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The IPEC core competencies were first adopted in 2011 and updated in 2016. In the years since the original document's release and update, the IPEC core competencies have been widely disseminated throughout the health professions and embedded into both curriculum and accreditation standards.
IPEC Core Competencies for Interprofessional Collaborative Practice Revision, 2021-2023
In May 2021, IPEC announced plans to begin a formal process to review and revise the 2016 IPEC Core Competencies. Key drivers for the 2021-2023 revision include the need to empower the IPE community with the best available evidence and research related to IPE and CP; conduct a cyclical review on common definitions for competence, competency and competency framework; and ensure that this framework accurately reflects any changes in research, policy, and practice.

A preliminary draft of proposed 2023 revisions to the IPEC Core Competencies for Interprofessional Collaborative Practice: 2016 Update is now available for open comment.

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IPEC Core Competencies for Interprofessional Collaborative Practice: 2016 Update
This 2016 update reflects the changes that have occurred in the health system since the release of the original report, two of the most significant of which are the increased focus on the Triple Aim (improving the experience of care, improving the health of populations, and reducing the per capita cost of health care) and implementation of the Patient Protection and Affordable Care Act in 2010.
IPEC Core Competencies for Interprofessional Collaborative Practice: 2011 Original
This report is inspired by a vision of interprofessional collaborative practice as key to the safe, high quality, accessible, patient-centered care desired by all. The intent was to build on each profession's expected disciplinary competencies in defining competencies for interprofessional collaborative practice. The IPEC panel identified four core competency domains: 1) values and ethics; 2) roles and responsibilities for collaborative practice; 3) interprofessional communication; and 4) teamwork and team-based care.
Team-Based Competencies, Building a Shared Foundation for Education and Clinical Practice
This summary document is based on the February 2011 meeting that was held to advance interprofessional education, which provides both academic and clinical experiences for students from two or more health professions to work in a collaborative partnership to provide patient-centered care.

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Nursing informatics: Scope and Standards of Practice

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Nursing informatics: Scope and Standards of Practice

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Ovid: An innovative course to prepare advanced practice registered nurses to spearhead quality and safety initiatives for older adults.

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Inter-professional Teams-current trends & future direction

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Inter-professional Teams-current trends & future direction

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E-Learning University Medical Center Groningen

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Interprofessional collaboration (IPC)-the idea that health care is best conceptualized and practiced as a team activity-has grown in popularity to the point of becoming accepted "common sense." In the practice setting, IPC has grown up alongside changes in health care delivery, particularly the move away from single-practitioner models and patient-provider dyads, to team-based delivery of care., Its influence in the educational domain is unquestionable, evident both in competency frameworks identifying it as an essential competency and in calls for interprofessional education (IPE), which together represent a fundamental pedagogical shift emerging in many health professional curricula.

A quick scan of the scholarly literature confirms the emergence of IPC over the past few decades as a topic for thriving scholarly discourse. Today (June 7, 2013), a single PubMed search using the terms interprofessional collaboration and medical education retrieved 319 articles from the past five years alone, while a search of the term interprofessional collaboration through a corpus of millions of digitized books via Google Ngrams revealed a sixfold increase over the last 40 years. With this growth has come the development of scholarly institutions dedicated to IPC, such as peer-reviewed research journals (e.g., Journal of Interprofessional Care) and policy initiatives.

Although IPC's status is not in question, its definition and characteristics are the subject of ongoing debate. Medical researchers, educators, and authors have advanced multiple models and frameworks, not always with reference to-or resonant with-one another. Further, although IPC implementation in health care delivery and health professions education has moved ahead regardless of questions of ontology, implementation is often fraught with tension, and outcomes remain ambiguous., This situation has led us to our research questions: Is there clarity on the idea of IPC? And if not, what does that mean for its adoption into physician training?

Method

We used the methodology of critical discourse analysis (CDA) to explore these questions. Epistemologically, CDA takes knowledge to be socially constructed and perpetuated, and it explores instances of spoken and written language to understand how these influence what persons within a sociopolitical and cultural context understand as, or consider to be, "known."(p39) CDA probes the question of how some knowledge claims are beyond dispute at particular historical moments, and it pays particular attention to the contradictions within and among discourses that become visible when the probing of this "common sense" occurs. Those contradictions manifest as "irregularities" and-where the construction of the social world changes altogether-as "ruptures." Beyond simply describing the patterns of discourse, CDA is also concerned with understanding what institutions or concepts ("objects") gain legitimacy and power as a result of particular discourses.,

Specifically, we draw on Michel Foucault, who treated the history of knowledge/ideas as serial rather than progressive. Rather than viewing the history of ideas as a stepwise progress through which ideas are refined and improved, Foucault (and others) argued that there are "ruptures" in the conception of "truth" over time. For example, ruptures, rather than a progression in the "truth," characterize the history of the understanding of "madness," which changed from possession by evil spirits to social deviance and today to a chemical imbalance. But even within a single conception of the "truth" there may be irregularities; differences and tensions arise from how an idea is conceived and knowledge constructed. Like Foucault, we have examined how the truth around IPC has changed over time, specifically through the lens of irregularities and ruptures. This Foucauldian orientation to the study of ideas has proven fruitful both for questioning the origins of long-standing ideas in health care and for tracing the development of emerging ones. Others have used a Foucauldian orientation to explore questions of direct and indirect relevance to the domain of IPC, including the history of medical competency frameworks, the idea of reflective practice, the emerging role of nurses in health promotion, and the epistemological limits on nurse-physician collaboration.

A Foucauldian CDA requires gathering and studying an archive of texts "neither entirely linguistic, nor exclusively material"(p86) that together constitute a discourse; in other words, the texts should be reflective of the social world the discourse is constructing. The archive includes statements, objects, institutions, practices, and traditions that collectively make-or are made possible by-a discourse. Its delineation poses a major methodological decision because its size must not only be manageable but also allow for sufficient depth that discourses can be meaningfully identified and characterized. As Foucault(p146) pointed out, the "archive of a society ... cannot be described exhaustively; or even, no doubt the archive of a whole period." Foucault himself undertook archeological examinations drawing on both extensive, and limited archives.

We limited our archive in four ways. First, we limited the archive to published, peer-reviewed literature. Although "statements" in the Foucauldian sense are limited neither to written texts nor to published literature, the published literature represents a domain within which individuals, ideas, and methods interact, and it is, therefore, a defensible research starting point. Second, we limited the archive to nurse-physician IPC in order to focus on what is arguably the dominant interprofessional axis in modern health care. Furthermore, Foucault highlights the importance of considering statements in their context, and nurse-physician relationships are arguably unique given that the historical relationship between these two professions predates the emergence of some other professions now participating in the health care workplace. Third, the archive includes literature from the 1960s through December 2011, a time frame chosen both for convenience and relevance. Demographic changes and the technological advances of the mid-late 1950s strongly influenced the current health care system in Canada and the United States, such that, although a discourse analysis can be informed by a longer historical lens, limiting the starting period for the current analysis to the 1960s allows for analysis of a historically connected period. Fourth, the archive is limited to U.S. and Canadian, and to a lesser extent British, texts. Although we do not consider these countries to be homogenous, they do share similarities of medical and training culture, and a degree of cross-pollination in their IPC literatures allows for constructing a meaningful archive. Finally, we excluded literature relating to IPE and items dealing exclusively with gender conflict. Both of these areas constitute distinct discourses in themselves and deserve separate treatment.

To compile our archive, we conducted a search in PubMed and CINAHL using an expansive search strategy developed with the help of a librarian. We initiated our search in November 2010 and continually updated it through December 2011 using the terms "interprofessional relations," "interdisciplinary communication," and "collaboration" both as subject headings and as key words. One researcher (W.H.) reviewed titles and abstracts. He retrieved full papers (articles, reports, letters, commentaries, etc.) if they fell within the limits described above and if they related to the theory, conceptualization, or implementation of IPC. Sampling in CDA research is not intended to be exhaustive; rather, it continues until stable description of discourses is achieved. In CDA, a comprehensive archive is not the goal, and the size of the archive is less salient than the insight afforded into the question; thus, the sufficiency of the sample is judged by the richness of the characterization of the discourse(s) that emerges from the analysis.

CDA has been called an approach rather than a fixed method,(pp1,145) in part because of its resistance to formulaic rules for analysis.,(p249) Nevertheless, researchers should articulate their analytic methods. We drew largely on the method of Wodak and Meyer.(pp53-56) We defined our discourse plane as published, peer-reviewed texts with the above-mentioned delineations (primarily from the United States and Canada, dealing with nurse-physician collaboration, dating from the 1960s through 2011, etc.). We noted the peculiarities of each particular paper including the journal, the authors' affiliations, and the genre (e.g., research report, descriptive article, letter). We processed the texts using an iterative analytic process in which we examined texts for themes, truth statements about IPC, objects enabled, and language used. We analyzed the texts for irregularities, ruptures, and transformations until a stable description of the various discourses emerged. One researcher (W.H.) read each text in the archive. Then, during regular meetings, the principal author (W.H.) and a second researcher (L.L., an education researcher familiar with IPC) discussed patterns emerging from the analysis. These discussions aimed to distinguish the patterns that constituted discourses through identifying and refining the truth statements, language, and objects produced by and linked to the emergent themes. These researchers explored questions about the interactions between these discourses through revisiting the texts themselves. They also undertook additional literature searches to further validate the presence of the discourses identified.

Results

The papers we retrieved included empirical studies, systematic reviews, conference proceedings, editorials, and commentaries. Our final archive consisted of 188 texts, the earliest published in 1965 and the most recent in 2011.

The fundamental insight from our analysis is that, over the last 50 years, the term "interprofessional collaboration" has not signified the same thing to all who use and apply the term. Different discourses of IPC exist and result in different truth statements, objects, and language. The two major discourses to emerge from our analysis are the "utilitarian" and "emancipatory" discourses ( Table 1). We describe below the recognizable features of each discourse, including the truth statements each embodies, the objects each creates, and the language each employs. We also illustrate the spectrum that exists within each discourse and the nuances possible within its truth statements. Importantly, although these two discourses are distinct, they are not mutually exclusive; in fact, a subset of our archive invokes both. Finally, we do not imply that these discourses are the only discourses of IPC in published literature nor that all literature on IPC contributes to or exists within one or both of these discourses.

Table 1:

Emancipatory and Utilitarian Discourses Within the Peer-Reviewed Literature on Health Care Delivery and Medical Education Interprofessional Collaboration (1960-2011)

Utilitarian discourse

Truth statements.

The central truth statement in the utilitarian discourse is that IPC is necessary because it produces better patient care and improves patient outcomes. A related but less overt truth statement is that the utility of IPC can and should be demonstrated through positivist, experimental research; hence, IPC is a valuable innovation only if it can be empirically shown to improve "outcomes," ideally through randomized controlled trials.

Language and objects.

The utilitarian discourse is evident in the emergence of formalized interactions between organized medicine and nursing groups, which create the conditions for new language and objects to emerge. Such interactions include proceedings and recommendations from conferences cosponsored by the American Medical Association and the American Nursing Association (starting as early as 1964). The titles, objectives, and content of each of the conferences cast IPC within a utilitarian framework: the 1965 conference, for instance, was titled "Nurse-physician collaboration toward improved patient care."

These conferences were followed by the establishment (in 1972) of a National Joint Practice Commission (NJPC) to promote "quality health care." The principal objectives of the NJPC further promoted the utilitarian discourse of IPC by instigating a number of hospital "demonstration projects" that implemented and reported the benefit of IPC practices.

In line with this positivist ethos of "demonstration," a body of literature has emerged breaking collaboration down into characteristics or mechanics, testing its association with clinical outcomes, and tracing causality through studies aimed at distilling the "necessary" aspects of collaboration for improved outcomes. Bates,, an early and influential researcher in this field, set the tone for language in this discourse by emphasizing "effective team functioning" and "the importance of physician-nurse relations to patient care." Indeed, the very use of the term "demonstration" in the NJPC's original demonstration projects suggests that a utility or benefit is to be demonstrated and that, in the absence of such demonstration, IPC could be abandoned.

In line with this language, a central object enabled by the utilitarian discourse is the IPC interventional trial. The early interventional trials, failing to conclusively demonstrate "impact," spurred the refinement and implementation of additional trials, each seeking to demonstrate the utility of IPC more conclusively, often through a better trial design. Prominent examples include Knaus and colleagues, who reported that predicted mortality was inversely correlated to self-reported "coordination of care" in intensive care units. This influential report (cited 1,329 times by June 7, 2013, according to Google Scholar) encouraged further efforts to demonstrate the links between IPC and "hard" patient outcomes.

In the last 10 years (2002-2011), 22 randomized controlled trials of IPC were indexed in PubMed, of which more than a third were published in the last two years. The proliferation of interventional trials has produced another object of the utilitarian discourse: measurement tools designed to track the relationship among IPC practices and system and patient outcomes.,

As the interventional trial and its measurement tools have proliferated, another object, with its associated language, has emerged: the systematic review of IPC, published as early as the 1960s and continuing unabated. The systematic review is a powerful example of how a discourse creates objects through its truth statements and how these objects, in turn, consecrate the discourse by defining acceptable knowledge. Using language such as "rigor," "methodological quality," and "evidence," systematic reviews reinvest the interventional trial with power even as they critique the vast utilitarian literature made up of hundreds of published studies. The authors of a recent Cochrane review deemed only five studies "valid," and all five of these are interventional trials, themselves a function of the utilitarian discourse of IPC.

In summary, the utilitarian IPC discourse constructs the process of team practice in the clinical setting as a tool for better health care outcomes. In doing so, the utilitarian discourse enables certain objects and language and legitimizes particular forms of knowledge as acceptable.

Emancipatory discourse

Truth statements.

The central truth statement in the emancipatory discourse is that IPC is necessary because it is a means to diminish medical dominance. This truth statement is situated in the premise that health care delivery has long been compromised by the dominance of physicians and the medical paradigm. Hence, common among all the papers evidencing the emancipatory discourse is a leveling of the professional field away from the dominance or leadership of medicine.

Language and objects.

Like the utilitarian discourse, the emancipatory discourse enables certain language and gives rise to specific objects. In the textual archive, this discourse is strongly represented in particular genres such as opinion pieces, editorials, sociologic works, and qualitative research centering on individual experiences.

Whereas the language within the utilitarian discourse is relatively uniform, the language in the emancipatory discourse covers a wide spectrum. At one end, papers have a tone of confrontation, hostility, or militancy, and they use language consistent with this tone. The common genre at this end is the editorial or opinion piece, marked by exclamatory or imperative statements. These papers characterize medicine-nursing relations as rooted in "deception, paternalistic hostility and blatant sexism," and they describe medicine as having "an ethic of domination,"(p39) as promoting "subservience and [the] second class status of nurses,"(qtd p729) and as generally acting dictatorially toward other nonmedical, health professions.,

To illustrate, Friedson's 1970 sociological description of "medical dominance" in the division of health care labor has had broad uptake, engendering "a body of literature ... exploring the structural components contributing to the subordination of the allied health professions."(qtd p173) Although this language is less hostile, it retains a confrontational flavor in its explicit challenge of the distribution of power across the professions. Arising from the body of work at this end of the spectrum is the assertion of the notion of IPC as a tool for "flattening the hierarchy" in health care.,,

Not all texts in the emancipatory discourse take as strong a stance as those at the confrontational end of the spectrum. One highly influential paper that straddles the continuum between confrontation and conciliation is Stein's "Doctor-nurse game," in which Stein describes the interaction between nurses and physicians as a classic game with specific rules. The game metaphor still implies confrontation, but it portrays a less oppositional stance than metaphors of "domination" and "liberation."

At the opposite end of the emancipatory discourse spectrum, the language becomes more neutral, invoking less antagonism and less personal investment. Empirical papers are the most common genre at this end of the emancipatory spectrum; most papers explore IPC through primary research, including interviews and fieldwork, or through concept analyses.,,, Power remains a central theme in these texts, which construct IPC as overcoming a power differential; however, their overall tone is more declarative and descriptive than imperative and exclamatory. One author, Rose, provides an example of the former, more descriptive tone in a review of the definitions of IPC. She writes that IPC "implies sharing, partnership, interdependency, but also power. Many barriers to successful interprofessional collaboration exist, including problematic power dynamics."(p6)

Texts at the nonconfrontational end of the emancipatory spectrum are much less overt about the issue of power leveling, but it is often convincingly portrayed nonetheless. For instance, the term "nonhierarchical" suggests an emancipatory stance without invoking the potential resistance associated with the language of dominance and liberation. In fact, texts taking this more subtle stance often use the concept of nonhierarchical working relationships without ever explicitly mentioning the group that must give up power for such relationships to be possible: medicine. In her analysis of Baggs and Schmitt's original use of "nonhierarchical" to define an element of IPC, Taylor(p66) notes:

It is immediately apparent that whilst patients and nurses gain from collaborative practice according to this summary, doctors are not mentioned. It seems feasible that Baggs and Schmitt have either assumed that the medical staff will focus upon better patient outcomes as reason enough to support collaboration, or that they have marginalized the medical staff.

Objects created within this emancipatory IPC discourse are distinct from those in the utilitarian IPC discourse, even if they share superficial similarities. For example, literature reviews are present at this end of the emancipatory spectrum, but they differ importantly from those falling within the utilitarian discourse. Literature reviews classified as emancipatory characterize a flat hierarchy as a sine qua non of IPC, almost irrespective of the empirical findings of the review.,, For example, Taylor reviewed the literature for definitions of IPC and reported little empirical evidence indicating that common definitions of IPC included a purported benefit for patient outcomes; nevertheless, she uses the little evidence supporting this definition to uncritically define IPC as a "nonhierarchical" working arrangement for doctors and nurses.

The emancipatory discourse has produced other objects besides peer-reviewed papers. One is the "shared leadership model," a model for administering clinical units that draws on both nursing and physician leadership. Another is the "magnet hospital" designation, granted by a nursing accrediting body to hospitals deemed exceptional, as measured by, among other factors, their collaborative work structures. Finally, the emancipatory discourse enabled its own set of measurement tools, rooted in ideas of hierarchy and power. One example is the Jefferson Scale, developed by Hojat et al, which is based on an "attitudes towards nursing" survey and the culture, organization, and management in the intensive care unit.

In summary, the emancipatory discourse constructs IPC as a corrective for the domination of nursing by medicine. The papers falling within the emancipatory discourse represent a spectrum, ranging from opinion pieces and editorials that employ imperative, exclamatory, and confrontational language to papers that use empiricist approaches, nonconfrontational language, and a more covert positioning of the power-leveling agenda.

Discussion

We have identified two prominent discourses in the literature on IPC-utilitarian and emancipatory-each of which constructs IPC in different ways and makes possible certain objects and language.

The utilitarian discourse is expressed through randomized trials, before-and-after comparisons, meta-analyses, measurement tool validations, and systematic reviews. It gives rise to the language of "outcomes," "evidence," "proof," and "utility" in relation to IPC. This language signals the epistemological stance of positivism, which makes possible the search for truth. Consistent with the Foucauldian conception of power/knowledge, this discourse legitimizes and delegitimizes certain knowledge, by setting standards of "rigor" and "validity" for interventions.

Interestingly, as the utilitarian discourse constructs IPC as a tool to achieve better-quality care, scholars drawing on this discourse can investigate the "truth" of such claims, opening up the possibility of concluding that IPC is not effective at producing better patient care. Recently, the authors of a systemic review asked, "What is so great about collaboration?" suggesting that the positivist stance of the utilitarian discourse may carry within it the seeds of its own demise.

The emancipatory discourse constructs IPC as a means of empowering health professions that are traditionally subordinate to medicine in the health care division of labor: namely, in our review, nursing. This discourse emphasizes the issue of power and the goal of flattening the power hierarchy; it elaborates its own set of objects such as "shared leadership models" and tools for "measuring" IPC that are rooted in theories of conflict and power. Epistemologically, the stance of this discourse is critical and constructivist: IPC is viewed as being able to reshape a social reality in need of radical change.

Our results suggest an intriguing answer to the question that motivated this study: No, there is no clarity on what constitutes IPC. At a minimum, the presence of two dominant discourses suggests that we health care practitioners and medical educators may not all be talking the same language, or sharing the same purposes, when we invoke the term "interprofessional collaboration." Even more concerning, our purposes may be in direct conflict, and our progress stymied unless we expose this conflict for critical reflection and debate.

Interestingly, almost 30 years ago, in an historical analysis of health care teams, Brown pointed to the presence of different types of language used to describe teams. Although he does not characterize these in terms of discourses, nor trace their impact in terms of producing truths, objects, and language in health care, he does make the following observation which resonates with our findings: "It may take the discussants quite some time to realize that a multilevel transaction actually took place during team talk and that neither party fully understood or agreed with the other." Brown's point-that we may be talking at cross-purposes and not realizing it-is hammered home in a recent review by Lurie and colleagues, who assessed medical education's progress in measuring the competencies. In discussing the failure of attempts to measure the Accreditation Council for Graduate Medical Education (ACGME) competencies in a robust and valid manner, Lurie et al conclude that the question at stake is not so much the nature of the psychometrics as it is the nature of the constructs themselves, which medical educators are trying to measure. They argue that these constructs (e.g., professionalism and collaboration) are the product of political and social compromises between disparate forces-that, in essence, they do not objectively exist but are ideas whose definitions are dictated by societal forces, and that it is no wonder that physician educators struggle to create valid measurement tools to capture these ideas. Our analysis of the two dominant discourses underpinning IPC offers rich insight into the very problem Lurie and his coauthors have identified.

Our results also show that the relationship between the utilitarian and emancipatory discourses is neither a developmental trajectory-one does not replace the other in time-nor a simple binary opposition. Rather, as Hodges found with the discourses of competency, and as Martimianakis and Hafferty discovered with the discourses of global physician competency, the two IPC discourses we identified interact in various and complicated ways. For instance, papers at the less confrontational end of the emancipatory spectrum may be infused with utilitarian language; that is, they may emphasize the power-leveling aspects of IPC while suggesting associations between power leveling and benefits for patient care.

