Conditions that Foster Interprofessional Practice: A Case Study of Two Health Care Institutions

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Conditions that Foster Interprofessional
Practice A Case Study of Two Health Care
Institutions

• Margaret Purden, RN, Ph.D.
• Hélène Ezer, RN, Ph.D
• David Fleiszer, M.D.
• Fay Strohschein, RN., M.Sc.(A)
• Liliane Asseraf Pasin, PT, Ph.D.(C)
• Bruce Shore, Ph.D.
• Yvonne Steinert, Ph.D.
• Krista Redden, M.A.Camelia Birlean, M.Ed.

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Introduction

• Previous work has focused on
• Characteristics of interprofessional teams
  (DAmour, 2004 2005 Headrick, 1998 West
  1997)
• Determinants of interprofessional practice
  (DAmour, 2004 Heinemann, 2002 Rodriguez, 2005)
  
• Outcomes of interprofessional practice

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Characteristics of Interprofessional Teams

• Shared beliefs
• Nature of Partnership
• Interdependencysynergy
• Shared Responsibility
• Process

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Determinants of Interprofessional Practice

• Systemic determinants (definitions of
  professional jurisdictions)
• Organizational determinants (governance
  structures, availability of space, time)

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Outcomes of Interprofessional Practice

• In relation to the team members
• Satisfaction
• Higher job productivity
• Feeling of solidarity
• Improved achievement of clinical goals
• (Corser, 1998)

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Outcomes of Interprofessional Practice

• In relation to patients and families
• Interprofessional practice improves outcomes in a
  number of patient populations studied to date
• Geriatrics, ER care for abused women, STD
  screening, Adult immunization, fractured hips
  neonatal ICU care, depression care, and in
  simplifying medications
• 
  (Zwarenstein et al., 2004)

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Study Questions

• What are the characteristics of the IPP sites in
  our system?
• Is there a fit with the existing literature on
  IPP sites?
• What implications does this have?

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Methods

• Phone survey to medical, nursing, allied health
  leaders in the 2 institutions to identify IPP
  sites
• Selection of two sites
• Open-ended interviews with key informants
• Participant observation at the 2 sites

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Telephone Survey

• Sample Questions
• What sites come to mind for you as demonstrating
  exceptional interprofessional collaboration?
• Can you describe them to me?
• What makes the site outstanding or unique?

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Site Visits

• Sample Interview Questions
• What do you think makes the team work well
  together?
• Can you describe a patient/family situation that
  was a challenge for the team and how the team
  dealt with this?
• What would you recommend to sites that are
  developing their interprofessional practice ?

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Site Visits

• Observations
• General layout of the unit
• Who are the key players
• Where and how do interactions happen
• The nature of interactions between professionals
  and with patients and families
• Meetings (who guides the meeting, who
  participates)

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Results

• Telephone Survey
• 11 respondents nominated 22 sites in Hospital A
• 25 respondents nominated 45 sites in Hospital B
• Nominated settings included
• Geriatrics, Oncology, Neurology, Psychiatry,
  Palliative Care
• ICU, General medical, Surgery

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Results

• Inpatient Geriatrics Unit
• 36 bed unit
• Team together 5 years
• Team composition
• Head nurse - 2 social workers
• 6 Geriatricians (rotate) - 29 nurses
• 1 physiotherapist - 5 orderlies
• Clinical nurse specialist - Unit agent
• Occupational therapist - Dietician
• Speech language therapist - Pharmacist

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Results

• Traumatic Brain Injury Program
• Provided service to over 500 patients/year,
  followed 45 patients at any given time
• Team formed 12 years ago
• Team composition
• 2 Neurosurgeons - Physiatrist
• 2 Clinical nutritionists - 2 Physiotherapists
• 2 Speech Therapists - Neuropsychologist
• 2 Social Workers - Coordinator
• Administrative Technician - Secretary

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A Balance Between the Common and the Unique
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Common Attributes of Interprofessional Practice
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Team Characteristics

• Sharing information
• Working towards consensus
• Dealing with disagreements
• Valuing the contributions of others
• Understanding other professional roles
• Evolving over time

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Determinants of Collaboration

• Leaders who coordinate the group effort, bring
  professionals together
• Shared goals, clear objectives
• Group discussions
• Flattened hierarchy among professionals
• Time to interact

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Unique Attributes of Interprofessional Practice

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The Heart of IPP

• Standing around the board
• Its our town square its where we gather
• A lot of informal conversations are in front
  of the board because you will have several
  professionals gathering there
• That board is the focal point, the nucleus of
  the floor
• It is a religious moment looking at the
  board.(it) indicates what we do here, very very
  important

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The Heart of IPP

• Coming to the table
• There is this interdisciplinary play back and
  forth, where people share information, openly,
  freely and particularly in this rounds setting
  that we have once a week
• All the team members hold different pieces to
  the same puzzle and rounds is where they come
  together to put those pieces together
• To share as wellthe small celebrations of
  successes

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Tuning into our Partners

• Learning the dance
• If you have a dance partner that you are with
  for a whileyou almost know how the moves are
  going to go and you can predict a little bit.
  For me it is knowing other people well enoughso
  I can adapt myself

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Tuning into our Partners

• Listening for the cues
• Listening and hearingthe reactions that each
  of the team members have when they hear certain
  facts - if they have a reaction like oh it would
  have helped to know this in advance So a lot of
  it is just good listening

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Not for the Novice

• A steep learning curve
• Walking into the TBI program is not an easy
  walkto produce concise assessments in a short
  period of time
• Its basically a TBI 101..in terms of what kind
  of acronyms will you hear, what kind of markers
  do you look for in a medical chart, and the
  biggest part of the learningwas the importance
  of sharing information

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Not for the Novice

• High expectations
• Expectations are high here...you have to know
  your cases, you have to be on top of things...
  I've been on other services so it was easier for
  me....but in rounds at the beginningI spoke
  before the dietician and they said, 'No, you have
  to wait your turn...' 'My turn?' and I looked
  around and said, 'What are you talking about?'
  'No, we go in order. and I thought, Okay, it
  wasn't a big deal but...

