Pamela Grassau

``Not Everyone Who Needs One Is Going to Get One'': The Influence of Medical Brokering on Patient Candidacy for Total Joint Arthroplasty

Background. Many patients in Ontario, despite being appropriate candidates for total joint arthroplasty (TJA), are not offered surgery. To understand this discrepancy, the authors sought to explore the process by which physicians determine patient candidacy for TJA. Methods. Six focus groups (2 each of orthopedic surgeons, of rheumatologists, and of family physicians) and subsequent in-depth interviews were conducted with 50 practicing clinicians in Ontario. Results. Health care system constraints, including extensive waiting lists, lack of homecare and postoperative support, and, for surgeons, access to operating rooms and resources, are perceived by physicians to routinely influence the ultimate choice of candidates for TJA. Medical brokering, defined as strategies used by physicians in a constrained health system to prioritize patients and to negotiate relationships with other physicians, was an important factor in determining candidacy for TJA. Because individual physicians and surgeons appear to use their own criteria for making these decisions, and because these criteria are modified from time to time in response to specific institutional and system conditions, brokering results in varied decisions about candidacy regardless of patient suitability. Conclusions. Lack of consensus on the necessary patient characteristics for TJA candidacy does not in and of itself account for the discrepancy between the number of patients who are suitable candidates for TJA and those who receive the procedure. Until the process by which health care system constraints affect and complicate the decision-making process around TJA candidacy is more fully explored, patients may not receive appropriate and timely access to this procedure.

The Richmond Agitation-Sedation Scale modified for palliative care inpatients (RASS-PAL): a pilot study exploring validity and feasibility in clinical practice

BackgroundThe Richmond Agitation-Sedation Scale (RASS), which assesses level of sedation and agitation, is a simple observational instrument which was developed and validated for the intensive care setting. Although used and recommended in palliative care settings, further validation is required in this patient population. The aim of this study was to explore the validity and feasibility of a version of the RASS modified for palliative care populations (RASS-PAL).MethodsA prospective study, using a mixed methods approach, was conducted. Thirteen health care professionals (physicians and nurses) working in an acute palliative care unit assessed ten consecutive patients with an agitated delirium or receiving palliative sedation. Patients were assessed at five designated time points using the RASS-PAL. Health care professionals completed a short survey and data from semi-structured interviews was analyzed using thematic analysis.ResultsThe inter-rater intraclass correlation coefficient range of the RASS-PAL was 0.84 to 0.98 for the five time points. Professionals agreed that the tool was useful for assessing sedation and was easy to use. Its role in monitoring delirium however was deemed problematic. Professionals felt that it may assist interprofessional communication. The need for formal education on why and how to use the instrument was highlighted.ConclusionThis study provides preliminary validity evidence for the use of the RASS-PAL by physicians and nurses working in a palliative care unit, specifically for assessing sedation and agitation levels in the management of palliative sedation. Further validity evidence should be sought, particularly in the context of assessing delirium.

Theories, relationships and interprofessionalism: learning to weave.

In this article, we illustrate the application of a number of theoretical frameworks we have used to guide our work in interprofessional education (IPE) and collaborative interprofessional care (IPC). Although we do not claim to be experts in any one of these theories, each has offered important insights that have broadened our understanding of the complexities of interprofessional learning and practice. We have gained an appreciation for an increasing number of theories relevant to IPE and IPC, and, as a result, we have woven together more key principles from different theories to develop activities for all levels of interprofessional learners and clinicians. We pay particular attention to relational competencies, knotworking/idea dominance, targeted tension and situational awareness. We are now drawing on the arts and humanities and complexity theory to foster relationship-building learning. Evaluation of our endeavors will eventually follow these latter theories for methods that better match the human and social experiences that underpin learning. Our “theoretical toolbox” therefore may be of value to educators who develop and implement creative interprofessional learning activities, as well as clinicians interested in moving toward more effective collaboration.

Listening to the Voices of Lesbians Diagnosed with Cancer

Abstract This paper focuses on the operations of heterosexism and strategies to counter it in a particular service context: the context of psychosocial support services for women with cancer. The paper draws on findings from a participatory, qualitative study set in Ontario, Canada in which 26 lesbians were interviewed about their experiences of cancer diagnosis, treatment, health care and social support, and their feelings and perceptions about shifts in identity, body, sexuality and relationships. This paper focuses on findings related to the changes research participants perceived as necessary in the provision and organization of cancer support services, in order to increase access and ensure equity for lesbians with cancer and their families.