The findings of this CDA suggest that clinicians and educators involved in IPC initiatives may find acknowledging the existence and legitimacy of both discourses useful. Likewise, they may find value in considering the underlying societal forces that inform each of them. Consciously asking, Are we all on the same page? may help articulate and negotiate the tensions that currently underpin-and limit-IPC efforts.

Our work focused on a specific body of literature, mostly nurse-physician interactions in Canadian, U.S., and British contexts. These discourses may not be as dominant-or other discourses may be foregrounded-in a textual archive that includes literature from outside these three places and that extends beyond nurse-physician collaboration. Also, undoubtedly, our appreciation of these discourses would be refined by the inclusion of a more varied corpus of artifacts, including interviews with IPC leaders, organizational vision documents, and-most interesting perhaps-the architectural and technological structures that have grown up around IPC in recent decades.

Notwithstanding these limitations, however, our results raise important and pressing questions for health professional practitioners and educators. What "version" of IPC do existing training programs purport to teach-a utilitarian or an emancipatory one? To what extent does the CanMEDS Collaborator role or the ACGME systems-based practice competency reflect a utilitarian or emancipatory discourse-or both? Are we physician educators clear on which kinds of collaborative practices (those oriented towards utility or those oriented towards emancipation) we are trying to assess when we complete the collaborator dimension on in-training evaluation reports for trainees? Specifically, given the pervasiveness of 360-degree assessments and the use of feedback-dependent in-training evaluation forms, do we truly agree on what is being assessed? And, perhaps most pressing given its enormous popularity in current health professional curricula, how does IPE reflect these two discourses? When educators from nursing, medicine, pharmacy, social work, and other health professional programs sit down together to design and implement IPE initiatives, how are the two IPC discourses interacting, visibly and invisibly, and how does this interaction shape the nature and eventual success of IPE?

Our discourse analysis opens up the possibility that these are not straightforward, self-evident conversations, and that, when multiple discourses are in play, those using them need to attend to their intersection and their impact on the educational practices that emerge.

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Are We All on the Same Page? A Discourse Analysis of... : Academic Medicine

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a shared IPC discourse underpins these current efforts. Method Using a critical discourse analysis methodology informed by Michel Foucault's approach, the authors analyzed an archive of 188 texts published from 1960 through 2011. The authors identified the texts through a search of PubMed and CINAHL.

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Identify and define the core competencies that should be covered in collaborative inter-professional education and the QSEN?

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Ovid: Quality and Safety Education for Nurses Competencies in Doctor of Nursing Practice Education: Exemplars From Education and Practice.

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Application Standards of Performance

In an interprofessional team, it is imperative that there is effective communication, as most of the errors in the healthcare provision emanate from poor communication, and when healthcare workers from diverse specialties work together, there are augmented likelihoods of miscommunication, and this exacerbates the probabilities of error. Imperatively, there is a need for a defined code of communication in the interprofessional team, which guarantees a seamless flow of information between the diverse specialties in a team.

There is also a necessity for leadership in the interprofessional team, which encompasses the leadership of the registered nurses with an objective of tackling the technical hitches that emerge during the execution of the work, including in the management of communication and conflicting working styles among the members.

In the conduct of the nursing practice, the nurse cooperates with other healthcare professionals, with the intention that they will uphold the quality of the services and, hence, the outcome of the patient, and this will contribute to the team accomplishing its objectives and through collaboration, the nurses will benefit in that they will be able to set aside their ambitions and interests and be able to pursue a collective agenda for the sake of the patients.

The nurses in the interprofessional teams require to guarantee that they observe environmental health, where they need to practice in a safe environment and in a healthy manner, for example, in the sharing of information, there are demands to be standards and proprieties to warrant data security, such that it does not fall into the wrong hands.

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Simulation

Interprofessional simulation is an indispensable aspect of the collaboration process in that it guarantees that there is effective skill transfer between the diverse groups in that it facilitates learning, where the more endowed workers can transfer skills to the less endowed. Furthermore, interprofessional simulation is also vital in that it facilitates the collaboration of the professionals in that it aids in communicating the modalities of communication and engagement (Gustin et al., 2020). Significantly, in the interprofessional collaboration, the simulation will be vital in practice as it allows for the replication of the clinical care without the pressure and the intricacy that is orchestrated by the real environment and thus permits the members of the interprofessional team to learn and thus augment their aptitude in handling such challenges in future, and thus results in better healthcare outcomes.

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Patient Centricity

The endeavor of the interprofessional teams needs to be centered around the benefits to the patients, including enhancing the level of patient safety and promoting the overall outcome of the patients after the treatment. The driving objective of the interprofessional team in the provision of healthcare includes interprofessional partnerships that unequivocally concentrate on certifying the utmost quality of care to the patients, including effective coordination of activities across the continuum. Interprofessional teams are driven by an unambiguous understanding of patient-centered care, perfect articulation of the patient-centricity behavior, choosing metrics that are actionable and measurable, competency in developing functional collaboration, teamwork, and partnerships, and the process that intends to reinforce the organizational culture that supports interprofessional practice and sustains that patient’s needs (Stollings et al., 2020).

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Here's how HIT can support the future of IPE/C:

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Here's how HIT can support the future of IPE/C:

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HIT platforms, such as electronic health records (EHRs) and telemedicine systems, are able to allow for communication and coordination among healthcare team members. Professionals from different disciplines can access patient information, share updates, and collaborate on treatment plans in real-time, regardless of their physical location.

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HIT systems can help reduce the duplication of tests, procedures, and interventions by ensuring that all healthcare team members are aware of each other's actions. This can lead to a more streamlined and efficient care process while minimizing the risk of errors.

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With the rise of telehealth and telemedicine, HIT can facilitate interprofessional remote consultations. Experts from various specialties can collaborate on patient cases without the need for physical presence, leading to quicker and more efficient diagnosis and treatment planning.

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HIT can create virtual simulations and training scenarios that involve professionals from different disciplines working together. This can help students and practitioners develop the skills needed for collaboration in a risk-free environment. Simulations can mimic complex cases, allowing interprofessional teams to practice their teamwork and communication skills.

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Artificial intelligence in virtual reality simulation for interprofessional communication training: Mixed method study

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Virtual reality simulations are shown to be an effective approach for interprofessional nurse-physician communication training. However, its scalabili...

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A patient-centric approach has been a buzzword in the healthcare industry for the last decade. Patients are becoming more active participants and want to contribute to their own care process while medical practitioners have to recognize and consider what is the most important and beneficial.
The patient-centric approach involves providing special medical services fashioned to cater to the individual values, needs, and preferences of a patient in addition to professional consultations and guidance of a health expert.

There is a paradigm shift in the healthcare system. It is gravitating away from the old model of doctors usually making medical treatments based only on tests and their personal experience with a patient.

Other than in the past, patients are now open to more information about their illness and viable options for treatment. With the latest advancements in healthcare and technology, patients have access to the information and tools that can enable them to make a choice and decide the method of medical treatment that suits their lifestyle and health conditions. In other words, a choice of clinical decision is based on how acceptable and responsive a patient might be to such medical treatment.

What Is Patient-Centricity?

Although it has become the industry's catchphrase, it's quite unlikely that all players are on the same page on the definition of patient-centricity. So prior to exploring the essence and key drivers of this approach, let's first cover what it implies.

As the name suggests, it means designing such a process of treatment, clinical trials, or other healthcare service delivery that is focused on the patient. While it's more about the mindset centered around listening to what the patient thinks and feels, tech tools and solutions directly help propel this approach and forge a positive healthcare environment.

The Importance of Patient-Centric Care

The patient-centric approach is overall approved by many medical experts as a very qualitative method with positive outcomes from both the medical and business side.

From the business perspective, patient-centric healthcare has been reported with engaging experiences and positive results leading to retention of patients and continuity of their health care.

The medical perspective is that patients respond better to treatments, show fewer symptoms, and also have a lower possibility of relapse or readmission to the hospital.
Advantages of patient-centric healthcare include:

Increased engagement between patients, healthcare providers, and other stakeholders makes patients better informed about their health conditions and treatment options, which leads to better care.

Participation, communication, and collaboration of healthcare experts with patients make the process of health decisions more timely and successful.

Improved health outcomes and increased patient satisfaction with the provided healthcare services.

Improved resource allocation and multilevel care planning.

Increased competitive advantage based on cost and quality of healthcare provision among hospitals.

Delivery of Patient-Centric Healthcare

The Role of Technology

The application of such technologies as wireless communications, video conferencing, streaming media, mobile solutions, AI, and IoT are frequently used today to directly or indirectly deliver medical care focused on the patients' demands.

Processed data is a principal factor for providing patient-centric healthcare and its engagement strategies, especially multilevel care planning. IT technologies allow medical organizations to collect and process large volumes of applicable data, which is essential and critical to the support of modern healthcare services.

The Role of Social Enterprises

Today's global market requires entrepreneurial thinking to solve various problems including those of patient-centricity. The consideration of the existing health and IT regulations, in this case, is impeccable.

IT professionals, medical experts, health insurance companies and health agencies who are up to date with medical privacy, data security, and other policies need to cooperate to make a patient-centric model affordable and efficient.

Patient-Centric Strategies

While focusing on patients, it's essential to build the right strategy for delivering medical services. There are several tactics to keep in mind that drive a positive patient experience, which is eventually something to center your efforts around.

Cost-Effectiveness

Now the cost of medical treatment affects patient experience more than ever. In the era of consumerism, healthcare providers need to shift their focus on using the tools and technologies that foster cost-effective care aligned with patient values.

Advanced Technology

As we've mentioned above, the role of technologies is vital for supporting the patient-centric approach. The application of advanced software tools helps address patient needs, keep them engaged, and fuel the business growth of healthcare providers.

Quality Service

All patients want to receive better, faster, and more accurate services. Thus, the quality of healthcare should be a focal point for medical organizations. The right combination of tools, technologies, and strategies offers robust opportunities to deliver excellent service.

Expanding the Healthcare Experience

With the combinations of IT technology and medical care, we are experiencing new solutions that serve the needs of healthcare. Adopting the right technologies facilitates the implementation of the patient-centric approach. Some outstanding outcomes have been already recorded in the following areas:

Virtual Care

The demand for virtual healthcare is continually growing. For patient-centric providers, it is extremely important to have all the necessary tools for supporting different types of interactions with patients in addition to in-person appointments.

Virtual care is aimed to deliver timely medical attention to patients via telemedicine consultations, regular check-ins during the treatment, remote health data monitoring, online treatment, and prescriptions adjustment. It simultaneously includes providing information and responding to the questions from patients.

Virtual care can be sufficient for minor illnesses. In general cases, it complements healthcare experience and helps provide care in a consistent manner for each patient.

Digital Consultations

Today, many patients and healthcare providers take advantage of telemedicine. It encompasses various communication channels to establish real-time interaction and provide long-distance patient care.

Live audio and video chats, instant messaging, mobile apps, and other telehealth solutions help diagnose patients remotely, provide medical advice and recommendations, address concerns and walk through instructions.

Remote Patient Monitoring

Remote patient monitoring or telemonitoring is another way to support the patient-centric approach in healthcare. It allows for remote patient health data collection and tracking with the help of wearable medical devices. RPM is a good choice for monitoring vitals after surgeons and observing medical conditions for outpatient care.

Learn more: Telemedicine - A Win-Win for Patients and Healthcare Providers

Mobile Health

In patient-centric healthcare, the use of mobile health plays a major role. It is highly preferable to the new generation because of its convenience of accessing healthcare in a few taps. As an engagement and communication tool, it provides health services, collects, manages and communicates health data.

mHealth promotes the participation of both healthcare consumers and providers in health education, remote consultations, disease surveillance, treatment alignment, drug reference, and so on.

Care Coordination

PMS or EHR

An effective practice management system for hospitals and clinics is a gateway to the patient-centric approach. Besides being engaging, it solves the problems of coordination and related activities. Basic functionality of PMS include:

Learn more: 8 Essentials of Efficient Practice Management System

On the other hand, the electronic health record system provides room for storing patient details including allergies, disease codes, treatment and lab reports. It enables sharing patient information with specialists of different medical practices.

Healthcare providers can take advantage of the complete digitalization of their services. This can be done by streamlining the workflows with a PMS system and integrating with an EHR solution to make it even more patient-centric.

Read how we Integrated Appointment Scheduling and PMS Software for a Dental Marketplace

Store-and-Forward Interactions

A good method for administering and coordinating medical data is asynchronous communication. Also known as store-and-forward, it is a facilitator for sharing medical information such as health history, medical images, scans, and reports between health professionals and even patients.

Store-and-forward allows data to be shared, acted upon, and be accessible to physicians in multiple locations. It employs the use of multichannel communications to relay data for applicable health decisions.

Emerging Technologies for Patient-Centric Approach Enhancement

Personal Medical Experience Using AI

The joy of patient-centric healthcare is a personal medical experience. With the availability of AI and family health records, detailed diagnostics and medical decisions can be more precise and specific for patients.

Prescribing drugs, advising healthy diets and treating allergies will be more effective. A patient can also be warned in advance of illnesses that are genetically inherited and advised on the best way to avoid them.

Another practical application of AI and ML is the use of deep structured learning for health decision-making. AI consultations allow for making diagnoses and providing detailed medical actions to a specific patient based on millions of examples of relevant cases.

Learn more: Applicable Uses of Artificial Intelligence in Healthcare

Blockchain

Unlocking the potential of blockchain technology can solve the most pressing challenges in the healthcare industry. A distributed ledger addresses the problems of compliance, interoperability, and data security and makes it a choice for enabling new patient-centric business models.
The use of blockchain will ensure:

The integrity of medical records

Consent data management

Trust between health stakeholders

Blockchain is a safe haven for medical data. A smart contract can be used to protect the privacy of a patient's medical information. Thus, focusing the healthcare ecosystem on patients empowered with data as the most valuable asset.

Learn more: Blockchain in Healthcare

Cloud Solutions

Cloud-based solutions are a standard in modern software systems. It enables interoperability among stakeholders and works well with remote work locations unifying all the branches in a healthcare system.

Hospitals and professional healthcare providers should consider platforms that allow for easy communication and access to health records in real-time. The use of cloud-based systems and communication platforms can enable fast and secure data collection, integration, and synchronization.

Data put together from clinical, financial, and operational departments should be used in developing new metrics for quality, patient satisfaction, and healthcare performance. The resulting data can be used to give medical advice and treatment plans to fit individuals based on the metrics.

IoT and Big Data

The Internet of Medical Things is a golden opportunity to shape medicine that supports the patient-centric strategy. From the enhanced quality of treatment and improved patient experience to reduced costs and elevated efficiency - IoT provides the immense potential to help healthcare professionals drive the industry forward.

Read more about the Internet of Things in Healthcare

The ecosystem of connected devices and tech solutions generates massive volumes of digital information, or Big Data, that can be leveraged to make better diagnoses, enhance treatment, and deliver more personalized services. Coupled with AI and data science technologies, IoT allows for analyzing PHI to create the most appropriate medical decision upon the patient's situation and even boost preventive care.

AR & VR Technology

Other technologies that drive innovation within a patient-centric environment are Augmented and Virtual Realities. We see that the number of use cases where AR & VR solutions build new opportunities for healthcare providers is growing steadily.

For example, these technologies can help patients ease the symptoms of mental disorders like depression or anxiety. On the other hand, doctors adopting AR & VR solutions can increase the accuracy of treatment and perform surgeries more efficiently.

Digital and Data Analytics Opportunities to Engage Patients

Nowadays, patients ask for more personalized approaches in healthcare and expect a better experience. Helping respond to these demands, digital tools and data analytics provide medical organizations with vast opportunities to address unmet patient needs.

Digital technologies enable patients to control their data, participate in decision-making, transform patient care, and rely on better clinical outcomes. In this regard, patients are interested in adopting tools to take an active role in their well-being.

For example, they commonly use various wearables, sensors, and mobile apps that promote a new level of connectivity between patients and healthcare providers. It allows both sides to prevent diseases and achieve desired treatment results.

To leverage digital and data analytics opportunities and support the patient-centric approach, medical organizations should focus on the key thoughts. Aim to:

Create a patient journey map to define touchpoints where patient experience can be improved with tech tools

Prepare to collect and process a vast amount of data that's generated along the way, for example, with the help of medical IoT solutions

Consider data ownership, inform patients about the benefits of sharing their information and be transparent about its usage

Challenges of Implementing a Patient-Centric Approach

Today, the transition to a patient-centric approach is more about changing the mindset and culture. Current healthcare still tends to operate in a provider-centric mode, and this is the biggest issue. The shift means new experiences for the entire organization, including healthcare professionals and administrative staff. Thus, everyone should be prepared, well-trained, and have proper expectations.

Moreover, the adoption of this approach often entails the adoption of new technologies. It means that the existing healthcare ecosystem and IT infrastructure should be ready to accommodate new built-in solutions in order to support an effective patient-centric strategy.

The Best Way to Patient-Centric Healthcare

Implementation of the patient-centric model is impossible without the use of technology. Therefore, healthcare providers must consider the most beneficial technology solutions that facilitate making data-driven decisions, providing consistent medical care, and taking into account individual factors of each patient.

Patients' participation and contribution combined with the right tools will lead to improving a patients' medical experience and indeed make patient-centric solutions the best adaptation for healthcare providers.

Velvetech is a reliable software vendor with vast expertise in custom software development and delivery of practical solutions for the healthcare industry. Reach out to us today for our consultations and services.

About the author

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Patient-Centric Healthcare: What Providers Must Know - Velvetech

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Discover patient-centric healthcare as a quality medical approach and explore the technologies involved in migrating patients to more participatory services.

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Practice management models and software are becoming more accessible and efficient than ever before. Thanks to the emergence of patient-centric healthcare, patients' voices are heard and recognized as a valuable health resource. Health organizations have found an operational model that fosters the quality of healthcare everybody deserves.

What Are Patient-Centric Healthcare and Its Benefits

The patient-centric approach has been prevalent in the healthcare industry for some time now. Technological innovations and software development are integral to this healthcare industry revolution. These technological developments support medical and administrative services that can dramatically ease and enhance healthcare processes, communications, and workflow.

Patient-centric healthcare raises patient satisfaction levels, which creates benefits for healthcare providers and practices.

Understanding Patient-Centric Healthcare

As a delivery service model, patient-centric healthcare emphasizes the patient's participation, preferences, values, and decisions in diagnosing, treating, and managing their health conditions.

It's a healthcare model that empowers patients to be responsible and active in their healthcare, whether they are healthy or have illnesses or diseases. A patient-centric approach promotes collaboration and trust between healthcare providers and their patients.

Our existing healthcare system is too dependent on hospital or clinical care with insufficient focus or effort put into proactive preventive care. Healthcare providers can educate patients and reinforce their confidence in participating in their health management. As a result, patients are more likely to comply, make healthier lifestyle choices and take their prescriptions as directed.

During the COVID-19 pandemic, for example, patients have expressed high satisfaction with their healthcare provider's ability to provide the care and guidance they need at the right time and wherever they are, thanks to a patient-centric technology, such as telemedicine . It enables patients to communicate with their providers and get the care they need regardless of their location.

This patient-centric messaging platform helps contain COVID-19 and streamline the testing process. These efforts minimize exposure and maximize healthcare services in times of crisis.

Promoting physician-guided at-home care is an effective way to improve healthcare quality and patient outcomes. Encouraging patient engagement with patient-centric care may be the key to unlocking a high-quality, comprehensive, and inexpensive care model.

Patient-centric care may also reduce the risk of patients jumping from one doctor to another or hospital shopping. When patients have a strong relationship with their healthcare provider, they are more likely to keep appointments, follow advice, and stay healthier overall. It reduces the strain on the healthcare system as well as the out-of-pocket costs and inconvenience for patients.

In other words, the fewer times a patient makes repeat visits to a hospital or a doctor, the more effective and efficient our health care system becomes.

A patient-centered approach could develop a more collaborative healthcare environment for providers, patients, families, and staff.

Common Elements and Benefits of Patient-Centric Healthcare

The following elements and benefits demonstrate what patient-centric healthcare is and differentiates it from other operating care models.

The Patient Is the Main Player

Instead of focusing on the efforts and actions of health professionals, the patient-centric approach elevates the role and the participation of individuals in healthcare. Providers educate and empower patients, helping them become main actors, not just passive healthcare receivers.

Comprehensive Care Plan

A patient-centered approach incorporates comprehensive, multidisciplinary wellness programs that consider all aspects of a patient's overall health. Preventive healthcare - taking steps to address unhealthy lifestyle choices and other root causes of potential health problems - can reduce a patient's risk of needing advanced care.

Responsive Treatment and Recovery Program

A common patient-centric element of healthcare involves incorporating and respecting patients' values, cultures, and decisions in managing health conditions. It's a more holistic approach to the treatment and recovery of patients. As patients are more likely to comply with treatment, the rate of recovery increases, and readmissions decline. Patients' cooperation and compliance increase the effectiveness of treatment plans.

Integrated Mental and Social Needs Assessment

Patient-centric health care includes equal and timely evaluation of a patient's mental and social needs. Healthcare providers can direct patients toward social and mental health resources.

Cost-Efficient and Affordable Care

Business-wise, a patient-centric approach optimizes resources and lowers operational costs. In the same way, patients may save much money from going back and forth for readmissions or consultations.

Consistency and Continuity

Satisfied patients are more likely to remain with the same doctor or hospital. They are less likely to jump from one doctor or hospital to another, looking for a better care experience.

Overall, the patient-centric approach provides long-lasting benefits to the patients and their families, healthcare providers, and the system.

Amplifying Patient-Centric Healthcare Benefits through Technology

Technology innovations and software development have been helping resolve challenges that practices and healthcare providers have faced for some time.

Healthcare technologies offer convenience and efficiencies to medical practices, providing resolutions to their customer's pain points.

One solution to the fragmented and cumbersome healthcare communications situation is a secure, 2-way messaging platform.

Software like this can bring about significant changes in medical offices and how patients interact with healthcare providers. It makes appointments, confirmations, and rescheduling easy to handle.

