Health care providers' roles and responsibilities in management of polypharmacy: Results of a modified Delphi.

BACKGROUND: Little is known about the roles that allow interprofessional teams to effectively manage older patients experiencing polypharmacy. OBJECTIVES: To identify and examine the consensus on salient interprofessional roles, responsibilities and competencies required in managing polypharmacy. METHODS: Four focus groups with 35 team members practising in geriatrics were generated to inform survey development. The sessions generated 63 competencies, roles or responsibilities, which were categorized into 4 domains defined by the Canadian Interprofessional Health Collaborative. The resulting survey was administered nationally to geriatric health care professionals who were asked to rate the importance of each item in managing polypharmacy; we sought agreement within and across professions using a confirmatory 2-round Delphi method. RESULTS: Round 1 was completed by 98 survey respondents and round 2 by 72. There was high intra-professional and interprofessional consensus regarding the importance of competencies among physicians, nurses and pharmacists; though pharmacists rated fewer competencies as important. Less consensus was observed among other health care professionals or they indicated the nonimportance of competencies despite focus group discussion to the contrary. DISCUSSION: Although there is a strong consensus of polypharmacy management competencies across team members who have been more traditionally involved in medication management, there continue to be health care providers with differing understandings of competencies that may contribute to reduced reliance on medication. Lower importance ratings suggest pharmacists may not acknowledge or recognize their own potential roles in interprofessional polypharmacy management. CONCLUSION: Further exploration to understand the underutilization of professional expertise in managing polypharmacy will contribute to refining role clarity and translating competencies in practical settings, as well as guiding educators regarding curricular content.

Making quality improvement stick and stay: Two lines of insurance.

This article examines issues related to sustaining Quality Improvement (QI) initiatives in a Canadian subacute care hospital and recommends strategies to address them. The authors define two levels of sustainability, the QI project and the corporate/organizational and how they influence a LEADS (Lead Self, Engage Others, Achieve Results, Develop Coalition and System Transformation) culture. The authors then reflect on the differing factors for QI sustainability and present them under five essential categories of accountability, education, communication, monitoring and reporting, and structure and processes.

Learning collaborative teamwork: an argument for incorporating the humanities.

A holistic, collaborative interprofessional team approach, which includes patients and families as significant decision-making members, has been proposed to address the increasing burden being placed on the health-care system. This project hypothesized that learning activities related to the humanities during clinical placements could enhance interprofessional teamwork. Through an interprofessional team of faculty, clinical staff, students, and patient representatives, we developed and piloted the self-learning module, "interprofessional education for collaborative person-centred practice through the humanities". The module was designed to provide learners from different professions and educational levels with a clinical placement/residency experience that would enable them, through a lens of the humanities, to better understand interprofessional collaborative person-centred care without structured interprofessional placement activities. Learners reported the self-paced and self-directed module to be a satisfactory learning experience in all four areas of care at our institution, and certain attitudes and knowledge were significantly and positively affected. The module's evaluation resulted in a revised edition providing improved structure and instruction for students with no experience in self-directed learning. The module was recently adapted into an interactive bilingual (French and English) online e-learning module to facilitate its integration into the pre-licensure curriculum at colleges and universities.

Theories, relationships and interprofessionalism: learning to weave.

In this article, we illustrate the application of a number of theoretical frameworks we have used to guide our work in interprofessional education (IPE) and collaborative interprofessional care (IPC). Although we do not claim to be experts in any one of these theories, each has offered important insights that have broadened our understanding of the complexities of interprofessional learning and practice. We have gained an appreciation for an increasing number of theories relevant to IPE and IPC, and, as a result, we have woven together more key principles from different theories to develop activities for all levels of interprofessional learners and clinicians. We pay particular attention to relational competencies, knotworking/idea dominance, targeted tension and situational awareness. We are now drawing on the arts and humanities and complexity theory to foster relationship-building learning. Evaluation of our endeavors will eventually follow these latter theories for methods that better match the human and social experiences that underpin learning. Our "theoretical toolbox" therefore may be of value to educators who develop and implement creative interprofessional learning activities, as well as clinicians interested in moving toward more effective collaboration.

