Chris Kenaszchuk

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.

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

BackgroundStudies 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.MethodsA 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.ResultsThree 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.ConclusionsThis 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.

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.

Psychiatric and Substance Use Disorders in Late Adolescence: The Role of Risk and Perceived Social Support

This article explores how measures of risk and perceived social support relate to different configurations of adolescent psychopathology using data from a community-based, longitudinal investigation of 284 individuals interviewed in 1982 at age 5 and again at age 19. Discriminant analysis was used to assess differences in risk and social support variables among eight clusters of youth: anxious, anxious drinkers, depressed, depressed drug abusers, antisocial, antisocial drinkers, drug abusers, problem drinkers, and a ninth group representing those participants without a diagnosis. The results indicated that one function, defined by loadings for (low) family support and (high) early cumulative risk, accounted for the majority of between-group associations. Two groups of drug-abusing youth with multiple adjustment problems were highest on this function, while non-disordered youth and a group of participants with substance abuse alone were lowest. Findings are discussed in terms of the need to consider comorbidity when examining risk factors for later disorder.

An inventory of quantitative tools measuring interprofessional education and collaborative practice outcomes

The Canadian Interprofessional Health Collaborative (CIHC) has published several interprofessional resources over the past few years. This inventory is the latest. It aims to provide a “comprehensive inventory of quantitative tools measuring outcomes of interprofessional education and collaborative practice [ . . . ] designed to assist researchers and evaluators in determining which [ . . . ] published tools to use in various contexts.” The tools were selected from a literature search if they related to an outcome relevant for interprofessional education and collaborative (IPE/IPC) practice outcomes, i.e. attitudes, knowledge, behavior, organizational culture and patient/provider satisfaction. The inventory has 128 tools. The CIHC’s term “tool” refers mainly to a measurement scale having the familiar fiveor seven-point response scale, or more, or less, e.g. yes/no. The CIHC’s literature search was comprehensive and its close reading of the source literature is evident. The recent surge in tool development is striking. The selection criteria were a factor; most of the tools are ,10 years old. The median of the distribution of publication years is 2006. The most productive year was 2008 when 22% of the inventory entries appeared. “Recency” being the keyword, scale refinement should come next. The scales should improve when they are better known to critics and allies. Attitudes dominate the tools. It is thought that survey respondents possess the measured attitudes – at least minimally – and researchers want to know them. This is understandable but there is reason for caution too. IPE/IPC ideas represented in the scales are new and novel. Some respondents encounter the ideas for the first time when read in a questionnaire. Notations on Cronbach’s alpha dominate psychometric descriptions. Alpha was provided for 92 (51%) of the inventory’s entries. What does this reflect about the tools? Surely a desire for information on internal consistency of responses, and this is good. It reflects effective reporting of an objective (get information on internal consistency) and a statistic for it (alpha). Alpha is easily seen in journal articles; this is also good. But I believe that alpha’s visibility probably is enhanced by inadequate practices in naming and describing the diverse procedures and statistics needed for other scale development tasks. I have in mind difficulties reporting item development, factor extraction and evaluation, and validity. The inventory shows that classical test theory (CTT) is the primary approach. Two innovations have had no impact on IPE/IPC measurement, namely item response theory (IRT) and concerns that are known either as differential item functioning (DIF) or measurement invariance (MI). IRT is a highly relevant alternative to CTT; it deserves consideration. DIF and MI are important because scale items may not be uniformly appropriate for all of the groups of health professions and respondents that use IPE/IPC scales. The traditions of uniprofessional education, socialization and acculturation to the occupation; student self-selection into the professions; and achievement-based admissions to educational institutions are major sorting mechanisms that produce IPE/IPC respondent populations. They have people who may respond to items differently even if they are equivalent on the underlying latent trait’s continuum. Nurse–physician judgments of attitudes and behaviors may exemplify this best. Nurses judge physicians and workplaces lower on collaboration than physicians judge nurses and workplaces; this is so common that it seems factual. But most studies have used observed scale scores instead of latent variables and, concurrently, have assumed that DIF is absent from their nurse–physician comparisons and/or that MI holds. This is a questionable assumption. No psychometric information was found in 33% of the inventory’s entries. A significant segment of IPE/IPC measurement lags behind contemporary standards. Nevertheless, the field’s overall high regard for quantitative measurement is impressive.

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.

Nurse-Physician Collaboration in General Internal Medicine: A Synthesis of Survey and Ethnographic Techniques

BACKGROUND Effective collaboration between hospital nurses and physicians is associated with patient safety, quality of care, and provider satisfaction. Mutual nurse–physician perceptions of one another’s collaboration are typically discrepant. Quantitative and qualitative studies frequently conclude that nurses experience lower satisfaction with nurse–physician collaboration than physicians. Mixed methods studies of nurse–physician collaboration are uncommon; results from one of the two approaches are seldom related to or reported in terms of the others. This paper aims to demonstrate the complementarity of quantitative and qualitative methods for understanding nursephysician collaboration. METHODS In medicine wards of 5 hospitals, we surveyed nurses and physicians measuring three facets of collaboration—communication, accommodation, and isolation. In parallel we used shadowing and interviews to explore the quality of nurse–physician collaboration. Data were collected between June 2008 and June 2009. RESULTS The results indicated difference of nurse–physician ratings of one another’s communication was small and not statistically significant; communication timing and skill were reportedly challenging. Nurses perceived physicians as less accommodating than physicians perceived nurses (P<.01) and the effect size was medium. Physicians’ independent schedules were problematic for nurses. Nurses felt more isolated from physicians than physicians from nurses (P<.0001) and the difference was large in standardized units. Hierarchical relationships were related to nurses’ isolation; however this could be moderated by leadership support.

Development and evaluation of interprofessional care practices through clinical simulation

Zwarenstein and Reeves (2006) suggest improvements in communication among professionals result in greater evidence-based prescribing practices. Interprofessional education (IPE) for preand post-licensure health care providers has been identified as a mechanism to achieve improved communication, trust and collaboration. Yet there is little systematic research demonstrating causal relationships between IPE, collaboration and patientand staff-related outcomes such as evidence-based prescribing, rates of readmission, staff retention, and trust across professional disciplines (Zwarenstein & Reeves, 2006). Therefore better linkages between education and practice are required to determine if IPE can affect the attitudes, knowledge and behaviours required for long term changes to interprofessional collaboration (IPC) (Freeth & Reeves, 2004; Posel et al., 2008).

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.

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.