Medical offices that use the proper communications and practice management software have experienced dramatic changes. They have fewer phone calls and patient no-shows, making a significant difference in their bottom line.

Front desk staff have more time to streamline their office management function and administrative responsibilities.

Patient-centric healthcare software helps practices reduce patient no-shows, quickly fill in vacated slots, and reschedule appointments without the hassle of making dozens of phone calls. Therefore, front office teams increase productivity, making their workdays more manageable while supporting business growth and increasing revenue.

The patient-centric approach encourages telemedicine, which has made patients' access to healthcare more convenient. As the COVID-19 pandemic forced people to distance themselves and avoid public places socially, more people are getting used to and looking forward to doing almost everything remotely from the comfort of their homes.

Patients can now use telehealth services to consult with health professionals about weight management, mental health, chronic disease management, and physical therapy.

Curogram is a leading provider of patient-centric communications and practice management software that streamlines and improves health communications.

A HIPAA-compliant organization like Curogram proves how a patient-centric approach in health messaging can dramatically improve office operations and patient satisfaction for healthcare businesses of all sizes.

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Learn about a patient-centric approach and its benefits, as well as why it could be the key to an improved and high-quality healthcare system.

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Simulation-based training (SBT) offers an effective approach to cultivating the knowledge, skills, and abilities (KSAs) required for dependable teamwork. It gathers interdisciplinary learners in a safe setting to practice handling high-risk, low-frequency situations without any risk to a patient.

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Introduction

Today, more than ever, effective inter-professional team communication, collaboration, and coordination in the care of patients with increasingly more complex disorders in the fast-paced, dynamic, evolving healthcare environment is paramount. Inter-professional teamwork is now a worldwide-recognized core inter-professional competency that all healthcare providers should acquire. Simulation-based training (SBT) is an excellent format for fostering the knowledge, skills, and abilities (KSAs) needed for highly reliable team interaction by bringing together inter-professional learners in a nonthreatening environment in which they can practice addressing high risk, low-frequency situations without any risk to a patient.[1] By doing so, these inter-professional teams can internalize these KSAs to make them automatic in the actual clinical environment.

Although the high technology simulators and complex scenarios of SBT tend to focus more attention on its technology, methodology, and curricular components, the ultimate utility of SBT as an educational format relies on the effectiveness of the debriefing rendered during a session.[2] Some authors consider it the most crucial element of SBT.[3] It is within the debriefing that SBT participants identify their learning gaps and develop strategies for improving them, usually under the guidance of the educator/facilitator leading the SBT session. Such guidance can be particularly challenging in the setting of an inter-professional team in which, by definition, learners come from different backgrounds and perspectives.

Debriefing has played an integral role in the medical simulation since its implementation, and its advantages are well-founded in educational theory. Debriefing strategies are based upon learner types, scenario objectives, and preference of the educator leading the debrief. Irrespective of technique, debriefing leads to meaningful learning opportunities via experiential reflection. Reflective practice outlines how it is not the experience alone but the deliberate reflection on experience that leads to active learning. When appropriately applied to clinical practice and educationally productive debriefing following medical simulation can inevitably improve patient safety.[4]

Medical debriefing is based upon the military and aviation fields, which have team building, crisis management, and high-risk situations in common. Anesthesiology debriefing specifically has its origins within aviation crew resource management (CRM). Military debriefing was developed by Colonel S.L.A Marshall, the chief United States Army historian in World War II, Korea, and Vietnam.[2] He conducted debriefings of the entire military unit immediately following an event. Jeffrey Mitchell, a psychologist, developed the Critical Incident Stress Debriefing (CISD) for civilians, also commonly viewed as the framework for medical debriefing today.[5] CISD is contingent upon its seven phases, including introduction, information discovery, detection of individuals' thought processes, reaction, symptom description, teaching, and reentry. After repeated plane accidents in the 1960s and 1970s, pilot interviews revealed a lack of adequate training in leadership, decision making, judgment, communication, and crew coordination.[6] When CRM training resulted in improved outcomes for the aviation industry, Gaba et al. developed anesthesia CRM to improve safety in the operating room.[7]

Function

Structurally, a debriefing has seven elements. The facilitator guides and fosters learning. The participants, in an inter-professional setting, learn with, from, and about each other. The experience element in SBT includes the scenario and the after-action review. The impact of the experience focuses on participants' experiences, comparing their experiences to a standard. The recollection element has the participants recalling and self-assessing their actions. Mechanisms for reporting events include video playback, verbal discussion, or simulator feedback. Finally, the last element, timing, relates to the length of the debrief and the interval between it and the actual SBT. Although several theoretical frameworks exist related to the interaction between SBT and debriefing, Kolb's experiential learning model is a useful schema.[11] For an inter-professional team involved in an SBT activity, it begins with the participants' concrete experimentation in the form or the simulated scenario. The debriefing then leads the participants through the process of reflective observation and abstract conceptualization, promoting active experimentation and behavior change.

Debriefing refers to facilitator-guided reflection in experiential learning to help identify and bridge gaps in participants' knowledge and skill acquisition. Successful debriefing involves the active participation of learners as opposed to passive receipt of feedback. Performance reviews should be predicated on learning and improvement compared to a specific standard and open discussion of events during the simulation.[12] Facilitator-guided post-event debriefing is most commonly utilized to ensure the achievement of learning objectives and that conversation is organized and inclusive of all participants.[13] One theory suggests it is helpful for facilitators to position themselves not as experts but as co-learners to facilitate educational goals, as indicated by Fanning and Gaba.[14] Alternatively, the facilitator can function as a subject matter expert and provide useful guidance based on their training, experience, and expertise.[15]

Scripted or structured debriefing during clinical care and simulation-based education may aid facilitators. The EXPRESS (Examining Pediatric Resuscitation Education using Simulation and Scripting) trial aimed to standardize Pediatric Advanced Life support (PALS) course debriefings for novice instructors. Learning and performance outcomes were measured based on a scripted debriefing tool.[16] Novice instructors that utilized the debriefing script were more effective at expanding learners' knowledge acquisition and procedural skills than those who did not use a script. Following the EXPRESS study, the authors collaborated with the American Heart Association (AHA) to develop a novel debriefing tool for both the PALS and the Advanced Cardiac Life Support (ACLS) course.[17] The AHA debriefing tool utilized the "gather, analyze and summarize (GAS)" debriefing model to codify PALS and ACLS scenarios. This tool was ultimately incorporated into the 2011 PALS and ACLS instructor materials to facilitate learning.

The advocacy inquiry technique is commonly utilized by educators to unearth a shared mental model during simulation scenarios. Educators aim to elucidate a learner's rationale for action by stating a concrete observation before inquiring about the participant's perspective. A robust and interactive discussion results when facilitators elicit alternatives to clinical decisions, risks, and benefits of interventions, varying management options, or other pertinent performance implications.[18] Focused facilitation methods allow learners to explore mental models to enable comprehensive discussions and potentially improve patient safety.

Issues of Concern

Organizational-, participant-, and debriefer-specific barriers can adversely influence inter-professional team SBT debriefings. At the organizational level, both a lack of institutional support for SBT and the absence of an appropriate learning structure for it can undermine SBT activities. Manifestations may include off-limit topics of discussion or the absence of a safe learning environment. Identifying and recruiting a champion within the leadership group can address these difficult issues. Participant-specific barriers can arise due to learner-specific characteristics or situation-specific issues that lead to difficulties with participants during the debriefing process. Learner-specific examples include the shy participant, the indifferent participant, the dominating participant with poor insight, and the dominating participant showing off. Situation-specific examples include participants who react emotionally or defensively because of the scenario.[19] Strategies to address participant-specific barriers include both non-verbal and verbal communicative techniques. Important non-verbal methods involve remaining silent to invite participant input, establishing eye contact, and using body language to project an inviting attitude. Communicative strategies include a variety of techniques such as normalization, validation, generalization, paraphrasing, broadening, previewing, and naming the dynamic.[19]

Debriefer-specific barriers to effective debriefing in inter-professional team SBT can arise due to a lack of knowledge of the facilitator related to debriefing technique, human factors, or teamwork dynamics. Additionally, they can result from the inherent cognitive biases, heuristics, and errors of attribution of the facilitators themselves. Furthermore, the debriefer may fail to create a learning environment with the necessary psychological safety needed to allow participants to contribute. Finally, the facilitator may end up focusing on "who is right" instead of "what is right."[20]

Employing the Debriefing Duties can help a facilitator in avoiding debriefer-specific barriers. These duties are threefold: Make it Safe, Make it Stick, Make it Last. In making it safe, the facilitator engages the learner, creates an inviting learning environment, and establishes psychological safety. In making it stick, the debriefer guides the participants to identify their performance gaps and develop solutions to them. Finally, in making it last, the facilitator challenges each participant to identify at least one take-home learning point on which to work in the clinical environment.

Curriculum Development

The two main types of facilitator-guided post-event debriefing models include a 3-phase structure and a multi-phase structure. Each debriefing method consists of an analysis of events and a summary or application phase, in which learning is reinforced and teaching objectives are reviewed. The glaring difference between these two conversational structures is when dealing with learners' emotional responses or reactions. Reaction time allows participants to engage in exploration in a less emotionally charged environment.[24]

The obstacles that may hinder a successful debriefing session include the prohibitively high cost of simulation educator training, limited educator exposure in debriefing experience or education, and the lack of experienced simulation facilitators to provide mentoring to junior faculty. Inadequate or incomplete debriefing can take away from medical knowledge and procedural skill acquisition, and learner attitudes. Novice simulation educators are challenged in creating a structured debriefing session that encourages meaningful discussions, promotes critical reflection, codifies simulation events, and provides open and honest performance feedback to learners.

Clinical Clerkships

There are various ways to structure an effective debriefing session that allows learners to uncover their frame of reference and reorganize their educational agenda. The Center for Medical Simulation in Cambridge, Massachusetts, has lead simulation educator courses called "Debriefing with Good Judgement."[25] The approach is characterized by four basic principles, including (1) outlining learning objectives before the simulation session, (2) setting clear cut expectations for the simulation session, (3) approaching participants with feedback and curiosity, and (4) organizing the debriefing session into the reaction, analysis and summary phases utilizing the advocacy inquiry technique.

Three-Phase Debriefing Structures

The GAS model was developed in 2009 by the Winter Institute for Simulation, Education, and Research in Pittsburgh in conjunction with the AHA.[28] The first, or gather phase, encourages the team to establish a shared mental model during the summary of simulation events. The analysis phase focuses on learner-centered reflection during the unfolding of the simulation scenario. Learners are asked pointed questions to promote rumination and reflection on thought processes. The final or summary phase ensures that learning objectives have been reviewed and teaching points are solidified. The AHA has adopted this method for the PALS course. Yet another 3 phase debriefing method, the "diamond debriefing" method, omits a reaction or defusing phase.[29] This structure utilizes a description, analysis, and application phase. The application phase inquires how learners will apply lessons learned during the simulation debriefing to their clinical practice.

Multi-Phase Debriefing Structures

Another 7-phase model known as healthcare simulation after-action review (AAR) is based upon the US Army's AAR construct.[15] The phases can be remembered using the acronym DEBRIEF. This methodology is unique in that it emphasizes the review of teaching objectives, relies on performance benchmarks, and urges the simulation facilitator to reveal the expected outcome of the scenario. As a shared mental model is created, the learners' performance is objectively compared to a known standard or performance benchmark.

Table 1. Debriefing Structures: 3 Phase Models

Table 2. Multiphase Debriefing Structures

Procedural Skills Assessment

According to Sawyer et al., seven elements are considered essential to a successful debrief, including psychological safety, establishing clear cut boundaries or debriefing rules, commencing the simulation session with a "basic assumption," creating a shared mental model, addressing teaching objectives, using open-ended questions, and utilizing silence appropriately.[32] Psychological safety is essential to optimize learning during the simulation. Psychological safety is defined as the ability to ''behave or perform without fear of negative consequences to self-image, social standing, or career trajectory."[33] For this requirement, learners must express their opinions without fear of personal harm or rejection. If the team is not performing up to expected standards, the facilitator should dissect the frame of reference that leads to the actions observed. Learners should be active participants in a confidential debrief discussion, and the focus is on performance improvement as opposed to individual criticism. A shared mental model allows both the facilitator and learners to have a mutual understanding of events. Typically, this is accomplished by having team members review the events of each scenario with facilitator-guided input.

Medical Decision Making and Leadership Development

First described in business and organizational behavior literature, the advocacy inquiry technique allows the facilitator to explain their observation of intervention and then enquire about the learners' frame of mind concerning this action. The guided team self-correction method enables simulation participants to correct their own actions.[36] Learners compare themselves to a predefined benchmark of teamwork skills and can analyze what they executed well and poorly. The facilitator serves to guide the conversation through leading questions and allows the team to analyze and self-correct their actions, before sharing his/her insights.

Continuing Education

As stated previously, the debriefing process must create a psychologically safe environment that allows active engagement from learners despite potential threats to their professional and social identity. Rudolph et al. describe four activities that foster such an environment.[39] Firstly, the facilitator should introduce him or herself along with credentials and previous experience while all learners do the same. Faculty can also share a personal goal, which models an environment of frank and candid communication. At the beginning of each simulation session, learning objectives, simulator properties, and formative or summative assessment of performance should be clearly defined for learners. Effective simulation is dependent upon the learners' suspension of disbelief. The instructor should acknowledge the simulation environment and mannequin's limitations while seeking a commitment from learners to perform as though they were in a real clinical situation. Simulation educators should also convey curiosity and concern for the learner's perspective, which can help foster a psychologically safe learning environment.[39] As learners progress from formative to summative evaluations and competency-based education has become mandatory, debriefing is an effective tool in assisting learners through competency levels.[40] Debriefing also serves as a valuable device to evaluate the Core Entrustable Professional Activities and ACGME resident milestones.[41]

There are several well-established methods for assessing the debriefer, including the Objective Structured Assessment of Debriefing (OSAD) and the Debriefing Assessment for Simulation in Healthcare (DASH). Personal and institutional preferences are largely responsible for the chosen method. Developed by the Imperial College London, OSAD consists of a 1-page rubric for simulation and clinical debriefings for both novice and advanced educators.[42] Eight components, including the approach of the debriefer, the establishment of a learning environment, learner engagement, reaction, reflection, analysis of performance, performance gaps, and future application to clinical practice, are rated based on poor, average, or good practice, leading to a score from 1 to 5 points. Harvard's Center for Medical Simulation developed DASH.[43] This debriefing inventory rates various elements, including establishment and maintenance of an engaging learning environment, debriefing organization and structure, and identification and exploration of performance gaps rated on a scale from 1 to 7.

Clinical Significance

Reducing the time between performance and debriefing as much as possible

Identifying and addressing performance and perception gaps

Creating a safe environment to enhance learner comfort and participation

Learner engagement in self-reflection

Instructors should espouse strong facilitation and debriefing skills

Debriefing should not be comprehensive and should focus on only a few learning objectives or educational goals that are manageable

Structured debriefing should preclude broad, open-ended questions, such as "what happened" and utilize questions such as "what was your thought process when you first encountered the patient?"

Faculty should engage in active listening and pay particular attention to nonverbal cues from learners

The "conscious competence" learning model can aid in guiding the debriefing process.[47] Learners with a perception gap are at the start of the "unconscious incompetence" stage of learning. The ability to recognize their performance deficiency serves as the impetus for a perception gap. The second stage in this model is "conscious incompetence," whereby learners are conscious of the discrepancy in their thinking process or skills. A simulation session can have the simple goal of enlightening the learner to the presence of a perception gap and closing the gap with the aid of the facilitator. The conscious incompetence phase is the perfect time to introduce cognitive aids, short didactics with management strategies, or useful algorithms to enhance medical knowledge and skills training. This aids the learner in transitioning to the "conscious competence" phase. At this phase, the learner has sufficient prerequisite knowledge and ability but must focus on performing well.[48]

Enhancing Healthcare Team Outcomes

To optimize team outcomes related to debriefing inter-professional teams in SBT, the learning objectives, curriculum, and scenarios should focus on team-based competencies in lieu of task-based ones. In this manner, the participants will avoid the burden of learning both technical and non-technical skills. Other essential strategies include involving the entire team in the debriefing and meeting their multiple needs, focusing on team-based concepts rather than individual-based topics, and employing reliable, valid assessment tools to measure the teamwork during the SBT to allow for objective use to guide the debriefing. By focusing on team communication, cooperation, and coordination during the debriefing of inter-professional team SBT, the likelihood of their transfer to the actual clinical environment with concomitant improvement of patient care increases.[52]

The most commonly used and studied method for simulation debriefing, facilitator-guided post-event debriefing, has been shown to improve individual and team performance in many contexts.[53] With effective debriefing, learners can improve upon technical skills, achieve mastery learning, and improve adherence to resuscitation guidelines.[22] There is some evidence to suggest that post-event debriefing is preferred to within-event debriefing by learners due to improved skill retention.[54] A debriefing session's success depends on the expertise of the facilitator and the group of learners relative to the simulation scenario and teaching objectives.[55] Novice learners require more directive feedback from facilitators than those with more experience. Facilitators can create a memorable debriefing experience by enumerating educational objectives before the simulation activity, matching simulation content to learner experience level, and using appropriate techniques such as GAS or the advocacy inquiry method.

There is a form of debriefing with several clinical experiences, including intraoperative arrest or patient death. These can range from discussing a medical error to a complex interdisciplinary trauma response in a formal or informal setting. Structured debriefings are most commonly found in the resuscitation literature.[56] Debriefing allows the formative evaluation of a resident or medical students' clinical performance. In daily practice, the skills for simulation debriefing can be extrapolated to provide feedback to learners in the operating room or intensive care unit setting. Veloski et al. found that prolonged and persistent feedback from faculty had a profound impact on learners' clinical performance.[57] In an environment where all medical personnel has the responsibility to teach throughout their careers, debriefing skills developed during simulation can have an essential impact in the clinical arena. Aiding healthcare practitioners in developing the habitual practice of eliciting and delivering feedback effectively can help in contributions to patient safety.

Because there is no formalized or structured curriculum for the development of debriefing techniques, simulation educators should rely on the principles of learning theory to guide their approach. Rudolph et al. stress the need to alter pre-existing cognitive frames to construct new understanding and practice regimens for learners.[57] Participants should be encouraged to increase their cognitive capacity for learning, and facilitators should provide ample opportunities for the practice of clinical skills while providing constructive feedback. The medical knowledge and clinical skills gained during simulation would seamlessly transfer to clinical practice and patient care. This is more likely if facilitators integrate learning into larger frameworks and if participants have a foundational understanding of the underlying principles being taught. Most importantly, the nuances of successful debriefing require the development of trust between the facilitator and learner, as the emotional and cognitive dimensions of learning are intimately intertwined. In this way, a successful learning environment is attuned to the learners' emotional state and motivations.[58]

References

Disclosure: Irim Salik declares no relevant financial relationships with ineligible companies.

Disclosure: John Paige declares no relevant financial relationships with ineligible companies.

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Debriefing the Interprofessional Team in Medical Simulation

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Today, more than ever, effective inter-professional team communication, collaboration, and coordination in the care of patients with increasingly more complex disorders in the fast-paced, dynamic, evolving healthcare environment is paramount. Inter-professional teamwork is now a worldwide-recognized core inter-professional competency that all healthcare providers should acquire.

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Patient centered, interprofessional (IP) teams have proven to be a successful approach to healthcare delivery, enhancing effectives, as well as both patient and staff satisfaction. Therefore, the adoption of team-based care is becoming more prevalent across various healthcare environments. This growing trend underscores a heightened demand for interprofessional education within healthcare training. Simulation is an interactive education approach suitable for facilitating interprofessional (IP) education. Simulation-enhanced interprofessional education refers to scenarios where participants and facilitators from multiple professions partake in simulated healthcare experience, aiming to accomplish interconnected objectives and outcomes.

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Introduction

Patient-centered, interprofessional (IP) teams are an effective method of delivering healthcare that has improved efficiency, patient satisfaction, and staff satisfaction. As a result, team-base care is on the rise in many healthcare settings.[1] With this rise, there is now an increased need for interprofessional education in healthcare training. Some healthcare training programs require the use of IP education to meet accreditation standards. Implementation of IP educational experiences early in training improves team communication and teamwork.[2][3][4] Poor communication is a leading cause of medical errors, and training healthcare professionals early to work collaboratively in a team environment must be a cornerstone of their training.[5]Early introduction to the roles and responsibilities of other professions has the potential to improve the utilization of their specific expertise and, subsequently, to improve patient outcomes.[2]

Simulation is an active learning strategy that can be used for conducting IP education.[6] Simulation-enhanced interprofessional education (Sim-IPE) is "when participants and facilitators from two or more professions are engaged in a simulated health care experience to achieve shared or linked objectives and outcomes." [7] Sim-IPE allows learners to interact in a shared experience to achieve shared learning outcomes or goals. Also, it can provide insight into the roles and responsibilities of the various disciplines within healthcare.

The purpose of this review is to provide insight into the necessary components of Sim-IPE curricular development, identify and overcome potential barriers to successful implementation, and improve collaborative practice.

Issues of Concern

There are many obstacles associated with implementing robust IP simulation. However, the value of Sim-IPE in aiding learners to achieve team competencies mandates the identification of creative ways to address these barriers. Educators need to ensure learners are included in a meaningful way throughout the simulation (pre-brief, scenario, and debrief). Table 2 provides recommendations to implement a successful IP simulation.

Table 2. Suggestions to Overcome Barriers to Implementation

1. Obtain Institutional Support

Identify champions and stakeholders at multiple levels

Reduce costs by enhancing patient care and decreasing burnout[8]

Obtain protected faculty time as it is crucial for the sustainability of Sim-IPE[9]

2. Train and develop faculty on the implementation of Sim-IPE[10]

Include formal training courses, observations, mentoring, and feedback

Create a united philosophy and adhere to best practices in facilitation

Train debriefers to encourage reflection and generate meaningful conversation[11]

3. Promote collaboration by developing interprofessional relationships

Maintain communication with regular meetings

Identify a champion or liaison from every participating profession to serve on the design team

Communicate schedule changes early and be flexible with classes and clinical rotations

4. Structure the implementation of the simulation

Identify a date for the simulation early in the planning. Flexibility and negotiation are paramount.