A method to enhance student teams in palliative care: piloting the McMaster-Ottawa Team Observed Structured Clinical Encounter.

BACKGROUND: The need for palliative and end-of-life care (PEOLC) education in prelicensure education has been identified. PEOLC requires effective collaborative teamwork. The competencies required for effective collaborative teamwork are only now emerging and methods to evaluate them must be developed. OBJECTIVE: The adaptation of the traditional Objective Structured Clinical Examination (OSCE) for assessment of a student team addressing palliative care issues was undertaken. The McMaster-Ottawa Team Observed Structured Clinical Encounter (TOSCE) is intended as a formative evaluation tool for both competencies in interprofessional collaboration for patient-centered practice and PEOLC. METHODS: Three stations based on palliative care scenarios were developed. From January 2007 to January 2008, a total of 141 students and 38 observers participated in the evaluation of three stations, with 6-7 students per group and two observers per station. Observers completed checklists for both PEOLC and interprofessional collaborative competencies and, after completing the TOSCEs, students and observers completed questionnaires on their feasibility and acceptability. RESULTS: Eighty-nine percent of the students and 44% of the observers were from medicine. Students and observers found the TOSCE to be an acceptable and feasible assessment tool for both sets of competencies. Reliability and validity data show that the items in both the clinical and interprofessional checklists fit well together, and interrater reliability is readily achieved. CONCLUSIONS: The new formative evaluation TOSCE tool, adapted from the traditional OSCE, was acceptable and feasible to students and observers.

Health information systems design to support a nursing model of care: opportunities and challenges.

The design and implementation of health information systems (HISs) in team-based settings is complex owing to the multiple users with different perspectives who interact with the system. We argue that such perspectives must be understood prior to designing and implementing HISs. One specific type of team-based model is a nursing care model. In such a model, care is provided through an interdisciplinary team that is lead by the nursing staff. We analyze a nursing-based model of care according to the context of the organization, clinical unit, and individual as defined by the Contextual Implementation Model [1]. We then discuss how the nursing model will be affected by automation using different HISs.

Developing leadership in rural interprofessional palliative care teams.

This project brought together community-based practitioners and academics to develop and deliver interventions designed to enhance the leadership abilities of the designated leaders of seven rural/small town-based palliative care teams. Members of these community-based teams have already gained recognition for their teams' leadership and service delivery in their communities. All of the teams had worked closely with most members of the academic team prior to this project. The team members participated in a needs assessment exercise developed by the Sisters of Charity of Ottawa Health Service and University of Ottawa academic team. Results of the needs assessment identified leadership qualities that had contributed to their success, as well as their needs to further enhance their individual leadership qualities. The team effort, however, was the most important factor contributing to the success of their work. The interventions developed to address the identified needs had to be adapted creatively through the collaborative efforts of both the community and academic teams. The educational interventions facilitated the integration of learning at the individual and community level into the busy work schedules of primary health care providers.

Developing collaborative person-centred practice: a pilot project on a palliative care unit.

Maximizing interprofessional collaborative patient-centred practice holds promise for improving patient care and creating satisfying work roles. In Canada's evolving health care system, there are demands for increased efficiency, cost-effectiveness, and quality improvement. Interprofessional collaboration warrants re-examination because maximizing interprofessional collaboration, especially nurse-physician collaboration, holds promise for improving patient care and creating satisfying work roles. A palliative care team seized the opportunity to pilot a different approach to patient and family care when faced with a reduction in medical staff. Grounded in a collaborative patient-centred practice approach, the Canadian Hospice Palliative Care Association's National Model to Guide Hospice Palliative Care (2002), and outcomes from program retreats and workgroups, a collaborative person-centred model of care was developed for a 12-bed pilot project. Preliminary findings show that the pilot project team perceived some specific benefits in continuity of care and interprofessional collaboration, while the presence of the physician was reduced to an average of 3.82 hours on the pilot wing, compared with 8 hours on the non-pilot wings. This pilot study suggests that a person-centred model, when focused on the physician-nurse dyad, may offer improved efficiency, job satisfaction and continuity of care on a palliative care unit. Incorporating all team members and developing strategies to successfully expand the model across the whole unit are the next challenges. Further research into the impact of these changes on the health care professionals, management and patients and families is essential.

