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Wednesday, June 28, 2017

Blog Article: What does Interprofessional communication look like in an inner city emergency room? Some observations and reflections

What does Interprofessional communication look like in an inner city emergency room? Some observations and reflections

Christine Holland, MMS, PA-C
Instructor at Rush University PA Program

It is well-accepted that good interprofessional communication is a precondition for optimal care and treatment for patients in addition to good cooperation between healthcare providers (e.g. Berry, 2007). Healthcare providers are facing a complicated healthcare system where team communication is increasingly even more essential due to this complexity of collaboration between caregivers (King et al., 2012). While great progress has been made in the areas of interprofessional practice and interprofessional education (IPE), the literature continues to report a number of challenges related to interprofessional communication (Foronda et al., 2016). The aim of this paper is to report observations of interprofessional team communication with patients in an inner-city emergency department during a physician’s shift. What I witnessed was surprising and disheartening, especially in relation to the fact that the attending physician would state to every patient that they would be treated by an interprofessional team. As a PA myself, and a Interprofessional Studies PhD student, I greatly appreciate the importance of an interprofessional team. The whole PA profession was birthed from the notion of building a team relationship with physicians. It is this team approach that the PA-MD team cares for patients. It is through these lenses, both as a PA and an Interprofessional Studies PhD student, that I have made the following documentation and some thoughts for improvement.

My observations were gathered from an inner-city emergency room which contained 60 beds. There were four pods, each covered by an attending physician, two residents, a physician assistant student and a nurse. There was also a “pit doctor” and one nurse who triaged patients, ensuring: (1) emergent cases were addressed immediately, (2) low acuity patients were seen by the pit doctor and then released (3) or appropriate labs or x-rays were ordered and completed prior to the patient being seen by the emergency room physician. The team also included two social workers, administrative staff, and a nurse manager. These providers worked either a nine or 12-hour shift. There was no formal communication training that these providers received prior to working in the emergency room. The physicians did reference some team training, but could not tell me what it stood for nor what they learned from it. Thus, this ‘training’ did not seem to play an important role in impacting how these providers worked. Also, it is worth noting that none of these providers had received any form of IPE to help support their interprofessional teamwork.

During my time in the emergency room various patients presented ranging from those with congestive heart failure, head laceration, loss-of-consciousness, shortness of breath, possible seizure, vertigo, back pain to headache and more. The average amount of time the physician and I spent with a patient was between 3-5 minutes, during which there was no interprofessional team communication evident. Rather, the physician would advise the patient to get the nurse if they had any questions. The nurse would then address the patient’s question(s). There was however, a whiteboard in each examining room where the physician would circle orders he/she wanted (i.e. labs, x-ray, CT scan) as a means of communicating about patient needs.

Once the physician saw the patient for the second (and usually final time) to communicate the diagnosis and treatment plan, the communication with the patient was a one-sided conversation (i.e. “your dad has water on his lungs. We gave him Lasix so he can urinate. He has to be admitted.”).  During one case, the patient (a 78-year-old, Hispanic, Spanish speaking man) did not know what was being said by the physician. The physician did not even address the patient until the very end of the conversation, only communicating with the family who were surprised by the diagnosis. Unfortunately, the physician did not seem to notice any of her body language. Rather, he continued stating his plan for their father never asking the family or patient if they had any questions until the very end. The physician also was not at eye level with anyone in the room when he was speaking to them. He stood while everyone else sat putting him in an authoritative position. He also introduced me as a “team member,” stating patients’ are seen by teams in this emergency room. After my time there, however, the interprofessional team communication appeared fragmented.

This inner-city emergency room experience provided a useful example of the gap between what is taught about interprofessional communication in classrooms and what is happening in clinical practice. While this was only a single observational encounter relating to interprofessional communication, my findings were concerning given it was a very busy emergency room, impacting thousands of patients’ lives on an annual basis. Therefore, even these few observations provide some indication about the possible difficulties with interprofessional communication.

In regards attempting to enhance this situation, one improvement would be to make sure nurses are present while students and or residents are giving their clinical presentations to the attending physician. This will allow the nurse to be involved with the patient’s interprofessional plan and if anything was forgotten or overlooked by the resident/student, the nurse can add to the details.