Pilot test the simulation with all professions involved to refine details and timing

Utilize a structured pre-brief to establish psychological safety and orient learners to the logistics of participation in the sim

Provide a structured debrief to encourage reflection and explore frames[12]

Obtain feedback from facilitators for continued program improvement

5. Include challenging communication and teamwork scenarios[2]

Develop learners' skills to communicate within authority gradients effectively

Utilize the IPEC competencies as a framework to develop respect for the expertise of other professions[4][1][4]

Reinforce values and ethics related to interprofessional practice

Curriculum Development

Simulation programs differ concerning resources, mission, and needs. However, there is a common set of core components needed in curricular development for the successful implementation of simulation.[13] The essential components are provided (Table 1) to ensure that learners have a safe, educational experience to equip them better to provide efficient and effective patient care.

Table 1. Essentials Elements of Curricular Design[14]

1. Perform a needs assessment and integrate interprofessional learning outcomes

Incorporate learning models of each health care profession involved

Gather data from all professions about practice or accreditation standards and performance gaps.

Create mutual learning objectives, involving all professions, that are measurable and achievable

Include one objective linked to teamwork[1]

2. Create appropriate interprofessional teams by aligning the level of the learners

Provide appropriate balance as the learners interact

Enhance communication and role clarity between each group

Align the objectives with the content to which all learners have been exposed

3. Integrate team concepts into simulation scenarios

Utilize evidence-based teamwork tools to provide a framework[15]

Map each Sim-IPE activity to an IPEC competency.)[4][1]

Create scenarios where teamwork concepts are integral to successful patient care

4. Develop Sim-IPE as a formative assessment to reinforce a collegial environment[16]

Avoid Sim-IPE as a high stakes summative assessment; this helps promote a safe learning environment.

Focus on clinical and communication objectives instead of completing extensive checklists of summative assessments

Clinical Significance

The IOM report published in 2015 discusses the importance of interprofessional teamwork for providing efficient and productive healthcare to patients.[4] As mentioned previously, an early introduction to the role and responsibilities of other professions is an important way that we can encourage and support collaborative practice for providers in future practice.

The 2015 report further describes a vision of "informal education" that helps form a collaborative practice identity early on in the education continuum. Therefore, it is vital that faculty model working in interprofessional teams throughout the curriculum and especially in Sim-IPE design and implementation. This demonstration, in and of itself, is a learning opportunity for the students as part of a positive hidden curriculum. It is crucial for faculty to be mindful of this during their interactions with other members of the planning committee. Additionally, debriefing of the faculty after the event ensures continued collaboration.[4]

Another benefit of Sim-IPE is that faculty gain insight into students' ability to apply course material. Examinations provide limited information about the medical knowledge and critical thinking, even if they are written as higher-order questions. Simulation provides students with the opportunity to apply knowledge in a time-sensitive matter, convey urgency in a professional setting, communicate effectively, seek input from and expertise of others, distribute workload, and function in a team. Faculty members can use Sim-IPE as an assessment for these vital patient care skills.

Enhancing Healthcare Team Outcomes

By incorporating Sim-IPE as an integral part of formal education, students learn the fundamental teamwork and communication principles that help transition them to functioning effectively on interprofessional teams once they graduate and are in the clinical practice setting. Likewise, Sim-IPE should be used in continuing education and designed intentionally to align with interprofessional collaborative practice competencies.[1] Prioritizing Sim-IPE across the educational continuum, including clinical practice, provides the opportunity to examine its impact on collaborative behavior and patient outcomes.[4]

References

1.

2.

3.

4.

Committee on Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes; Board on Global Health; Institute of Medicine. Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes. National Academies Press (US); Washington (DC): Dec 15, 2015. [ PubMed: 26803876 ]

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Boet S, Bould MD, Layat Burn C, Reeves S. Twelve tips for a successful interprofessional team-based high-fidelity simulation education session. Med Teach. 2014 Oct;36(10):853-7. [ PMC free article: PMC4245993 ] [ PubMed: 25023765 ]

15.

16.

Disclosure: Neena Xavier declares no relevant financial relationships with ineligible companies.

Disclosure: Michelle Brown declares no relevant financial relationships with ineligible companies.

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Interprofessional Education in a Simulation Setting

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Patient-centered, interprofessional (IP) teams are an effective method of delivering healthcare that has improved efficiency, patient satisfaction, and staff satisfaction. As a result, team-base care is on the rise in many healthcare settings.[1] With this rise, there is now an increased need for interprofessional education in healthcare training.

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Interprofessional Education Is At The Heart Of Simulation-Based Training For USF Health CAMLS

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Simulation plays an important role in education as it allows healthcare professionals safe practicing of skills and teamwork under direct supervision.

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Neonatal nursing is offered by nurses with expertise in the care of premature and critically ill newborns with congenital and/or acquired injuries and diseases, as well as their caregivers, siblings, and other family members. Neonatal nursing care ranges from minimally supportive to highly complex intensive care in the neonatal period, defined as the first month of life. However, many neonatal intensive care units (NICU) take care of infants beyond this age.

When newborn infants need resuscitation, neonatal nurses participate in the interdisciplinary effort. Such situations are relatively infrequent and often unanticipated. It is therefore essential that each healthcare professionals is fully aware of their role in the team and what the role requires (Garvey and Dempsey, 2020).

Stabilization and resuscitation of the newborn requires teamwork and communication skills under an intense time pressure (Yamada et al., 2019). Involved healthcare professionals need knowledge and abilities to manage both technical and non-technical skills needed for safe and effective practice (Finn et al., 2015).

The neonatal resuscitation guidelines represent a step-by-step approach that describes evidence- and consensus-based practice. Each step is important, as suboptimal stabilization and resuscitation may cause the infant to experience prolonged hypoxia and bradycardia (Morley, 2018). Providing effective positive pressure ventilation (PPV) is the cornerstone of neonatal resuscitation (Garvey and Dempsey, 2020).

In Norway, the Norwegian Resuscitation Council's guidelines for resuscitation of newborns apply (Norsk Resuscitasjonsråd, 2015), complying with international guidelines (Perlman et al., 2015; Wyllie et al., 2015). Healthcare professionals who resuscitate infants at birth or at any time during the initial hospitalization should follow these guidelines (Wyckoff et al., 2015).

Unfortunately, errors and deviations from the resuscitation guidelines range from 15.9% to 54.5%, and in over 50% of resuscitations PPV is interrupted (Mccarthy et al., 2013; Yamada and Halamek, 2015; Skare et al., 2015). Poor communication is strongly correlated with non-compliance with the guidelines (Sawyer et al., 2013; Carbine et al., 2000).

Healthcare professionals resuscitating infants should be trained in resuscitation skills, which include: basic measures to maintain open airways, bag-mask ventilation, and chest compression as well as teamwork and communication to ensure the safety of the newborn infants (Wyllie et al., 2015; Garvey and Dempsey, 2020).

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From simulation room to clinical practice: Postgraduate neonatal nursing students' transfer of learning from in-situ resuscitation simulation with interprofessional team to clinical practice

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The purpose of this study was to investigate how postgraduate neonatal nursing students transfer learning from in-situ resuscitation simulation with i...

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Virtual simulations facilitate engagement and collaborative learning opportunites for students in health-related fields.

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Highlights

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IVRS provides an immersive learning experience for health profession students.

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Experiences of students participating in IVRS center on enhanced cooperation and communication across their disciplines.

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Students gained valuable insight into the roles of different health professionals.

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Students believed that this experience would benefit their role as a health care team member.

Abstract

Background

Contemporary healthcare systems are in dire need of teamwork and interprofessional collaboration, however, existing curricula of health education programs offer few opportunities to build these capabilities. Virtual simulations enable interaction and cooperative learning for students pursuing health majors.

Objective

To explore the effectiveness of immersive virtual reality simulation (IVRS) in interprofessional education (IPE) and the experience of students from various disciplines in a virtual clinical environment.

Design, data sources and methods

A scoping review was conducted. Literature was systematically searched from CINAHL, EMBASE, ERIC, MEDLINE/PubMed, ProQuest, PsycINFO, Scopus, Science Direct, Cochrane Library and Open Grey databases. Among 2352 records, 12 research articles were found and analyzed.

Results

The experiences of students participating in IVRS centered on enhanced cooperation and communication across their disciplines. They obtained a more accurate picture of the patient and developed an interdisciplinary care plan. After the IPE session, they had greater appreciation of the importance of a team approach and shared learning. Students acknowledged the usability of virtual worlds (VWs) and appreciated the immersive learning experience that was offered. They gained valuable insight into mutual roles and believed that this experience would benefit their role as a health care team member.

Conclusions

This study supports the usability of VWs for IPE. As a new teaching modality, the IVRS experience effectively promotes interprofessional collaboration and communication. Future advances in the use of these technologies are expected to revolutionize health science education.

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The integration of immersive virtual reality simulation in interprofessional education: A scoping review

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Contemporary healthcare systems are in dire need of teamwork and interprofessional collaboration, however, existing curricula of health education prog...

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The Summer 2019 issue of MCW Magazine features a cover story on interprofessionalism and how it influences learning, care and collaboration among students, healthcare providers and scientists. This first installment in a two-part series focuses on interprofessionalism in education and research. (Source for all infographics: Association of American Medical Colleges.)
Our ever-changing healthcare system is marked by the increasingly complex health needs of patients - and requires innovative and efficient models of patient care. These models, in turn, require key competencies - such as effective communication, teamwork and interprofessional collaboration among healthcare professionals. An effective interprofessional collaboration helps ensure high-quality patient care and is having a positive impact on team members who work together daily.

Individuals with differing perspectives in healthcare offer unique ideas and talents to help improve patient care. By promoting a constant exchange of expertise, interprofessionalism helps to break down barriers among everyone involved in patient care - resulting in better learning and the best possible health outcomes. In both clinical practice and education, interprofessionalism encourages a focus on teamwork - based not on a specialty or hierarchy, but rather on effectiveness and outcomes.

In today's healthcare workplaces, interprofessional patient care isn't the exception - it's the new norm. Whether practicing in a hospital, clinic or primary care office, medical professionals work side by side with a multitude of other healthcare disciplines, including nurses at different levels, certified medical assistants, dietitians, nutritionists, pharmacists, physician assistants, social workers, mental health workers, health navigators, health coaches, community health workers, exercise physiologists and quality improvement and informatics specialists. This means that students must be prepared to work on multidisciplinary teams from day one.

To that end, an important component of interprofessionalism is interprofessional education (IPE) - a model in which individuals from two or more professions in healthcare learn together during all or part of their professional and postgraduate training with the goal of cultivating collaborative practice. This form of education is particularly effective in subspecialties, in which the need for interprofessional collaboration and learning is most acute. IPE helps develop and promote interprofessional thinking and acting; promotes beneficial information and knowledge exchange and mutual understanding; and ensures the acquisition of shared knowledge.

In 2007, the Association of American Medical Colleges (AAMC) released its strategic priorities, clearly stating that IPE and interprofessional practice were key areas of focus. Shortly thereafter, many medical schools began to actively incorporate some form of IPE into their curricula to prepare students for a future of healthcare in a patient-centered, team-oriented system. IPE focuses on values and ethics; roles and responsibilities; interprofessional communication; and teams and teamwork.

Several advantages of IPE have been reported, including increased mutual respect and trust; improved understanding of professional roles and responsibilities; effective communication; increased job satisfaction; and positive impact on patient outcomes. Studies have shown that students trained in an IPE approach have better interprofessional collaborative practice competencies compared to students without IPE training. This can be attributed to students' more positive attitudes toward each other, a better understanding about each other's competencies, the ability to share knowledge and skills and improved team identity.

MCW has embraced interprofessionalism and IPE across its missions of education, clinical care, research and community engagement - positioning team-based patient care and team-based learning as hallmarks of its successful approach to 21st-century healthcare.

What follows is a glimpse into MCW's commitment to interprofessionalism and IPE through the lens of students, healthcare providers and scientists - although this merely scratches the surface of the institution's interprofessional endeavors.

Interprofessional Education

MCW School of Medicine

The MCW School of Medicine's Milwaukee campus offers IPE sessions for many of its 11 early clinical and basic science courses as well as some elective Pathway courses. IPE sessions offered in 2018-2019 included collaborations with nursing, physical therapy, clinical and medical laboratory science students, dietetic interns from area institutes of higher learning and MCW School of Pharmacy students. The sessions included simulations, interactive activities and case-based discussions focused around the health needs of the patient. "The IPE sessions offer a realistic view of the work experience and allow students to practice using the communication and collaboration skills they need to optimize team-based care," says Erica Y. Chou, MD '09, pediatric hospitalist, director of medical school interprofessional education, and curriculum pillar faculty member for MCW's Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education (the Kern Institute).

Third-year medical student Monique Graf participated in six IPE sessions during her first two years, helping organize several. "Each of the professionals approaches the patient and case from a different perspective," Graf says. "We are trained differently, but we all have the same goal of doing what's best for the patient - and that requires we come together when developing a care plan."

David Holzer, also a third-year medical student, says the IPE sessions helped him learn his course materials more effectively. "During our hematology unit, the lab tech students who worked with us did an excellent job teaching me how to analyze a blood smear. We learned from their unique strengths and wisdom, just as we shared ours with them."

MCW-Green Bay and MCW-Central Wisconsin have comparable IPE sessions for their students, but also offer unique sessions that take advantage of their respective regional partnerships. For example, James R. Warpinski, MD, course director of the continuous professional development course in the second year at MCW-Green Bay, coordinates a session that brings together medical students and social work students to diagnose and treat geriatric patients. As part of the session, teams observe and discuss works of art - an exercise that improves their ability to function as a team and teaches them to respect each other's opinions.

The Kern Institute

The Kern Institute, launched in 2017, employs a variety of methods to enhance medical education. In April 2019, leaders conducted a Design Thinking Workshop that was attended by 180 first- through third-year medical students, and first- and second-year School of Pharmacy students. The course introduced students to the five steps of design thinking, which focus on empathy and the needs of the patient. Instructors walked the students through the process of what a "critically ill patient" experiences, and then they participated in a team-based interdisciplinary exercise in which they used this new creative problem-solving method to design a process improvement.

"Participants learned how to ask effective questions, be excellent listeners and draw informed conclusions," notes M. Christopher Decker, MD, GME '98, MCW professor of emergency medicine and director of the culture and systems pillar and the entrepreneurial mindset/design thinking program with the Kern Institute. "The exercise allowed the students to creatively collaborate to find solutions that will benefit the patient."

Another effort of the Kern Institute is its annual Transformational Ideas Initiative. This year, more than 50 ideas were submitted by faculty, staff and students, and 10 projects were selected to receive funding as well as yearlong technical and coaching support.

MCW School of Pharmacy

The School of Pharmacy's curriculum was designed to improve how pharmacists contribute to healthcare through interprofessional, team-based practice experiences. Students in the School of Pharmacy's inaugural class, which matriculated in the summer of 2017, are now entering their Advanced Pharmacy Practice Experience rotations. Students in the doctor of pharmacy (PharmD) program undertake approximately 200 hours of IPE within their lecture- based, clinical and elective courses.

"The MCW School of Pharmacy has integrated IPE into its curriculum from orientation to graduation in order to prepare the next generation of pharmacists to advance healthcare team collaboration and quality of patient care," says George E. MacKinnon III, PhD, MS, RPh, founding dean of the MCW School of Pharmacy.

Students attend an average of 15 different IPE sessions in classes such as Human Anatomy and Physiology, Principles of Drug Action and Pharmacogenomics, Renal and Cardiovascular, and Patient Care Lab. The School of Pharmacy collaborates with MCW's doctor of medicine and anesthesiologist assistant programs and has IPE affiliation agreements with five other local academic institutions: Columbia College of Nursing; Marquette University; Milwaukee Area Technical College; Milwaukee School of Engineering School of Nursing; and the University of Wisconsin-Milwaukee. Additional partnerships that could enhance the IPE program are continually being identified.

During IPE sessions, pharmacy students learn about, with and from students from different healthcare professions, including physicians, anesthesiology assistants, nurses, medical interpreters, occupational therapists and physician assistants. The sessions offer a wide range of experiences, from hands-on activities, role-play, lectures, group and case-based discussions to simulations using high-fidelity mannequins and standardized patients.

One notable IPE experience for second-year pharmacy student McKenzie Yerks involved the MCW anesthesiologist assistant (AA) students. "We used mannequin patients that presented with a kind of toxicity syndrome," he says. Along with his fellow pharmacy students, Yerks worked collaboratively with the AA students to decide how to treat the illness. "It was really neat to see what they were learning in their program and how it applied to what we were learning. The IPE sessions make you more well-rounded."

Scholarly Pathway courses are multi-year courses with interprofessional components that are undertaken by both medical and pharmacy students and led collaboratively by pharmacy and physician clinicians. These students have four interprofessional Pathways available to them.

Third-year pharmacy student Becka Anton recently finished her coursework in her Bioethics Scholarly Pathway. In class, a student usually presents on a topic, after which group discussions among the medical and pharmacy students ensue. The Pathway course also covers topics that aren't covered in Anton's pharmacy classes. "It has exposed me to a lot of difficult situations and opened my mind to think about them in many different perspectives," remarks Anton.

Nastassjia deBourbon is an MCW medical student in the Health Systems Management and Policy Pathway alongside pharmacy students. "I'm thankful that MCW has these interprofessional sessions. We work together and learn together to form a genuine connection," she notes.

In addition to Pathway electives, pharmacy students can take part in hands-on IPE exposures at Milwaukee-area sites where they experience interprofessional healthcare teams in action, including the Bread of Healing Clinic and the Saturday Clinic for the Uninsured.

MCW is one of the few schools in the country that requires all School of Pharmacy students to complete one 10-week IPE introductory clinical rotation in their second year that is precepted by a non-pharmacist. Student Claire Solofra rotated with the hospice and palliative medicine team at Froedtert Hospital and experienced an interdisciplinary team comprising diverse professions such as physicians, nurse practitioners, chaplains and child services. She had the unique opportunity to shadow a chaplain as he interacted with patients. "Sometimes while obtaining medical histories, people mention their religions. Now I am better prepared to respond in that situation."

During her rotation, Solofra was consulted by other members of the interprofessional team for questions regarding medications - as there wasn't a pharmacist located on-site. "Compared to other rotations, this one felt like the most realistic in-practice setting," she adds.

Interprofessionalism in Science

Research Centers are a Nexus

At MCW, research centers provide an environment in which experts across specialties and departments connect to advance team science. Some research centers focus on scientific fields such as population health while others are more narrowly focused on biological systems or specific diseases. The MCW Cancer Center (MCWCC) is an example of a large research center, comprising more than 300 physician and scientist members from more than 40 departments, divisions or institutes at three institutions: MCW; Versiti's Blood Research Institute; and the University of Wisconsin-Milwaukee.

"The MCW Cancer Center is very active in its efforts to bring clinicians and scientists together across many disciplines," says Carol Williams, PhD, Joan K. Van Deuren Professor in Breast Cancer Research, professor of pharmacology and toxicology at MCW and co-director of the MCWCC's Cancer Biology program.

In addition to three overarching research programs - Cancer Biology, Cancer Prevention and Outcomes, and Discovery and Developmental Therapeutics - the MCWCC facilitates interdisciplinary research working groups and disease-oriented research teams that meet regularly to collaborate. Dr. Williams credits these groups and interactions for sparking many new collaborative projects - including two of her own. She works with Jennifer Knight, MD '04, MCW assistant professor of psychiatry and behavioral medicine, to study how stress may affect certain hormones that, in turn, may promote cancer progression and metastasis.

In addition, Dr. Williams met Mark McNally, PhD, MCW associate professor of microbiology and immunology, at an MCWCC symposium, and together they are now testing prospective cancer therapies. "Mark and I now have a patent on a potential drug with Ionis Pharmaceuticals, and we are working on a manuscript together," notes Dr. Williams. She doesn't believe these productive partnerships would have formed without the MCWCC serving as a nexus and helping her to meet, learn from and work with colleagues across MCW.

Clinical and Translational Science

In addition to MCW's many research centers, the Clinical and Translational Science Institute of Southeast Wisconsin (CTSI) is a major interprofessional hub at MCW - bringing together basic scientists and healthcare providers across MCW and partner academic institutions in the region.

Alison Kriegel, PhD '08, MCW associate professor of physiology, knows that partnering with physicians to expand on her basic science background helped sharpen the direction of her experiments.

"There are a million questions that I'd love to explore," she states. "But there simply isn't enough time. Working with physicians who understand limitations in current treatments and the challenges faced by their patients helps me address clinically impactful gaps in knowledge."

Dr. Kriegel accelerated her learning curve in clinical and translational science by participating in the Clinical Research Scholars Program, a two-year guided apprenticeship sponsored at MCW by the CTSI. Dr. Kriegel says that this training, along with networking opportunities hosted by MCW's CTSI, help bring together the worlds of clinical practice and basic science.

"No one can be an expert in everything, so it is really important for physicians and basic scientists to work together," she says.

Graduate Degree Programs

MCW's Graduate School partners with the CTSI to offer Master of Science (MS) and Doctor of Philosophy degrees along with a certificate program in clinical and translational science.

"Many master of science degree students are clinicians at early stages of their academic careers. They are interested in forming new collaborations and participating in clinical and translational studies to advance knowledge alongside their treatment of patients," says Dr. Kriegel.

The MS degree program is designed for healthcare professionals, clinical investigators, research scientists and individuals working in biomedical industries. The certificate program often attracts doctoral students in other Graduate School programs, and the doctoral program caters to students pursuing academic research careers in basic, clinical and translational science.

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The Importance of Interprofessionalism: Education and Research

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The first installment in a two-part series about the importance of interprofessionalism in education and research.

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Definition of patient centricity is "putting the patient first in an open and sustained engagement of the patient to respectfully and compassionately achieve the best experience and outcome for that person and their family".

