Pippa Hall

Interprofessional teamwork: professional cultures as barriers.

Each health care profession has a different culture which includes values, beliefs, attitudes, customs and behaviours. Professional cultures evolved as the different professions developed, reflecting historic factors, as well as social class and gender issues. Educational experiences and the socialization process that occur during the training of each health professional reinforce the common values, problem-solving approaches and language/jargon of each profession. Increasing specialization has lead to even further immersion of the learners into the knowledge and culture of their own professional group. These professional cultures contribute to the challenges of effective interprofessional teamwork. Insight into the educational, systemic and personal factors which contribute to the culture of the professions can help guide the development of innovative educational methodologies to improve interprofessional collaborative practice.

The Last 48 Hours of Life in Long‐Term Care: A Focused Chart Audit

TAs a component of palliative care educational program development, the faculty at the University of Ottawa Institute of Palliative Care wished to assess end‐of‐life care for patients in long‐term care (LTC) settings to develop an educational strategy for physicians.

Communication skills, cultural challenges and individual support: challenges of international medical graduates in a Canadian healthcare environment

Physicians require good communication skills to develop effective patient–physician relationships. Externally funded international medical graduates (IMGs) move directly from their home countries to complete residency training at the University of Ottawa, Canada. They must learn quickly how to work with patients, families and colleagues. A detailed needs assessment was designed to assess IMGs’ communication skill needs through focus groups, interviews and surveys with IMGs, program directors, allied healthcare professionals and experts in communication skills. There was a high degree of consensus amongst all participants concerning specific educational needs for communication skills and training issues related to the healthcare system for externally funded IMGs. Specific recommendations include (1) English-language skills; (2) how to get things done in the hospital/healthcare system; (3) opportunities to practise specific skills, e.g. negotiating treatment, (4) adequate support system for IMGs; (5) faculty and staff education on the cultural challenges faced by IMGs.

Making interprofessional education work: the strategic roles of the academy.

Faculties (i.e., schools) of medicine along with their sister health discipline faculties can be important organizational vehicles to promote, cultivate, and direct interprofessional education (IPE). The authors present information they gathered in 2007 about five Canadian IPE programs to identify key factors facilitating transformational change within institutional settings toward successful IPE, including (1) how successful programs start, (2) the ways successful programs influence academia to bias toward change, and (3) the ways academia supports and perpetuates the success of programs. Initially, they examine evidence regarding key factors that facilitate IPE implementation, which include (1) common vision, values, and goal sharing, (2) opportunities for collaborative work in practice and learning, (3) professional development of faculty members, (4) individuals who are champions of IPE in practice and in organizational leadership, and (5) attention to sustainability. Subsequently, they review literature-based insights regarding barriers and challenges in IPE that must be addressed for success, including barriers and challenges (1) between professional practices, (2) between academia and the professions, and (3) between individuals and faculty members; they also discuss the social context of the participants and institutions. The authors conclude by recommending what is needed for institutions to entrench IPE into core education at three levels: micro (what individuals in the faculty can do); meso (what a faculty can promote); and macro (how academic institutions can exert its influence in the health education and practice system).

Interprofessional Communication and Medical Error: A Reframing of Research Questions and Approaches

Progress toward understanding the links between interprofessional communication and issues of medical error has been slow. Recent research proposes that this delay may result from overlooking the complexities involved in interprofessional care. Medical education initiatives in this domain tend to simplify the complexities of team membership fluidity, rotation, and use of communication tools. A new theoretically informed research approach is required to take into account these complexities. To generate such an approach, we review two theories from the social sciences: Activity Theory and Knotworking. Using these perspectives, we propose that research into interprofessional communication and medical error can develop better understandings of (1) how and why medical errors are generated and (2) how and why gaps in team defenses occur. Such complexities will have to be investigated if students and practicing clinicians are to be adequately prepared to work safely in interprofessional teams.

Low Dose Ketamine as an Analgesic Adjuvant in Difficult Pain Syndromes: A Strategy for Conversion from Parenteral to Oral Ketamine

Ketamine is a non-competitive N-methyl D-aspartate (NMDA) receptor antagonist with analgesic and dissociative anesthetic properties. Low dose or sub-anesthetic doses of ketamine have been used effectively as either a primary analgesic or analgesic adjuvant in a variety of pain syndromes. In this paper, three patients with difficult to treat, predominantly neuropathic pain syndromes will be described. Their pain syndromes were initially managed successfully with the addition of low dose parenteral ketamine as an analgesic adjuvant. The strategy of concurrently starting ketamine at a low dose, i.e., 40-60 mg over 24 hours, with a benzodiazepine proved effective in preventing psychotomimetic side effects. An unavoidable shortage of ketamine prompted a literature search, which suggested that the equianalgesic dose of oral ketamine could be lower than the parenteral dose. Subsequently the patients were converted to oral ketamine at doses 30 to 40% of the previous parenteral dose. Their pain syndromes remained controlled on the lower dose of oral ketamine with remarkably few side effects. The implications of this warrant further discussion and study.

