Interprofessional education for students of the health professions: the "Seamless Care" model.

"Seamless Care" was one of 21 grants awarded by Health Canada to inform policymakers of the effectiveness of interprofessional education in promoting collaborative patient-centred practice among health professionals. The "Seamless Care" model of interprofessional education was designed with input from three Faculties at Dalhousie University (Medicine, Dentistry and Health Professions). The design was grounded in relevant learning theories--Social Cognitive Theory, Self-efficacy, Situated Learning theory and Constructivism. The intervention was informed by principles of active learning, problem-based learning, reflection and role modeling. The primary goal of Seamless Care was to develop students' interprofessional patient-centred collaborative skills through experiential learning. Fourteen student teams, each including one student from medicine, nursing, pharmacy, dentistry and dental hygiene, learned with, from and about each other while they were mentored in the collaborative care of patients transitioning from acute care to the community. Student teams providing collaborative care assisted patients experiencing a chronic illness to become more active in managing their health through development of self-management and decision-making skills. This paper describes the Seamless Care model of interprofessional education and discusses the theoretical underpinnings of this experiential model of interprofessional education designed to extend classroom-based interprofessional education to the clinical setting.

Illness intrusiveness among survivors of autologous blood and marrow transplantation.

BACKGROUND: Illness-induced disruptions to lifestyles, activities, and interests (i.e., illness intrusiveness) compromise subjective well-being. The authors measured illness intrusiveness in autologous blood and bone marrow transplantation (ABMT) survivors and compared the results with survivors of solid organ transplants. METHODS: Forty-four of 64 consecutive ABMT survivors referred to the University of Toronto ABMT long-term follow-up clinic completed the Illness Intrusiveness Ratings Scale (IIRS), the Affect Balance Scale (ABS), the Atkinson Life Happiness Rating (ATKLH), the Beck Hopelessness Scale (BHS), and the Center for Epidemiologic Studies Depression (CES-D) Scale. Mean time from ABMT to evaluation was 4.6 +/- 2.8 years. All patients were in remission or had stable disease at the time of evaluation. Autologous blood and bone marrow transplantation patients' IIRS scores were compared with scores reported by recipients of kidney (n = 357), liver (n = 150), lung (n = 77), and heart (n = 60) transplants. RESULTS: Mean IIRS score for the 44 ABMT patients was 37.2 +/- 17 (maximum possible score, 91; minimum possible score, 13). Higher IIRS scores correlated with lower scores on the ABS (r = -0.54; P < 0.0001), and ATKLH (r = -0.44; P = 0.004), and with higher scores on the BHS (r = 0.58; P < 0.0001) and CES-D (r = 0.48; P < 0.0001). The authors compared IIRS scores from the ABMT survivors with scores from recipients of solid organ transplants. Scores were corrected for age, gender, and time from transplant to evaluation. Corrected mean IIRS scores for the marrow (37.5), kidney (38.9), heart (40.0), lung (30.1), and liver (32.3) transplant recipients differed significantly (P < 0.0001 by analysis of covariance). Higher scores among marrow, kidney, and heart transplant survivors were caused by increased scores in the instrumental domain of the IIRS that measures disruptions in health, work, financial situation, and active recreation. CONCLUSIONS: Despite achieving a remission after ABMT, patients continue to experience illness intrusiveness compromising subjective well-being.

Structure of lifestyle disruptions in chronic disease: a confirmatory factor analysis of the Illness Intrusiveness Ratings Scale.

BACKGROUND: The Illness Intrusiveness Ratings Scale (IIRS) measures the extent to which disease or its treatment or both interfere with activities in important life domains. Before comparing IIRS scores within or across groups it is crucial to determine whether a common underlying factor structure exists across patient populations. OBJECTIVE: To investigate the factor structure underlying the IIRS and evaluate its stability across diagnoses. METHODS: IIRS responses from 5,671 respondents were pooled from 15 separate studies concerning quality of life in eight patient groups: rheumatoid arthritis; osteoarthritis; systemic lupus erythematosus; multiple sclerosis; end-stage renal disease (maintenance dialysis); renal transplantation; heart, liver, and lung transplantation; and insomnia. Data were gathered by different methods (eg, interview, self-administered, mail survey) and in diverse contexts (eg, individual vs. group). RESULTS: Exploratory maximum-likelihood factor analysis identified three underlying factors in a randomly selected subset of respondents (n = 400), corresponding to "Relationships and Personal Development," "Intimacy," and "Instrumental" life domains. Confirmatory factor analysis corroborated the stability of this structure in an independent subsample (n = 2100). Complementary goodness-of-fit indices confirmed the consistency of the three-factor solution, corroborating that IIRS scores are uniquely defined across patient populations. Coefficient alpha was high for total and subscale scores. CONCLUSIONS: IIRS scores can be compared meaningfully within and across patient groups. Both total and subscale scores can be used depending on research objectives.

A clinimetric evaluation of specialized geriatric care for rural dwelling, frail older people.

