Development, psychometric assessment, and predictive validity of the comprehensive breastfeeding knowledge scale.

AIM: To develop a breastfeeding knowledge scale that aligns with the Baby Friendly Hospital Initiative and psychometrically test it among expectant parents. BACKGROUND: Although breastfeeding is recommended by all leading health authorities, rates remain suboptimal with women often not achieving their breastfeeding goals. One factor found to positively influence infant feeding behaviours is increased maternal breastfeeding knowledge. However, little research has been conducted validating the dimensions of breastfeeding knowledge to guide interventions to promote positive breastfeeding outcomes. DESIGN: Following an extensive literature review, the 28-item Comprehensive Breastfeeding Knowledge Scale (CBKS) was developed and psychometrically tested. METHOD: A sample of 217 Canadian expectant parents (113 women and 104 coparents) was recruited and administered the CBKS with follow-up questionnaires at 4 and 12 weeks postpartum. Psychometric analyses included exploratory factor analysis, internal consistency, concurrent validity, and predictive validity. RESULTS: Exploratory factor analysis resulted in three dimensions: (1) managing milk supply; (2) persisting through challenges; and (3) correcting misconceptions. Coefficient alpha for the total scale was 0.83 and support for concurrent validity was demonstrated through significant positive correlations with the Iowa Infant Feeding Attitude scale. Further, higher total and subscale scores in pregnancy were associated with exclusive breastfeeding at 4 and 12 weeks postpartum, providing good evidence for predictive validity. CONCLUSION: Preliminary data suggest the CBKS is a valid and reliable measure of breastfeeding knowledge. Upon further testing, this self-report measure may be used to (1) identify women with low breastfeeding knowledge requiring targeted support, (2) individualize health professional care with breastfeeding women, and (3) evaluate the effectiveness of breastfeeding interventions and programs.

Levels and predictors of participation in integrated treatment programs for pregnant and parenting women with problematic substance use.

BACKGROUND: Women who are seeking services for problematic substance use are often also balancing responsibilities of motherhood. Integrated treatment programs were developed to address the diverse needs of women, by offering a holistic and comprehensive mix of services that are trauma- and violence-informed, and focus on maternal and child health promotion and the development of healthy relationships. METHODS: Using system-level administrative data from a suite of outpatient integrated programs in Ontario, Canada, we described the clients and rates and predictors of treatment participation over a 7-year period (2008-2014; N = 5162). RESULTS: All participants were either pregnant or parenting children under 6 years old at admission to treatment. Retention (length of time between the first and last visit) averaged 124.9 days (SD = 185.6), with episodes consisting of 14.6 visits (SD = 28.6). The vast majority of women attended more than one visit (87.2%), typically returning within 2 weeks (mean 12.3 days, SD = 11.1). In addition to being pregnant or new mothers experiencing problematic substance use, most were unemployed, on social assistance, and single. CONCLUSIONS: Programs appeared to be able to successfully engage most women in treatment once they accessed the programs. Although rates of treatment participation did vary across subgroups defined by sociodemographic and admission characteristics, effect sizes tended to be small on average, providing little evidence in general of sociodemographic inequities in participation. Further work is needed to study the influence of program-level factors on participation, and how these link to maternal and child outcomes.

A system-level study of initiation, engagement, and equity in outpatient substance use treatment.

Understanding the nature of variations in the quality of substance use treatment is critical to ensuring equity in service delivery and maximizing treatment effectiveness. We used adapted versions of the US Healthcare Effectiveness Data and Information Set (HEDIS) treatment initiation and engagement measures to assess care quality in specialized outpatient services for substance use in Ontario, Canada. Using administrative data, we calculated rates of outpatient treatment initiation and engagement (N = 120,394 episodes) and investigated variation by client characteristics and treatment mandates. About half of clients who entered outpatient treatment met the criteria for initiation (i.e., had a second visit within 14 days) and 30% met the criteria for engagement (i.e., had another two visits within 30 days of initiation). The likelihood of treatment initiation and engagement was greater among older people, those with more education, those who were not mandated to enter treatment, and those with greater substance use at admission. People who entered treatment for cannabis were less likely to engage. Engagement was less likely among men than women, but gender differences were slight overall. This study demonstrates the feasibility of using adapted versions of two common measures to characterise care quality in substance use treatment services in the Canadian context. Overall, the magnitude of associations with client characteristics were quite small, suggesting that initiation and engagement were not overly localized to specific client subgroups. Findings suggest that the Ontario system has difficulty retaining clients who enter treatment and that most outpatient treatment involves care episodes of limited duration.

