Conditions that Foster Interprofessional
Practice: A Case Study of Two Health
Care Institutions
Margaret Purden, RN, Ph.D.
Hélène Ezer, RN, Ph.D
David Fleiszer, M.D.
Fay Strohschein, RN., M.Sc.(A)
Liliane Asseraf Pasin, PT, Ph.D.(C)
Bruce Shore, Ph.D.
Yvonne Steinert, Ph.D.
Krista Redden, M.A.
Camelia Birlean, M.Ed.
Introduction
Previous work has focused on:
Characteristics of interprofessional teams
(D’Amour, 2004 & 2005; Headrick, 1998; West 1997)
Determinants of interprofessional practice
(D’Amour, 2004; Heinemann, 2002; Rodriguez, 2005)
Outcomes of interprofessional practice
Characteristics of
Interprofessional Teams
Shared beliefs
Nature of Partnership
Interdependency—synergy
Shared Responsibility
Process
Determinants of
Interprofessional Practice
Systemic determinants
(definitions of professional jurisdictions)
Organizational determinants
(governance structures, availability of space,
time)
Outcomes of
Interprofessional Practice
In relation to the team members:
Satisfaction
Higher job productivity
Feeling of solidarity
Improved achievement of clinical goals
(Corser, 1998)
Outcomes of
Interprofessional Practice
In relation to patients and families:
Interprofessional practice improves
outcomes in a number of patient
populations studied to date
Geriatrics, ER care for abused women, STD
screening, Adult immunization, fractured
hips & neonatal ICU care, depression care,
and in simplifying medications
(Zwarenstein et al., 2004)
Study Questions
What are the characteristics of the IPP
sites in our system?
Is there a fit with the existing literature
on IPP sites?
What implications does this have?
Methods
Phone survey to medical, nursing, allied
health leaders in the 2 institutions to
identify IPP sites
Selection of two sites
Open-ended interviews with key
informants
Participant observation at the 2 sites
Telephone Survey
Sample Questions:
What sites come to mind for you as
demonstrating exceptional interprofessional
collaboration?
Can you describe them to me?
What makes the site outstanding or unique?
Site Visits
Sample Interview Questions:
What do you think makes the team work well
together?
Can you describe a patient/family situation
that was a challenge for the team and how
the team dealt with this?
What would you recommend to sites that are
developing their interprofessional practice ?
Site Visits
Observations:
General layout of the unit
Who are the key players
Where and how do interactions happen
The nature of interactions between
professionals and with patients and families
Meetings (who guides the meeting, who
participates)
Results
Telephone Survey:
11 respondents nominated 22 sites in
Hospital A
25 respondents nominated 45 sites in
Hospital B
Nominated settings included:
Geriatrics, Oncology, Neurology, Psychiatry,
Palliative Care
ICU, General medical, Surgery
Results
Inpatient Geriatrics Unit:
36 bed unit
Team together 5 years
Team composition:
-
Head nurse
6 Geriatricians (rotate)
1 physiotherapist
Clinical nurse specialist
Occupational therapist
Speech language therapist
-
2 social workers
29 nurses
5 orderlies
Unit agent
Dietician
Pharmacist
Results
Traumatic Brain Injury Program:
Provided service to over 500 patients/year,
followed ~ 45 patients at any given time
Team formed 12 years ago
Team composition:
- 2 Neurosurgeons
- 2 Clinical nutritionists
- 2 Speech Therapists
- 2 Social Workers
- Administrative Technician
-
Physiatrist
2 Physiotherapists
Neuropsychologist
Coordinator
Secretary
A Balance Between the
Common and the Unique
Common Attributes of
Interprofessional Practice
Team Characteristics
Sharing information
Working towards consensus
Dealing with disagreements
Valuing the contributions of others
Understanding other professional roles
Evolving over time
Determinants of Collaboration
Leaders who coordinate the group effort,
bring professionals together
Shared goals, clear objectives
Group discussions
Flattened hierarchy among professionals
Time to interact
Unique Attributes of
Interprofessional Practice
The ‘Heart’ of IPP
Standing around the board
“It’s our ‘town square’ it’s where we gather”
“A lot of informal conversations are in front of
the board because you will have several
professionals gathering there”
“That board is the focal point, the nucleus of
the floor”
“It is a religious moment looking at the
board….(it) indicates what we do here, very
very important”
The ‘Heart’ of IPP
Coming to the table
“There is this interdisciplinary play back and
forth, where people share information, openly,
freely and particularly in this rounds setting
that we have once a week”
“All the team members hold different pieces
to the same puzzle and rounds is where they
come together to put those pieces together”
“To share as well…the small celebrations of
successes”
Tuning into our Partners
Learning the dance
“If you have a dance partner that you are with
for a while…you almost know how the moves
are going to go and you can predict a little bit.
For me it is knowing other people well
enough…so I can adapt myself”
Tuning into our Partners
Listening for the cues
“Listening and hearing…the reactions that
each of the team members have when they
hear certain facts - if they have a reaction like
‘oh it would have helped to know this in
advance…’ So a lot of it is just good listening”
Not for the Novice
A steep learning curve
“Walking into the TBI program is not an easy
walk…to produce concise assessments in a
short period of time”
“Its basically a TBI 101..in terms of what kind
of acronyms will you hear…, what kind of
markers do you look for in a medical chart,
and the biggest part of the learning…was the
importance of sharing information”
Not for the Novice
High expectations
“Expectations are high here...you have to know
your cases, you have to be on top of things...