One of the approaches that has become fashionable in healthcare services in recent years is patient-centricity. So what does patient-centricity mean and why is it so important in healthcare? In our article, we examined in detail why all stakeholders in health services should focus on patients in order to survive. If you are ready, we can start to examine the issue of patient-centricity together.

Nowadays, because of the increasing competition, healthcare providers have to improve health outcomes with less cost. Many sectors preferred to focus on customer empowerment strategies, as they had great problems in getting better output with less cost. For example, we can handle our banking transactions ourselves, we can do our flight ticket transactions ourselves. This customer empowerment process transforms the healthcare industry with patient-centricity.

What Is Patients Empowerment?

With the rapid development of technology and communication, consumers in all sectors, including the health sector, have become much empowered. According to a survey, more than 75 percent of US adults have accessed health information online in the past year. Thanks to applications and devices such as social media, patient groups, health and wellness mobile applications, wearables, it has become very easy for patients to access health information over the internet, thus patients have an active role in their own health than ever before.

Thanks to the rapid advancement of the Internet and technology, patients today are much better equipped, knowledgeable, engaged and able to conduct their own research very effectively for their own health. Therefore, the limited messages offered for the products are not sufficient for the empowered patient population. In order to stand out in the competitive environment, healthcare providers should base their healthcare management, support, and education strategies on patient focus.

What Is Patient Adherence?

One of the most important issues in the health sector is the issue of patient adherence. According to a study conducted by the World Health Organization, 50 percent of patients with chronic diseases do not take their medicines in accordance with their prescriptions. This situation causes very poor health outcomes. This situation also leads to wasted resources and increased costs. If products or services are developed without considering patient needs and priorities, it is an expected result that patient adherence will remain at a very low level.

On the contrary, services designed by considering the patient's priorities, needs and the path they will follow will increase both patient adherence and patient engagement. Manufacturers are aware of the need to be output oriented today, but they do not have a clear understanding of what the ideal patient outcome is. Even greater success can be achieved by placing patients' needs at the core of company strategies and treating patients as if they were a partner of the company.

It is not possible for healthcare providers to survive if they cannot adopt the concept of patient-centricity in the health sector and cannot implement this approach. Institutions that best understand patient needs and can respond to these needs in the fastest and most appropriate way will be one step ahead of their competitors in the coming years. For this reason, all healthcare providers should understand the patient-centric approach very well and educate their employees and patients on this issue.

The most effective way to improve health outcomes while reducing costs is to apply the patient-centric approach in all parts of the organization. In order to put this approach into practice effectively, it is necessary to receive feedback from patients, educate and supervise patients and employees. Healthcare providers that make this transformation in the fastest way will always be one step ahead in the race.

In addition, you can get detailed information about wearable technology by reading our article titled Does Wearable Technology Improve Health? See you on different topics.

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Why Is Patient-Centricity Important in Healthcare?

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Definition of patient centricity is "putting the patient first in an open and sustained engagement of the patient to respectfully and compassionately achieve the best experience and outcome for that person and their family."

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Practical experience with new models of care involving advanced practice nurses and medical practice assistants may also influence the regulation of the scope of practice of these health professionals in Switzerland.

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BMC Nursing 19, Article number: 1 (2020) Cite this article

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Abstract

Background

The increase in the number of chronically ill patients due to ageing is calling existing models of primary care (PC) into question. New care models have recently been implemented in Swiss PC and involve interprofessional teams. This paper aimed to investigate the practice of interprofessional collaboration between advanced practice nurses, registered nurses, and medical practice assistants within new models of PC in Switzerland using the National Interprofessional Competency Framework.

Methods

An ethnographic design comprising semi-structured interviews and non-participant observations was conducted. Sixteen interviews were conducted with care providers at their PC practice. Interviewees included four advanced practice nurses, two registered nurses, six medical practice assistants, and four general practitioners. Nine other health professionals were subsequently observed in their practice. Interviews and observations were conducted by the first author from February to April 2019.

Results

Our analysis of interview and observational data confirmed that role clarification, team functioning, collaborative leadership, interprofessional conflict resolution, patient-centered care, and interprofessional communication have a significant influence on the interprofessional collaboration among health professionals in Swiss PC. Among these domains, role clarification and team functioning were the most frequently raised issues. Both were found to have the potential to negatively influence and, therefore, hinder efficient interprofessional collaboration within PC.

Conclusion

From the analysis, it emerged that role clarification is crucial for effective interprofessional collaboration within new care delivery models in the Swiss PC context. Our study results may inform international health policymakers and practitioners about six important domains of interprofessional care when implementing new care models. Practical experience with new models of care involving advanced practice nurses and medical practice assistants may also influence the regulation of the scope of practice of these health professionals in Switzerland.

Peer Review reports

Introduction

For various reasons, including the increasing number of chronically ill patients and significant advances in medicine in recent times, through which patients are living longer and longer, the demand for primary care (PC) and community care services is on the rise. Meanwhile, patients' needs are becoming more complex with an increase in multi-morbidity rates. This situation calls into question today's care delivery models.

In light of the current shortage of general practitioners (GPs), countries such as the Netherlands, Sweden, and the UK have successfully introduced Advanced Practice Nurses (APNs) into interprofessional PC teams to fulfill defined tasks and relieve GPs [ 1, 2, 3, 4].

This study focuses on Switzerland, where APNs' roles and tasks have been studied in in-patient care settings but, thus far, rarely in the context of PC. Only recently some APNs and medical practice assistants (MPAs) have started to work in PC practices (PCPs) who have implemented new models of care. Those care models involve interprofessional teams in which health professionals assume new roles and tasks. This article aims to investigate the practice of interprofessional collaboration within new models of care involving APNs, registered nurses (RN) without APN education, and MPAs in Swiss PC using an established international framework.

Background

The Swiss PC sector mainly consists of GPs working in individual private practices. In 2016, around 50% of GPs worked in single practices, while only 10% worked in group practices with other specialists [ 5]. Such group practices often enable the integration of new professional groups into practices, providing additional care and thus facilitating more integrated and coordinated care. New models of care delivery are needed as, for some Swiss regions, a shortage of GPs is expected [ 6]. A sufficient recruitment of GPs in the future cannot be guaranteed because too few physicians are trained in Swiss medical schools, and too few young doctors specialise in family medicine [ 7, 8]. The Swiss Health Observatory has projected that, in order to cope with increasing demand, the GP workforce would have to increase by up to 40% by 2030 compared to 2004 [ 6]. The shortage of GPs today predominantly affects rural areas in Switzerland, where people already encounter difficulties locating a GP in their area.

Evidence from the US shows that integrating APNs into PC teams can play a central role in alleviating physician workforce pressures and improve the care and management of chronic care needs in the patient community [ 9, 10, 11]. However, the roles and tasks that nurses with advanced roles perform differ widely, depending on the clinical setting and country. In Switzerland today, APNs today work mainly in in-patient care settings, but some APNs have recently started working with advanced roles in PC. The professional roles and competencies of APN are however not yet clarified for the PC setting and, therefore, need to be individually negotiated in every practice. The responsibility for the patient stays with the GP as no clinical protocols for APNs exist yet. Furthermore, APNs are not regulated by law, impeding the further development of the role and the implementation of a clear scope of practice. A further factor that impedes the development of APN roles is remuneration. In other European countries such as the Netherlands or Sweden that have implemented APNs, PC is mainly funded by capitation or a combination of capitation and pay-for-performance measures [ 12]. By contrast, Swiss PC is almost exclusively funded by a fee-for-service scheme (TARMED). This reimbursement scheme only allows for the reimbursement of services provided by medical doctors which means that PC practices employing APNs need to negotiate with insurance companies on how the services provided by APNs are remunerated.

Unlike APNs, MPAs have since long been an established workforce to perform administrative and coordinative tasks in Swiss GP practices. New care approaches now involve MPAs with advanced competencies in health coaching for chronically ill patients [ 12, 13, 14, 15]. Further education programs for MPAs in chronic care management (CCM) have recently been established. These MPA training courses aim to impart the skills necessary to counsel patients with chronic diseases (e.g., diabetes or coronary heart diseases). However, the educational pathways of APNs and MPAs differ significantly as MPAs are vocationally trained for 3 years, while APNs obtain a master's degree in nursing sciences at the university level.

When newly trained health professionals with newly developed roles are integrated into healthcare teams, interprofessional collaboration (IPC) and collaborative practice are crucial to establishing a well-functioning team that can provide optimal care for patients [ 16]. International literature found that IPC can improve health outcomes for individuals with chronic diseases, improve patient care and safety, decrease complications, and reduce mortality rates [ 17]. Furthermore, evidence showed that IPC improves the quality of care [ 16]. To support the analysis of IPC in diverse contexts, the National Interprofessional Competency Framework (NICF) [ 18] was created by the Canadian Interprofessional Health Collaborative. The NICF identifies six competency domains for effective interprofessional collaboration (Fig. 1). The four core competencies (role clarification, team functioning, collaborative leadership and interprofessional conflict resolution) are complemented by two domains that support and influence the other domains (patient-centred care and interprofessional communication). The core competencies describe skills, knowledge, attitudes and values needed for effective IPC. Additionally, the way the framework is applied and the way interprofessional collaboration approaches are framed is according to the framework are dependent on three additional considerations: complexity, contextual issues, and quality improvement [ 18].

Framework domains of the CIHC National Interprofessional Competency Framework

As IPC is a major issue which influences how healthcare teams perform within newly composed healthcare settings, and has not yet been studied within Swiss PC, this article presents our research focused on the interprofessional collaboration within new professional roles of APNs, RNs without APN education, and MPAs in Swiss PC using the NICF [ 18].

The study

Design

An ethnographic design [ 19, 20] involving semi-structured individual interviews and non-participant observations was used for this study. Ethnography focuses on social processes such as behaviours, meanings, and perceptions, as well as the institutional practices that occur within teams, organisations, or communities [ 21, 22], and was therefore chosen as a method to study the nature and context of new roles of health professionals in PC and to investigate the practice of interprofessional collaboration in this setting.

In the Swiss PC context, in which there are few instances allowing researchers to observe these newly evolving roles and how IPC occurs in practice, ethnography has enabled the detailed investigation of a small number of cases and the interpretation of the meanings and functions of human actions [ 21]. Semi-structured interviews, in which the sequence of questions is participant-led, have facilitated free-ranging conversations about the research topic [ 23] and have therefore been considered a reasonable method to capture the views of health professionals on their roles in PC.

Following the semi-structured interviews, non-participant observations were carried out to better understand the health professionals' working environments and to study how health professionals fulfilled their new roles, how they collaborated within healthcare teams, and how they interacted with patients. For the purpose of this research, non-participant observations in which the subject under research was aware of the researcher's identity and the research purpose [ 19] were deemed acceptable to observe health professionals in practice.

Setting and participants

Contact lists for the recruitment of participants were available through a previous study that the first author had conducted on the skill mix of APNs and MPAs [ 24]. In this previous study, a convenience sampling strategy was applied to recruit group practices for an online survey in Switzerland. PCPs were included if they operated as group practices with three or more PC doctors. The online survey identified group practices employing APNs, RNs or MPAs. These three groups of health professionals were recruited as potential participants for the present study by the first author by phone or email between December 2018 and January 2019. Potential study participants were informed about the study aim, the design and what their contribution and time effort would be if they participated in the study. As there are very few practices that employ APNs, nurses, or MPAs with specific roles in PC, it was impossible to recruit more participants. All interviews and observations were conducted in the German-speaking part of Switzerland in which the new roles for APNs and MPAs in PC are more established compared to other parts of the country. Interviews and observations were conducted by the first author from February to April 2019. Two APNs, two nurses, and one MPA refused to participate in the study because of time pressures at work or because the institution they worked for did not agree.

Data collection

Semi-structured interviews

In total, 16 interviews with health professionals and GPs were conducted at their respective workplace. Each interview lasted about 35 to 60 min. An interview guide with questions and prompts was created beforehand by the first and second authors. The main study aim guided the development of the interview guide. Authors followed the advice by Braun and Clarke [ 25] on designing and piloting the interview guide. Interview questions were drafted by the first author and revised by the second author. Through discussion among authors the interview questions were finalised. APNs, nurses, and MPAs were asked about their specific role in the PCP, their clinical tasks, and how their new roles influenced teamwork and the coordination of care. They were also asked about their perceptions of the new roles for health professionals in PC and the possible advantages and disadvantages of the introduction of these new roles. GPs were asked about their perceptions of the new roles of these health professionals in PC and their motivations to employ these health professionals in their practices. Open questions were asked so that participants could freely describe and explain their roles in practice and how they influenced IPC.

With the consent of participants, interviews were audio-recorded and transcribed verbatim. Transcriptions were not returned to participants for checking. To record important thoughts about the interviews to assist the qualitative analysis, the researcher took notes following the interviews.

Observations

Non-participant observations, used as an instrument for ethnography [ 21], were conducted with nine health professionals in order to collect data on the enactment of the roles of APNs, RNs and MPAs in new care models in Swiss PC. Health professionals were observed in their PCP, or outside the practice if they visited patients at home for a short period of 1.5-2.5 h. As the roles of APNs, RNs and MPAs are new to the PC sector, observation data provide important information on how these new roles are enacted in practice shortly after implementation and how IPC functions within these newly composed teams. The observations focused on the tasks fulfilled by the health professionals and whether their statements made during the interviews could be verified in practice. During the observations, notes were taken using an observation scheme and were completed and expanded following the observation. The observation scheme was structured by tasks performed before, during, and after the consultation with the patient. After the completion of the field notes they were critically reflected by the first author. The aim was to assess possible biases in and own feelings towards the observed situation [ 26, 27].

Ethical considerations

Prior to starting the study, the Ethics Committee did not require ethical approval, as this study is not covered by the Swiss Human Research Act [ 28]. Nevertheless, written consent was obtained from all participants prior to the interview. All confidential information was protected by removing personal details from the data.

Data analysis

Transcripts of the interview data, as well as field notes of the observations and observation schemes, were coded by the first and partly by the third author using Atlas.ti 8®. Interview transcripts were coded and then extracted to a processing file to compare and discuss the linked citations of each code or concept among the two researchers. In order to identify themes from the data and to analyse them, authors followed the six-stage framework for thematic analysis proposed by Braun and Clarke [ 25]. The field notes of the observations were subsequently coded using the concepts and themes identified before. Data from interviews and observations were triangulated and analysed using thematic analysis [ 29]. Thematic analysis was chosen as data analysis method because of its flexibility in terms of theoretical framework as well as research question [ 25]. Numerous other studies in the field of nursing have already used thematic analysis for ethnographic data [ 30, 31, 32].

The researchers' discussion of the concepts and codes derived from the interview and observation data revealed that the concepts found during the analysis should be analysed and compared to the existing literature by using a theoretical framework on IPC. Using an a priori theoretical framework for data analysis allows us to connect research findings to existing literature and to analyse and further develop the research findings [ 33, 34]. For purpose of analysis we extracted the four competency domains (role clarification, team functioning, collaborative leadership and interprofessional conflict resolution) of the NICF Framework and compared them to our themes and concepts in order to analyse by how far these framework domains apply to the Swiss PC setting and to newly composed healthcare teams in this setting. We have also considered the two supporting domains (patient-centred care and interprofessional communication) in our analysis.

Coding consistency

The first author coded all data gained through interviews and observations, whereas the third author coded 25% of the total amount of data. This approach serves to establish coding consistency with the first coder [ 35]. Only minor discrepancies between the two authors' codes evolved and were resolved by discussion. This approach gave evidence for the consistency of the first author's codes. For the final analysis, the codes of the first author were used.

Findings

Participant and practice characteristics

Interviews were conducted with four APNs, two nurses without an APN education, six MPAs, and four GPs. All participants except for the medical doctors were female. All four APNs, one nurse, and four MPAs agreed to be observed in practice. Participants worked in ten different PCPs. Practice and participant characteristics are summarized in Tables 1 and 2.

Table 1 Participant characteristics

Table 2 Practice characteristics

Key themes

Concepts and themes relating to IPC were all allocated to the NICF domains and are presented in a synthesized form. Additional file 1: Figure S1 shows the allocation of the themes and concepts to the framework domains. Results regarding the clinical tasks of the different professional groups and organisational issues that arose during the implementation of new roles in PC will be presented in a future article.

Role clarification

The three concepts 'promotion of the acceptance of new roles', 'role profile of APN in the GPs view' and 'skepticism towards APN in PC' coming from our data were connected to this competency domain. These concepts included data on how health professionals and GPs see the importance of promoting new roles of health professionals as well as why it is important that roles are clarified within teams and communicated to patients.

All participants stated that establishing their role in the general practice when they started working in the PCP was a difficult process, as these new roles are yet to be fully established in every practice. For health professionals, it is crucial that their new roles are accepted and recognized by patients and by the GPs they work with. How the GPs communicate the new health professional roles to patients is vital to increasing patients' acceptance of these new roles, as well as to promoting these roles more broadly.

It mainly depends on how I phrase it. (GP2).

It's most important how the GP communicates with patients, or, umm, only just to say that I exist and that they (patients) will see me; that is, they don't say "you're poorly controlled with your blood sugar and you have to see Miss X now" but "you are now allowed to see Miss X because she knows more about it." (MPA6).

Within health professional practice teams, it is essential that the team members' roles and competencies are clear to GPs so that they recognize the benefit APNs, nurses, or MPAs can provide to patients and that they refer their patients to them. The competencies and roles of health professionals are clarified through the concepts put into place when the health professionals started working in the practice, as explained by an MPA:

Before I started, we have determined with the GPs which tasks I am allowed to fulfill independently and which not. (MPA1).

Others had to explain their competencies to GPs:

In the beginning, I once presented my work so that they know a bit what the aim of my work is and what are my competencies and what do they (doctors) do, and I have the impression that it helped. (MPA5).

In practices where the roles and competencies of APNs, MPAs, or nurses are less clear to GPs, there is often more skepticism and fewer referrals from GPs to these health professionals.

The role profile of an APN from a GP's point of view was discussed in two interviews with one GP who works with an APN who described her role as:

At the moment, many things are still discussed with me (by the APN), but I think maybe, most of all, chronically ill patients or follow-up checks with diabetic patients and adjustments can be handled autonomously (by the APN). (GP4).

Another GP, who works with an MPA in his practice, describes his vision of the APN's role as not focusing on general practice but on community care:

These colleagues that I know who have employed a nurse as APN, I find it the wrong way; for me, an APN should be in the "Spitex" (community care). Nursing belongs to nursing. (GP1).

I would like to rely on a competent "Spitex" where I know they provide the services I would expect from my APN and especially also in further education, coaching, where she should have a certain leading function in Chronic Care so that I can delegate it. (GP1).

These statements show that there are different opinions about which roles health professionals should take on in general practice, and role clarification is crucial for health professionals and GPs to practice effective interprofessional collaboration.

Team functioning

This competency domain includes the concepts 'Motivation of GPs to delegate or not to delegate tasks to the health professionals', 'motivation of health professionals to assume new roles', 'role of trust in collaborative working' and 'support of health professionals among each other". These concepts contain data on the process of delegation of tasks from the GP to health professionals, the role of trust in this process and how health professionals worked together with each other.

After the inclusion of an APN, a nurse, or an MPA into care teams in the observed PCPs, health professionals and GPs had to adapt to the new composition of the team and to a new distribution of responsibilities. GPs stated that, in the beginning, it was difficult to delegate tasks previously performed by themselves to an MPA or an APN:

The first step was really to let go and to say I'm not the only one who knows everything but that really this is something that could maybe even work better interdisciplinarily. (GP2).

Another GP confirmed:

In the beginning, one controls probably more often but, umm, in the beginning, it was not easy, for sure not. (GP4).

One nurse argued that the reason not to delegate tasks to her could be the doctor's fear that she would "steal them some work" (N2). Health professionals assumed that it is difficult for doctors to give away full control of their care for the patient:

There are still doctors who want to do everything by themselves and want to bear the full responsibility and know everything about their patient; I do that all by myself. (APN1).

During the observations of APNs and MPAs, only a few occasions of IPC between those two professional groups could be observed. These few occasions illustrate that the collaboration between APNs or MPAs and GPs could be improved by initiating more of these collaboration opportunities. On both occasions, the observations confirmed what the qualitative data analysis had already shown: The clarification of profession-specific roles and team functioning is crucial for effective IPC. But also building trust was crucial for team functioning. For APNs and MPAs, it is crucial that the GPs have trust in their competencies, as described by an APN and an MPA:

They trust that I will refer back to them if I'm not sure and that is, also, there I must ethically take the responsibility for what I'm doing. (APN1).

They give us all a lot of freedom in our practice, and they know very well that when something is not good, that I would give feedback. (MPA1).

On the other side, one GP confirmed:

It is correct that I have to have trust that she is doing it well. (GP2).

After trust was built, many participants gave diverse reasons for GPs to delegate tasks to health professionals. The most important reason was that GPs are relieved from workload pressures through the work of an MPA or an APN. One GP also saw an advantage for the patient:

In my opinion, this is really also a good and useful supplement where I also think that patients are better cared for if one does it like that...I think it can make everything even more interesting if this model develops and we care for patients as a team. (GP2).

For APNs and MPAs, taking on new roles and responsibilities was a challenge but, at the same time, increased their motivation for their work, which, in turn, positively influenced teamwork. Notably, the MPAs regarded their new roles as an opportunity to advance their career:

It is a challenge and an additional motivation to manage something or keep on working (as an MPA) for a longer time. (MPA1).

Some health professionals felt that often tasks that the GPs do not like to perform themselves are delegated. One example is the control of feet in diabetic patients. One nurse described it the following way:

All the tasks that I don't like, and I don't have time for, I'm very happy that you are there to do it. And everything else is still under competition. (N2).

In those practices where APNs and MPAs work together, they did not see each other as competitors but supported each other in their work and their new roles.

We never have a discussion on what I should do and what you should do but more 'could you help me with this?' (APN1).

In difficult patient situations, the nurse or APN was described as a source of help and advice for the MPA.

