Abstract
Abstract
Background:
A basic tenet of palliative care is interprofessional collaboration. Palliative care educators and practitioners lead the way in responding to the Institute of Medicine's (2003) challenge to transform educational and health care systems through interprofessional collaboration. Through exemplary commitment to interprofessional collaboration, a college's academic and palliative care leader, in collaboration with Department Chairs and Directors of nursing and allied health professions, can illustrate and analyze the processes of interprofessional collaboration through the development of a simulated case study of a combat veteran with traumatic brain injury.
Methods:
Methodologic components: (1) interprofessional development of a palliative care case study and (2) debriefing interviews regarding the experience of collaboration of interprofessional team members.
Results:
The results provide the identification of steps of the interprofessional process and the shared and unique disciplinary competencies in determining a comprehensive health history, physical examination, identifying and prioritizing diagnoses, and determining collaborative discipline-specific interventions. Content analysis of debriefing team interviews provides a description of group composition, structure, process, development, and performance, as well as team member's perceptions of what fosters and challenges collaboration, benefits, and drawbacks, and what could have been done differently in developing an interprofessional initiative.
Discussion:
Transformative change in healthcare education and clinical practice involves interprofessional collaboration of colleagues within, across, and beyond universities/colleges and healthcare systems and agencies. Advocating for teamwork has to go beyond talking about being a team player or not to having the language and behaviors we need to observe and measure. This article not only provides key processes in interprofessional collaboration but also identifies key attitudes and behaviors critical to teamwork. It provides a starting point to determine observable and measurable outcomes for interprofessional education, practice, and research. This article highlights expert behavior to move professionals from being novices in interprofessional collaboration to mastering the skills.
Introduction
I
It begins with a paradigm shift in education and practice with an appreciation of shared values and codes of conduct, as well as a sense of interdependence rather than autonomy or independence. The philosophical lens of a profession provides a unique perspective as knowledge of the sciences and humanities is synthesized and new knowledge is created or applied for that particular profession. However, it is also recognized that there is shared knowledge and skills, resulting in shared competencies of healthcare professionals and which are fundamental to healthcare education, practice, and research. 7 Particularly in palliative care, there is an understanding that interprofessional education (IPE) does not dilute well-established health professions and their identity, but augments each by their association with the others. 6
Through interprofessional collaboration, professionals with a broad array of knowledge, expertise, and skills enhance the integration and communication of services with a sense of group accountability, resulting in continuous, reliable, and high-quality care.5,8 Thus, institutions of higher learning are being called to lead the transformation process in education and the translation of interprofessional collaboration in clinical practice. 9 Institutions are being asked to perform a self-study, which involves a review of the curriculum and educational outcomes of various health disciplines, 7 and to develop structures and processes within and across colleges and programs that allow students, as a routine component of their education, to engage in interactive learning with those outside their profession. 4
The Center for Advancement of IPE 10 describes IPE as collaborative work supported by teaching and learning strategies that improve the quality of care offered by two or more health professions. Both in educational settings and clinical practice, the underlying principles of interprofessional healthcare are care that is (1) patient centered and community/population focused rather than profession centered; (2) relationship focused; (3) process oriented; (4) linked to educational strategies and learning activities that are developmentally appropriate and integrated across the learning continuum; (5) applicable across professions by acquiring essential knowledge, attitudes, values, and skills, which allow for team-based problem solving and brainstorming; (6) sensitive to the systems context with applicability across practice settings; and (7) outcomes driven.11,12
Within a College of Nursing and Health Sciences, the interprofessional development of a simulated case study involved the participation of nursing (NGR), physical therapy (PT), occupational therapy (OT), communication sciences and disorders (CSD), athletic training (AT), and health services administration (HSA) and serves as a tool to teach interprofessional collaboration. 7 The case involves a combat veteran with traumatic brain injury (TBI). Preparation of the case required the development of a template for an interprofessional comprehensive health history, physical examination, determination of diagnoses formulated based on shared and discipline-specific assessment data, and the development of an interprofessional plan of care.
The goals of this interprofessional initiative were twofold: (1) to illustrate the processes of interprofessional collaboration while identifying the unique and shared competencies of various healthcare professionals in providing care; and (2) to analyze the perceptions and experience of healthcare professionals in participating in an interprofessional initiative while illuminating the relevance of interprofessional collaboration in healthcare.