I've been on other services so it was easier for
me....but [in rounds] at the beginning…I spoke
before the dietician and they said, 'No, you
have to wait your turn...' 'My turn?' and I looked
around and said, 'What are you talking about?'
'No, we go in order.’ and I thought, ‘Okay, it
wasn't a big deal but...’”
Negotiating Boundaries
Establishing boundaries
“In the beginning it was not obvious that
people would let go of their territory. They
have many areas that overlap…[but] who has
the best tools and knowledge to do it? It was
really by discussing, giving examples and
describing roles that things settled slowly and
now they are all working together.”
Negotiating Boundaries
Knowing the boundaries
“On this floor there is very little overlapping. The
division of labour is quite boundary clear and it
is very, very important…it has to do with the
patient who is admitted and what their needs
are”
“As a social worker I have to listen to [patients’]
grievances….after I listen I will acknowledge
their complaints—I will direct them appropriately
to the HN, the ombudsman, the physician or the
physiotherapist. I will let my colleagues work on
their issues. They do that reciprocally.
Part of our Culture
The way we see things
“A team represents a small society, different
people with different personalities with
different strengths, weaknesses…You have
to make sure that you always go and get the
best from each person in your little society”
Part of our Culture
The way we do things
“There are a lot of contributory individuals who
are going into this river. . . like different
streams, and that is how the floor works”
“On a floor like this, everything is up for
discussion”
“That is part of the culture on the floor that
continuous access to each other and having
these formal mechanisms and informal
mechanisms, like looking at the board”
Discussion
The findings support previous work and also
highlight unique attributes that presented
differently in the two settings.
Methodology that is sensitive to the nuances
of interprofessional practice
Implications
Promoting interprofessional practice
requires:
Fundamental building blocks
A culturally sensitive approach
Resources that enable
Acknowledgements
Health Canada Initiative on
Interprofessional Education and
Practice
All of the health professionals in these
two settings who welcomed us into
their teams and gave of their time to
help us learn how they do what they do.
We’re in this Together!
Systematic Review of Recent Trials of
Effective Collaboration Interventions
Study
Source
Intervention
A randomized clinical trial of
outpatient geriatric evaluation
and management
Boult et al. J Am
Geriatr Soc
2001;49:351-9.
Comprehensive
assessment followed by
interdisciplinary primary
care.
An evaluation of a systemchange training model to
improve emergency department
response to battered women.
Campbell et al.
Acad Emerg Med
2001;8:131-8
Team participated in 2 day
didactic training and team
planning exercise.
Can differences in management
processes explain different
outcomes between stroke unit
and stroke-team care?
Evans et al.
Lancet, 358
(9293), 11-102001, 1586 – 1592
Stroke unit, no specific
interventions to encourage
collaboration of team.
Interdisciplinary inpatient care
for elderly people with hip
fracture: A randomized
controlled trial.
Naglie et al. CMAJ
2002;167:25-32.
Interdisciplinary rounds to
discuss each patient twice
weekly.
Systematic Review of Recent Trials of
Effective Collaboration Interventions
Study
Source
Intervention
GEMU, the treatment strategy
emphasized interdisciplinary
assessment of all relevant
disorders, prevention of
complications and iatrogenic
conditions, early
mobilization/rehabilitation, and
comprehensive discharge
planning.
Reduced mortality in treating
acutely sick, frail older patients
in a geriatric evaluation and
management unit (GEMU). A
prospective randomized trial.
Saltvedt et al. J
Am Geriatr Soc
2002;50:792-8.
Effect of a clinical practice
improvement intervention on
Chlamydia screening among
adolescent girls.
Shafer et al. JAMA Audit and feedback, barrier
2002;288:2846-52 identification, team building
and meetings, iterative
approach.
Cluster randomized controlled
trial of an educational outreach
visit to improve influenza and
pneumococcal immunization
rates in primary care.
Siriwardena et al.
Br J Gen Pract
2002;52:735-40
Academic detailing to team
in each practice to promote
immunization, combined
with audit and feedback.
Control group received
audit and feedback only.
Systematic Review of Recent Trials of
Effective Collaboration Interventions
Study
Source
Intervention
Reducing medication regimen
complexity: A controlled trial.
Muir et al. J Gen
Intern Med
2001;16:77-82
For intervention patients, a
medication grid was created that
displayed all of the patients’
medicines and the times of
administrations for 1 week. This
grid was delivered to the admitting
resident soon after admission.
Information transfer intervention.
Economic implications of
neonatal intensive care unit
collaborative quality
improvement.
Rogowski et al.
Pediatrics
2001;107:23-9.
Multidisciplinary teams doing
collaborative quality improvement,
reviewing performance data,
developing shared goals,
designing improvements to their
practices.
A CQI intervention to change
the care of depression: A
controlled study.
Solberg et al. Eff
Clin Pract
2001;4:239-49
CQI intervention in which
participants from intervention
clinics developed an approach to
depression care.
Resources that Enable
Dedicated Personnel
“Being here 2 and a half days a week I see the team on a regular
basis….they know me now”
Stability of the team
“ They have the most stable team. They don’t change, they are there
forever. They are stable . We have not had that many people that
have left. So now they know how to work together.”
Resources that Enable
Dedicated Personnel
“We sort of have our own dietician that covers our unit so we know
her name”
“ We have a physical therapist just for us”
Stability of the team
“ It continues to improve and one of the reasons it has been
improving is there has been historically a consistency in the staff”
“ people have been working together for years and we are equally
informed about all our issues”