The clustering of psychopathology among adults seeking treatment for alcohol and drug addiction.

Beyond the high prevalence of co-occurring mental and substance use disorders, little is known about more complex patterns of psychopathology and multimorbidity, particularly in treatment populations. We sought to identify a parsimonious set of latent classes to describe the structure of mental disorder comorbidity among adults entering outpatient addiction treatment, and explore differences in the structure and prevalence of classes across sociodemographic characteristics. Participants (N=544) completed the Psychiatric Diagnostic Screening Questionnaire at treatment admission. We used latent class analysis to identify classes of clients with specific patterns of co-occurring mental disorders. The best-fitting solution identified 3 classes, characterized by no comorbidity (i.e., substance use disorders only), co-occurring major depression, and multimorbidity or a high degree of psychopathology. Older age was associated with lower probability of being in the class with co-occurring major depression, women were more likely than men to be in the multimorbid class, and being married or partnered was associated with a lower probability of being in either of the comorbid classes. These results are consistent with general population research on the patterning of psychiatric disorders, implying that while clients in addiction treatment may have extraordinarily high levels of psychopathology, the patterns of symptoms and the groups most affected are not markedly different than in other settings. By capturing the complexity of interrelationships among the many factors that are known to influence prognosis and outcomes, latent class analysis offers a useful way to examine and represent case-mix in clinical populations.

Disengaged: a qualitative study of communication and collaboration between physicians and other professions on general internal medicine wards.

BACKGROUND: Poor interprofessional communication in hospital is deemed to cause significant patient harm. Although recognition of this issue is growing, protocols are being implemented to solve this problem without empirical research on the interprofessional communication interactions that directly underpin patient care. We report here the first large qualitative study of directly-observed talk amongst professions in general internal medicine wards, describing the content and usual conversation partners, with the aim of understanding the mechanisms by which current patterns of interprofessional communications may impact on patient care. METHODS: Qualitative study with 155 hours of data-collection, including observation and one-on-one shadowing, ethnographic and semi-structured interviews with physicians, nurses, and allied health professionals in the General Internal Medicine (GIM) wards of two urban teaching hospitals in Canada. Data were coded and analysed thematically with a focus on collaborative interactions between health professionals in both interprofessional and intraprofessional contexts. RESULTS: Physicians in GIM wards communicated with other professions mainly in structured rounds. Physicians' communications were terse, consisting of reports, requests for information, or patient-related orders. Non-physician observations were often overlooked and interprofessional discussion was rare. Intraprofessional interactions among allied health professions, and between nursing, as well as interprofessional interactions between nursing and allied health were frequent and deliberative in character, but very few such discussions involved physicians, whose deliberative interactions were almost entirely with other physicians. CONCLUSION: Without interprofessional problem identification and discussion, physician decisions take place in isolation. While this might be suited to protocol-driven care for patients whose conditions were simple and courses predictable, it may fail complex patients in GIM who often need tailored, interprofessional decisions on their care.Interpersonal communication training to increase interprofessional deliberation may improve efficiency, patient-centredness and outcomes of care in hospitals. Also, electronic communications tools which reduce cognitive burden and facilitate the sharing of clinical observations and orders could help physicians to engage more in non-medical deliberation. Such interventions should take into account real-world power differentials between physicians and other health professions.

Rasch model of the GAIN substance problem scale among Canadian adults seeking residential and outpatient addiction treatment.

BACKGROUND: The GAIN Substance Problem Scale (SPS) measures alcohol and drug problem severity within a DSM-IV-TR framework. This study builds on prior psychometric evaluation of the SPS by using Rasch analysis to assess scale unidimensionality, item severity, and differential item functioning (DIF). METHODS: Participants were attending residential or outpatient treatment in Alberta and Ontario, Canada, respectively (n=372). Rasch analyses modeled a latent problem severity continuum using SPS scores at treatment admission and 6-week follow-up. We examined DIF by gender, treatment modality (outpatient vs. residential), and assessment timing (baseline vs. follow-up). RESULTS: Model fit was good overall, supporting unidimensionality and a single underlying continuum of substance problem severity. Relative to person severity, however, the range of item severities was narrow. Items were too severe for many clients to endorse, particularly at follow-up. Overall, the rank order of item severities was stable across gender, treatment modality, and time point. Although traditional Rasch criteria indicated a number of statistically significant and substantive DIF estimates across modality and time points, effect size indices did not suggest a net effect on total scale scores. CONCLUSIONS: The analysis broadly supports use of the SPS as an additive measure of global substance severity in men and women and both residential and outpatient settings. Although DIF was not a major concern, there was evidence of item redundancy and suboptimal matching between items and persons. Findings highlight potential opportunities for further improving this scale in future research and clinical applications of the GAIN.