Through this initiative, the concept of interprofessional collaboration was deconstructed, clarifying the knowledge, attitudes, and behaviors related to interprofessional collaboration and providing the next steps to observe and measure the characteristics and outcomes of interprofessional collaboration in education, clinical practice, and research.
Methods
The first component of this interprofessional initiative was the development of the simulated case study by the Chairs and Directors of each of the college's departments through monthly meetings over a six-month time frame. The interprofessional process was documented in minutes of team meetings and culminated in a written interprofessional template for assessment, diagnosis, and interventions.
The second component of the initiative was analysis of the collaborative process through descriptive and qualitative debriefing interviews of the college's Chairs and Directors by the first author. These one-hour interviews occurred within two months of completion of the case study. Based on the interprofessional work of Gaboury et al. 13 and Burzotta and Noble, 14 the interview guide (Table 1) included questions related to the description of (1) group composition (characteristics of group members); (2) group structure (pattern of positions and roles); (3) group development (changes in perspectives); (4) group process (patterns of interactions); and (5) task performance (quantity, quality, and speed of performance), as well as questions asking (6) what fosters collaboration; (7) what challenges collaboration; (8) what are the benefits of collaboration; (9) what are the drawbacks of collaboration; and (10) in future experiences, what would you do differently? Participants' responses to the interview questions were documented as verbatim statements and subsequently presented in a word document.
Content analysis of the debriefing interviews was based on Carini's principles 15 and included the following steps of qualitative data analysis: (1) developing detailed knowledge of the content of the interviews by reading line by line with the highlighting of specific words or phrases; (2) reviewing the related researcher's analytic memos and adding further impressions of the participant's statements; (3) listing tentative headings and reflecting on recurring ideas; (4) analyzing verbatim statements and listing them under the identified headings with the grouping of similar concepts or ideas; (5) summarizing new impressions; (6) comparing the data so that the commonalities and differences in participant's statements can be examined; and (7) establishing themes that describe the patterns and observations found between the interviews of the participants.
To ensure reliability of the analysis, the first author analyzed the interview data and in a process of peer debriefing asked a colleague, not involved in the initiative, to verify the findings based on the interviews. Any discrepancies were resolved through discussion. To further promote trustworthiness through member checking, all participants were asked to read the first draft of the article to validate the illustrative processes of interprofessional collaboration, as documented, as well as the results presented based on the interprofessional interviews. There was complete congruency of the analysis of the team's debriefing interviews with individual perceptions of the collaborative experience.
Results
The results of the first component of this interprofessional initiative were the illustration and identification of the seven steps of the collaborative process, which occurred during the development of the simulated case study.
Step 1: Determine the leadership of the group. Although one individual spearheaded the initiative, at the first meeting, the group discussed who had the expertise to assume leadership of the group, irrespective of discipline, as well as discussion of coleadership or rotating leadership based on the problems and issues to be addressed.
Step 2: Determine group process. To promote group commitment and accountability, the best day and time for future meetings were decided upon by the group, including the determination that meetings would occur biweekly. The group asked the leader to call the meeting to order, review the progress of the group, and provide the current focus of the meeting. The leader agreed to ask other group members to lead a discussion of specific topics, particularly those relevant to their discipline.
Step 3: Identify underlying assumptions and premises regarding interprofessional collaboration. A valuable starting point to the development of the case study was discussion of the group's assumptions and premises related to interprofessional collaboration, as identified in Table 2.
Step 4: Identification of the patient population of interest and review of the literature regarding the population. The goal was to clarify the definition of a combat veteran, the clinical issues experienced by this population, and to promote an evidence-based approach to assessment, diagnosis, and interventions for the combat veteran population with TBI. Team members were given links to related articles found in Medline and CINAHL and were provided an overall written summary of the information. During the second team meeting, the articles were reviewed and each team member addressed the relevance of their discipline to the specific patient population. This discussion promoted an understanding of the education and scope of practice of members of various health disciplines.
