Lesley Gotlib Conn

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.

The impact of space and time on interprofessional teamwork in Canadian primary health care settings: implications for health care reform

Aim This paper explores the impact of space and time on interprofessional teamwork in three primary health care centres and the implications for Canadian and other primary health care reform. Background Primary health care reform in Canada has emphasized the creation of interprofessional teams for the delivery of collaborative patient-centred care. This involves the expansion and transformation of existing primary health care centres into interprofessional family health teams (FHT) promising to provide patients better access, more comprehensive care, and improved utilization of individual health professionals. Benefits for providers include improved workplace satisfaction and organizational efficiencies. Currently, there is little evidence for how effective interprofessional teamwork happens and little is known about how to create high-functioning teams in the primary health care setting. Methods We used ethnographic observations and interviews to gain a deep understanding of the nature of interprofessional teamwork. Three academic family health centres participated in a total of 139 h of observation and 37 interviews. Team members in all three centres from the disciplines of medicine, nursing, physiotherapy, occupational therapy, social work, dietetics, pharmacy, and office administration participated in this study. Findings We found that both the quantity and quality of interprofessional communication and collaboration in primary health care is significantly impacted by space and time. Across our research sites, the physical layout of clinical space and the temporal organization of clinical practice led to different approaches to, and degrees of success with, interprofessional teamwork. Varied models of interprofessional collaboration resulted when these factors came together in different ways. These findings have important implications for the transition to interprofessional family health teams in Canada and beyond.

Development of an Enhanced Recovery After Surgery Guideline and Implementation Strategy Based on the Knowledge-to-action Cycle.

Background: Enhanced Recovery After Surgery (ERAS) protocols have been shown to increase recovery, decrease complications, and reduce length of stay. However, they are difficult to implement. Objective: To develop and implement an ERAS clinical practice guideline (CPG) at multiple hospitals. Methods: A tailored strategy based on the Knowledge-to-action (KTA) cycle was used to develop and implement an ERAS CPG at 15 academic hospitals in Canada. This included an initial audit to identify gaps and interviews to assess barriers and enablers to implementation. Implementation included development of an ERAS guideline by a multidisciplinary group, communities of practice led by multidiscipline champions (surgeons, anesthesiologists, and nurses) both provincially and locally, educational tools, and clinical pathways as well as audit and feedback. Results: The initial audit revealed there was greater than 75% compliance in only 2 of 18 CPG recommendations. Main themes identified by stakeholders were that the CPG must be based on best evidence, there must be increased communication and collaboration among perioperative team members, and patient education is essential. ERAS and Pain Management CPGs were developed by a multidisciplinary team and have been adopted at all hospitals. Preliminary data from more than 1000 patients show that the uptake of recommended interventions varies but despite this, mean length of stay has decreased with low readmission rates and adverse events. Conclusions: On the basis of short-term findings, our results suggest that a tailored implementation strategy based on the KTA cycle can be used to successfully implement an ERAS program at multiple sites.

Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions’ experiences

BackgroundEnhanced recovery after surgery (ERAS) is a multimodal evidence-based approach to patient care that has become the standard in elective colorectal surgery. Implemented globally, ERAS programmes represent a considerable change in practice for many surgical care providers. Our current understanding of specific implementation and sustainability challenges is limited. In January 2013, we began a 2-year ERAS implementation for elective colorectal surgery in 15 academic hospitals in Ontario. The purpose of this study was to understand the process enablers and barriers that influenced the success of ERAS implementation in these centres with a view towards supporting sustainable change.MethodsA qualitative process evaluation was conducted from June to September 2014. Semi-structured interviews with implementation champions were completed, and an iterative inductive thematic analysis was conducted. Following a data-driven analysis, the Normalization Process Theory (NPT) was used as an analytic framework to understand the impact of various implementation processes. The NPT constructs were used as sensitizing concepts, reviewed against existing data categories for alignment and fit.ResultsFifty-eight participants were included: 15 surgeons, 14 anaesthesiologists, 15 nurses, and 14 project coordinators. A number of process-related implementation enablers were identified: champions’ belief in the value of the programme, the fit and cohesion of champions and their teams locally and provincially, a bottom-up approach to stakeholder engagement targeting organizational relationship-building, receptivity and support of division leaders, and the normalization of ERAS as everyday practice. Technical enablers identified included effective integration with existing clinical systems and using audit and feedback to report to hospital stakeholders. There was an overall optimism that ERAS implementation would be sustained, accompanied by concern about long-term organizational support.ConclusionsSuccessful ERAS implementation is achieved by a complex series of cognitive and social processes which previously have not been well described. Using the Normalization Process Theory as a framework, this analysis demonstrates the importance of champion coherence, external and internal relationship building, and the strategic management of a project’s organization-level visibility as important to ERAS uptake and sustainability.