OBJECTIVE: To test Comprehensive Geriatric Assessment (CGA) as an adjunct to usual care. DESIGN: A randomized controlled trial with 3, 6, and 12 months follow-up. SETTING: Rural communities. PATIENTS: A total of 182 of 265 frail older patients (52 refused, 2 withdrawn, 27 ineligible, 2 deaths) referred by family practitioners with allocation to intervention (n = 95) or usual care (n = 87). INTERVENTION: Three-month implementation of CGA recommendations by a Mobile Geriatric Assessment Team (MGAT) with follow-up assessments at 3, 6, and 12 months. Geriatric nurse assessors, blinded to group assignment, performed each assessment. MAIN OUTCOME MEASURE: Goal Attainment Scaling (GAS). RESULTS: Baseline characteristics were comparable between groups. At 3 months, the intervention group was more likely to attain their goals (GAS total: chi = 46.4 +/- 5.9; GAS outcome chi = 48.0 +/- 6.6) compared with controls (total: chi = 38.7 +/- 4.1; outcome chi = 40.8 +/- 5.6) (P < .001). Standard assessments of function (Barthel index, instrumental activities of daily living), cognition (Mini-Mental State Examination), and quality of life (modified Spitzer quality of life index) showed no difference over 12 months. No difference in survival (intervention: chi = 320 days, SE = 6; control: chi = 294 days, SE = 6; P = .257) or time to institutionalization (intervention: 340 days, SE = 9; control: 342 days, SE = 8; log rank = 0.661; P = .416) were observed. CONCLUSIONS: A MGAT can target rural dwelling, frail older persons, perform in-home CGA, and develop an intervention strategy. Although the intervention did not prolong life or delay institutionalization, clinically important benefits were observed.

Personality traits and self-care in adults awaiting renal transplant.

This article reports the pretransplant findings of the first phase of a three-phase, longitudinal study examining relationships among personality traits and self-care abilities and behaviors of Ontario adults pre- and post-renal transplant. A consortium of Ontario nurse researchers representing three of Ontario's five renal transplant centers conducted this research. All adults on the cadaver transplant lists of 15 Ontario dialysis centers were invited to participate. One hundred ninety-eight adults awaiting renal transplant were enrolled in the study, representing a 70% response rate. A cross-sectional, correlational design was used for the pretransplant phase. Self-report measures with known psychometric properties were used; validity and reliability of the measures were supported by the sample. Data were analyzed using descriptive approaches, correlational analyses, multiple regression, and path analysis. Relationships were supported among selected personality traits, health state and self-care abilities and behaviors. Further research to examine personality traits and health state in relation to adult self-care is warranted.

Psychosocial impact of illness intrusiveness moderated by self-concept and age in end-stage renal disease.

This study assesses whether a person's self-concept as a "chronic kidney patient" differentially moderates the psychosocial impact of illness intrusiveness--illness-induced lifestyle disruptions--across the life span. Renal transplant (n = 52) and maintenance dialysis patients (n = 49) completed the illness Intrusiveness Ratings Scale, a semantic-differential self-concept measure, and structured interviews measuring psychosocial well-being and emotional distress. Across ages, distress rose with increasing illness intrusiveness when self-concept was similar, but not dissimilar, to the chronic kidney patient stereotype. The relation between illness intrusiveness and psychosocial well-being differed significantly between younger and older respondents depending on whether they construed themselves as similar versus dissimilar to the chronic kidney patient. Although self-definition moderates the psychosocial impact of chronic disease, this varies across the life span and across affect states.

Evaluating the competence of clinical nurses from beginning to advanced practitioner.

Frequently, clinically competent nurses leave direct patient care for non-clinical positions or other careers to achieve greater professional advancement and recognition. The drain of clinical nursing expertise away from the patient prompted the development and evaluation of a clinical promotion program to appraise and recognize clinical nursing competence. At the beginning of the evaluation period, 205 nurses were appraised for clinical competence and categorized as: Level 1--a beginning practitioner or a nurse returning to service; Level 2--a skilled clinical practitioner; and Level 3--an advanced clinical practitioner. Nurses volunteered information related to demographic characteristics, education, clinical experience, and attitudes to their work and work environment. Reassessments were completed after one year. Evaluation of the program employed a longitudinal comparative design. The major finding shows significant shift in clinical nurses' competence over time with a greater percentage of nurses at higher levels of ability. Further evaluation of the program is in process.

Recruiting and retaining competent clinical nurses. The Clinical Promotion Project Victoria General Hospital, Halifax, Nova Scotia.

A career advancement program for nurses has been developed and implemented at the Victoria General Hospital, Halifax, as part of a manpower planning strategy for recruitment and retention of clinical nurses. A competency based performance appraisal system was developed and implemented as part of the program. This system identifies four levels of clinical expertise. Progression through each level indicates that a nurse has achieved a certain level of skill, knowledge and abilities. Demonstrated competence in one level is a prerequisite to promotion to the next level of practice. Implementation of this system provides clinical career opportunities for nurses in direct patient care. This article will provide the nurse administrator with an insight into the development and implementation of a clinical career advancement program. Future articles will described the research evaluation of the Clinical Performance Appraisal System and clinical nurses' reactions to the new system.

Ambulatory care nursing. A new approach.

This article describes one hospital's experience with integrating inpatient and outpatient nursing services. Nursing services integration enabled nursing management to combine the nursing resources allocated to the inpatient and outpatient components of a clinical service under the direction of one nurse manager. This new and creative approach was implemented in thirteen clinical services at the Victoria General Hospital, Halifax. This organizational structure was considered to be an effective approach for managing ambulatory care nursing services. The introduction of integration facilitated a change in the ambulatory care nursing role. It also provided for increased continuity of patient care and afforded nurses the opportunity to practice in another setting. Nursing services integration is considered a more effective approach for managing nursing resources.