Learning collaborative teamwork: an argument for incorporating the humanities

Abstract A holistic, collaborative interprofessional team approach, which includes patients and families as significant decision-making members, has been proposed to address the increasing burden being placed on the health-care system. This project hypothesized that learning activities related to the humanities during clinical placements could enhance interprofessional teamwork. Through an interprofessional team of faculty, clinical staff, students, and patient representatives, we developed and piloted the self-learning module, “interprofessional education for collaborative person-centred practice through the humanities”. The module was designed to provide learners from different professions and educational levels with a clinical placement/residency experience that would enable them, through a lens of the humanities, to better understand interprofessional collaborative person-centred care without structured interprofessional placement activities. Learners reported the self-paced and self-directed module to be a satisfactory learning experience in all four areas of care at our institution, and certain attitudes and knowledge were significantly and positively affected. The module’s evaluation resulted in a revised edition providing improved structure and instruction for students with no experience in self-directed learning. The module was recently adapted into an interactive bilingual (French and English) online e-learning module to facilitate its integration into the pre-licensure curriculum at colleges and universities.

Looking and listening for learning in arts‐ and humanities‐based creations

The arts and humanities are gradually gaining a foothold in health professions education as a means of supporting the development of future clinicians who are compassionate, critical and reflexive thinkers, while also strengthening clinical skills and practices that emphasise patient‐centredness, collaboration and interprofessional practices. Assignments that tap into trainee creativity are increasingly used both to prepare learners for the demands of clinical work and to understand the personal and professional challenges learners face in these contexts. Health professions educators need methods for interpreting these creations in order to understand each learners expressions. This paper describes two theoretical frameworks that can be used to understand trainees’ unique learning experiences as they are expressed in arts‐ and humanities‐based creations.

A Technology-Enabled Solution to Manage Referrals to Hospice and Palliative Care Beds: The Ottawa SMART System as a Case Study

Ottawa has a 31-bed palliative care unit (PCU) and two residential adult hospices (total 19 beds). In 2013, we initiated a project to improve the referral and triage processes to these beds. Previously, there were two separate paper-based systems with duplication, inefficiencies, delays and inappropriate patient placements. The multipronged approach included clarifying the respective roles of the PCU and hospices, creating a single referral and triage office and developing an e-platform. We leveraged technology that was available in the public-funded system. This paper describes the development processes, lessons learned, and the final system, referred to as System to Manage Access, Referrals and Triage (SMART).

Health care providers’ roles and responsibilities in management of polypharmacy: Results of a modified Delphi

Background: Little is known about the roles that allow interprofessional teams to effectively manage older patients experiencing polypharmacy. Objectives: To identify and examine the consensus on salient interprofessional roles, responsibilities and competencies required in managing polypharmacy. Methods: Four focus groups with 35 team members practising in geriatrics were generated to inform survey development. The sessions generated 63 competencies, roles or responsibilities, which were categorized into 4 domains defined by the Canadian Interprofessional Health Collaborative. The resulting survey was administered nationally to geriatric health care professionals who were asked to rate the importance of each item in managing polypharmacy; we sought agreement within and across professions using a confirmatory 2-round Delphi method. Results: Round 1 was completed by 98 survey respondents and round 2 by 72. There was high intra-professional and interprofessional consensus regarding the importance of competencies among physicians, nurses and pharmacists; though pharmacists rated fewer competencies as important. Less consensus was observed among other health care professionals or they indicated the nonimportance of competencies despite focus group discussion to the contrary. Discussion: Although there is a strong consensus of polypharmacy management competencies across team members who have been more traditionally involved in medication management, there continue to be health care providers with differing understandings of competencies that may contribute to reduced reliance on medication. Lower importance ratings suggest pharmacists may not acknowledge or recognize their own potential roles in interprofessional polypharmacy management. Conclusion: Further exploration to understand the underutilization of professional expertise in managing polypharmacy will contribute to refining role clarity and translating competencies in practical settings, as well as guiding educators regarding curricular content.