Step 5: Develop the components of the comprehensive health history and physical examination from an interprofessional perspective. A preliminary outline of the components of a comprehensive health history and physical examination from a general healthcare perspective was developed. It was recognized that each health discipline may have common as well as unique areas of focus regarding clinical assessment. In the second meeting, all team members reviewed the clinical assessment and added areas that would represent an inclusive interprofessional clinical assessment template. For example, OT team member added the assessment of instrumental activities of daily living, while the team member from HSA identified the importance of documenting insurance status. From a palliative care perspective, questions related to culture and advance directives were included. The members of this interprofessional team used brainstorming to develop the details of this simulated case study, synthesizing their cumulative knowledge and experience to fill in the data for a comprehensive health history, physical examination. Next was the determination and prioritization of diagnoses and development of an interprofessional treatment plan, including pharmacologic, nonpharmacologic, and complementary interventions, the need for further laboratory data or diagnostic tests, relevant health education, or needed referrals. Knowledge of the patient population and related clinical experience led to the development of a fascinating, robust clinical presentation of a combat veteran with a TBI. The “group think” was particularly impressive as the chief complaint and history of present illness were being constructed. Each discipline identified shared clinical data and related problems or added a unique dimension as the history of the illness evolved. For example, the team member from CSD questioned whether the results of the brain CT scan seven months post-trauma would be the appropriate test given that it has less specificity than an MRI in a patient who has anterior frontal lobe brain injury with extensive damage to the eye orbit. Nurse practitioners on the team focused on obtaining information regarding the patient's prior psychiatric diagnosis, which would have implications for his current level of mental health and post-traumatic stress. From a palliative care perspective, additional spiritual assessment data, beyond religious affiliation, were included such as a sense of connection to self, others, nature, and God and the sense of meaning and purpose in his life. The AT team member was particularly focused on developing the patient's leisure history, particularly his highly active background as a high school athlete, his passion as a drummer in a band, and his enjoyment in using an I-pad and playing electronic games. This would be particularly relevant in identifying ways of engaging the patient in various rehabilitation techniques and was of shared interest to the OT member.
Although the basic clinical data of a comprehensive physical examination (Head to Toe) were generated by the nursing members of the team, particularly the nurse practitioners, the members of each discipline sharpened the focus on assessment data needed from their professional perspective. For example, the physical finding regarding examination of the head and neck (eyes, ears, nose, mouth, and throat) was not only important to nursing but was equally if not more important to the members of CSD and OT, who conduct swallow studies. The team member from CSD emphasized the need to conduct an audiological evaluation to determine hearing acuity, speech perception and discrimination, and the processing of more complex auditory information, which would be relevant to a diagnosis of central auditory processing deficit. Similarly, the level of detail regarding findings related to the musculoskeletal system and neurological system was critical to diagnoses and interventions offered by PT, OT, AT, and nursing. For example, the PT member's assessment detailed gait pattern, hip flexion, and heel strikes, while the OT member's assessment focused on observing patient's ability to button clothing, feed self, or brush teeth. Similar to colleagues from NGR, the PT and AT members outlined the results of the neurological examination, including sensory deficits, such as discriminative touch and perceptual deficits, and motor function, including muscle tone and strength, balance, and equilibrium, as well as results related to reflexes and the testing of cranial nerves. Team members from OT and CSD asked whether the patient's inability to do specific tasks was related to paresis, spasticity, or ideomotor apraxia.
The interprofessional team determined the need for a further detailed evaluation of his attention, memory, executive functioning, and an oral–facial examination of motor speech abilities. Recommendations were made regarding instruments that would provide further specific clinical data. Team members were alerted to the fact that the results of these further tests would support the possible diagnosis of anterograde amnesia and possible executive functioning deficits (cognitive flexibility, planning, self-regulation, organization, impulsivity, and distractibility), all of which have relevance to interprofessional care offered by the team. The ongoing dialog across disciplines resulted in an extremely comprehensive assessment of the patient's health condition beyond the assessment completed by any single discipline. The dialog among team members reflected not only an understanding of shared knowledge and competence but also an appreciation of the complexity of the case and the unique laser-focused assessment and examination required by other disciplines to generate significant clinical diagnoses.
