Wider Multidisciplinary Team Research Articles

‘The outsider looking in’: Trainee reflections on working within teams

This paper reflects on the valuable insights on team dynamics trainee clinical psychologists can bring. It explores how these perspectives are shared with the Psychology team to broaden awareness of influences on their behaviour within the wider multi-disciplinary team.

Preventing infection in rehabilitation centres.

Recent military conflicts have provided new challenges for Defence Medical Services, and the specialty of infection prevention and control has not been exempt from these. The mechanisms of injury and the harsh environments in which military injuries are sustained have resulted in unusual infections with multiple resistance to antimicrobial agents. Although the multidisciplinary team faces many issues in the acute phase of the patient's rehabilitation, it is the continued infection risk to patients that is the biggest challenge for both the infection prevention and control team and the wider multidisciplinary team. Rehabilitation centres may evoke an image of healthy individuals who require little nursing care but, for those attending the Defence Medical Rehabilitation Centre, this is not always so and staff are often challenged by continuing infection problems. There is also a risk of patients developing new infections as a result of unhealed wounds and the use of invasive devices, such as indwelling catheters, which are essential if patients are to maintain their everyday activities.

Physiological and hormonal changes and GI problems experienced in pregnancy

Pregnancy can be a time of uncertainty for many would-be parents. For those mothers with a pre-existing gastrointestinal (GI) disorder, it can cause many uncertainties and concerns, particuarly relating to medication and the effect of the disease on the unborn baby. This is the first in a four-article series focusing on the management of GI conditions in relation to fertility, the preconception period, during pregnancy, and the postnatal period including breast feeding. For nurses and midwives to protect and promote health and wellbeing, it is vital for them to have good insight into GI function in order to recognise abnormalities when they occur, both as part of the expected physiological adaptation of pregnancy and when intervention is required. Having this insight will allow the GI nurse to safely plan and implement evidence-based and holistic support to those who want to conceive, pregnant women, and their families as part of the wider multidisciplinary team. This article explores the various GI problems caused by pregnancy.

G539(P) Trainee-led quality improvement in enhancing service in community paediatrics

Context We planned to address two key areas of service provision in our secondary level hospital. Firstly, in keeping with many Community Paediatric Departments, our hospital has experienced an increase in the number and complexity of referrals. As a result many families had long waits for consultations. Secondly in our trust safeguarding work had historically represented a large proportion of the acute workload. Problem and Assessment 1. Child Development Centre (CDC) appointments Long waiting lists for medical appointments were negatively affecting patient care. The department was not compliant with the NICE guidance on the timeframe for assessment of children with possible social communication disorders. Patient satisfaction surveys had also identified this as an area of concern for families. 2. Child Protection Assessments Vulnerable children competed with acute admissions for assessments and were often seen out of hours, when Consultant medical staff were not on site. Social Care had highlighted concerns about long and unpredictable waits for assessments. Intervention Firstly, trainees in consultation with their consultant supervisors developed a flexible clinical arrangement to target service provision and meet community competencies in the CDC setting. Trainees were expected to complete six CDC clinics during their six month rotation, which were tailored to the trainee’s acute rota. Secondly, a daily child protection medical clinic was implemented and delivered by trainees under consultant supervision. Monthly safeguarding peer review meetings were initiated in line with Royal College of Paediatrics and Child Health guidance to provide support and facilitate training in this area. Strategy for change To instigate and review the response to change, the Plan-Do-Study-Act (PDSA) cycle was used. An initial multi-disciplinary team (MDT) meeting was used to formalise plans and disseminate information, with three monthly MDT feedback meetings planned. Measurement of improvement During the initial six month period, review of waiting lists has shown that trainee delivered CDC clinics have resulted in a reduction of waiting lists by 56 patients (the equivalent of 0.4 PA Consultant time). Urgent new patient appointments have fallen from 12 to 0, although routine new patient appointments have increased from 45 to 68. Feedback from the MDT is largely positive. Review of child protection referrals has shown that following the instigation of child protection medical clinics the number of assessments occurring out of hours has fallen to 19% compared to 44% previously. 81% of children are now seen at a prearranged time, without delay, compared to approximately 23% previously. Trainees report feeling more supported in carrying out safeguarding work. A repeat CDC patient satisfaction survey and a planned audit of the child protection clinics will provide further feedback on the success of these interventions, which will lead to further action (PDSA). Effects of changes Developing a flexible approach to encompass trainees’ acute commitments, has required meticulous planning. Room availability was an unexpected factor needing close consideration in the plans. Involvement of trainees has required support and supervision both from Consultants, and the wider MDT, thus requiring some changes to their previous practice. Lessons learnt Managing a change in service provision requires consideration of many different priorities. When trainees take a key role, it ensures the changes work at their level. Message for others Working within the European Working Time Directive and today’s financial constraints, a flexible approach to service provision is necessary. This initiative has highlighted that direct trainee involvement in the design of service delivery can result in significant changes that benefit patients, trusts and trainees alike. Moreover this venture has enhanced community training, as well as providing trainees with valuable experience in management of change.