In addition to having nurses present during medical case presentation, implementing an interprofessional communication skills lab is another action that can be taken to improve interprofessional communication. Salvatori et al (2006) for example, introduced a mandatory IPE curriculum for all their health profession programs at McMaster University in Canada. In this curriculum, competency-based, small group, problem-based learning, IPE competencies were identified. One of these competencies was making team decisions (which seemed to be lacking in my emergency room observations). Their findings indicated that communication skill labs were not only a positive experience for the participants, but they were effective in providing exposure to collaborating with other healthcare professionals. Interprofessional simulation has also been recognized as a crucial step to incorporate into healthcare students’ training to better prepare them to practice in the clinical setting (Sanfey et al., 2011). I would further suggest incorporating this interprofessional simulation in existing emergency rooms to improve interprofessional team communication between providers and with patients.

My last suggestion is to train interprofessional team members about basic inter-personal and body language skills along with the sociological and psychologic elements of teams. By providing these type of training, providers would better understand about the nature of communication and how language can be perceived by others. Not only should interprofessional teams learn about their members and communication styles, but more importantly learn how to adjust their communication styles when communicating with one another. This can be better achieved with DISC training (Disc Profile, 2017) that teaches a common language for people to use when adapting their behavior with others in addition to better understanding themselves. In combination with DISC training, a simple body language course may serve to be quite beneficial toward improving interprofessional team communication when interacting with patients. With this said, the best communication will fall short if teams do not understand the sociological and psychological elements of working together. Stereotypes and hierarchical positions of professions need to be broken or at least discussed since they can result in an imbalance of power (Sharma et al., 2011; Boet et al., 2014).  Furthermore, as noted by Boet et al (2014) emotional and psychological safety need to be maintained during team simulation debriefings. Buhler et. al. (2016) noted certain professions tend to have more of particular personality types than others. These professional personality differences may set-up a challenging situation for interprofessional team members where the less dominant personality may feel their opinion is not welcomed or valued as an equal team player. This triad of communication, sociological, and psychological elements is crucial to maintain balanced when teaching how to work as a productive interprofessional team.

Concluding comments
Team communication is a crucial part of any clinical team that can lead to better delivery and access to care (e.g. Brock et al., 2013). This experience suggests there is still a long way to go in relation to providing effective interprofessional and patient communication. However, as suggested above, the use of number of interprofessional learning activities could be implemented to help improve this situation, and begin closing the gap between what is taught in the classroom and what actually happens in practice.

Berry B. (2007). Health Communication: Theory and Practice. Berkshire, UK:
Open University Press.

Boet, S., Bould, M., Burn, C., Reeves, S. (2014). Twelve tips for a successful interprofessional team-based high-fidelity simulation education session. Medical Teacher, 36: 853-857.

Buhler, A., Coplen, A., Davis, S., Nijjar, B. (2016) Comparison of Communications Styles Among Students in Allied Health Professions Programs: How Do Our Students Communicate with Other Healthcare Providers? Journal of Research in Interprofessional Practice and Education; 6.2.

Brock, D., Abu-Rish, E., Chiu, C., Hammer, D., Wilson, S., Vorvick, L., Blondon,
Schaad, Liner, and Zierler, B. (2013). Interprofessional education in team communication: working together to improve patient safety. BMJ Quality & Safety; 22(5): 414-423. doi:10.1136/bmjqs-2012-000952

Disc Profile. (2017). DISC Overview. Retrieved from

Foronda C, MacWilliams B, McArthur E. (2016). Interprofessional communication in
healthcare: An integrative review. Nurse Educ Pract., 19:36-40.

King, S., Chodos, D., Stroulia, E., Carbonaro, M., Mackenzie, M., Reid, A., Torres, L
and Greidanus, E.  (2012). Developing interprofessional health competencies in
a virtual world. Medical Education Online; doi:10.3402/meo.v17i0.11213

Salvatori, P., Mahoney, P., & Delottinville, C. (2006). An interprofessional
communication skills lab: A pilot project. Education for Health: Change in Learning & Practice,19(3), 380-384. doi:10.1080/13576280600938653

Sanfey, H., Mcdowell, C., Meier, A. H., & Dunnington, G. L. (2011). Team training
for surgical trainees. The Surgeon,9. doi:10.1016/j.surge.2010.11.018

Sharma, S., Boet S., Kitto, S., Reeves, S. (2011). Interprofessional simulated learning:  The need for ‘sociological fidelity’. Journal of Interprofessional Care, 25(2):81-83.