Step 6: Identify and prioritize clinical diagnoses. Overarching symptom issues, such as pain and constipation, were identified by all team members as clinical diagnoses, which must be addressed. The second diagnosis identified impaired neurological/cognitive function, while the third shared diagnosis was impaired activities of daily living, particularly relevant to team members from NGR, OT, and PT, as well as AT. The fourth diagnosis was the psycho–social–spiritual distress experienced by the patient and his family, including sense of hopelessness, isolation, limitations of family support and caregiver burden, anger with God, and loss of meaning and purpose in life.
Step 7: Develop and evaluate diagnosis-specific interventions. For each diagnosis or clinical problem, the team acknowledged that there would be discipline-specific interventions and complementary interventions in which the care of one discipline would complement or be synergistic to the care offered by another discipline and collaborative interventions. There was team member discussion and collaboration regarding pharmacologic, nonpharmacologic, and alternative modalities/interventions, as well as the need for related health education and possible additional referrals to disciplines not represented by our team. Although the pharmacologic management of pain was within the realm of nursing, members from PT or AT would offer nonpharmacologic interventions such as use of heat or cold or positioning, and all team members would evaluate the efficacy of pain interventions during their patient encounters. It was agreed that early interventions were critical to achieving maximal health outcomes and that each member of the interprofessional team would visit the patient regularly, if not daily, to determine the appropriate time frame for initiating discipline-specific or collaborative interventions. Through informal team communication and during weekly team meetings, healthcare services and interventions would be effectively integrated and coordinated to ensure a timely, efficient, and effective approach to whole-person care.
From a humanistic perspective, every team member had the intention of promoting healing, health, and well-being through their interpersonal interactions. It was acknowledged that early referral of this patient and family to social work, counseling services, or chaplaincy was appropriate, but like the assessment and management of pain, each team member had a responsibility to provide care with recognition of the importance of the mind–body–spirit connection.
The team member representing HSA considered the patient's clinical diagnoses with regard to care offered in an acute rehabilitation facility. Team members considered future care at home or in another community setting, including care offered at VA hospitals. Although social work was not represented on the team, the member from HSA considered the resources available to the veteran population given his complex diagnosis and the ability of his family to participate in his care. Future funding for his care and maximal support for long-term recovery were a critical focus of the health services administrator. All members of the team recognized the accountability of the group in ensuring appropriate ongoing assessment, implementation, and evaluation of all interventions.
The results of the second component of this interprofessional initiative are based on debriefing interviews of the Department Chairs and Directors who participated in the development of the simulated case study, as guided by the framework proposed by Gaboury et al. 13 and Burzotta et al. 14
Group composition (characteristics of the group members)
Group composition included faculty from undergraduate and graduate nursing (n = 4), OT (n = 1), PT (n = 1), CSD (n = 1), AT (n = 1), HSA (n = 1), and a doctoral student research assistant (n = 1). The interprofessional team members ranged from a full professor with tenure, associate professors with tenure, clinical associate and assistant professors, and a doctoral student. The team members ranged in age from 27 to 60 years. There were three men and eight women.
Group structure (pattern of positions and roles)
Interprofessional representation from all of the college's departments was achieved. One replacement was needed given a department accreditation commitment by a Department Chair. Early discussion of group leadership was determined and team members each expressed their support of the first author's leadership throughout the interprofessional initiative. One team member made the analogy that the initiative needed to first successfully launch before rotating leadership. Another member also believed that momentum had to be gained.
Group process (pattern of interactions)
The interprofessional team member described the pattern of interaction as self-motivated, united, decisive, respectful, cohesive, compromising, negotiated, engaged, thoughtful, active listening, interactive, accountable, and shared decision making.
Group development (changes in perspective)
When team members were asked if the experience of collaboration changed their perspective regarding interprofessional collaboration, their reflections included improved outlook on teamwork, recognition of alternative approaches, offered a new frame of reference and approach to patient care, an understanding of how collaboration would enrich student experiences, led to an evaluation of personal values, knowledge, and skill, a recognition of the philosophical foundation of a discipline and shared as well as unique perspectives, differences in focus in assessments, and a change in beliefs about interprofessional care. Last, a team member emphasized the appreciation of shared values.