In general, teams in the observed practices functioned well because mutual trust was built over time, and the responsibilities of the health professionals were mostly clear to all team members. This enabled task division between GPs and MPAs or APNs who were willing and motivated to take on new tasks and roles. Team functioning was furthermore found to be highly dependent on interprofessional communication, but the observed health professionals were already highly skilled in these areas and therefore functioned well as a team.

Collaborative leadership

To this framework domain the concepts 'dealing with self-responsibility and consultation with the doctor' and 'requirements for the implementation of interprofessional teams' were allocated. They give valuable information on how self-responsibility influenced the work of APN and MPA and what was needed for effective collaboration in practice.

In the observed PCPs, the collaboration between GPs and health professionals was very tight. MPAs and nurses performed most services on the instruction of GPs. Oversight remained with the GP, who defined the specific need of the patient and the goal of the consultation, which was then performed by the MPA or the nurse.

It is clear that I can make a suggestion, or I can say "I would maybe do it like this or that," but the decision and the prescription how it should happen remains clearly with the doctor. (MPA6).

APNs worked with a high level of responsibility but in close cooperation with GPs. Decisions were often made together, or the APN provided feedback to the GP after consultation with the patient, as described by an APN:

If I can bear the responsibility, I decide by myself but afterward, I inform the responsible doctor. (APN2).

In order to collaborate effectively when decisions were made, for health professionals, it was important that trust was built, competencies were clarified, and GPs could hand over some of the responsibility. One nurse explained it in the following way:

What is important is that everyone knows what he or she is allowed to do, where his or her competencies are and at the end, if this is clarified and it works at the interpersonal level this is all no problem. (N1).

A GP explained further that:

One has to get to know each other well and has to know what she can (the health professional) do on her own responsibility and where am I really needed in addition. (GP4).

Interprofessional conflict resolution

This competency domain included the concept named 'Difficult situations in practice'. Under this concept participants described conflicts that occurred in practice and how they have resolved them.

In the observed PCPs, conflicts were rarely mentioned or observed. The APN stated that tensions in the team sometimes occurred when new GPs or assistants started working in the practice:

If a doctor starts working in our practice, they don't really know what I can and cannot do and what not and then it happens that they keep controlling me more often. (APN2).

Such conflicts were then resolved through discussion and by showing the doctors or assistants what competencies the APNs have and that they are able to work autonomously.

One nurse said that she initially did not feel welcomed by the team:

...where I recognized that a nurse is not so welcome among the MPA because I can imagine that there are still places (practices) where one clearly still says 'I do have more competencies than you have'. (N2).

This same nurse resolved the situation by showing the other team members that she wished to collaborate with them and did not want to be seen as someone at a higher hierarchical level.

There appeared to be some potential for conflict when health professionals referred patients to the GP for a further check or examination. In some cases, these patients were not referred back to the health professional to continue consultations after the initial consultation.

And then I realised that I have to see that patients are coming back to me, otherwise then they (doctors) keep them, and I think these are in fact, my patients. (APN2).

Interprofessional communication

Interprofessional communication comprised the concepts 'communication between APN and nurses or MPA' and 'communication between GPs and APN, nurses or MPA'. These concepts describe how communication worked in practice and which communication strategies were applied in order to facilitate effective collaboration.

Communication between GPs and health professionals was based on personal dialogue or the electronic health record, which enabled them to indicate if an in-person consultation was not possible during the working day. One MPA said:

Everything we discuss during the consultation the GP is informed about. That means I make good entries in the electronic health record where the GP can trace what we have discussed or what has been done. (MPA2).

If there were urgent questions, it was in most cases possible to immediately ask the GP in the practice, as explained by an APN:

If I have a question, I can go and get the doctor immediately. (APN2).

One GP explained that good interaction between team members was essential:

If we have good contact and we are engaged in conversation and try to find a common language, that is very relieving. (GP1).

In teams where APNs worked together with MPAs, it was important that the APN knew who in the MPA team was in charge of MPAs' issues in order to communicate and organise task-sharing.

For me, it's important if I have to know something from an MPA, I know that she (Name) is my contact person because she is the team leader. (APN1).

Patient-centered care

To this competency domain the concepts 'patients' views on care they receive from health professionals' and 'trust from patients towards health professionals' were allocated. They comprise important information on how patient-centred care is carried out and on how the patients' view influenced professional practice of health professionals and their collaboration. It furthermore shows, how health professionals think the care provided to patients is seen by patients.

From the participant's perspective, their care was patient-centered and resulted in positive outcomes for patients. Health professionals believed that their care increased the quality of PC. They also remarked that they felt that patients are not concerned with who is caring for them as long as the quality of care is high, and they feel they are being treated well. An APN said:

I always tell them that I am a nurse and not a doctor and then they always say 'I don't care that much' well, they don't care that much, they want that someone listens to them and they want to be taken seriously. (APN2).

Another APN added:

I think it has a lot to offer to them, in my opinion, they enjoy optimal care for diabetes and wounds delivered by MPA. (APN1).

Participants also affirmed that they had more time at their disposal for patients, which, in turn, appeared to be much appreciated by patients.

It's mostly the time I think that one has more time for them, that one listens to them, that they can talk about their issues, I think this is what doctors cannot offer anymore. (MPA4).

Health professionals also observed that their care led to an increase in patients' self-management.

And if you discuss with patients what they can do themselves, how important it is to take medication if they have to, if you discuss everything in detail, they can do so much, and that serves a lot because they have to come to the practice less often. (MPA4).

MPAs, APNs, and nurses felt that patients trusted them and that the barriers to trust-building were lower for them than for GPs.

One MPA stated:

It's more that barriers are lower, they can recount more confident things, and they know if I know this, all will be good. (MPA3).

Another MPA added:

Patients dare to ask more, "I'm having this diabetes for ten years but actually, I don't know what it is or what exactly I have," or they maybe dare to write an email to me. (MPA6).

Discussion

We investigated interprofessional collaboration within ten Swiss PCPs, which have implemented new care models involving APNs, nurses, and MPAs in CCM. Our results confirm that the six competency domains defined in the NICF have a significant influence on the practice of interprofessional collaboration. In our sample of newly composed primary healthcare teams, health professionals already had a high level of skill through their education regarding the domains of the framework. We found that role clarification and team functioning were the most frequently raised issues, which in some situations were found to be hindering effective collaborative practice.

The six competency domains of the NICF are influenced by the institutional context and the complexity of care. Unlike other countries such as the Netherlands or Canada, Switzerland does not yet have regulations for the professional practice of APNs or MPAs with new roles in CCM. A lack of regulation negatively influences the role clarification process of health professionals in PC [ 36]. In the Swiss context, where advanced roles for nurses and new roles in CCM for MPAs are implemented only in a limited number of PCPs in pilot projects, role clarification is a major issue, and it also has a negative impact on team functioning. As only a limited number of practices have so far tried out new models of care, experiences with the implementation of APNs assuming certain tasks of GPs are very limited. When new health professional roles are established, a special effort has to be made by teams and individual professionals to define their roles and to communicate them to others. According to Brault et al. [ 37], the best performing interprofessional teams are those who have introduced institutional processes to support role clarification. In our sample, those practices who had defined the roles and competencies of the APNs and MPAs before or at the start of the implementation experienced fewer role conflicts after the introduction of the new roles. Furthermore, according to Brault et al. [ 37], professionals themselves need to make an effort to know their own roles and communicate them to others to support role clarification. Complex care situations, as often the case in chronically ill patients, require a higher number of health professionals working together. This collaboration requires precise role profiles and trust in each other's competencies. We found that, in complex care situations, tasks were divided according to the competencies of the individual professionals. APNs as well as nurses could support MPAs when challenged by complex care situations. Such a task division according to competencies supports IPC whereby different skills can be combined to optimize patient care.

The analysis of the practice of IPC within a few Swiss PCPs that have implemented new models of care shows that the six competency domains are not easy to attain in practice. When new models of care are implemented in contexts lacking regulations for the professional practice of APNs or MPAs with new roles in CCM, role clarification requires a considerable effort by all team members and takes time. The experience from our sample practices, however, also shows that these interprofessional teams function well and have succeeded in defining the roles of the different professionals so that they can collaborate well and optimize patient care. This could be attributed to the willingness and openness of physicians, as well as other team members, to integrate new professional groups with newly developed roles.

Other European countries such as the Netherlands, Sweden, and the UK have successfully introduced new care models involving nurse practitioners and APN in PC and have documented positive experiences [ 1, 2, 3, 4]. International literature has shown that APN can provide an equivalent or higher level of care compared to physicians in PC [ 11, 38, 39, 40]. Literature also shows positive patient outcomes when MPAs take over the health coaching of chronically ill patients [ 41, 42] but such new care models involving APN are so far only rarely implemented. In Dutch PCP integrative interdisciplinary care models involving APN and so called 'Doktersassistenten' have been widely adopted for CCM [ 43]. The Dutch 'Doktersassistenten' have a similar job profile as MPA with further education in Switzerland [ 44]. Our findings could also inform these countries on what is needed for PC teams in order to collaborate and work effectively. A new model of care - as implemented in some practices in Switzerland - which combines APNs with new roles for MPAs or nurses in CCM, is unique to the PC sector. This practical experience can help to analyse such new care models and to evaluate the extent to which new care models can be transferred from other countries and adapted to the local health system. Further research should focus on investigating how patients experience these new care models and evaluate how widespread implementation of such models of care can be supported at the health policy level.

Limitations

There are some limitations to this study. First, we could only recruit a small number of health professionals and GPs. It was impossible to recruit participants outside of the German-speaking part of Switzerland as only recently have some practices implemented new models of care involving these health professionals. Second, we only recruited health professionals who were already employed in PCPs and have taken up advanced or new roles. This selection could influence the results, as practitioners and health professionals who already work in this setting are more likely to be in favor of the implementation of such new care models. Additionally, we collected very few critical statements regarding new models of PC provision.

Conclusion

This study has deepened the understanding of interprofessional collaboration in the context of newly evolving roles for APNs, nurses, and MPAs in Switzerland. It emerged from our analysis that role clarification is crucial for efficient interprofessional collaboration within new models of care in the Swiss PC context. The experience from our sample practices can inform international health policymakers and practitioners about the importance of the six domains of IPC presented in this article when implementing new models of care. Moreover, the Swiss experience with a care model that combines APN and MPAs or nurses is unique and shows that interprofessional collaboration can be enhanced through such a combination of health professionals. This practical experience with new models of care involving APNs and MPAs may also influence the regulation of the scopes of practice of these health professionals in Switzerland.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available but are available from the corresponding author on reasonable request.

Abbreviations

APN:

Advanced practice nurse

CCM:

Chronic Care Management

GP:

General practitioner

MPA:

Medical practice assistant

MScN:

Master in Nursing Sciences

NICF:

National Interprofessional Competency Framework

PC:

Primary care

PCP:

Primary care practice

RN:

Registered nurse

References

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Acknowledgements

We would like to thank all participants for their openness to give us an insight into their daily work and for their contribution to this study.

Consent to participate

With the signed written consent the participants agreed to take part in the study.

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Authors and Affiliations

1. Department of Business Economics, Health and Social Care, SUPSI University of Applied Sciences and Arts of Southern Switzerland, Manno, Switzerland

Renata Josi & Monica Bianchi

2. Global Health Policy Unit, Social Policy, School of Social & Political Science, University of Edinburgh, Edinburgh, UK

Sophie Karoline Brandt

Contributions

RJ, MB and SKB have contributed substantially in the conception and design of the study as well as data collection and analysis. SKB served as a coder to assure coding consistency of the codes derived by RJ. RJ has drafted the article and MB and SKB have critically revised it and approved the version to be published.

Authors' information

RJ is a third-year PhD student in Health sciences at the University of Lucerne, Switzerland and the University of Applied Sciences of Southern Switzerland. MB is a professor of nursing sciences and the Head of the Master in Nursing Sciences at University of Applied Sciences of Southern Switzerland. SKB holds an MSc in Physiotherapy from the Bern University of Applied Sciences in Switzerland as well as an MSc in Global Health Policy from the University of Edinburgh, UK.

Corresponding author

Correspondence to Renata Josi.

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The cantonal Ethics Committee of Berne did not require ethical approval, as this study is not covered by the Swiss Human Research Act. Written consent was obtained from all participants prior to the start of the study.

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Josi, R., Bianchi, M. & Brandt, S.K. Advanced practice nurses in primary care in Switzerland: an analysis of interprofessional collaboration. BMC Nurs 19, 1 (2020). https://doi.org/10.1186/s12912-019-0393-4
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Keywords

Advanced practice

Primary care

Ethnography

Multi-professional practice

Nurse roles

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Advanced practice nurses in primary care in Switzerland: an analysis of interprofessional collaboration - BMC Nursing

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Background The increase in the number of chronically ill patients due to ageing is calling existing models of primary care (PC) into question. New care models have recently been implemented in Swiss PC and involve interprofessional teams. This paper aimed to investigate the practice of interprofessional collaboration between advanced practice nurses, registered nurses, and medical practice assistants within new models of PC in Switzerland using the National Interprofessional Competency Framework.

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Effective interprofessional collaboration – also known as interdisciplinary collaboration, is an essential component in the delivery of comprehensive, safe and therapeutic patient care.

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Effective interprofessional collaboration - also known as interdisciplinary collaboration, is an essential component in the delivery of comprehensive, safe and therapeutic patient care. In today's healthcare marketplace, stressors such as heavy patient loads, increasing demands on nurses and other direct care providers, and system-wide financial strain can lead to a wide variety of miscommunications and tensions among members of the healthcare team. As a result, a focus on enhancing interprofessional collaboration is much needed to help minimize undesirable events, and improve teamwork, communication, and most importantly - improve patient outcomes.
Identifying Common Collaboration Challenges

Major factors that affect collaboration include communication, respect and trust, unequal power, understanding professional roles, and task prioritizing. Let's take a look at how each one of these factors plays an integral role in the effectiveness of collaboration:

Communication

Let's face it, our entire healthcare system is built upon the ability to communicate patients' needs to the appropriate services and providers. In a system that is already overwhelming, breaks in communication happen often. From in-person communication to telecommunications, there are lots of opportunities for miscommunication to occur between members of the interprofessional team. The bottom line is that when communication is ineffective, the interprofessional team does not work together in harmony, thus collaboration efforts become compromised. Nurses advocate for enhanced communication that focuses on streamlining communication practices, such as implementing clinical rounds, safety huddles, staff meetings, and documentation/reporting systems that are compatible with essential electronic data management systems.

Respect and Trust

There's been a long-running issue with mutual respect and trust between the different healthcare providers. According to a recent study, nurses report that some physicians are unwilling to listen to their inputs regarding patient care. Whether the physician has valid reasons for not acknowledging the nurses' input or not, this is often perceived as disrespectful. Naturally when someone feels disrespected by a person or group of people, then trust for that person(s) becomes diminished. This phenomenon occurs among all members of the interprofessional team, and is not unique to nursing alone. Nurses are helping to change this culture by role modeling respect and trust, while holding their peers accountable, thus setting an example for the rest of the interprofessional team.

Unequal Power and Autonomy

Power and autonomy disparities are often attributed to the different levels of education, status and prestige that is unique to each profession. Additionally, the influence of traditional stereotypes where nurses were often viewed as the handmaidens of physicians and should not question a doctor's order also plays into this barrier to collaboration. Unfortunately, even in the year 2019, nurses are not regularly invited to the table to share their problem-solving skills, offer innovative solutions, or contribute in the decision making processes that ultimately affect them and the work environment around them. In response to this antiquated process, many nurses are empowering themselves with higher degrees and moving into positions of power where they are better suited for leveraging negotiations surrounding nursing practice.

Understanding Professional Roles

It is not uncommon for healthcare professionals to have a vague understanding of the roles and responsibilities of other healthcare professionals. For example, nurses understand what a physical therapist does for their patients, however, they do not understand the intricate details of the assessments, tools, billing and documentation that physical therapists complete throughout the day. If healthcare professionals knew more about the specific roles and responsibilities of each of their team members, then collaborative efforts would come much easier. In an effort to better understand individual roles and responsibilities of each member of the interdisciplinary team, nurses have been including each discipline in new employee orientations and educational in-services.This provides a great opportunity for staff to learn more about the diverse roles and responsibilities of each member of the healthcare team.

Task Prioritizing

One of the biggest challenges with effective collaboration is task prioritizing. One example that appears a lot in research is nursing's lack of attendance and participation in interdisciplinary rounds. From nursing's perspective, patient care does not cease during rounding and for that reason, many nurses have a difficult time pulling away from providing care long enough to participate in interprofessional collaboration. Similarly, doctors often demonstrate a sense of "urgency" and "lack of time"when communicating with nurses. As a result, nurses feel that providers are "bothered or uninterested" in what we have to say. In both examples, task prioritizing is misunderstood among healthcare team members, and provides a major barrier to collaborative efforts. Charge nurses, nurse educators, managers and supervisors help to decrease these task prioritizing misunderstandings by facilitating safety huddles, clinical rounds, and assisting the team during urgent patient matters.

Negative Impacts of Inadequate Interprofessional Collaboration Efforts

Whether interprofessional collaboration efforts are interrupted by poor communication or misunderstandings of roles and responsibilities, patient safety becomes compromised. Breaks in communication, decreased respect and trust, unequal power and autonomy, not understanding professional roles, and interdisciplinary task prioritizing conflicts are all contributing factors to decreased patient safety practices. When patient safety practices, such as initiating the high falls risk protocol, or interviewing the patient for allergies, are not completed for any or all of the above reasons, poor patient outcomes are soon to follow.

According to Gobis, Yu & Reardon (2018), patients always suffer the consequences of ineffective interprofessional collaboration. For example, when doctors do not include the nurse in care planning, or spend a limited amount of time explaining findings and expectations to their patients, it can lead to nonadherence and distrust in the doctor's ability to manage their care. Medication and care plan nonadherence is an important public health consideration, which affects health outcomes and overall healthcare costs. If collaborative efforts among all members of the healthcare team are suboptimal at any point, the patient may not receive the care that they need.

Although decreased job satisfaction may be common among all members of the healthcare team due to high levels of stress caused by ineffective interprofessional collaboration efforts, nurses are among the most dissatisfied. According to the 2018 National Health Care Retention & RN Staffing Report, the current United States nurse turnover rate is 16.8% and is projected to increase over the next decade. Evidence suggests that increased nurse turnover directly impacts decreased patient access, patient safety and quality of care which ultimately leads to adverse patient outcomes. If interprofessional collaboration efforts do not improve across all care settings, turnover rates will create catastrophic disparities for our patients and our communities.

Current Initiatives to Improve Interprofessional Collaboration, Communication and Streamlined Care Practices

There are a lot of recommendations that current researchers are making to improve upon interprofessional collaboration efforts. Let's take a look at the top five recommendations:

Improving Communication Practices

Effective communication is key. One of the best ways to enhance communication is by streamlining communication processes to reduce the amount of hand-off. Hand-off can be defined as "an exchange of information from one source to another, or from one person to another." One of the ways that healthcare facilities addressed this issue many years ago was by eliminating the 8-hour shift option and implementing 12-hour nursing shifts. Not only did the hospitals save money by having one less shift to staff, but they also improved hand-off communication among nurses. Much like the game telephone, when messages are passed from person to person without streamlined efforts to help keep messages clear and accurate, some of the information may get missed, or misunderstood. Additionally, implementation of standardized hand-off reporting tools have also improved communication between shifts. The use of standardized hand-off reporting tools among doctors, nurses, and other members of the interprofessional healthcare team improves communication and decreases miscommunications regarding patient needs and care that is required. Research suggests that healthcare facilities invest in communication streamlining products and processes that will help to enhance interprofessional collaboration. Nurses should always be at the decision making table when it comes to investing in communication streamlining products and processes.

Increasing Mutual Respect and Trust Among All Members of the Healthcare Team

Mutual respect and trust among all members of the healthcare team is essential to effective collaborative efforts. Professionalism, collegiality and accountability are some of the suggested concepts to be considered. In addition, having a shared understanding of specific roles and responsibilities across the healthcare team also helps to improve trust and accountability. When roles and responsibilities are clearly defined, all members of the healthcare team can effectively work together in anticipating the needs of their patients.

Creating a Culture that Supports Equal Power and Autonomy

When members of the interprofessional team support one another by recognizing each member's unique skill set, strengths, and individual contributions to safe and effective patient care, this helps to build a culture of equal power and autonomy over each specific profession. For instance, when doctors understand that nurses work towards upholding patient safety standards at all times, regardless of time, financial, or other organizational constraints, they are able to better support nurses in achieving this goal. By allowing each healthcare professional to have autonomy over their contributions and skills sets in the delivery and coordination of patient care, collaborative efforts improve. Rather than hospital administrators making decisions over patient care processes and unit flow, each interdisciplinary profession should have an equal voice in making these decisions and doing their part in making the magic of teamwork happen.

Incorporating More Resource Personnel to help Cover Patient Needs During Interprofessional Collaboration - such as during Care Plan Meetings and Clinical Rounds

One of the biggest challenges in establishing effective interprofessional collaboration efforts has been "lack of time and resource personnel" (Reeves, Xyrichis & Zwarenstein, 2017). Many nurses report that making interprofessional rounds is difficult when there are patient needs that need to be addressed. One recommendation to help alleviate this barrier to effective collaboration would be to establish "coverage" while the healthcare professional is removed from their patient care and coordination tasks so that they can spend quality time focusing on collaborative efforts. Much like nurses rely on the charge nurse, or another staff nurse to cover their patients while they take a break, members of the interprofessional team can have their colleagues cover their pages, phone calls, and patient care needs while they are participating in interprofessional collaborative activities such as clinical rounds.

Holding Nurse Leaders and Healthcare Facility Administration Accountable

It is important that we communicate our needs to nurse leaders and facility administration when moving towards establishing effective interprofessional collaboration. If administrators are not provided with this essential information, then we cannot hold them accountable for meeting our needs. One way to ensure that your nursing leadership, as well as facility administrators, are receiving the message is by submitting your communications via company email. Communication via email creates a permanent and traceable communication log that is helpful in tracking a discussion, thus reducing the likelihood of the receiver "forgetting" about the conversation.

