Kathleen Rice

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.

Failure to cope: the hidden curriculum of emergency department wait times and the implications for clinical training.

Purpose The study explored optimal intraprofessional collaboration between physicians in the emergency department (ED) and those from general internal medicine (GIM). Prior to the study, a policy was initiated that mandated reductions in ED wait times. The researchers examined the impact of these changes on clinical practice and trainee education. Method In 2010–2011, an ethnographic study was undertaken to observe consults between GIM and ED at an urban teaching hospital in Ontario, Canada. Additional ad hoc interviews were conducted with residents, nurses, and faculty from both departments as well as formal one-on-one interviews with 12 physicians. Data were coded and analyzed using concepts of institutional ethnography. Results Participants perceived that efficiency was more important than education and was in fact the new definition of “good” patient care. The informal label “failure to cope” to describe high-needs patients suggested that in many instances, patients were experienced as a barrier to optimal efficiency. This resulted in tension during consults as well as reduced opportunities for education. Conclusions The authors suggest that the emphasis on wait times resulted in more importance being placed on “getting the patient out” of the ED than on providing safe, compassionate, person-centered medical care. Resource constraints were hidden within a discourse that shifted the problem of overcrowding in the ED to patients with complex chronic conditions. The term “failure to cope” became activated when overworked physicians tried to avoid assuming care for high-needs patients, masking institutionally produced stress and possibly altering the way patients are perceived.

Best Practices for the Prevention and Management of Diabetes and Obesity-Related Chronic Disease among Indigenous Peoples in Canada: A Review.

OBJECTIVES To carry out a systematic review of interventions that have aimed at improving screening, treatment, prevention and management of type 2 diabetes and obesity-related chronic disease in Indigenous communities in Canada from 2008 to 2014, with the aim of identifying current best practices. METHODS A comprehensive literature review was carried out through an electronic database search using Medline, EMBASE, PubMED and Google scholar. RESULTS We identified 17 publications, comprising 13 evaluated interventions. Of them, 7 were school-based programs focused on children, 5 focused on adults, and 1 included both adults and children. Most interventions aimed at encouraging behaviour change, especially dietary change, but did little to address the underlying context of systemic marginalization and colonialism experienced in many Indigenous communities. Interventions focused on improving fitness were more effective than those aimed at dietary change. Overall, we found a range of successes among these interventions. Those that met with limited success reported that complex social issues and poverty presented challenges to effective intervention work in these communities. Participatory action research methods and community ownership of the intervention were found to be essential for project success. CONCLUSIONS Diabetes-focused intervention research in Indigenous communities appears to be a low priority for Canadian funders and policymakers. More intervention research is urgently needed in these communities. To be effective, this work must take an approach that is historically deep and sufficiently broad as to enable the ideologic, policy and institutional changes necessary in order to achieve true equity. This will involve addressing colonialism, racism and social exclusion as broader determinants of health.

Medical Trainees’ Experiences of Treating People With Chronic Pain: A Lost Opportunity for Medical Education

Purpose Evidence suggests that physicians’ opinions about patients with chronic pain become progressively negative over the course of medical training, leading to decline in empathy for these patients. Few qualitative studies have focused on this issue, and thus the experiences shaping this process remain unexplored. This study addressed how medical trainees learn about chronic pain management through informal and formal curricula. Method This study adopted a constructive qualitative approach informed by the theoretical lens of the hidden curriculum. Thirteen open-ended interviews were conducted with medical students and residents at various training stages; interviewees had experience treating patients with chronic pain, shadowing the care of these patients, or both. Interviews elicited information about stage of medical training, general descriptions of work, and concrete experiences of managing patients with chronic pain. All interviews were collected in Toronto between June and August 2015. Results Most interviewees described the management of chronic pain as challenging and unrewarding and attributed this at least in part to their perception that pain was subjective. Trainees also recounted that their inability to cure chronic pain left them confused about how to provide care, and voiced a perception that preceptors seemed to view these patients as having little educational value. Conclusions Specifically because chronic pain is subjective and incurable, listening and communication become crucial for patient care. Instead of sheltering trainees, medical educators should be offered the opportunity to reflect on the skills that are required to provide patient-centered care for this population. This approach has the potential to greatly benefit both trainees and patients.

Understanding ukuthwala: bride abduction in the rural Eastern Cape, South Africa

ABSTRACT While marriage rates in South Africa are exceptionally low, ukuthwala (‘abduction marriage,’ or ‘bride abduction’) appears to be increasing in some rural communities despite declining rates of marriage overall. Moreover, contemporary abductions seem to be increasingly characterised by gendered violence. Drawing on 18 months of ethnographic fieldwork in a rural Xhosa village, in this article I link the growing incidence and escalating violence of contemporary ukuthwala to the decline of the migrant labour system, and secondarily, to ideological transformations in desired forms of conjugal intimacy. Grounded in ethnographic fieldwork, I discuss contemporary forms of ukuthwala as an outcome of loss of security and status for older women, masculine economic marginalisation, and a growing conviction among young women that marriage should be premised on autonomous spousal choice. In so doing, I show connections between contemporary ukuthwala and broader issues of political economy, domesticity, and gendered and generational sociality. Situating ukuthwala within broader social, economic, and political contexts, as I do in this article, can offer a richer appreciation of the motivations and moral values that scaffold it, and can contribute to broader conversations about violence, social change, gendered and generational struggles in South Africa today.