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Negotiating Boundaries

• Establishing boundaries
• In the beginning it was not obvious that
  people would let go of their territory. They have
  many areas that overlapbut who has the best
  tools and knowledge to do it? It was really by
  discussing, giving examples and describing roles
  that things settled slowly and now they are all
  working together.

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Negotiating Boundaries

• Knowing the boundaries
• On this floor there is very little
  overlapping. The division of labour is quite
  boundary clear and it is very, very importantit
  has to do with the patient who is admitted and
  what their needs are
• As a social worker I have to listen to
  patients grievances.after I listen I will
  acknowledge their complaintsI will direct them
  appropriately to the HN, the ombudsman, the
  physician or the physiotherapist. I will let my
  colleagues work on their issues. They do that
  reciprocally.

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Part of our Culture

• The way we see things
• A team represents a small society, different
  people with different personalities with
  different strengths, weaknessesYou have to make
  sure that you always go and get the best from
  each person in your little society

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Part of our Culture

• The way we do things
• There are a lot of contributory individuals who
  are going into this river. . . like different
  streams, and that is how the floor works
• On a floor like this, everything is up for
  discussion
• That is part of the culture on the floor that
  continuous access to each other and having these
  formal mechanisms and informal mechanisms, like
  looking at the board

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Discussion

• The findings support previous work and also
  highlight unique attributes that presented
  differently in the two settings.
• Methodology that is sensitive to the nuances of
  interprofessional practice

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Implications

• Promoting interprofessional practice requires
• Fundamental building blocks
• A culturally sensitive approach
• Resources that enable

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Acknowledgements

• Health Canada Initiative on Interprofessional
  Education and Practice
• All of the health professionals in these two
  settings who welcomed us into their teams and
  gave of their time to help us learn how they do
  what they do.

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Were in this Together!
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Systematic Review of Recent Trials of Effective
Collaboration Interventions
Study Source Intervention
A randomized clinical trial of outpatient geriatric evaluation and management Boult et al. J Am Geriatr Soc 200149351-9. Comprehensive assessment followed by interdisciplinary primary care.
An evaluation of a system-change training model to improve emergency department response to battered women. Campbell et al. Acad Emerg Med 20018131-8 Team participated in 2 day didactic training and team planning exercise.
Can differences in management processes explain different outcomes between stroke unit and stroke-team care? Evans et al. Lancet, 358 (9293), 11-10-2001, 1586 1592 Stroke unit, no specific interventions to encourage collaboration of team.
Interdisciplinary inpatient care for elderly people with hip fracture A randomized controlled trial. Naglie et al. CMAJ 200216725-32. Interdisciplinary rounds to discuss each patient twice weekly.
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Systematic Review of Recent Trials of Effective
Collaboration Interventions
Study Source Intervention
Reduced mortality in treating acutely sick, frail older patients in a geriatric evaluation and management unit (GEMU). A prospective randomized trial. Saltvedt et al. J Am Geriatr Soc 200250792-8. GEMU, the treatment strategy emphasized interdisciplinary assessment of all relevant disorders, prevention of complications and iatrogenic conditions, early mobilization/rehabilitation, and comprehensive discharge planning.
Effect of a clinical practice improvement intervention on Chlamydia screening among adolescent girls. Shafer et al. JAMA 20022882846-52 Audit and feedback, barrier identification, team building and meetings, iterative approach.
Cluster randomized controlled trial of an educational outreach visit to improve influenza and pneumococcal immunization rates in primary care. Siriwardena et al. Br J Gen Pract 200252735-40 Academic detailing to team in each practice to promote immunization, combined with audit and feedback. Control group received audit and feedback only.
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Systematic Review of Recent Trials of Effective
Collaboration Interventions
Study Source Intervention
Reducing medication regimen complexity A controlled trial. Muir et al. J Gen Intern Med 20011677-82 For intervention patients, a medication grid was created that displayed all of the patients medicines and the times of administrations for 1 week. This grid was delivered to the admitting resident soon after admission. Information transfer intervention.
Economic implications of neonatal intensive care unit collaborative quality improvement. Rogowski et al. Pediatrics 200110723-9. Multidisciplinary teams doing collaborative quality improvement, reviewing performance data, developing shared goals, designing improvements to their practices.
A CQI intervention to change the care of depression A controlled study. Solberg et al. Eff Clin Pract 20014239-49 CQI intervention in which participants from intervention clinics developed an approach to depression care.
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Resources that Enable

• Dedicated Personnel
• Being here 2 and a half days a week I see the
  team on a regular basis.they know me now
• Stability of the team
• They have the most stable team. They dont
  change, they are there forever. They are stable .
  We have not had that many people that have left.
  So now they know how to work together.

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Resources that Enable

• Dedicated Personnel
• We sort of have our own dietician that covers
  our unit so we know her name
• We have a physical therapist just for us
• Stability of the team
• It continues to improve and one of the reasons
  it has been improving is there has been
  historically a consistency in the staff
• people have been working together for years
  and we are equally informed about all our issues