Wednesday, May 24, 2017

Blog Article: Using interprofessional education to enhance knowledge and skills for integrated and person-centred care

Using interprofessional education to enhance knowledge and skills for integrated and person-centred care 

Dr Teresa Burdett
Facilty of Health and Social Sciences
Bournemouth University 

An educational, person-centred initiative was designed to bring individuals from different clinical arenas and professions together. It was intended to enhance working collaboratively and move person-centred care forward jointly across the organisations involved, and in the practitioner’s own clinical arenas. This programme was designed, whilst being aware of potential implications such as limited resources, to achieve an impact in a number of areas including on the participants, their colleagues and their own patient populations. This interprofessional activity was assessed before and after its implementation and findings revealed that participants perceived it to be a valuable experience. Strategies on interprofessional education and person-centred care resulting from this programme are now being implemented. The programme has evolved in response to student feedback and evaluation and aims to continue to enhance interprofessional education, integration, workforce development and person-centred care.

Multiple issues including resource limitations, an ageing workforce and increasing patient populations currently face health care systems both in the United Kingdom and internationally. Working together is often seen as a way forward and yet interprofessional education and collaboration but repeatedly curtailed due to modes of thinking, perceived time implications, organisational challenges and physical resources (Barr, 2013).  This innovation was designed so that all the individuals in health and social care would feel and be empowered so that they could learn and work together with equality to generate new knowledge and strategies so that person centred care could be improved through working together in a more integrated manner (Goodwin et al., 2012). It is believed that this innovative project could be replicated, nationally and internationally, to create new understanding and solve issues facing public services, leading to greater person centred care and level of services.

Two programmes funded by Health Education Wessex were delivered across the South of England. Through the use of interprofessional education the aims of the programmes included enhancing the student’s knowledge and practical skills base through discussing and demonstrating integration in relation to seeing each person as an individual. This is an intrinsic aspect of person-centred care (Hewitt-Taylor, 2015). It was anticipated that this programme would lead to an enhanced level of care being offered.

Each participant was drawn from different professional groups, including, registered adult and mental health nurses, social workers, social care assistants, occupational therapists, rehabilitation therapists and health and social care co-ordinators. This mixed cohort supported the belief in the value of interprofessional education to enable “two or more professions to learn with, from and about each other to improve collaborative practice and quality of care” (CAIPE, 2002). The practitioners were drawn from primary and secondary care and a combination of genders, ages and work locations were represented in each cohort.

Participants were encouraged to work together in a pro-active manner to address issues that could potentially be enhanced by learning and working together in a more integrated manner.  A number of topics were covered in the programme including the challenges and benefits of integration (Ling et al., 2012) and local, national and international perspectives of integration (Rosen et al., 2011).  Ideas of how to enhance person-centred care through integration for specific groups (e.g. mental health service users) were also discussed.

 A variety of teaching methods and strategies were utilised including seminars, media and group participation. Solution-focused strategies and reflective exercises including individual and team-orientated sessions were utilised. Group work was deliberately designed to ensure individuals from different professions worked productively together. All participants were asked to work on an integrated, person-centred project based in their own sphere of care. A plethora of ideas came from the students, many of which were adopted in the clinical arenas including improving referral systems, a greater co-ordination between services and enhancing discharge packages. This array of approaches proved very useful for the individuals and their practice arenas resulting in significant, positive feedback.

This feedback was gained by utilising pre-and post-programme questionnaires and the participants were asked, for example, “...please identify three key points which have had an impact on you...”  Open-ended questions were utilised in the questionnaires to gain a deeper understanding of the participant’s perspective including, “...what are your feelings about integration?”  Opportunities were offered have frank face-to-face discussions between the students to obtain qualitative data. Students also had a booklet to complete which asked a series of questions on each day of the programme including, “, if at all, do you envisage this will impact on your practice”.  Students were also given the opportunity to write and verbalise their thoughts and feelings in an unstructured and open format, “ you have any other comments”.

Initial impressions were positive, from the qualitative data received from the students undertaking both programmes and also from the practice arenas. This has included written, verbal, and ad hoc feedback that enhanced integration has been occurring, which has resulted in an improved level of workforce satisfaction, increased workforce initiatives and an increased focus and level of care being offered to the recipient of care. Other areas addressed included amending services and enhancing patient access to services.