Care interrupted: Poverty, in-migration, and primary care in rural resource towns

Internationally, rural people have poorer health outcomes relative to their urban counterparts, and primary care providers face particular challenges in rural and remote regions. Drawing on ethnographic fieldnotes and 14 open-ended qualitative interviews with care providers and chronic pain patients in two remote resource communities in Northern Ontario, Canada, this article examines the challenges involved in providing and receiving primary care for complex chronic conditions in these communities. Both towns struggle with high unemployment in the aftermath of industry closure, and are characterized by an abundance of affordable housing. Many of the challenges that care providers face and that patients experience are well-documented in Canadian and international literature on rural and remote health, and health care in resource towns (e.g. lack of specialized care, difficulty with recruitment and retention of care providers, heavy workload for existing care providers). However, our study also documents the recent in-migration of low-income, largely working-age people with complex chronic conditions who are drawn to the region by the low cost of housing. We discuss the ways in which the needs of these in-migrants compound existing challenges to rural primary care provision. To our knowledge, our study is the first to document both this migration trend, and the implications of this for primary care. In the interest of patient health and care provider well-being, existing health and social services will likely need to be expanded to meet the needs of these in-migrants.

How to Make Feedback More Effective? Qualitative Findings from Pilot Testing of an Audit and Feedback Report for Endoscopists

Background. Audit and feedback (A/F) reports are one of the few knowledge translation activities that can effect change in physician behavior. In this study, we pilot-tested an endoscopist A/F report to elicit opinions about the proposed reports usability, acceptability and usefulness, and implications for knowledge translation. Methods. Semi-structured qualitative interviews were conducted with eleven endoscopists in Ontario, Canada. We tested an A/F report template comprising 9 validated, accepted colonoscopy quality indicators populated with simulated data. Interview transcripts were coded using techniques such as constant comparison and themes were identified inductively over several team meetings. Results. Four interrelated themes were identified: (1) overall perceptions of the A/F report; (2) accountability and consequences for poor performance; (3) motivation to change/improve skills; and (4) training for performance enhancement and available resources. The A/F report was well received; however, participants cited some possible threats to the reports effectiveness including the perceived threat of loss of privileges or licensing and the potential for the data to be dismissed. Conclusions. Participants agreed that A/F has the potential to improve colonoscopy performance. However, in order to be effective in changing physician behavior, A/F must be thoughtfully implemented with attention to the potential concerns of its recipients.

Improving access to emergent spinal care through knowledge translation: an ethnographic study

BackgroundFor patients and family members, access to timely specialty medical care for emergent spinal conditions is a significant stressor to an already serious condition. Timing to surgical care for emergent spinal conditions such as spinal trauma is an important predictor of outcome. However, few studies have explored ethnographically the views of surgeons and other key stakeholders on issues related to patient access and care for emergent spine conditions. The primary study objective was to determine the challenges to the provision of timely care as well as to identify areas of opportunities to enhance care delivery.MethodsAn ethnographic study of key administrative and clinical care providers involved in the triage and care of patients referred through CritiCall Ontario was undertaken utilizing standard methods of qualitative inquiry. This comprised 21 interviews with people involved in varying capacities with the provision of emergent spinal care, as well as qualitative observations on an orthopaedic/neurosurgical ward, in operating theatres, and at CritiCall Ontario’s call centre.ResultsSeveral themes were identified and organized into categories that range from inter-professional collaboration through to issues of hospital-level resources and the role of relationships between hospitals and external organizations at the provincial level. Underlying many of these issues is the nature of the medically complex emergent spine patient and the scientific evidentiary base upon which best practice care is delivered. Through the implementation of knowledge translation strategies facilitated from this research, a reduction of patient transfers out of province was observed in the one-year period following program implementation.ConclusionsOur findings suggest that competing priorities at both the hospital and provincial level create challenges in the delivery of spinal care. Key stakeholders recognized spinal care as aligning with multiple priorities such as emergent/critical care, medical through surgical, acute through rehabilitative, disease-based (i.e. trauma, cancer), and wait times initiatives. However, despite newly implemented strategies, there continues to be increasing trends over time in the number of spinal CritiCall Ontario referrals. This reinforces the need for ongoing inter-professional efforts in care delivery that take into account the institutional contexts that may constrain individual or team efforts.

The development and implementation of an electronic departmental note in a colposcopy clinic.

Hospital-wide electronic medical records can be limited in addressing clinical department needs. A study was undertaken to examine the development and implementation of an electronic informaton system in a colposcopy unit in a large teaching hospital in Canada. A case study design was used, and 24 semistructured interviews were conducted with nurses and physicians working in the colposcopy clinic and individuals from the information technology team. Interviews occurred in two phases—directly after implementation and again 9 months later. Computerized audit data were gathered to examine usage patterns. The results provide insight into the processes and challenges of defining and capturing information for both clinical and research purposes and creating a standardized referral note. The findings demonstrated some initial uncertainty around roles and responsibilities concerning the electronic system and its integration into clinical routines. After a period of 12 months, and further refinement, it was found that the system was accessible and user-friendly, although some concerns raised during the developmental stage persisted. Audit data revealed that 9 months after its introduction, nurses’ adoption of the system rate reached 89%, and physicians, 96%. This study has demonstrated that practitioners in a colposcopy clinic successfully collaborated with information technology specialists and each other to develop and implement a clinical departmental information system. While certain challenges were encountered, nurses and physicians have bought into the system, recognize its potential for research and patient care, and are therefore committed to figuring out how to adapt to the changes in communication both within the clinic and with referring physicians.