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.

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.

It's Parallel Universes: An Analysis of Communication Between Surgeons and Intensivists.

Objectives:The intensivist-led model of ICU care requires surgical consultants and the ICU team to collaborate in the care of ICU patients and to communicate effectively across teams. We sought to characterize communication between intensivists and surgeons and to assess enablers and barriers of effective communication. Design:Qualitative interview study. An inductive data analysis approach was taken. Setting:Seven intensivist-led ICUs in four academic hospitals. Subjects:Surgeons (attendings and residents), intensivists (attendings and residents), and ICU nurses participating in the care of surgical patients in the ICU. Interventions:None. Measurements and Main Results:Communication enablers and barriers existed at two distinct levels: 1) organizational and 2) cultural. At an organizational level, participants identified that formally sanctioned communication structures and processes often acted as barriers to communication. Participants had developed informal strategies to improve communication. At a cultural level, surgical and ICU participants often expressed conflicting perspectives regarding patient ownership, scope of practice, and clinical expertise. Conclusions:Major barriers to optimal communication between surgical and ICU teams exist in the intensivist-led ICU environment. Many are related to the structures and processes meant to facilitate communication across teams and others to how some aspects of care in the ICU are conceptualized. Multiple actionable opportunities exist to improve communication in the intensivist-led ICU.

Career Satisfaction Among General Surgeons in Canada: A Qualitative Study of Enablers and Barriers to Improve Recruitment and Retention in General Surgery

Purpose To understand what influences career satisfaction among general surgeons in urban and rural areas in Canada in order to improve recruitment and retention in general surgery. Method Semistructured interviews were conducted with 32 general surgeons in 2010 who were members of the Canadian Association of General Surgeons and who currently practice in either an urban or rural area. Interviews explored factors contributing to career satisfaction, as well as suggestions for preventive, screening, or management strategies to support general surgery practice. Results Findings revealed that both urban and rural general surgeons experienced the most satisfaction from their ability to resolve patient problems quickly and effectively, enhancing their sense of the meaningfulness of their clinical practice. The supportive relationships with colleagues, trainees, and patients was also cited as a key source of career satisfaction. Conversely, insufficient access to resources and a perceived disconnect between hospital administration and clinical practice priorities were raised as key “systems-level” problems. As a result, many participants felt alienated from their work by these systems-level barriers that were perceived to hinder the provision of high-quality patient care. Conclusions Career satisfaction among both urban and rural general surgeons was influenced positively by the social aspects of their work, such as patient and colleague relationships, as well as a perception of an increasing amount of control and autonomy over their professional commitments. The modern general surgeon values a balance between professional obligations and personal time that may be difficult to achieve given the current system constraints.

Enhanced recovery after vascular surgery: protocol for a systematic review

BackgroundThe enhanced recovery after surgery (ERAS) programme is a multimodal evidence-based approach to surgical care which begins in the preoperative setting and extends through to patient discharge in the postoperative period. The primary components of ERAS include the introduction of preoperative patient education; reduction in perioperative use of nasogastric tubes and drains; the use of multimodal analgesia; goal-directed fluid management; early removal of Foley catheter; early mobilization, and early oral nutrition. The ERAS approach has gradually evolved to become the standard of care in colorectal surgery and is presently being used in other specialty areas such as vascular surgery. Currently there is little evidence available for the implementation of ERAS in this field. We plan to conduct a systematic review of this literature with a view to incorporating ERAS principles into the management of major elective vascular surgery procedures.MethodsWe will search EMBASE (OVID, 1947 to June 2012), Medline (OVID, 1948 to June 2012), and Cochrane Central Register of Controlled Trials (Wiley, Issue 1, 2012). Searches will be performed with no year or language restrictions. For inclusion, studies must look at adult patients over 18 years. Major elective vascular surgery includes carotid, bypass, aneurysm and amputation procedures. Studies must have evaluated usual care against an ERAS intervention in the preoperative, perioperative or postoperative period of care. Primary outcome measures are length of stay, decreased complication rate, and patient satisfaction or expectations. Only randomized controlled trials will be included.DiscussionMost ERAS approaches have been considered in the context of colorectal surgery. Given the increasing use of multiple yet different aspects of this pathway in vascular surgery, it is timely to systematically review the evidence for their independent or combined outcomes, with a view to implementing them in this clinical setting. Results from this review will have important implications for vascular surgeons, anaesthetists, nurses, and other health care professionals when making evidenced-based decisions about the use of ERAS in daily practice.