Research capacity of respiratory therapists: A survey of views, opinions and barriers.

BACKGROUND: Evidence-based practice (EBP) is increasing in health care services. This means that respiratory therapists (RTs) should be effective consumers, users and producers of scientific research pertaining to respiratory therapy technology and respiratory physiology. However, little is known about RT opinions and attitudes toward research. Survey instruments to measure them are also uncommon. OBJECTIVE: The present article presents the results of a survey of RTs regarding research attitudes including interest, self-perceived skill and barriers. METHODS: A survey was developed in consultation with practicing RTs and education researchers. It was fielded in six academic hospitals in Toronto, Ontario. Surveys were completed and returned anonymously. Descriptive statistics and associations were examined. Subgroup differences were tested using ANOVA methods. RESULTS: Surveys were completed by 112 RTs (response rate 26.9%). The majority (approximately 80%) of respondents agreed that respiratory therapy research is important, that research can advance the profession and that RTs are suited to performing respiratory therapy research. More than 70% were interested in performing research as long as barriers were eliminated. Among eight potential barriers, lack of time was ranked as the top barrier 59% of the time. Lack of interest in performing research was the least relevant barrier. RTs' educational attainment was positively associated with willingness to perform research and belief in having the skills needed for research. CONCLUSION: Many RTs want to conduct research. They would need substantial support, including increased research exposure during respiratory therapy training, more time and support from trained researchers.

HISTORIQUE: La pratique fondée sur des données probantes (PDB) augmente dans les services de santé. Ainsi, les inhalothérapeutes (IT) devraient être des consommateurs, des utilisateurs et des producteurs efficaces de recherche scientifique portant sur la technologie en inhalothérapie et en physiologie respiratoire. Cependant, on ne sait pas grand-chose de l'avis et des attitudes des IT envers la recherche. De plus, il y a peu d'instruments de sondage pour les mesurer. OBJECTIF: Le présent article contient les résultats d'un sondage auprès des IT au sujet des attitudes envers la recherche, y compris l'intérêt, les compétences autoperçues et les obstacles. MÉTHODOLOGIE: Les chercheurs ont préparé un sondage en consultation avec les IT et les chercheurs en enseignement. Ce sondage a été envoyé dans six hôpitaux universitaires de Toronto, en Ontario. Les sondages ont été remplis et remis de manière anonyme. Les chercheurs ont examiné les statistiques descriptives et les associations. Ils ont vérifié les différences de sousgroupe selon les méthodes de l'analyse de variance. RÉSULTATS: Au total, 112 IT ont rempli le sondage (taux de réponse de 26,9 %). La majorité des répondants (environ 80 %) ont convenu que la recherche en inhalothérapie est importante, qu'elle peut faire progresser la profession et que les IT possèdent les compétences pour faire de la recherche en inhalothérapie. Plus de 70 % souhaitaient faire de la recherche, pourvu que les obstacles soient éliminés. Parmi huit obstacles potentiels, le manque de temps était classé comme le principal dans 59 % des cas. Le manque d'intérêt à effectuer de la recherche était le moins pertinent. Le niveau d'éducation des IT s'associait de manière positive à leur volonté de faire de la recherche et à leur conviction de posséder les compétences nécessaires pour en faire. CONCLUSION: De nombreux IT désirent faire de la recherche. Ils auraient besoin d'un appui considérable, y compris une plus grande exposition à la recherche pendant leur formation en inhalothérapie et plus de temps et de soutien de la part de chercheurs formés.

Interprofessional communication with hospitalist and consultant physicians in general internal medicine: a qualitative study.