Task performance (quantity, quality, and speed of performance)
In response to the question regarding team performance, members stated that they were committed to participation and made attendance at meetings a priority. Three members indicated that as time moved on, they had conflicts of time, but were able to keep up with group work as email summaries kept everyone up to date and specific questions addressed to team members helped keep the processes on track. All participants agreed that three months into the process, there was a break due to excessive end-of-semester commitments as well as a break for the winter holiday. At the beginning of the spring semester, there was a disruption for another month due to an unforeseen administrative event experienced by the leader. Although there was a high level of collaboration, this disruption created uncertainty and stress for group members. Within one month, the leader reconvened the group first by email, followed by three in-person group meetings in the subsequent two months. However, not all group members were present at the meetings with one member stating, “We didn't know how to respond to the administrative-related issues,” yet “we felt it was important to continue this work.”
What fosters collaboration?
The team members believed that collaboration is fostered when there is emphasis on collaboration at the university level. Collaboration is promoted when you have someone who is willing to serve as the champion and assume leadership of the group, yet with the ability and skill to engage all team members. Collaboration is enhanced when the leader is willing to facilitate the process, with members demonstrating equal responsibility and accountability. There is also increased collaboration when there is lateral recognition and respect for the knowledge of other group members, and the creation of collective energy when you are brainstorming. It was emphasized that collaboration is fostered when there is an opportunity to have a shared purpose with a common goal and that accountability increases the stakes. Several team members were willing to come to the meetings because they enjoyed the conversation feeling “Too often, we sit in our silos with little to no opportunity to engage on a topic of mutual interest, but now we had a project that involved all of our interests.” It was further stated by members that when a meeting is respectful, people can agree to disagree, when people convey an openness, and are engaged and attentive to the ideas of each other, listening without interrupting, and showing a level of cooperation, then it is really pleasant to work together.
What challenges collaboration?
It was emphasized that the challenges to collaboration are competing time demands, high faculty workloads, and differing obligations of health professionals. Challenges also exist in coordination of schedules and meeting times. For one member, the challenge is moving from a more autonomous focus to an interprofessional focus and finding their niche among other members of the healthcare team. For example, “There are natural collaborations among OT and PT, or between AT and PT, but less natural collaborations between let's say AT and CSD.” One team member commented that “the challenge exists when the focus of a discipline is primarily on prevention of illness or promotion of health, with care that is not motivated by reimbursement. Then, the mindset is different.”
Collaborative efforts are clearly disrupted by “external issues which were out of our hands,” or if there would be “retribution by administration if we continued our work given politics.” There could be challenges to collaboration when there are personality conflicts or turf wars, not to mention individuals who speak disrespectfully in group meetings. Yet, this group modeled professional interactions. Last, a team member voiced concern that “curriculum is driven by accreditation, so it makes it difficult to have interprofessional courses when the criteria for accreditation are different in many disciplines.” In discussing challenges to IPE in academic settings, many colleges have different academic calendars, so there are challenges in when to offer an interprofessional course, where does an interprofessional course fit best in already full program curriculums, as well as who gets the credit hours not only in terms of faculty workload but also student tuition. It was emphasized that IPE should start early and go beyond the classroom to learning together during clinical placements despite the logistical challenges.
What are the benefits of collaboration?
It was agreed by all team members that the simulated case developed during this initiative could be used as an exemplary case study for IPE opportunities in our college. One group member recognized that this initiative was one step in breaking down disciplinary boundaries, and this initiative was an example of leading by example. Group members commented that the benefits of collaboration are shared experiential learning, improved socialization among members of the disciplines, sharing of knowledge, and increased awareness regarding the education and competence of other team members. Another member valued the idea of a collective identity and shared responsibility, “In clinical practice, there is improved coordination and utilization of healthcare resources, the potential for improved work satisfaction because you have a sense of support, and coordinated care of higher quality because you have shared problem solving and shared trust.”
What are the drawbacks of collaboration?
As a response to the question regarding drawbacks to collaboration, one team member stated, “Sometimes it is easier to just make the time yourself to work on a project,” while another team member said, “There is usually someone who wants to take charge and make sure their agenda is met, maybe that is more a challenge than a drawback.” Another commented, “In this economy, we are also being asked to do more with less; shared teaching and shared responsibility for academic outcomes of other professions may make us all wear even more hats.” A point raised by two colleagues was captured in the comment, “It is hard enough coordinating class schedules of students from our own disciplines and their clinical placements, we can only imagine the nightmare of doing this for all of our students.”