Interprofessional education in palliative care: a pilot project using popular literature.

A need to introduce the concepts of death and dying to the medical and health sciences undergraduate curriculum was identified at the University of Ottawa, Ontario, Canada. As care of the terminally ill is complex and requires the collaborative involvement of a diverse group of health care professionals, an interprofessional educational approach was utilized to address this need. A seminar course was developed using popular literature as the basis for learning, and offered to first and second year medical students, fourth year nursing students and graduate students in spiritual care. The discussion of roles and the provision of care within the context of works of selected literature provided a focus that enabled the students to transcend their disciplinary barriers, and to better understand the perspectives and contributions that other team members bring to patient care. Evaluation findings suggest that meaningful interprofessional education can be introduced effectively to students either prior to or while they are maturing in their professional roles.

Structured interview assessment of symptoms and concerns in palliative care.

OBJECTIVE: Assessment in palliative care requires a multidimensional review of physical symptoms and psychosocial concerns in a format appropriate for patients with advanced illness. In this study, we describe the initial development and validation of a structured interview for assessing common symptoms and concerns faced by terminally ill individuals. METHOD: We constructed a 13-item Structured Interview for Symptoms and Concerns (SISC) based on a review of end-of-life issues and administered it to 69 patients receiving palliative care for advanced cancer. Along with the interview, each participant completed visual analog scales (VAS) addressing the same constructs. Test-retest and interrater reliability were determined, as was the concordance between interview ratings and VAS scores. RESULTS: Overall, the interview items had excellent interrater reliability (intraclass correlations were > 0.90) and at least moderate temporal stability (test-retest correlations ranged from 0.50 to 0.90). Concurrent validity was evident in the good concordance between interview items and VAS measures (correlations were > 0.70). The SISC was also sensitive to individual differences between subgroups of participants who did or did not meet diagnostic criteria for anxiety or depressive disorders. CONCLUSIONS: This study demonstrates that structured interviews provide a reliable and valid approach to assessment in palliative care and may be an appropriate alternative for some research applications.

The last 48 hours of life in long-term care: a focused chart audit.

OBJECTIVES: As a component of palliative care educational program development, the faculty at the University of Ottawa Institute of Palliative Care wished to assess end-of-life care for patients in long-term care (LTC) settings to develop an educational strategy for physicians. DESIGN: A chart audit, focusing on the last 48 hours of life of residents dying in LTC facilities. SETTING: Five LTC facilities in a city in Canada. PARTICIPANTS: Residents who died in the LTC facilities in a 12-month period. Those who died suddenly (i.e., with no palliation period) or in a hospital were excluded. MEASUREMENTS: Symptoms highlighted in the literature as commonly found in the terminally ill and the matching treatments were recorded on an audit form created by the authors. Included were pain, dyspnea, noisy breathing, delirium, dysphagia, fever, and myoclonus. RESULTS: One hundred eighty-five charts were reviewed. A large number of patients were cognitively impaired. Cancer was the final diagnosis in 14% of cases. Respiratory symptoms were the most prevalent symptom, with dyspnea being first and noisy breathing third. Pain was second, with a prevalence similar to that found in studies of cancer patients. Dyspnea was not treated in 23% of the patients with this symptom; opioids were used in only 27% of cases with dyspnea. Ninety-nine percent of patients who experienced pain were treated for it. Less than one-third of patients with noisy breathing were treated. Delirium was not treated in 38% of the cases, and no anti-dopaminergic medications were administered. Nurses were primarily responsible for documenting end-of-life issues, supporting the families of the dying residents, and communicating with other team members. CONCLUSION: The focused chart audit identified the high prevalence of cognitive impairment in the patient population, which complicates symptom management. Respiratory symptoms predominated in the last 48 hours of life. This symptom profile differs from that of cancer patients, who, according to the literature, have more pain and less respiratory trouble. Management of symptoms was variable. Nurses played a crucial role in the care of dying residents through their documentation and communication of end-of-life issues. Appropriate palliative care education can provide knowledge and skills to all health-care professionals, including physicians, and assist them in the control of symptoms and improvement of quality of life for patients dying in LTC facilities.