In addition to email communications, scheduled meetings with a recorder - someone who types up summaries of meeting topics, discussion and outcomes, is also a helpful method to bring forth necessary change within facilities. Advocating for scheduled meetings, shared governance, and leadership accountability are great ways to ensure that your voice and ideas for improving interprofessional collaboration efforts are being heard. Begin by asking for an opportunity to meet with your nursing leadership so that you can have a detailed discussion. Be sure to always send a follow-up email that summarizes the discussion you had, and the expectations established. This will create an agreement in writing that will help to hold everyone accountable for doing their part in enhancing interprofessional collaboration.
Do you have any tips, recommendations, or strategies to help improve interprofessional collaboration in your healthcare workplace? Have you participated in a committee that focuses on improving interdisciplinary collaboration? If so, please contribute to this discussion by leaving your thoughts in the comments section below!
Best Wishes,

-Damion
References
2018 National Health Care Retention & RN Staffing Report. (n.d.). Retrieved from Source

Gobis, B., Yu, A., Reardon, J., Nystrom, M., Grindrod, K., & Mccarthy, L. (2018). Prioritizing intraprofessional collaboration for optimal patient care: A call to action. Canadian Pharmacists Journal / Revue Des Pharmaciens Du Canada, 151(3), 170-175. doi:10.1177/1715163518765879

Reeves, S., Perlone, F., Harrison, R., Goldman, J., & Zwarenstein, M. (2017, June 22). Interprofessional collaboration to improve professional practice and healthcare outcomes. Retrieved July 6, 2018, from http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD

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Nurses Enhance Interprofessional Collaboration - The Nurse Speak

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Damion Jenkins, RN, MSN - lead Innovator at The Nurse Speak, LLC., discusses enhancing the interprofessional collaboration in nursing.

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Effective communication, teamwork, and interprofessional collaboration, or teams of health and non-health professionals working together, are critical to improving the patient experience of care; improving population health; and reducing healthcare costs

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By a considerable margin, nurses comprise the largest healthcare workforce in the United States (U.S.; Bureau of Labor Statistics, 2016). With 3.6 million registered nurses serving the nation's diverse healthcare needs ( McMenamin, 2016), nurses are prominently placed at a healthcare communication intersection with millions of patients, families, and other healthcare providers and professionals. As such, they develop partnerships upon which patient health outcomes depend.

...school nurses work to provide coordinated and complex care for many of the nation's 50 million public school students. Working within an education setting, and practicing across multiple healthcare domains, including public health, community agencies, hospitals, and insurance systems, school nurses work to provide coordinated and complex care for many of the nation's 50 million public school students ( McClanahan & Weismuller, 2015; National Center for Education Statistics, 2017). National healthcare changes emphasize effective, efficient, and quality care. As school nurse practice embodies those elements, this new direction in national healthcare positions school nurses as potential and actual leaders in the provision of care coordination and case management for millions of students ( McClanahan & Weismuller, 2015).

In recent years, a growing body of research has identified school nurse contributions as necessary to reduce costly and inappropriate use of emergency health services ( Wang et al., 2014); to improve economic efficiencies in education and in healthcare ( Wang et al., 2014); and to reduce health and academic disparities by serving a disproportionate number of some of the nation's most vulnerable children ( Fleming, 2011). By improving student attendance rates, school nurses help to extend educational and life opportunities for more youth, helping to create a more educated, and healthier, populace ( Kocoglu & Emiroglu, 2017). Surveillance, prevention, reporting of communicable disease, and increased population vaccine compliance rates are some examples of critical public health measures mediated by school nurses ( Swallow & Roberts, 2016).

Surveillance, prevention, reporting of communicable disease, and increased population vaccine compliance rates are some examples of critical public health measures mediated by school nurses. This article briefly reviews the background of interprofessional collaboration (IPC) and describes ways that school nurse practice aligns with core competencies to incorporate IPC. We discuss successes, such as case management and care coordination, and include challenges to IPC in the school setting.

It is estimated that 25% U.S. children have a chronic health condition. Increasing rates and complexities of chronic health conditions have shed light on the challenges of care coordination in the United States. In fact, chronic health management has become a key area of focus in many industrialized countries. It is estimated that 25% U.S. children have a chronic health condition ( Van Cleave, Gortmaker, Perrin, 2010; van der Lee, Mokkink, Grootenhuis, Heymans, & Offringa, 2007). Coordinated care requires collaboration between and among health and non-health professionals with specialized skills and knowledge to provide comprehensive, coherent, and continuous responses to patients' unique and changing healthcare needs ( Clark, Willgerodt, & Quinonez, 2017; McDonald et al., 2007). Historically, however, healthcare and other professionals have practiced in silos ( Rosenthal, 2014). Research is providing increasingly clear evidence that such silos create barriers to the provision of high quality healthcare and improved patient health outcomes ( Josiah M. Macy Jr. Foundation, 2013).

Recognition of the importance of interprofessional collaboration, effective communication, and teamwork in healthcare has grown. In 2011, the Interprofessional Education Collaborative (IPEC) Expert Panel produced Core Competencies for Interprofessional Collaborative Practice to promote patient-centered healthcare that improves safety, quality, accessibility, and efficiency. The original IPEC members represented dentistry, nursing, medicine, osteopathic medicine, pharmacy, and public health. The panel updated this report in 2016 in response to national health reforms, such as the Patient Protection and Affordable Care Act ( 2010) that emphasized the Triple Aim initiative to improve the patient experience of care; improve population health; and reduce healthcare costs ( Berwick, Nolan, & Whittington, 2008; IPEC, 2016).

The most significant updates in the 2016 report are the creation of a singular domain of Interprofessional Collaboration (IPC), and revisions of the four core competencies (and their sub-competencies) to better emphasize population health goals and to include non-health professionals as members of the healthcare team in health prevention and maintenance efforts ( IPEC, 2016). The core competencies and abbreviated descriptions of them are listed below:

Values/Ethics for Interprofessional Practice. Explicit maintenance of mutual respect and shared values.

Roles and Responsibilities. Understanding one's own and one's partners' roles and responsibilities in meeting individual patient and population health needs.

Interprofessional Communication. Communication with broad partners in health and other fields supports a team approach and helps to ensure timely responses to the promotion and maintenance of health and the prevention and treatment of disease.

Teams and Teamwork. Apply relationship-building values and principles of team dynamics to effectively plan, deliver, and evaluate patient/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable.

The new emphasis of the IPEC competencies... and collaboration with health and non-health professionals is particularly germane to school nursing... The new emphasis of the IPEC competencies on population health, prevention, and collaboration with health and non-health professionals is particularly germane to school nursing, as those elements are embodied in school nurse practice. They also are aligned with the National Association of School Nurses Framework for 21st Century School Nursing Practice ( 2016), which features five principles: care coordination, leadership, quality improvement, community and public health, and standards of practice. A chief goal of IPC, and an important reason it is embraced by an increasing number of organizations, is that its implementation is believed to better mediate the Triple Aim ( Berwick, Nolan, & Whittington, 2008). These aims also are facilitated through the work of school nurses, whose practices provide personalized onsite care, improve population health through multiple means (e.g., immunization, chronic disease management, primary prevention), and reduce healthcare and societal costs ( Baisch, Lundeen, & Murphy, 2011; Lineberry & Ickes, 2015; McClanahan & Weismuller, 2015; Swallow & Roberts, 2016; Wang et al, 2014).

The broad scope of school nursing practice requires multifaceted levels of collaboration and communication, including partnerships with non-health professionals such as teachers, school secretaries, and school administrators. School nurses must work seamlessly in the school setting (e.g., with students, parents, teachers, school administrators, coaches, athletic directors, school psychologists and counselors, speech therapists) and at the community level (e.g., with occupational and physical therapists, social workers, primary care physicians and specialists, advanced practice registered nurses, ophthalmologists, dentists, pharmacists, mental health providers, emergency medical technicians and paramedics). They must also be able to navigate complexities in healthcare such as hospital systems and health insurance providers. Successful child health outcomes rely on effective IPC and mutual adherence to its principles in this extensive communication network ( Foley, Dunbar, & Clancy, 2014).

The broad and diverse partnerships that characterize the practice of school nurses serve as an exemplar of IPC. Lessons learned from decades of IPC practiced by school nurses can foster knowledge through which IPC core competencies can be strengthened, and through which other healthcare providers and patients may benefit. The following sections of this article will address the strengths of IPC practiced by school nurses, and the barriers and facilitators that influence it.

In a recent survey, 41% of parents recently stated that case management is needed at school for their children. Care coordination and case management and are good examples of how IPC is operationalized. Both of these concepts are practiced frequently by school nurses. In a recent survey, 41% of parents recently stated that case management is needed at school for their children ( Toomey, Chien, Elliott, Ratner, & Schuster, 2013).

The Case Management Society of America ( 2016) defines case management as "a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality cost- effective outcomes" (para. 60). Care coordination is defined by McDonald et al. ( 2007) as the "deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of healthcare services" (p. 41).

In the school setting, care coordination begins with identification of students with healthcare needs. School nurses plan for and meet student health needs through a well-established process of identification that includes case finding (typically through surveillance activities such as sending home and analyzing student health registration forms) ( Educational Service District 105, 2015); conducting health screenings; and by in-person, telephone, or electronic notification (e.g., by parent, school staff, a different school district, healthcare provider, or community agency) ( Davis Alldritt, 2006). If there is a school-based health center on site, school nurses also may be notified of student health problems by practitioners working in the clinic.

Once a student health need has been identified, collaboration processes begin. Once a student health need has been identified, collaboration processes begin. Common school nurse partnerships include school-based interdisciplinary teams; teams involving various combinations of school/provider(s)/parents; and school-based health centers. The following sections describe the compositions of these teams and the dynamics that influence IPC within them, and offer recommendations for success.

School Interdisciplinary Teams
An important source of case finding is interdisciplinary teams in schools, which identify and respond to students at academic risk as required by the Individual with Disabilities in Education Act (IDEA) of 2004, and by Section 504 of the Rehabilitation Act of 1973, a federal civil rights law which prohibits discrimination on the basis of disability ( Zimmerman, 2013). These federal laws assure students' rights to access a free and appropriate public education (FAPE). All schools receiving federal funding must comply with these laws. Students referred for a special education evaluation must be assessed by qualified individuals to determine the causes of academic interference, and to develop, if necessary, an Individual Education Plan (IEP) for a student.

Students who do not qualify for special education but who have (or are suspected of having) a disability, must be assessed by a school's 504 team. Section 504 was amended in 2008, and the interpretation of disability was broadened. The law requires school districts to provide accommodations to students identified as having, or being perceived as having, a disability that limits any major life activity and hence their legal right to receive FAPE ( U.S. Department of Education, 2017). If a student is suspected of having a disability, the 504 team must meet to determine whether such disability exists or is suspected of existing, and if so, to put in place accommodations that the team determines necessary to allow the student to receive FAPE. In an analysis of data from the U.S. Office of Civil Rights, the Advocacy Institute found that 1.5% of the K-12 population reported having student plans for accommodations under Section 504. The most common impairment noted was Attention-Deficit/Hyperactivity Disorder (ADHD), followed by diabetes ( Holler & Zirkel, 2008).

The composition of interdisciplinary school teams is variable, but federal law requires that at minimum teams include the parent(s)/guardian(s), the child (if appropriate), a member who can interpret the instructional requirements of the evaluation results, and other individual(s) who have expertise in regard to related services necessary to make education accessible to the student ( Yonkaitis & Shannon, 2017). Typically, members include school administrator(s); the teacher or staff person making the referral; the school psychologist; the school lead special education or Section 504 staff member; the school nurse; and other staff who have frequent interactions with the student (e.g., music teachers, physical education teachers, librarians). A typical meeting schedule occurs weekly, but frequency of team meetings can vary based on student caseload and staff needs ( Department of Defense Education Activity, n.d.).

The school nurse is a vital participant in school interdisciplinary teams because factors that contribute to academic failure can be associated with health problems. The school nurse is a vital participant in school interdisciplinary teams because factors that contribute to academic failure can be associated with health problems. These health concerns may go undetected in the absence of a professional registered school nurse ( Yonkaitis & Shannon, 2017). Through communication that educates teachers and staff about implications of health problems and/or needed treatment; and coordinating various aspects of care, the school nurse facilitates IPC. This ensures that if an IEP and/or a 504 plan are prepared for the student, it is informed with appropriate health accommodations as needed. The most recent data (2013-14 school year) from the National Center for Education Statistics ( 2017) showed that of the nearly 13% of students who received special education services, 50% of them had documented health impairments. Such numbers highlight the importance of including school nurses on the interdisciplinary team.

Hospitals and Community Providers
If the student has or develops comorbidities, the school nurse adds a new partner and integrates new health information into the existing collaborative. In the course of providing daily healthcare for students with chronic health conditions (e.g., asthma, diabetes, seizure disorders, anaphylactic allergies), school nurses frequently collaborate to coordinate care with other healthcare professionals outside of the school setting. Such professionals typically include primary care and/or specialty providers, hospitals, and community health providers. For example, to serve an immigrant student with diabetes, IPC is critical. The school nurse may be required to interface with an endocrinologist, clinic nurse, social worker, and medical interpreter in addition to the student and family and appropriate school personnel. If the student has or develops comorbidities, the school nurse adds a new partner and integrates new health information into the existing collaborative. Other partners may be transient (e.g., in the case of a hospitalization or acute illness or injury) but necessitate communication extensions to hospital or clinic staff to incorporate any changes necessary to alter an ever-dynamic, school-based plan of care.

School-Based Health Centers
According to the School-Based Health Alliance ( 2017), there are 2,315 school-based health centers (SBHCs) operating in schools in 49 states and the District of Columbia. Most SBHCs are sponsored by hospitals, health departments, and federally qualified health centers. These centers offer primary care, but many offer also mental health and reproductive health services. Some offer dental services ( National Association of School Nurses, 2015).

When working with SBHC providers to assure coordinated care for students, school nurses face similar opportunities and challenges as with external entities. School nurses work across systems and navigate privacy laws, but do so with co-located health professional partners. Collaboration between school nurses and school-based health providers can be enhanced with mutual role definition to streamline information exchange, referrals, medication management, and other services ( Heuer & Williams, 2016).

...SBHCs should include school nurses as team members who provide health services for shared patients, collaborating to develop a shared case management structure to track care outcomes and coordinate care. The National Association of School Nurses ( NASN, 2011) advises school nurses to facilitate student access to SBHC services, an activity that can be accomplished in part by providing referrals and assisting student enrollment in SBHCs. This is common for school nurses, who routinely assist students to access health insurance, community providers, and other services. The NASN ( 2011) further advises that SBHCs should include school nurses as team members who provide health services for shared patients, collaborating to develop a shared case management structure to track care outcomes and coordinate care. To effectively collaborate and fulfill their independent and shared functions, SBHCs and school nurses should develop well-defined roles and responsibilities; practice mutual respect and support; engage in cooperative planning and implementation of school health services and programs; and share a focus on student academic outcomes ( National Association of School Nurses, 2001).

Informal Teams
There are times when student health concerns are managed more informally (i.e. outside the confines of federally mandated teams) with teams that consist of the core professional needed to develop plans of care for the student. Such team members can include parent(s); the student, if appropriate; outside provider(s); and school-based health center provider(s). The school nurse should facilitate and lead these teams ( Council of School Health, 2008).

With all teams, an important result, or product, of IPC is the development and maintenance of a student individual health plan. With all teams, an important result, or product, of IPC is the development and maintenance of a student individual health plan (IHP). This document guides health service delivery to students, and is critical to student safety, health, and sound management of chronic disease.

Individual Health Plans
As one of the few types of health providers who do not work within a dedicated healthcare setting, school nurses are practiced in flexibility and versatility as they communicate with a broad range of partners ( Wolfe, 2013). School is the place where students spend the majority of their time outside the home. Given this, and the critical contribution of good health to student learning, school nurses who serve as leaders of school-based health teams lead critical care coordination efforts ( Council of School Health, 2008). To protect student safety and improve health, part of these efforts include the integration of complex health information from multiple partners to create IHPs.

According to the National Council of State Boards of Nursing ([NCSBN], 2005), preparation of IHPs is a nursing responsibility based on standards of nursing care and regulated by state nurse practice acts. The school nurse also retains responsibility for implementing, evaluating, and updating IHPs as directed by student health outcomes based on frequent assessments of student health status in relation to specified IHP criteria ( NASN, 2016).

...the IHP integrates and clarifies student healthcare needs into a single document to promote care management in the school setting. IHPs serve multiple purposes. Zimmerman ( 2013) noted that the IHP integrates and clarifies student healthcare needs into a single document to promote care management in the school setting. The IHP establishes consistency and continuity of care, especially important for students who are frequently mobile. The clinical elements of the IHP establish care priorities, convey interventions necessary to provide that care, and coordinate services among school-based providers ( NASN, 2016).

In addition to the IHP, school nurses also plan and develop Emergency Care Plans (ECPs) to direct lay school staff in providing emergency care for students with potentially life-threatening health conditions. The ECP consolidates and distills important health information in clear language to assure that in a time of crisis, lay staff can better act with direct, clear, and succinct information ( Zimmerman, 2013).

The quality of the IHP, as with other care planning, implementation, and health outcomes, depends in part upon the quality of interprofessional communication and collaboration. IHPs are an important product of interprofessional collaboration and offer evidence to support school nurse contributions to navigating and leading the diverse, broad partnerships characteristic of IPC.

Interprofessional collaboration between and among school nurses and primary care and/or other outside healthcare providers is challenged by multiple conditions. Such challenges may include role restriction, privacy laws, conceptual and linguistic differences, and administrative and fiscal pressures ( Power, Blum, Guevara, Jones, & Leslie, 2013). These barriers are further explained in this section.

Privacy Laws
Embedded within privacy challenges are the mechanics of communication, particularly as related to electronic health records (EHRs) and sharing of information between entities. Health records maintained by school nurses become part of the school record and are subject to the Family Educational Rights and Privacy Act ( Bergren, 2001; [FERPA], 1974). Parents have a right to access such records, regardless of confidentiality laws governing student health privacy. As employees of school districts, school nurses also must abide by these education privacy laws governed by FERPA.

Health privacy laws governed by the Health Insurance Portability and Accountability Act do not govern school health records, but do govern communications between health providers. Health privacy laws governed by the Health Insurance Portability and Accountability Act ([HIPAA], 1996; Public Welfare, 2002), do not govern school health records, but do govern communications between health providers. Although HIPAA allows for communications between health providers for the purposes of coordinating care, some providers are reluctant to share identifiable patient information. Some entities, such as hospitals or clinics, may establish policies that delay the exchange of information.

Timely exchange of student health information is also compromised by the absence of shared electronic health records, in turn impeding the ability to coordinate care for healthcare providers working in or across different health systems ( Power et al, 2013). This limitation often requires school nurses to communicate via fax, e-mail, or in writing during face-to-face meetings.

Role Restriction
Many school nurses report exclusion from interdisciplinary school-based teams despite both legal directives for their presence and evidence of the multiple benefits of their participation... Barriers to nurse scope of practice are diverse, widespread, and negatively affect quality and value of care ( Institute of Medicine, 2011). Barriers that restrict the role/practice of school nurses reflect persistent silos in education and health. Many school nurses report exclusion from interdisciplinary school-based teams despite both legal directives for their presence and evidence of the multiple benefits of their participation (e.g., reduced duplication of services, improved student outcomes) ( Yonkaitis & Shannon, 2017).

While school nurses are expected to demonstrate (or at least be familiar with) knowledge of education, education law, and health law as it pertains to the provision of health services for students at school, the same knowledge about school nursing by educators is not required, or even recommended. The scarce presence of nurses in schools, due to lack of funding, is itself driven by lack of awareness of the powerful ways in which school nurses influence educational outcomes. This lack of awareness makes it difficult for educators to know and/or understand the impact of the school nurse contribution(s) on efforts of both teachers and students. There is a clear need for improvement in understanding roles and responsibilities of interdisciplinary team members and in demonstrating value for unique roles.

Fiscal and Administrative Pressures
The scarce presence of nurses in schools... is itself driven by lack of awareness of the powerful ways in which school nurses influence educational outcomes. Fiscal pressures in schools contribute to the scant and uneven presence of professional school nurses working within. This lack of school nurses imposes severe time constraints on existing nurses, limiting their availability for collaboration ( Power et al, 2013). In addition, limited time in school buildings (again, often due to fiscal pressures) exacerbates lack of understanding about the school nurse role, particularly by non-health professionals. In turn, this likely contributes to continued underfunding.

Fiscal pressures in schools contribute to the scant and uneven presence of professional school nurses working within. From an administrative perspective, in terms of case finding, school nurses report some communication barriers with providers and families, evidenced by lack of completed health history forms or timely required release of information forms ( Heuer & Williams, 2016; Svavarsdottir et al, 2013). Adaptations to this barrier have been to supplement this surveillance method with additional case finding strategies, such as screenings and outreach through classroom teaching. School nurses also are known to show leadership in IPC by working collaboratively with clinic and hospital system providers to develop streamlined processes for the timely exchange of student health information.

Conceptual and Linguistic Differences
School nurses effectively communicate and collaborate with a broad range of partners, including parents, teachers, coaches, and many health provider types. This is evidenced in part by their creation of a variety of IHPs to improve communication with different audiences. However, there can be both conceptual and linguistic differences that impede communication. Because school nurses routinely serve students with a broad spectrum of chronic diseases, they are often more conversant in the language of multiple health conditions than those who practice with focus on a single specialty. In addition, due to frequent contact and experience with different provider types, school nurses may have a better understanding of the classification systems and language under which different specialists operate ( NASN, 2016). Time and intentional effort is required to overcome these barriers as they present.

School nurses identify, treat, refer, and provide case management services for millions of students. School nurses identify, treat, refer, and provide case management services for millions of students ( McClanahan & Weismuller, 2015). As healthcare providers whose practices can both help to realize the national level Triple Aim goals and improve education and health outcomes, investment in interprofessional education is necessary.