BACKGROUND: Studies in General Internal Medicine [GIM] settings have shown that optimizing interprofessional communication is important, yet complex and challenging. While the physician is integral to interprofessional work in GIM there are often communication barriers in place that impact perceptions and experiences with the quality and quantity of their communication with other team members. This study aims to understand how team members' perceptions and experiences with the communication styles and strategies of either hospitalist or consultant physicians in their units influence the quality and effectiveness of interprofessional relations and work. METHODS: A multiple case study methodology was used. Thirty-one semi-structured interviews were conducted with physicians, nurses and other health care providers [e.g. physiotherapist, social worker, etc.] working across 5 interprofessional GIM programs. Questions explored participants' experiences with communication with all other health care providers in their units, probing for barriers and enablers to effective interprofessional work, as well as the use of communication tools or strategies. Observations in GIM wards were also conducted. RESULTS: Three main themes emerged from the data: [1] availability for interprofessional communication, [2] relationship-building for effective communication, and [3] physician vs. team-based approaches. Findings suggest a significant contrast in participants' experiences with the quantity and quality of interprofessional relationships and work when comparing the communication styles and strategies of hospitalist and consultant physicians. Hospitalist staffed GIM units were believed to have more frequent and higher caliber interprofessional communication and collaboration, resulting in more positive experiences among all health care providers in a given unit. CONCLUSIONS: This study helps to improve our understanding of the collaborative environment in GIM, comparing the communication styles and strategies of hospitalist and consultant physicians, as well as the experiences of providers working with them. The implications of this research are globally important for understanding how to create opportunities for physicians and their colleagues to meaningfully and consistently participate in interprofessional communication which has been shown to improve patient, provider, and organizational outcomes.

Consensus on interprofessional collaboration in hospitals: statistical agreement of ratings from ethnographic fieldwork and measurement scales.

RATIONALE: Few methods are available for analysing psychometric properties of combined qualitative and quantitative data. While conventional reliability of measures - meaning reproducibility or consistency - may not be meaningful in small-N research, in some health services studies agreement on perceptions arising from data generated by fieldwork and quantitative measures can be examined to good effect. METHODS: We studied interprofessional collaboration (IPC) in seven hospitals. An ethnographer shadowed and conducted interviews with regulated health professionals in medicine wards. Concurrently, nurses completed the nurse-doctor relations subscale of the Nursing Work Index (NWI-NDRS) and a new measurement scale for IPC with doctors in the domains of communication, accommodation, and isolation. After fieldwork, the ethnographer rank-ordered hospital sites on IPC from 1 to 7 based on interpretation of the qualitative data. Mean-scale scores were calculated for hospital sites and converted to ranks similarly. The Tinsley-Weiss T-index (Tinsley & Weiss, 1975) for agreement among rank orderings was calculated for dyadic combinations of fieldwork and measurement ranks. RESULTS: Perfect agreement was obtained for the most liberal agreement definitions considered - differences of two rank positions - involving qualitative data agreement with IPC subscales for accommodation and isolation. Defining agreement as a difference of 1 rank at most, the T-index was 0.77 for agreement between fieldworker and IPC accommodation and the same for NWI-NDRS and IPC isolation. CONCLUSION: Qualitative data from fieldwork rankings were substantially in accord with the contemporary IPC scales, less so with the NWI-NDRS. Qualitative data appear to be useful as an additional approach to confirming the validity of quantitative scale data in measuring a complex interpersonal relational construct.

Positive and null effects of interprofessional education on attitudes toward interprofessional learning and collaboration.

Interprofessional education (IPE) for health and social care students may improve attitudes toward IPE and interprofessional collaboration (IPC). The quality of research on the association between IPE and attitudes is mediocre and IPE effect sizes are unknown. Students at a college in Toronto, Canada, attended an IPE workshop. A comparison group of non-attenders was formed. Both groups completed pre- and post-workshop questionnaires and two measurement scales for IPE attitudes-the Interprofessional Education Perceptions Scale and the University of West England questionnaire. Eight multiple linear regressions modeled post-workshop attitude scores as a function of workshop attendance, pre-workshop attitudes, and background factors. Workshop effect sizes and relative importance of variables were estimated. Published results were used to calculate IPE effect sizes in other studies. Pre-workshop measures of post-workshop attitudes were dominant, positive predictors of outcomes; other predictors were subordinate to them. The relationship between workshop attendance and IPE attitudes was positive in seven models, statistically significant in four (P < 0.05), and not statistically significant in four. In hierarchical regressions the average workshop effect was small, about 0.08 in ΔR(2) terms, amounting to about one-quarter of a model's explained variance. The workshop was associated with improved IPE and IPC attitudes in some domains but not others. The results should help educators focus IPE efforts on IPE/IPC attitudes where small, short-term improvements can be obtained.