In the future, what would you do differently?
When asked what they would have done differently, there were no clear opinions. There was a positive sense that particularly in the early weeks of the initiative, the project was met with enthusiasm. It was reiterated—“leadership is important to keep the group moving forward despite challenges, you keep the ball moving.” The following comment was also made: “We need to keep this going; we need to do more things together. It has to be a part of the culture.” Another said, “This was a good first step. Now, we have to sit together and develop a course that addresses shared competencies that we identify across the different disciplines or at the very least, have faculty from other disciplines coteach a class so students can gain an interprofessional perspective.” All team members value collaboration and that maintaining the momentum together requires persistence, vision, and commitment.
It is recognized that possible limitations of this process were that the initiator of this interprofessional initiative was in an administrative leadership position in the college, and that Chairs and Directors of programs, although faculty, were also members of administration; therefore, they may have felt obligated to participate. It is also possible that there were unusually positive efforts to collaborate and cooperate with each other on the development of the case study, with less natural manifestations of conflict, which may exist in other academic institutions, beyond a simulated experience, and in actual clinical practice. However, with that said, the analysis of the interprofessional process was very positive and was a learning experience with several lessons learned, as described in Table 3.
Discussion
Palliative care leads the paradigm shift in the education of health professionals within academic and clinical settings by recognizing the value of interdisciplinary competence. 1 IPE is key to developing a workforce of the future that will provide comprehensive, compassionate, cost-effective, continuous evidence-based healthcare for varying patient populations, families, and communities. 5 That requires a change in the way education of disciplines is conducted within institutions of higher learning and in clinical organizations. 10 In academia, the creation of interprofessional curriculum must be consistent with the accreditation criteria of individual disciplines, yet be an opportunity to serve as a catalyst to shape standards relevant to IPE in all arenas of healthcare.
In accordance with principles set forth by the IPEC, 11 health professions are encouraged to develop core competencies for intercollaborative practice, embedding essential content of interprofessional communication, patient–family-centered care, role clarification, collaborative leadership, and conflict resolution in all professional curricula with the further translation and advancement of competencies in practice, and exemplified thorough mechanisms, such as grand rounds, unit rounds, or symposia.
The process of developing a simulated case study and analyzing the perceptions and experiences of collaboration led to several generalized conclusions about doing this kind of work. First, a good starting point is the articulation and documentation of the assumptions related to interprofessional collaboration before engaging in the work. Second, a collective set of values and sense of accountability to overcome internal and external challenges by all health professionals involved in the process are required for successful completion of the interprofessional initiatives. Third, it begins with informal and formal conversations, identification of team members needed to serve the population of care, and a sense of shared accountability and responsibility to effectively collaborate. Fourth, sharing or rotating overall group leadership or sharing leadership of specific group discussions should be dependent on the clinical issue or needed work. Fifth, the barriers to collaboration are often more logistical and technical than philosophical, and last, both in academia and in healthcare settings, there must be a top-down and bottom-up commitment to IPE with philosophical buy-in and resource support from university and hospital administrators, Chairs and Directors of academic or clinical departments, and faculty, as well as simultaneous processes of networking within, across, and beyond institutions and agencies.
Palliative care is a new specialty that requires interprofessional collaboration and which leads by example in healthcare. Transformative change in healthcare education and clinical practice is required, beginning with the ability of students and health professionals to engage in interactive learning with those outside of their profession. 4 Advocating for teamwork has to go beyond talking about being a team player or not to having the language, attitudes, and behaviors that can be observed and measured as exemplary characteristics of effective teamwork or collaboration and translated in outcomes for all stakeholders, particularly patients and families. 16 The interprofessional initiative presented in this article is a starting point to the development of an interprofessional assessment tool and case study relevant to interprofessional teaching and learning. Most importantly, it has moved interprofessional collaboration from a concept, which permeates the literature, to an action with deliverables. With an understanding of facilitators and challenges of the collaborative process, it is responsive to the IOM 5 challenge to prepare future health professionals and retrain the current healthcare workforce with new skills in effective communication and interprofessional collaboration.
Footnotes
Author Disclosure Statement
No competing financial interests exist.