Establishing a Supportive Care Register Improves End-of-Life Care for Patients with Advanced Chronic Kidney Disease

Background: End-of-life care for patients with advanced chronic kidney disease (CKD) is recognised as an important area for improvement. These patients have a significant mortality and, although some is unpredictable, there is a role for the nephrology multi-disciplinary team (MDT) and palliative care physicians to engage in advance care planning and support patients to discuss their preferences. Methods: Retrospective and prospective data were obtained to conduct a comparison observational study to assess the impact of introducing a supportive care register on the end-of-life care for patients with advanced CKD. An electronic supportive care register was implemented. This required a programme of multi-disciplinary staff education, collaborative working with Palliative Care to establish renal-specific protocols and dissemination activities. The impact of the intervention was assessed by analysing all deaths in two six-month periods where all those with an eGFR <15 ml/min/1.73 m² at the time of their death were included. Results: A total of 91 patients were included. Post-intervention, there was a 25.4% (95% CI: 6.5-44.3%, p = 0.008) improvement in patients having a documented discussion about end-of-life planning. There was also a 19.7% (95% CI: 4.0-35.5%, p = 0.01) improvement in establishing the place of death. All patients who expressed a preferred place of death died there. The intervention increased engagement with the wider MDT and led to significant improvements in access to specialist palliative care services. Conclusions: These results show that the interventions implemented to introduce a supportive care register resulted in meaningful improvements to the end-of-life care for patients in our region with advanced CKD.

Case study of the London 2012 Olympic and Paralympic pharmacy service preparations.

The Pharmacy Clinical Services Group (PCSG) was formed in 2009. Its aim was to design and deliver a world-class pharmacy service to 250 000 accredited persons and consider the pharmaceutical needs of 9.2 million visitors to the London 2012 Games. The explanatory case study method was used to investigate how the PCSG prepared and how they considered the wider vision of the Games. The study investigated two propositions: (1) that the PCSG has a communication function and (2) that it has a design function. A range of data were examined using NVivo 9 data management software. The study identified four emerging themes and a number of subthemes. The study validated the propositions and highlighted that the PCSG had a leading role within the wider multidisciplinary team. The study found that the PCSG embraced the wider vision of the Games and was exceptionally well prepared to deliver a world-class pharmacy service, anticipating a new gold standard for the provision of pharmacy services for future sporting events.