Interprofessional simulated learning: short-term associations between simulation and interprofessional collaboration.

BACKGROUND: Health professions education programs use simulation for teaching and maintaining clinical procedural skills. Simulated learning activities are also becoming useful methods of instruction for interprofessional education. The simulation environment for interprofessional training allows participants to explore collaborative ways of improving communicative aspects of clinical care. Simulation has shown communication improvement within and between health care professions, but the impacts of teamwork simulation on perceptions of others' interprofessional practices and one's own attitudes toward teamwork are largely unknown. METHODS: A single-arm intervention study tested the association between simulated team practice and measures of interprofessional collaboration, nurse-physician relationships, and attitudes toward health care teams. Participants were 154 post-licensure nurses, allied health professionals, and physicians. Self- and proxy-report survey measurements were taken before simulation training and two and six weeks after. RESULTS: Multilevel modeling revealed little change over the study period. Variation in interprofessional collaboration and attitudes was largely attributable to between-person characteristics. A constructed categorical variable indexing 'leadership capacity' found that participants with highest and lowest values were more likely to endorse shared team leadership over physician centrality. CONCLUSION: Results from this study indicate that focusing interprofessional simulation education on shared leadership may provide the most leverage to improve interprofessional care.

Nurse-physician relations and quality of nursing care: findings from a national survey of nurses.

This article investigates the association between nurse-physician working relations and nurse-rated quality of nursing team care.The analysis is based on a nationally representative sample of registered nurses working in Canadian hospitals. Multiple logistic regression was used to examine the association between the quality of nurse-physician working relations and nurses' reports of fair or poor nursing team care on the last shift worked. Unfavourable quality of nurse-physician working relations was significantly related to lower quality of nursing team care, controlling for other potential influences. These influences included low nurse co-worker support, job dissatisfaction, and self-rated poor general health, each of which was also related to lower care quality.The analysis highlights the importance of interprofessional working relations to nurse-perceived quality of patient care in Canadian hospitals.

An intervention to improve interprofessional collaboration and communications: a comparative qualitative study.

Interprofessional communication and collaboration are promoted by policymakers as fundamental building blocks for improving patient safety and meeting the demands of increasingly complex care. This paper reports qualitative findings of an interprofessional intervention designed to improve communication and collaboration between different professions in general internal medicine (GIM) hospital wards in Canada. The intervention promoted self-introduction by role and profession to a collaborating colleague in relation to the shared patient, a question or communication regarding the patient, to be followed by an explicit request for feedback from the partner professional. Implementation and uptake of the intervention were evaluated using qualitative methods, including 90 hours of ethnographic observations and interviews collected in both intervention and comparison wards. Documentary data were also collected and analysed. Fieldnotes and interviews were transcribed and analysed thematically. Our findings suggested that the intervention did not produce the anticipated changes in communication and collaboration between health professionals, and allowed us to identify barriers to the implementation of effective collaboration interventions. Despite initially offering verbal support, senior physicians, nurses, and allied health professionals minimally explained the intervention to their junior colleagues and rarely role-modelled or reiterated support for it. Professional resistances as well as the fast paced, interruptive environment reduced opportunities or incentive to enhance restrictive interprofessional relationships. In a healthcare setting where face-to-face spontaneous interprofessional communication is not hostile but is rare and impersonal, the perceived benefits of improvement are insufficient to implement simple and potentially beneficial communication changes, in the face of habit, and absence of continued senior clinician and management support.

Validity and reliability of a multiple-group measurement scale for interprofessional collaboration.

