Alliance for Continuing Medical Education 33rd (2008) Annual Conference

January 19-22, 2008 [ Orlando, Florida ]

IT'S NOT JUST WHERE YOU WORK, IT'S HOW YOU WORK

Allia Karim¹, Ivy Oandasan¹, Lorelei Lingard², Doreen Day¹

¹ Centre for Interprofessional Education, University Health Network, Toronto
² The Wilson Centre for Research in Education, University Health Network and University of Toronto, Toronto

• Objectives

  The participants will be able to: 1) learn about factors that impede and contribute to interprofessional communication and collaboration; 2) learn from an intervention tool that was created and implemented in this study.

• Methods

  This presentation will direct a structured small group discussion to assist participants in applying communication strategies to improve interprofessional communication and collaboration using theoretical and applied frameworks.

• Results

  The presentation will: 1) discuss the needs of clinicians strategizing to improve teamwork 2) disseminate learnings from the development and implementation a piloted communication toolkit; 3) demonstrate how contributing factors such as time, space interplay for successful collaboration.

The 46th Annual Conference on Research in Medical Education (RIME) 2007

November 2 - 7, 2007 [ Washington D.C. ]

INTERPROFESSIONAL COMMUNICATION IN REHABILITATION MEDICINE: RESULTS OF AN EXPLORATORY STUDY FOR THE SCRIPT PROGRAMME

Ravindra Mohabeer¹, Lynne Sinclair³,⁴, Lorelei Lingard¹,²

¹ Wilson Centre for Research in Education
² Department of Paediatrics, University of Toronto
³ Toronto Rehabilitation Institute
⁴ Department of Physical Therapy, University of Toronto

• Purpose

  Effective interprofessional collaboration (IPC) has been shown to improve patient care but little evidence exists for methods of fostering IPC in clinical teams. Preparatory to developing a situated tool for encouraging IPC in rehabilitation care, we conducted an ethnographic study of a clinical teaching unit (CTU) in a rehabilitation hospital.

• Methods

  With appropriate ethical approvals, we conducted 40 hours of observation over four weeks. A trained observer captured the content and process of collaboration and communication through general observations, close shadowing, 22 informal, and 7 formal interviews in a multidisciplinary CTU. Participants included 21 health team professionals, a physiatrist, 20 nurses, unit administrators, and a community care planner. Data were collected by ethnographic field notes and entered into NVivo qualitative analysis software. These data were coded for themes by the research team.

• Results

  Preliminary analysis reveals that communication around patient-goals provided key points at which to observe IPC on the team. Full integration of all nurses into team activities was inhibited by scheduling and budgetary issues. Finally, despite frequent collaborative encounters, occasional competing priorities were observed between physical and social/cognitive professionals.

• Conclusion

  This research suggests that focusing on patient-centered rather than discipline segregated goals facilitated IPC. While high levels of IPC were observed, gaps between nursing and other team members might be improved by a targeted intervention engaging nurses more in team meetings and co-locating therapeutic work by other professionals to the unit. Greater collaboration between physical and social/cognitive professionals could be promoted by joint delivery of therapy where appropriate.

Collaborating Across Borders: An American-Canadian Dialogue on Interprofessional Health Education

October 24-26, 2007 [ Minneapolis, Minnesota ]

AN EXAMINATION OF INTERPROFESSIONAL COLLABORATION AS A FACTOR IN TEAM COHESION: PRIMARY AND REHABILITATION CARE

Lorelei Lingard¹, Lynne Sinclair², Ravindra Mohabeer¹, Ivy Oandasan³, Allia Karim³, Doreen Day³

¹ University of Toronto
² Toronto Rehabilitation Institute
³ Centre for Interprofessional Education, University Health Network

• Objective:

  This paper seeks to advance our understanding of the social, organizational, structural and clinical features supporting effective interprofessional collaboration. Part of a Health Canada funded academic research partnership between the University of Toronto and the 13 Toronto Academic Health Sciences Network teaching hospitals, this paper draws on two large case studies to propose a model of the factors involved in 'team cohesion', and considers how this model advances existing theory in the domain.

• Study methods:

  Several hundred hours of qualitative observational and interview data were collected over 2 years on interprofessional teams in three clinical contexts: general internal medicine wards, primary care clinics, and specialized rehabilitation hospital units. For this paper, data from the two of these case studies, primary care and rehabilitation care, were analysed for emergent themes using a constant comparative method. Core similarities and salient differences were identified, and discrepant instances considered, yielding a robust, cross-cutting model of 'team cohesion'.