Development and validation of the interprofessional collaborator assessment rubric ((ICAR))

There have been increasing calls for a competency-based approach in interprofessional education (IPE). The purpose of this multi-site research project was to develop a validated set of interprofessional collaborator competencies and an associated competency-based assessment rubric, in both English and French languages. The first phase involved a detailed comparative analysis of peer-reviewed and grey literature using typological analysis to construct a draft list of interprofessional collaborator competency categories and statements. A two-round Delphi survey of experts was undertaken to validate these competencies. In the second phase, an assessment rubric was developed based on the validated competencies and then evaluated for utility, clarity, practicality and fairness through multi-site focus groups with students and faculty at both college and university levels. The paper outlines an approach to developing, constructing and validating a bilingual instrument for interprofessional learning and assessment. The approach was collaborative in nature, involving an interprofessional project team and respondents from across multiple health profession education programs. The Delphi survey ratings indicate a high level of agreement with the importance of the competency statements and focus group participants rated the rubric positively and felt it had value. The focus group results were also useful in pre-piloting the contextual application of the instrument across multiple health profession education programs. This rubric instrument may be used across a variety of professions and learning contexts. Future work includes evaluation of further dimensions of validity and reliability for this tool across a variety of settings.

Students' perceptions of interprofessional learning through facilitated online learning modules

Background: Asynchronous e-learning is an appealing option for interprofessional education (IPE) as it addresses the geographic and timetabling barriers often encountered when organizing activities across educational programs. Aim: This study examined the extent to which pre-licensure students were able to learn with, from, and about each other through completion of innovative online IPE learning modules. Methods: Seventy-seven students completed e-learning modules developed through a consortium of educational institutions. Evaluation was primarily qualitative through focus groups, interviews, analyses on off-line discussions and an online feedback form. Results: Qualitative analyses of the discussion fora revealed that students were able to solve problems collaboratively, clarify their professional roles, and provide information from their professional perspective. Focus groups and interviews reinforced that students recognized the importance of working together and implicate clinical education as an important venue to reinforce learning about collaborative practice. Analyses of the online feedback form suggest the need for clear processes related to group assignments and deadlines. Conclusion: Students learned about each others role, solved problems together and had positive perceptions of the online modules as a venue for interprofessional learning. Results are encouraging to those interested in using e-learning in IPE as part of an overall curriculum.

Developing collaborative person-centred practice: A pilot project on a palliative care unit

Maximizing interprofessional collaborative patient-centred practice holds promise for improving patient care and creating satisfying work roles. In Canadas evolving health care system, there are demands for increased efficiency, cost-effectiveness, and quality improvement. Interprofessional collaboration warrants re-examination because maximizing interprofessional collaboration, especially nurse-physician collaboration, holds promise for improving patient care and creating satisfying work roles. A palliative care team seized the opportunity to pilot a different approach to patient and family care when faced with a reduction in medical staff. Grounded in a collaborative patient-centred practice approach, the Canadian Hospice Palliative Care Associations National Model to Guide Hospice Palliative Care ([4]), and outcomes from program retreats and workgroups, a collaborative person-centred model of care was developed for a 12-bed pilot project. Preliminary findings show that the pilot project team perceived some specific benefits in continuity of care and interprofessional collaboration, while the presence of the physician was reduced to an average of 3.82 hours on the pilot wing, compared with 8 hours on the non-pilot wings. This pilot study suggests that a person-centred model, when focused on the physician-nurse dyad, may offer improved efficiency, job satisfaction and continuity of care on a palliative care unit. Incorporating all team members and developing strategies to successfully expand the model across the whole unit are the next challenges. Further research into the impact of these changes on the health care professionals, management and patients and families is essential.

A Method to Enhance Student Teams in Palliative Care: Piloting the McMaster-Ottawa Team Observed Structured Clinical Encounter

BACKGROUND The need for palliative and end-of-life care (PEOLC) education in prelicensure education has been identified. PEOLC requires effective collaborative teamwork. The competencies required for effective collaborative teamwork are only now emerging and methods to evaluate them must be developed. OBJECTIVE The adaptation of the traditional Objective Structured Clinical Examination (OSCE) for assessment of a student team addressing palliative care issues was undertaken. The McMaster-Ottawa Team Observed Structured Clinical Encounter (TOSCE) is intended as a formative evaluation tool for both competencies in interprofessional collaboration for patient-centered practice and PEOLC. METHODS Three stations based on palliative care scenarios were developed. From January 2007 to January 2008, a total of 141 students and 38 observers participated in the evaluation of three stations, with 6-7 students per group and two observers per station. Observers completed checklists for both PEOLC and interprofessional collaborative competencies and, after completing the TOSCEs, students and observers completed questionnaires on their feasibility and acceptability. RESULTS Eighty-nine percent of the students and 44% of the observers were from medicine. Students and observers found the TOSCE to be an acceptable and feasible assessment tool for both sets of competencies. Reliability and validity data show that the items in both the clinical and interprofessional checklists fit well together, and interrater reliability is readily achieved. CONCLUSIONS The new formative evaluation TOSCE tool, adapted from the traditional OSCE, was acceptable and feasible to students and observers.