BACKGROUND: Many measurement scales for interprofessional collaboration are developed for one health professional group, typically nurses. Evaluating interprofessional collaborative relationships can benefit from employing a measurement scale suitable for multiple health provider groups, including physicians and other health professionals. To this end, the paper begins development of a new interprofessional collaboration measurement scale designed for use with nurses, physicians, and other professionals practicing in contemporary acute care settings. The paper investigates validity and reliability of data from nurses evaluating interprofessional collaboration of physicians and shows initial results for other rater/target combinations. METHODS: Items from a published scale originally designed for nurses were adapted to a round robin proxy report format appropriate for multiple health provider groups. Registered nurses, physicians, and allied health professionals practicing in inpatient wards/services of 15 community and academic hospitals in Toronto, Canada completed the adapted scale. Exploratory and confirmatory factor analysis of responses to the adapted scale examined dimensionality, construct and concurrent validity, and reliability of nurses' response data. Correlations between the adapted scale, the nurse-physician relations subscale of the Nursing Work Index, and the Attitudes Toward Health Care Teams Scale were calculated. Differences of mean scores on the Nursing Work Index and the interprofessional collaboration scale were compared between hospitals. RESULTS: Exploratory factor analysis revealed 3 factors in the adapted interprofessional collaboration scale - labeled Communication, Accommodation, and Isolation - which were subsequently corroborated by confirmatory factor analysis. Nurses' scale responses about physician collaboration had convergent, discriminant, and concurrent validity, and acceptable reliability. CONCLUSION: The new scale is suitable for use with nurses assessing physicians. The scale may yield valid and reliable data from physicians and others, but measurement equivalence and other properties of the scale should be investigated before it is used with multiple health professional groups.

Interprofessional interaction, negotiation and non-negotiation on general internal medicine wards.

Research suggests that health care can be improved and patient harm reduced when health professionals successfully collaborate across professional boundaries. Consequently, there is growing support for interprofessional collaboration in health and social care, both nationally and internationally. Factors including professional hierarchies, discipline-specific patterns of socialization, and insufficient time for teambuilding can undermine efforts to improve collaboration. This paper reports findings from an ethnographic study that explored the nature of interprofessional interactions within two general and internal medicine (GIM) settings in Canada. 155 hours of observations and 47 interviews were gathered with a range of health professionals. Data were thematically analyzed and triangulated. Study findings indicated that both formal and informal interprofessional interactions between physicians and other health professionals were terse, consisting of unidirectional comments from physicians to other health professionals. In contrast, interactions involving nurses, therapists and other professionals as well as intraprofessional exchanges were different. These exchanges were richer and lengthier, and consisted of negotiations which related to both clinical as well as social content. The paper draws on Strauss' (1978) negotiated order theory to provide a theoretical lens to help illuminate the nature of interaction and negotiation in GIM.

Nursing emotion work and interprofessional collaboration in general internal medicine wards: a qualitative study.

AIM: This paper is a report of a study to examine nursing emotion work and interprofessional collaboration in order to understand and improve collaborative nursing practice. BACKGROUND: Nursing standards identify collaborative practice as necessary for quality patient care yet many nurses are often reluctant to participate in interprofessional teams. Strategies intended to improve participation often fail which suggests that the factors underpinning nurses' disinclination towards interprofessional collaboration have yet to be understood. The concept of emotion work has not been applied to nursing interprofessionalism, and holds the potential to improve collaborative practice. Nursing emotion work is defined as the management of the emotions of self and others in order to improve patient care. METHODS: Qualitative data were collected in 2006 using non-participant observation, shadowing and semi-structured interviews with nursing, medical and allied professionals in the general internal medicine wards of three hospitals in urban Canada. FINDINGS: Nurses' collaborations with other professionals are influenced by emotion work considerations. The establishment and maintenance of a nursing esprit de corps, corridor conflicts with physicians, and the failure of the interdisciplinary team to acknowledge the importance of nursing's core caring values are important factors underpinning nurses' interprofessional disengagement. CONCLUSION: Longstanding emotion work issues must be addressed before nurses will engage collaboratively. We suggest improving nursing collaboration through the refining of holistic nursing information, and reflections on practice by all interprofessional team members.

Interprofessional information work: innovations in the use of the chart on internal medicine teams.

An abundance of evidence suggests that communication in interprofessional healthcare teams is a complex endeavour. Even relatively simple communication processes involving information work - the gathering, storage, retrieval and discussion of patient information - may be fraught with pitfalls, and yet teams manage to conduct their daily information work, often with a high degree of effectiveness. In this article, we explore one commonplace dimension of information work - the use of patient charts to foster collaborative decision-making and care enactment - towards building an elaborated understanding of how teams innovate in the face of daily complexities in their information work processes. Drawing on results from an ethnographic study of team communication in two internal medicine inpatient wards, we describe the nature and use of patient charts, analyze recurrent problems, and explore adaptive strategies for carrying on team information work in the face of daily barriers.