• Results:

  'Team cohesion' is shaped by social factors, such as personal relationships, organizational factors such as the spatial layout of a workplace, structural resources such as patient-centred goals, and clinical features such as a shared purpose and passion for caring for patients with extended lengths of stay. These factors can directly impact how team members understand one another's roles, and contribute to opportunities for shared, patient-centred care. We will present a series of 'cohesion cases' to demonstrate how these complex factors interact to facilitate or constrain cohesion in primary care and rehabilitation clinical settings.

• Conclusions:

  Understanding how 'team cohesion' comes to exist is a critical step in the development of appropriate academic curricula that can subsequently encourage organizational changes to promote effective interprofessional collaboration. We expect that a careful delineation and demonstration of the factors involved in cohesion may advance our understanding of practical methods for improving role awareness, shared goals, and patient-centredness on interprofessional teams.

AN INNOVATIVE PRACTICE INTERVENTION TO FOSTER INTERPROFESSIONAL COLLABORATIVE COMMUNICATION IN GENERAL INTERNAL MEDICINE: A CANADIAN PERSPECTIVE

Ann Russell¹, Merrick Zwarenstein¹, Chris Kenaszchuk¹, Scott Reeves², Lorelei Lingard², Karen-Lee Miller¹, Lesley Gotlib Conn³

¹ Li Ka Shing Knowledge Institute, St. Michael’s Hospital and University of Toronto
² Wilson Centre for Research in Education, University of Toronto at the University Health Network
³ Centre for Interprofessional Education, University of Toronto at the University Health Network

Subsequent to the Romanow Commission (2002), interprofessional practice has emerged as a best practice model in health care in Canada; however, the evidence of the effectiveness is generally weak (Zwarenstein & Reeves 2006). This panel presentation seeks to describe the benefits and limitations of a program for a new model of care. Specifically, we present a cluster RCT that evaluates the effectiveness of an interprofessional collaborative communication intervention in general internal medicine departments of five Toronto teaching hospitals.

Objectives of Program/Intervention for a new model of care

1. To design an intervention to improve interprofessional collaborative communication in the daily practices of hospital-based GIM staff at five Toronto teaching hospitals.
2. To transform the culture of communication in GIM by breaking down the interpersonal and social barriers associated with lack of name and role recognition.
3. To increase name and role recognition in GIM by implementing a collaborative communication framework during informal unstructured encounters.
4. To increase the incidence of productive interprofessional planning for patient centred care by making elicitation of the other person’s perspective during collaborative communication, the routine, rather than the exception.
5. To pilot the 8-week intervention at one hospital (2 intervention CTUs and 2 control CTUs).
6. To use an iterative design methodology to re-engineer the intervention based on pilot evidence.
7. To implement and evaluate the intervention using a cluster RCT design at the remaining four hospitals.

Description of Program/Intervention for a new model of care
Over 200 hours of ethnographic observations of the daily activities of health care professionals on the GIM wards and interviews with staff have informed design of an intervention. The pilot study is currently underway in one hospital (4 clinical teaching units). The intervention focuses on improving key aspects of collaborative communication during unstructured opportunistic encounters outside of formal ward meetings (e.g., daily bullet rounds, kardex rounds, nursing shift report, etc.). Staff initiated interprofessional encounters will be characterized by the following: (1) self-introduction of name and role; (2) elicitation of other professionals' names and roles in relation to topic/patient under review; (3) sharing of opinion and elicitation of the other person’s perspective to arrive at a joint plan. As purposeful interprofessional collaborative communication becomes the norm in GIM, it is expected that staff and patient satisfaction will improve; and patient length of stay, readmission rates and inappropriate paging of physicians will decrease.

Results of Program/Intervention for a new model of care
Data analysis revealed three common barriers to interprofessional collaboration and communication across hospital sites: (1) lack of interpersonal awareness (e.g., name recognition, etc.); (2) lack of interprofessional awareness (e.g., surface level understanding of scopes and roles of practice, etc.); (3) limited interprofessional planning for patient centred care.

Despite the myriad of hospital specific tools and processes designed to facilitate interprofessionalism, making collaboration a cultural norm is a challenge in this complex setting.

By the time of the conference, we will have completed our pilot study and intervention implementation and evaluation at the 2nd hospital. We will report on both quantitative and qualitative results related to the pilot and RCT at that time. Of special interest to participants will be an innovative interprofessional survey tool designed by these authors and based on the Communication between Medical Staff Subscale of the Nurses Opinion Questionnaire as well as an innovative method of interaction analysis using shadowing data.

Key Lessons Learned to date:

1. Harmonization of the ethics process between the university and participating hospital REBs would make research of this kind more accessible.
2. Physician, nursing and other health professions' leadership at the ward level is essential for successful implementation.
3. Hospital based QI initiatives require multiple levels of organizational support which is at times difficult to negotiate.
4. The purposefulness of collaborative teamwork differs within and between professions.
5. “Generic” models and interventions for IPC and IPE have unique strengths and limitations.