Unique and proforma birth plans: A qualitative exploration of midwives׳ experiences

Backgroundbirth plans detailing a woman׳s preferences for intrapartum care are a common feature in British maternity units, and are a means of encouraging the implementation of choice. Proforma versions may be incorporated routinely in antenatal case notes, or the woman may devise her own unique birth plan. Although women׳s views of birth plans have been explored, the views of midwives have not to date been evaluated. The growth of midwife-led units in the UK has highlighted different philosophies of care, some of which can be reflected in the different types of birth plan. Given the increasingly diverse nature of UK midwifery workplaces we set out to explore and compare the experience of midwives working in midwife-led and obstetric-led settings in relation to unique and proforma birth plans. Methodqualitative study using focus groups of midwives in a midwife-led unit (MLU; n=5) and obstetric-led unit (OLU; n=4) in the East of England. We used an interpretative phenomenological analytical approach. Findingsthree main themes arose from the data. Firstly, the term ‘birth plan’ can be misleading, and was criticised for encouraging the belief that birth can be ‘planned’. In addition, midwives claimed that ‘unique’ birth plans, especially those influenced by some consumer advocacy groups, are becoming standardised in their rejection of policies and procedures and requests for intervention-free birth. Secondly, birth plans were a source of irritation for midwives in both groups, although the cause of the irritation differed between groups. Finally, it was found that midwives in both groups felt that birth plans put pressure on them, although again, the source of the pressure, and therefore the way in which midwives reacted to this pressure, differed between groups. Conclusionsthe term ‘birth plan’ can be misleading and create false expectations. If ‘unique’ birth plans are becoming ‘standardised’ in the sense that they routinely request the same things, they are little different to proforma birth plans. Some midwives perceive pressure both from women and the wider multidisciplinary team as a result of birth plans, a perception that causes some irritation.

Joint count reliability in psoriatic arthritis observational trials--an unreported problem

Sir, Multiple observers are a reality of large observational and multicentre studies and introduce the challenge of addressing inter-rater reliability. Long term Outcomes in Psoriatic Arthritis II (LOPAS II) is a multicentre prospective observational study investigating work disability in PsA. The primary endpoint is presenteeism (reduced effectiveness at work), but the secondary endpoints include tender and swollen joint scores. Clinical assessments will be undertaken at multiple sites across the UK. We set out to undertake a reliability exercise to estimate joint count reliability in LOPAS II. We invited assessors from each centre to an education day at the lead site. A 1-h seminar on the study was followed by a 45-min clinical training session on joint counts lead by two trainers, each with >10 years experience in PsA joint assessment. The session was followed by a joint count reliability exercise. Four patients of differing disease duration (1–33 years) and activity (from 22 tender and 9 swollen to 2 tender and 2 swollen joints as assessed by the instructors) were assessed using a modified (asymmetrical) Latin square design. Reliability was measured using Krippendorff’s α, a reliability coefficient that accommodates the modified Latin square design [1]. Analyses were undertaken on the group as a whole and then repeated excluding those who self-reported to be unconfident or who had never performed joint assessments before. Twelve assessors from seven units attended: one doctor, seven rheumatology nurse specialists, one occupational therapist and three research nurses (of whom one had rheumatology experience). Reliability is reported in Table 1. Inter-rater reliability for all was low irrespective of experience, but was higher among those with experience. Table 1 Joint count reliability using Krippendorff’s α There are limited reports of joint count reliability among physicians with an interest in PsA [2–5]. Even among such experts, inter-class correlation coefficients are poor for determining peripheral joint swelling—0.13, 0.55, 0.242—and moderate for tenderness (or activity)—0.73, 0.75, 0.72. It is noteworthy that none of these studies has included the wider multidisciplinary team. To our knowledge, none of the recently published large observational studies or registry reports has reported on joint count reliability [6–10]. Only the Toronto research group has reported on joint count reliability, and this was at the time of the cohort’s inception [4]. The Toronto study involved three rheumatologists and two trainees assessing five patients in a Latin square design. There was a <1% observer variance, indicating good reliability of assessment. To enable direct comparison, the analysis of variance in our study showed that the proportion of variance attributable to (all) raters was much higher; swollen joints 56% (P = 0.094) and tender joints 60% (P = 0.004). It is noteworthy that the Toronto study was undertaken over 20 years ago and since that time the expansion of the multidisciplinary team has meant that clinical assessments are now performed by a wider clinical team including doctors, nurses and extended scope therapists. The general lack of reporting of joint count reliability may reflect a mixture of publication bias, insufficient recognition of the potential problem or misplaced confidence. The poor reliability identified in our study is important to our current study (LOPAS II) and also to assessors from centres in the UK and further afield who collect data for other large observational studies in PsA. The joint count training offered in the LOPAS II training day was minimal, as we had only anticipated the need for some fine tuning to standardize the assessment techniques. More training is required, as was mentioned by the assessors themselves in the feedback from the training day. We are attempting to standardize assessments and improve our reliability by using an instructional joint count training video as well as offering one-to-one tuition at the lead site. We are also encouraging a period of mentoring within each unit for those with less experience as well as aiming to use the same assessor to perform the joint counts at serial appointments. A repeat assessment day is planned once all centres have completed the training. To our knowledge, this is the first study investigating the joint count reliability among assessors routinely contributing data in the PsA clinical and research setting. We suggest that future reporting of joint count outcomes should include some assessment of joint count reliability in order to interpret results, particularly negative findings. Furthermore, we suggest that to optimize data collection, individual units document joint count reliability with a view to determining a potential training need.