Other outcomes included devising an interprofessional programme that encouraged learning and working together which has further added to the body of knowledge about how to achieve this. Such an approach is not always viewed as the way forward and often profession-specific training is provided. The results from this programme do challenge this viewpoint and lessons have been also been learned included language use and ensuring a balance of professions in groups and individuals.

Focusing directly on integration in an interprofessional programme has been novel. It has resulted in creative strategies being devised and innovative projects being implemented, which it is anticipated will result in enhanced, sustainable patient care. As the following data extracts indicate:

“…This course has opened my mind to how we deliver care in the future…”
 “…Best outcomes for the patients with patients being the centre…”

Teaching the subject of integration in an interprofessional manner has raised the profile of interprofessional learning/working and integration. This has created a momentum and renewed vigour which can be focused on helping address the multiple issues currently being faced by health and social care systems both nationally and internationally:

“…I ensure I challenge attitudes and promote integration…”
“…This course has strengthened my belief in the importance and value of integration…”

Working together undoubtedly benefits the individuals we care for (World Health Organisation, 2016) and learning together can enhance and develop our skills with working with different disciplines (Frenk et al., 2010).  Hence the usefulness of this intervention which has gained a number of key outcomes including, providing students with more knowledge about integration and how to utilise it, and importantly, feeling more empowered to initiate change. Feedback has also identified that the students believed that their patient populations have gained from an enhanced person-focused level of services. The individuals on the programme gained more knowledge about each other’s roles and professions which led to increased levels of interaction and rapport which clearly continued into the clinical or community arenas.

The programme is now formalised as the Foundations of Integrated Care and Person Centred Services Programme because this more clearly reflects the philosophy of the curriculum. It is also being delivered on site at Bournemouth University which is in response to student feedback. Although, offsite delivery is still available if required. This is now an accredited programme and it can be undertaken as a standalone unit. The components of leadership and change and change management in integration have been strengthened in response to student feedback. This is due to the evolving and challenging nature of integration, in the UK and internationally and the need for change and leadership is inherent in the workforce who are seeing the patient population needs first hand.

Interprofessional education, learning and working together is one way of encouraging integration and enhancing person centred care. This innovative, interprofessional educational programme was designed to focus on these two issues and by bringing different disciplines together to learn together, according to participant and work force feedback this programme was successful. However, this was not without its challenges. These included venue choice, the differing needs of students, their perceived needs of specific professional roles, language use and knowledge base. There were also differing requests from the clinical arenas that needed to be accommodated. It was not a static programme and responded to the evolving nature of integration and the students, workforce development, the employer and clinical arena requirements and the patient and service user needs. Areas of the programme have already been re-developed and this will no doubt be an ongoing process to keep the programme relevant, up to date and responsive to student, work force and patient population needs and maintain its aim of being a truly interprofessional, educational programme.

Barr, H., (2013). Toward a theoretical framework for interprofessional education. Journal of Interprofessional Care. 27, (1) 4-9. Doi:10.3109/13561820.2012.698328

CAIPE. (2002).  Centre for the Advancement of Interprofessional Education – a definition.  

Frenk J., Chen, L., Bhutta, Z.A., Cohen, J., Crisp, N., Evans, T., … Serwadda, D., (2010). Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet. 376 1923-1958

Goodwin, N., Smith, J., Davies, A., Perry, C., Rosen, R., Dixon, A., Dixon, J., Ham, C., (2012). Integrated Care for Patients and Populations – improving outcomes by working together: a report to the Dept. of Health and the NHS Future Forum. London. Kings Fund

Hewitt-Taylor, H., (2015). Delivering Person Centred Care-A Practical Approach to Quality Health Care. Palgrave, London, UK

Ling, T., Brereton, L., Conklin, A., Newbould, J., Roland, M., (2012). Barriers and facilitators to integrating care; experiences of the English Integrated Care Pilots. International Journal of Integrated Care. 12 (24) 1-12

Rosen, R. Mountford, J. Lewis, G., Lewis, R., Shand, J., Shaw, S., (2011). Integration in action: four international case studies. London. Nuffield Trust

World Health Organisation (2016) Strengthening integrated people’s health services. Resolution WHA69.24 Geneva. Switzerland.