution in primary care; more economic evaluations are needed.

Skill mix in Swiss primary care group practices - a nationwide online survey

BackgroundIncreasing chronic conditions and multimorbidity is placing growing service pressures on health care, especially primary care services. This comes at a time when GP workforce shortages are starting to be felt across Switzerland, placing a threat on the sustainability of good access to primary care. By establishing multiprofessional teams in primary care, service capacity is increased and the pressures on the GP workforce can be alleviated. The roles of non-medical health professions in primary care are not established so far in Switzerland and the personnel composition of primary care group practices is not known. Therefore this study aims to provide insights into the current composition, educational background and autonomy of the these new professional roles in primary care.MethodsFor this descriptive exploratory study a web-based online survey methodology was used. Group practices were defined as being a medical practice with any specialisation where at least three physicians work together in a team. Based on this restriction 240 eligible group practices were identified in Switzerland. The following four tertiary-level health professions were included in the study: nurses, physiotherapists, occupational therapists and dietitians. Additionally medical practice assistants with couselling competencies were included.ResultsA total of 102 practices answered the questionnaire which is equivalent to an answer rate of 43%. The sample included data from 17 cantons. 46.1% of the practices employed non-physician health professionals. Among the tertiary-level health professions, physiotherapists were the most frequent profession with a total of 78 physiotherapists over all group practices, followed by nurses (43), dietitians (34) and occupational therapists (3). In practices which employ those professionals their average number per practice was 3.4. 25.5% of the practices had health professionals employed with advanced roles and competencies.ConclusionThe results from this study demonstrate that while nearly 50% of groups practices have established non-physician professionals, only 25% of practices integrate these professionals with advanced roles. Compared with other countries, there would appear to be significant scope to extent and broaden the uptake of non-physician professionals in primary care in Switzerland. Clear policy direction along with supporting regulation and financing arrangements are required.

Demand on Non-Medical Health Professions Training: Adaptation to New Challenges of the Aging Populations (letter)

Demand on Non-Medical Health Professions Training: Adaptation to New Challenges of the Aging Populations (letter)

Advancing interprofessional theory: Deliberative democracy as a participatory research antidote to power differentials in aged care

Abstract Introduction Interprofessional relations in health care have been examined through the frame of “clinical democracy”. Yet, traditional interpretations of democracy have assumed a zero-sum, competitive interpretation of power, leading to unelaborated invocations for health professionals to “collaborate” more or do “teamwork” better. The aim of this study was to understand the priorities that health professionals from different occupations have for individual patient care, and the opportunities they have to express those priorities, as a foundation for a more expansive democratic theory. Materials and methods The case setting was a mixed-method, pre-post, participatory research (PR) study examining the dynamics and levels of satisfaction of interprofessional information-sharing and decision-making on an acute aged care unit. Results Stage 1, pre-intervention, revealed that non-medical health professionals – nursing and, in particular, allied health professionals – lacked opportunities for input into decision-making for patient care. Following deliberative, public feedback of the findings to managers and health professionals, an intervention was negotiated to re-structure the weekly case conference and referral processes. Stage 2, the post-interventional findings showed an increase in perceptions of information-sharing, and participation in case conferences, as well as recognition of power differentials in interprofessional relations. Conclusions In the public negotiation of increased prominence of particular roles and aligning role clarity with the needs of particular patients, the findings show that the notion of deliberative democracy characterizes the qualitative-cumulative, rather than merely quantitative-redistributive power among health professionals in different occupational roles. As a case of conscientization, deliberation engages practical interprofessional improvement simultaneously as educational empowerment.

Does clinical supervision of health professionals improve patient safety? A systematic review and meta-analysis.

To determine whether clinical supervision (CS) of health professionals improves patient safety. Databases MEDLINE, PsychINFO, CINAHL, EMBASE and AMED were searched from earliest date available. Additional studies were identified by searching of reference lists and citation tracking. Two reviewers independently applied inclusion and exclusion criteria. Thirty-two studies across three health professions [medicine (n=29), nursing (n=2) and paramedicine (n=1)] were selected. The quality of each study was rated using the Medical Education Research Study Quality Instrument. Risk ratios (RR) were calculated for patient safety outcomes of mortality, complications, adverse events, reoperation following initial surgery, conversion to more invasive surgery and readmission to hospital. Results of meta-analyses provided low-quality evidence that supervision of medical professionals reduced the risk of mortality (RR 0.76, 95% CI 0.60-0.95, I(2)=76%) and supervision of medical professionals and paramedics reduced the risk of complications (RR 0.69, 95% CI 0.53-0.89, I(2)=76%). Due to a high level of statistical heterogeneity, sub-group analyses were performed. Sub-group analyses provided moderate-quality evidence that direct supervision of surgery significantly reduced the risk of mortality (RR 0.68, 95% CI 0.50-0.93, I(2)=33%) and direct supervision of medical professionals conducting non-surgical invasive procedures significantly reduced the risk of complications (RR 0.33, 95% CI 0.24-0.46, I(2)=0%). CS was associated with safer surgery and other invasive procedures for medical practitioners. There was a lack of evidence about the relationship between CS and safer patient care for non-medical health professionals.

Decline in medical students' attitudes to interprofessional learning and patient-centredness.

Interprofessional learning (IPL) is valuable in preparing health care students to work collaboratively in teams, with patients' needs at the core. Patient-centredness is the impetus for communication and collaboration in health care. Debate continues on when it is best to develop positive student attitudes towards these aspects of care. Should IPL commence early before attitudes to patients, professional stereotypes and identity are formed, or later for advanced learners with greater experience of their roles and responsibility in health care? This study explores graduate-entry medical students' attitudes to IPL and patient-centred care, on programme entry and after an early interdisciplinary clinical experience (ICE). An extended version of the Readiness for Interprofessional Learning Scale (RIPLS) was administered to four cohorts of medical students (n=279) on entry and after the 3-week placement. This 26-item RIPLS comprised four subscales: team work and collaboration; professional identity; roles and responsibilities; and patient-centredness. The impact of the placement on students' attitudes was assessed by using repeated measures analysis of variance to compare pre- and post-ICE subscale scores. There were significant main effects of time (pre- versus post-ICE) for the subscales of teamwork and collaboration, professional identity and patient-centredness, but not for roles and responsibilities. Scores for teamwork and collaboration, professional identity and patient-centredness were all lower post-ICE. The students' less positive attitudes to teamwork and collaboration and professional identity may be due to the experience itself, or because it reinforced negative beliefs about the value of learning from non-medical health professionals. Perhaps the students' idealised view of their future role as a doctor was challenged by the experience, or they had an underdeveloped professional identity. Limited student experience of patients having an active role in their own health care may explain the decrease in attitudes to patient-centredness. A longitudinal qualitative study will explore these results.