Use of audiovisual equipment (SKYPE) for the treatment of hand injuries for remote consultations

Introduction We present this case of a British patient living and working in Africa who used audiovisual (SKYPE) equipment as a treatment option for remote consultation. This was investigated in response to a request by the patient for further postoperative support at a distance after a complex hand surgery procedure. Methods Audiovisual (SKYPE) equipment was used by the team in combination with manual therapy as a means of seeking advice, progressing treatment and liaison with a specialist hand therapist and surgeon. The audiovisual equipment was used to complete follow-up of treatment episodes once the patient had returned to Africa. Results After five months of audiovisual consultations with the surgeon and clinical specialist hand therapist, the patient reported significant reductions in anxiety regarding the management of his extensive hand injury. The patient's active and passive range of movement and Disabilities of the Arm Shoulder and Hand scores had all improved. The wider multidisciplinary team in his local area was supported by a specialist service and evidence was gathered to support the organizational benefits of using audiovisual equipment. Conclusion This case report highlights the potential, clinical and cost benefits of utilizing audiovisual equipment in conjunction with other treatments in the management of remote hand injury patients.

The location of community palliative care nurse specialist patient assessments: patient perceptions

BackgroundIt is current practice for the Community Palliative Care Nurse Specialist (CPCNS) service at Wigan & Leigh Hospice (WLH) to provide all assessments in patients' own homes. While the value...

Does an admission booklet improve patient safety?

Background. The quality of admission clerking to psychiatry wards will influence initial management of patients suffering from mental illness. Incomplete clerking may put patient safety at risk.Aims. We sought to assess the completeness of clerking to general adult psychiatry wards and to evaluate whether the introduction of an admission booklet would improve clerking.Method. We analysed the completeness of clerking to general adult psychiatric wards by trainee doctors. Using an audit approach, the first phase assessed completeness of clerking when trainee doctors used continuation sheets to document the clerking in a free-hand manner. Thereafter, we developed a standardised admission booklet to document the clerking and assessed completeness of clerking in the second phase.Results. The admission booklet significantly improved the completeness of clerking. Notable improvements were seen in multiple components of history taking and initial management, particularly in documenting risk to self and others.Conclusions. Improving clerking by use of an admission booklet can lead to more informed management decisions particularly in regard to the patients' physical health and clinical risk management. This may consequently improve patient safety and help trainees communicate important aspects of the case to seniors and the wider multi-disciplinary team.

Strengthening midwifery: harnessing the climate

From a midwifery perspective, much of what is recommended in The Prime Minister's Commission on the Future of Nursing and Midwifery in England (2010) could be viewed as a simple revision of Maternity Matters, National Service Framework for Children, Young People and Maternity Services and Changing Childbirth before it. It reiterates the need for a named midwife, highquality care, the need to work in partnership with the woman and wider multidisciplinary team, and the benefits of midwifery-led care. Yet there are three significant elements within the report which may have far-reaching consequences and might strengthen midwifery.

