Conditions that Foster Interprofessional Practice: A Case Study of Two Health Care Institutions

1. 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.

3. 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

4. Characteristics of Interprofessional Teams • Shared beliefs • Nature of Partnership • Interdependency—synergy • Shared Responsibility • Process

5. Determinants of Interprofessional Practice • Systemic determinants(definitions of professional jurisdictions) • Organizational determinants (governance structures, availability of space, time)

6. Outcomes of Interprofessional Practice In relation to the team members: • Satisfaction • Higher job productivity • Feeling of solidarity • Improved achievement of clinical goals (Corser, 1998)

7. 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)

8. 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?

9. 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

10. 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?

11. 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 ?

12. 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)

13. 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

14. Results Inpatient Geriatrics Unit: • 36 bed unit • Team together 5 years • Team composition: • Head nurse - 2 social workers • 6 Geriatricians (rotate) - 29 nurses • 1 physiotherapist - 5 orderlies • Clinical nurse specialist - Unit agent • Occupational therapist - Dietician • Speech language therapist - Pharmacist

15. 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 - Physiatrist • 2 Clinical nutritionists - 2 Physiotherapists • 2 Speech Therapists - Neuropsychologist • 2 Social Workers - Coordinator • Administrative Technician - Secretary

16. A Balance Between the Common and the Unique

17. Common Attributes of Interprofessional Practice

18. Team Characteristics • Sharing information • Working towards consensus • Dealing with disagreements • Valuing the contributions of others • Understanding other professional roles • Evolving over time

19. 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

20. Unique Attributes of Interprofessional Practice

21. 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”

22. 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”

23. 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”

24. 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”

25. 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”

26. 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...’”

27. 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.”

28. 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.

29. 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”

30. 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”

31. 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

32. Implications • Promoting interprofessional practice requires: • Fundamental building blocks • A culturally sensitive approach • Resources that enable

33. 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.

34. We’re in this Together!

35. Systematic Review of Recent Trials of Effective Collaboration Interventions

36. Systematic Review of Recent Trials of Effective Collaboration Interventions

37. Systematic Review of Recent Trials of Effective Collaboration Interventions

38. 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.”

39. 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”