The process of adjustment: Providing support after a diagnosis of multiple sclerosis

This article reviews the impact a diagnosis of multiple sclerosis (MS) can have emotionally on an individual and his/her significant other, and discusses some of the ways in which the needs of this patient group can be met. The way in which the diagnosis of MS is communicated to the individual and the support he/she receives is known to have a bearing on subsequent coping with life with MS (Johnson, 2003). Response to diagnosis varies, although feelings of abandonment, isolation, anxiety, depression and anger are common reactions for both the patient and his/her partner or family (Porter and Keenan, 2003; Johnson, 2003) and the need for support at this life-changing time is crucial. Continuity of care following diagnosis, access to tailored information as and when required and having a point of contact are all important aspects of care following a diagnosis of MS. The role of the neurologist, the MS specialist nurse and the voluntary agencies in meeting these needs within the context of the wider multi-disciplinary team will be discussed in this article.

Management of pain

Pain is a common symptom that patients describe and clinicians have to manage. Management plans are tailored to the complexity of the pain. This may require a multi-modal approach while involving the wider multidisciplinary team.

Providing the nurse with a guide to tracheostomy care and management

To care for a patient with a tracheostomy requires a clear understanding of each patient's need for the tracheostomy and the type of tube that is required. The impact of a tracheostomy on the respiratory system includes thorough knowledge of respiration, methods of humidification and also suctioning techniques. In addition to this a tracheostomy may impact on swallowing, communication and body image. Appreciation of these effects will guide the nurse and the wider multidisciplinary team in future needs and care. Tracheostomy care and management is more and more necessary in both the intensive care setting and the general ward. It is, therefore, ever more important that trained nurses are equipped with the appropriate skills, knowledge and support to meet the unique needs of each patient safely and competently. This article aims to discuss the indications for a tracheostomy and also the care and management commonly carried out, with the purpose of increasing knowledge and interest of the care of a patient with a tracheostomy.

The development and implementation of an acute traumatic wound guideline

Accident and emergency (A&E) departments and minor injury units (MIUs) are faced with a wide variety of acute traumatic wounds on a daily basis. Yet despite the existence of a county-wide tissue viability policy, guideline and formulary in Worcestershire, there had been no attempt to standardize treatment for traumatic wounds in the county. This article describes the process of developing a guideline for acute traumatic wound care by a wide multidisciplinary team. It identifies key points that may be considered when developing similar guidelines, including planning, leadership, communication and the motivation to finish the project. Development of guidelines is advocated as a means not only of improving and standardizing care to patients, but as a means of fostering multiprofessional team building and improved communication between health professionals.

Organ donation.

<h3>Background</h3> GPs working in deprived areas, where all-cause mortality rates are higher compared to less deprived areas, face unique challenges. Despite 50 years passing since Tudor Hart’s seminal ‘inverse care law’ paper, the health inequities gap remains wide. Deep End GP groups are frontline GP-led initiatives working to close this gap and improve the health and lives of those most in need. <h3>Aim</h3> To use scoping methodology to map out the process of creating a Deep End GP group. <h3>Design &amp; setting</h3> A scoping review using Arksey and O’Malley’s framework. <h3>Method</h3> MEDLINE, Embase, Web of Science, and CINAHL databases, as well as non-peer reviewed publications, were searched and articles extracted, reviewed, and analysed according to iterative inclusion criteria. <h3>Results</h3> From an initial search number of 35 articles, 16 articles were included in the final analysis. Key steps in starting a Deep End GP group were: quantifying patients and practices in areas of deprivation; establishing GP-led objectives at an initial meeting; regular steering group meetings with close collaboration between academic and frontline general practice, as well as the wider multidisciplinary team; and adopting a local Deep End logo. <h3>Conclusion</h3> Deep End GP groups have made advances to reduce health impacts of systemic health inequities. Starting a Deep End GP group involves a multidisciplinary approach, beginning with the identification of patients and practices in areas of highest need. The findings and key themes identified in this scoping review will guide interested parties to start the journey to do the same in their locality and to join the Deep End movement.