As community-based healthcare continues to grow, interprofessional and intraprofessional collaborations are becoming increasingly important to ensuring quality and efficient case management and reduce the burden of chronic disease. This may be especially so with potential federal cuts to Medicaid that may increase the quantity and quality of school nurse caseloads. With a long history of collaboration and broad scope of partnerships, school nurses can increase understanding of the strengths and challenges of interdisciplinary communication in practice, thus helping to inform and improve IPC for nursing and other disciplines. As this article has noted, lack of understanding of the school nurse role is an impediment to attain elements of IPC core competencies, particularly the development and maintenance of mutual respect and shared values. Complexities of navigating dual education and health privacy laws; lack of interoperable electronic health records systems; and competition for scarce resources are problems that may be remedied by improvements in education and practice of IPC.

Interprofessional learning and education is necessary to break down isolated silos of practice and facilitate the development of IPEC competencies. As health providers increasingly work with community entities whose primary focus is not health, but whose outcomes are dependent on the health of the populations they serve, the need for IPE for health and non-health professionals grows stronger. For example, in Washington State, health reform efforts have given rise to development of Accountable Communities of Health (ACHs). The purpose of these regional entities is to convene diverse community partners to focus on preventive, community-based solutions to improve population health. Representatives on ACHs include persons from housing, criminal justice systems, education, hospital systems, school nursing, community health workers, environmental experts and others ( Washington State Health Care Authority, 2017).

As silos begin to dissolve, IPE for all partners can facilitate effective interprofessional collaboration and communication necessary to improve population health. Through case management and collaborative care, school nurse expertise in effective IPC fosters knowledge through which core competencies can be strengthened, with benefits for both patients and other healthcare providers.

Robin Fleming, PhD, MN, RN, NCSN
Email: fleming9@uw.edu

Dr. Fleming most recently served as Health Services Program Administrator at Washington State's education agency, the Office of Superintendent of Public Instruction. While there, she administered a statewide school nursing program, and helped to develop health policy for Washington State. Her interdisciplinary research in health and education, development of education programs for Washington State nurses, and her 13 years of service as a school nurse in Seattle Public Schools have provided rich experience in practicing and refining interprofessional and intraprofessional collaborations. Dr. Fleming received a PhD in Educational Leadership and Policy Studies at University of Washington, Seattle, and an MN and BSN from the University of Washington School of Nursing. She is an affiliate assistant professor in the Child and Family Nursing Department of the University of Washington School of Nursing, Seattle.

Mayumi A. Willgerodt, PhD, MPH/MS, RN
Email: mayumiw@uw.edu

Dr. Willgerodt earned a BSN from Georgetown University and a dual MPH/MS and PhD from the University of Illinois at Chicago. She has held faculty appointments at Rush University, UW Seattle and currently is Professor in Nursing and Health Studies at the University of Washington, Bothell campus. As a certified school nurse, Dr. Willgerodt's area of scholarship is focused on school-based health promotion research, including care coordination with children with special healthcare needs, and school nursing workforce. Dr. Willgerodt is on the editorial board of Journal of School Nursing, is on the research advisory for the National Association of School Nursing and a member of the School Nurse Organization of Washington. She is a member of numerous professional organizations, provides consultation services and volunteers with the homeless youth population in Seattle.

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key words: school nursing

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Interprofessional Collaborative Practice and School Nursing: A Model for Improved Health Outcomes

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Effective communication, teamwork, and interprofessional collaboration, or teams of health and non-health professionals working together, are critical to improving the patient experience of care; improving population health; and reducing healthcare costs (i.e., the Triple Aim). In 2016, the Interprofessional Education Collaborative (IPEC) Expert Panel updated its Core Competencies for Interprofessional Collaborative Practice.

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Nurses and providers who communicate their findings and work toward shared goals generally provide higher-quality results for patients. Imagine a patient who checks into the hospital because they’re experiencing pain while breathing. They may need to see multiple medical professionals to receive a full battery of tests and potential diagnoses.

By working together, these providers can share their findings, discuss the most likely scenarios, and create the most efficient and effective treatment plan. By arriving at the right conclusions as expediently as possible, care teams can improve patient satisfaction and lower readmission rates.

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To provide patients with the highest level of care, nursing professionals need more than just good bedside manner and advanced clinical acumen. They also need the ability to cooperate and collaborate with other health professionals, exhibiting the values of teamwork and professional camaraderie. Good teamwork is essential for not only employee morale but also the best patient outcomes.

What makes interpersonal collaboration in nursing so essential to the patient experience? For one, patients often need to receive care from multiple providers or specialists to have the most holistic, comprehensive treatment. For example, a patient who is treated for breast cancer may benefit from the interventions of an oncologist, a dermatologist, and a reconstructive surgeon.

The nurses involved need to work well with different professionals, ensuring that the full continuum of care provides the same high standards of quality and safety. Similarly, a patient who is in the hospital for an extended period of time may receive treatment from multiple nurses and doctors, making it essential for these providers to be on the same page, clinically and professionally speaking.

For nurses who wish to develop their skills in interprofessional collaboration, advanced training can be invaluable. An accelerated degree program provides the opportunity to hone various practical skills, including the skills related to teamwork in nursing.

What Is Interprofessional Collaboration in Nursing?

The concept of interprofessional collaboration is more complicated than it might seem at first. It's important to understand the definition of interprofessional collaboration in nursing, what separates it from other types of collaboration, and what skills are most essential for successful interprofessional collaboration in the nursing field.

What Is Interprofessional Collaboration?

Interprofessional collaboration occurs when professionals from different occupations work together to solve complex problems or to achieve shared goals. In the context of nursing, it means professionals from different healthcare disciplines are working together to provide patient-centered care.

For healthcare professionals, interprofessional communication usually involves three basic activities: research, education, and clinical work.

Research

To study a new disease or innovate pharmaceutical interventions, professionals from different disciplines may need to come together. For example, the development of a vaccine for children may require input from pediatricians as well as infectious disease specialists.

Education

Interprofessional collaboration is also an important aspect of education, as it gives nursing or medical students insight into different disciplines. For example, a nurse looking to develop comprehensive skills may benefit from learning under an urgent care professional, a psychiatric health provider, and a women's health specialist.

Clinical Work

Interprofessional collaboration matters in direct patient care as well. Providers from different specialties can share valuable insights into specific cases or into broader initiatives to improve an organization's safety, quality, and efficiency of care.

Comparison of Interprofessional, Multidisciplinary, and Interdisciplinary Approaches

To properly understand interprofessional collaboration in nursing, distinguishing it from both multidisciplinary and interdisciplinary approaches is important. These terms are sometimes assumed to be synonymous, but they have some important distinctions.

Interprofessional collaboration refers to any kind of team-up between different medical professionals, who may come from different disciplines or who may share the same areas of expertise.

An interdisciplinary approach can be more narrowly defined as caregivers from two different specialties interacting, such as an allergist and a dermatologist working together to help a patient with an unusual rash.

The term "multidisciplinary" may simply refer to professionals from different fields who happen to be working in the same space together. A facility housing different specialists may be called a multidisciplinary practice, even if the providers seldom collaborate directly.

Why Does Interprofessional Collaboration in Nursing Matter?

Interprofessional collaboration is important to the nursing profession because most of today's practices aim to connect patients with teams of professionals, as opposed to individual providers, to ensure holistic care. When different professionals work together in harmony, it allows them to create personalized care plans that treat the whole patient, as opposed to addressing isolated symptoms or complaints. Nurses who are skilled in collaboration can play an essential role in facilitating these interactions between providers and also in ensuring that the patient's needs remain paramount.

Key Skills for Interprofessional Collaboration

Numerous skills prove essential for nurses who wish to collaborate effectively with other nurses and providers. These skills include the following:

Clarity is key. Nurses need to be ready to convey details about a diagnosis, a treatment plan, or patient reactions to various providers and to write clear and accurate patient histories. The ability to communicate a care plan with patients and family members is also crucial.

This may seem obvious, but the significance of working well with others can't be overemphasized. Nurses need to understand that while they play an essential role, they're still part of a team in which every specialty or discipline matters.

Decision-making. Shared decision-making goes hand in hand with teamwork. The best nurses can collaborate with other providers to reach a consensus about how best to diagnose or treat a patient.

Emphasis on patient care. Most critical of all is the ability to provide personalized care to patients, exhibiting both clinical precision and a caring, compassionate bedside manner. The most effective nurses are those who can be patient advocates.

Examples of Interprofessional Collaboration in Nursing

There are many pertinent examples of interprofessional collaboration in nursing, showing how clinical professionals from many different disciplines can work together to provide the highest standards of patient care. These include examples that take place in the research, education, and clinical care settings, spanning hospitals, private practices, and community clinics.

Caring for Patients with Complex Conditions

Some of the clearest examples of interprofessional collaboration in nursing involve different providers coming together to develop effective treatments for patients who have complex medical conditions.

Countless examples of medical conditions exist that might require this type of collaborative approach. For example, consider a patient who's been in a serious accident that results in major and chronic musculoskeletal problems. This patient might require help from a pain management specialist to go about day-to-day life as well as from a rehabilitation nurse or physical therapist to regain mobility and function.

A primary care provider may also play an invaluable role in assessing long-term ramifications and in recommending strategies to promote recovery. Care for this kind of patient might take several months or years, requiring multiple clinicians to be on the same page at all times. In other words, interprofessional collaboration is key for ensuring the best patient outcomes.

Addressing Complex Pharmaceutical Plans

Another example of interprofessional collaboration in nursing is the relationship between nurses and pharmacists.

This relationship is especially important for patients who require the intervention of multiple pharmaceuticals, whether to manage a complex chronic illness or to help address multiple maladies that happen to coexist. Collaboration between nurses and pharmacists can ensure the most efficient treatment plan, preventing overmedication. It can also be an important safeguard against medications that interact in unexpected or adverse ways. Again, this is an example of collaboration as a means for achieving superior patient outcomes and for promoting patient safety.

Seeking Understanding of Social Determinants

While clinical care is one of the primary avenues for collaboration, it's also important for nurses to work with other specialists to advance clinical research.

One example of this is ongoing research into the social determinants that can affect wellness outcomes. For example, a condition like diabetes is often connected with diet, but what about other mitigating factors, such as income level, education level, and cultural context? Determining the factors that make a person more likely to have diabetes or less likely to seek treatment can be incredibly helpful, and this process can benefit from robust interprofessional collaboration between nurses, social workers, and other care professionals.

Providing Robust Clinical Education

Collaboration is also essential for ensuring that the next generation of nursing professionals receives a robust, comprehensive education.

Imagine a nursing program that offers training for helping patients who have eating disorders. This training would benefit from the input of nurses who can speak to the physical effects of an eating disorder on the body, including the potential for cardiovascular effects. At the same time, this training would be incomplete without the expertise of a psychiatric mental health practitioner who could speak to the mental and emotional dimensions of an eating disorder. Both disciplines are needed to ensure that nursing students have a clear understanding of how to intervene in the lives of their patients.

Benefits of Interprofessional Collaboration in Nursing

The benefits of interprofessional collaboration in nursing are numerous and include benefits to nurses, patients, and entire health organizations. Consider just a few of the most noteworthy benefits of interprofessional collaboration in nursing.

Improved Results

Nurses and providers who communicate their findings and work toward shared goals generally provide higher-quality results for patients. Imagine a patient who checks into the hospital because they're experiencing pain while breathing. They may need to see multiple medical professionals to receive a full battery of tests and potential diagnoses.

By working together, these providers can share their findings, discuss the most likely scenarios, and create the most efficient and effective treatment plan. By arriving at the right conclusions as expediently as possible, care teams can improve patient satisfaction and lower readmission rates.

Reduced Cost of Care

Interprofessional collaboration can reduce errors - and, in turn, reduce costs. Healthcare organizations that emphasize collaboration tend to have fewer redundant tests and unnecessary treatments; this not only helps the organization itself be more efficient but also lowers the end cost for patients. Consider that when a nurse reviews the diagnostic tests that a previous nurse has already performed, it may rule out the need to perform some of these tests again or even point toward a diagnostic path that might prove more fruitful.

Increased Job Satisfaction

A collaborative spirit generally creates a more positive work environment. After all, a workplace that emphasizes interpersonal collaboration will usually elevate diverse voices and help all nurses feel empowered to speak up and participate in clinical decision-making. By providing nurses with a greater sense of autonomy, health organizations can reduce burnout and turnover while promoting employee engagement. All this contributes to stronger, more cohesive teams and lowered human resources costs.

Easier Access to Information

Sometimes, a specific type of information or technology may be restricted to a particular specialty or department. Interpersonal collaboration can make these resources more widely available and help doctors and nurses have a more accurate and holistic sense of the entire patient care process. For example, when a primary care provider can easily access records from a specialist, it can lead to more efficient and data-driven decisions about patient treatment plans.

Skill Formation

Still, another of the benefits of interprofessional collaboration is that it gives nurses opportunities to cultivate diverse skill sets. This is true of collaboration across not only different clinical specialties but also different types of administrative work. For example, working closely with front-office team members can help nurses become more proficient in organization, computer skills, and customer service. Every collaborative relationship can be a learning experience for both parties.

A Curriculum to Prepare for a Nursing Career

Success in the nursing profession is predicated on sound training and thorough education. This is true even of fostering interprofessional collaboration in nursing. In order to develop the professional skills needed to work well with other caregivers, obtaining the right kind of training is essential.

Choosing a BSN to DNP Program

While registered nurses (RNs) only need to have undergraduate-level degrees, most commonly Bachelor of Science in Nursing (BSN) degrees, some nurses may wish to pursue a terminal degree in their profession. The Doctorate of Nursing Practice (DNP) leads to an opportunity to develop sophisticated nursing skills, including a deeper level of insight into health policy, nurse leadership, and clinical ethics.

Many nurses with a BSN may be drawn to a program like Maryville University's online BSN to DNP program because it not only affords the opportunity to hone DNP skills but also is condensed and accelerated. In other words, students can skip the Master of Science in Nursing (MSN) step, earning their DNP on a shorter timeline.

About the BSN to DNP Curriculum

Maryville's BSN to DNP program boasts a robust curriculum, supplying students with comprehensive insight into advanced practice nursing. Coursework includes the following:

Theoretical Foundations of Nursing Practice. In this course, nurses become more adept at applying different nursing paradigms, theories, and frameworks to real-world cases, arriving at the best clinical decisions to promote patient health and safety.

Evidence-Based Practice in Nursing. In this course, nursing students grow in their understanding of evidence-based practice as it relates to changing and improving nursing practice. Evidence-based practice is the deliberate use of current best practice in making informed decisions regarding patient treatment and care.

Ethics for Advanced Nursing Practice. In this course, DNP students analyze a wealth of interprofessional literature to consider real-life ethical conundrums and develop a fully formed ethic of nursing practice.

Professional Role Development. In this course, students evaluate all the different roles that advanced practice nurses can serve in the healthcare system, considering not just implications for patient care but also legal and ethical considerations.

Advanced Health Assessment. In this course, DNP students are furnished with a robust tool box for completing patient health assessments, which nurses must be prepared to conduct in various settings, efficiently and effectively, all with the ultimate goal of wellness promotion.

Foundations of Clinical Scholarship. In this course, students are allowed to work on their professional skills, including skills related to writing and to research. This can be an especially impactful course for those looking to develop interprofessional collaboration abilities.

Establish a Collaborative Nursing Career

The most successful nurses know how to work harmoniously and productively with other clinical professionals, advancing efficient treatment plans and pursuing the best possible patient outcomes. To develop a truly collaborative practice, the right education is essential.

Consider an advanced training path, such as Maryville's online BSN to DNP. In this program, students have the opportunity to develop the competencies needed to create workplace cultures that truly prioritize interprofessional collaboration in nursing. Find out more about the BSN to DNP program and how it can prepare you for a rewarding career as part of a patient care team.

Recommended Readings
Regional vs. National Accreditation for Nursing Programs Nurse Practitioner vs. LPN: Comparing Two Nursing Careers A DNP Nurse's Role in Hospitals of the Future
Sources:
American Journal of Critical Care, Interprofessional, Interdisciplinary, or Multidisciplinary? BMC Primary Care, "What Do Patients Experience? Interprofessional Collaborative Practice for Chronic Conditions in Primary Care: An Integrative Review" Indeed, Guide to Interprofessional Collaboration in Healthcare Indeed, Interprofessional Collaboration for Health Care Environments Journal of Nursing Management, "Interprofessional Collaboration as a Mediator in the Relationship Between Nurse Work Environment, Patient Safety Outcomes and Job Satisfaction Among Nurses" Oman Medical Journal, "Interprofessional Education and Collaboration: Strategies for Implementation" QliqSOFT, "5 Benefits of Interprofessional Collaboration in Healthcare"

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Interprofessional Collaboration in Nursing: Examples and Benefits | MVU

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What are some examples of interprofessional collaboration in nursing? Learn about the benefits of nurses working together in an interdisciplinary way.

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Recommendation: Update the Scope of Nursing Informatics Practice to include the informatics nurse as a key participant in the healthcare team and expert in collaboration.

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Recommendation: Update the Scope of Nursing Informatics Practice to include the informatics nurse as a key participant in the healthcare team and expert in collaboration.

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A relationship of continuous collaboration between physician and nursing informatics specialties is essential.

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Provide an example of how you have applied an IPEC or QSEN competency in your current role and describe the potential impact it had on patient outcomes.

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Viewing nurses’ work through the lens of quality and safety requires a contemporary approach that incorporates systems thinking. A crucial skill, systems thinking helps nurses to meet the challenge of improving healthcare as they move beyond the application of the QSEN competencies from individual patients and families to accelerate the overall improvement of healthcare quality and safety.

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Mary A. Dolansky, PhD, RN

Mary A. Dolansky, PhD, RN

Mary A. Dolansky is an Associate Professor at the Frances Payne Bolton School of Nursing, Case Western Reserve University in Cleveland, OH. Dr. Dolansky is Director of the QSEN Institute (Quality and Safety Education for Nurses) and Senior Fellow in the VA Quality Scholars program, mentoring pre- and post-doctoral students in quality and safety science. She has co-published two books on quality improvement, co-authored several book chapters and articles, and was guest editor on a special quality improvement education issue in the Journal of Quality Management in Health Care. She has taught the interdisciplinary course, "Continual Improvement in Health Care," at CWRU for the past 8 years and was chair of the quality and safety task force at the School of Nursing that integrated quality and safety into the undergraduate and graduate curriculum.

Shirley M. Moore, PhD, RN, FAAN

Shirley M. Moore, PhD, RN, FAAN

Shirley M. Moore is the Edward J. and Louise Mellon Professor of Nursing and Associate Dean for Research, Case Western Reserve University in Cleveland, OH. She is a past President of the Academy for Healthcare Improvement and is on the leadership team of the national Quality and Safety Education for Nurses (QSEN) project. She is currently leading the integration of nurse scholars in the VA Quality Scholars Program. She also is conducting NIH-funded studies testing a process improvement approach to health behavior change with patients.

Over a decade has passed since the Institute of Medicine's reports on the need to improve the American healthcare system, and yet only slight improvement in quality and safety has been reported. The Quality and Safety Education for Nurses (QSEN) initiative was developed to integrate quality and safety competencies into nursing education. The current challenge is for nurses to move beyond the application of QSEN competencies to individual patients and families and incorporate systems thinking in quality and safety education and healthcare delivery. This article provides a history of QSEN and proposes a framework in which systems thinking is a critical aspect in the application of the QSEN competencies. We provide examples of how using this framework expands nursing focus from individual care to care of the system and propose ways to teach and measure systems thinking. The conclusion calls for movement from personal effort and individual care to a focus on care of the system that will accelerate improvement of healthcare quality and safety.

Key words: QSEN, quality, safety, systems, QSEN competencies, education, measurement

...national healthcare quality organizations, such as the Leapfrog Group, report that the majority of hospitals have demonstrated little progress in improving quality and safety.Over a decade has passed since the Institute of Medicine (IOM) report, To Err Is Human: Building a Safer Health System, and the follow-up report, Crossing the Quality Chasm, which turned healthcare professionals' attention to the importance of improving healthcare outcomes ( IOM, 2000; Committee on the Quality, 2001). These reports highlighted the need to redesign systems of care to better serve patients in the complex healthcare environment. During the last decade, national initiatives to improve quality and safety have been implemented, such as the Institute for Healthcare Improvement's (IHI) Transforming Care at the Bedside, 5 Million Lives Campaign, and the Triple Aim ( IHI, 2013a; IHI, 2013b; IHI, 2013c). To accelerate change, regulatory agencies have implemented National Patient Safety Goals, Core Measures, ( Joint Commission, 2013a; 2013b; 2013c), and Hospital Acquired Conditions (HAC) Never Events ( Kuhn, 2008). Yet national healthcare quality organizations, such as the Leapfrog Group, report that the majority of hospitals have demonstrated little progress in improving quality and safety. For example, although we know that zero central line infections should be a reality in hospitals, thousands of infections are still reported each year ( Clark, 2013).

QSEN is a national movement that guides nurses to redesign the 'what and how' they deliver nursing care so that they can ensure high-quality, safe care. In 2005, nursing leaders responded to the IOM call to improve the quality of healthcare by forming the Quality and Safety Education for Nurses (QSEN) initiative funded by the Robert Wood Johnson Foundation. The QSEN initiative consisted of the development of quality and safety competencies that serve as a resource for nursing faculty to integrate contemporary quality and safety content into nursing education ( QSEN Institute, 2013). The focus of QSEN, now the QSEN Institute, has expanded from undergraduate nursing students' education to include quality and safety education for all nurses. The mission of QSEN is to address the challenge of assuring that nurses have the knowledge, skills, and attitudes (KSA) necessary to continuously improve the quality and safety of the healthcare systems in which they work. QSEN is a national movement that guides nurses to redesign the 'what and how' they deliver nursing care so that they can ensure high-quality, safe care. Linda Cronenwett, PhD, RN, FAAN, the founder of QSEN, often states that QSEN helps nurses to identify and bridge the gaps between what is and what should be and helps nurses focus their work from the lens of quality and safety (Personal Communication, 2013).

Viewing nurses' work through the lens of quality and safety requires a contemporary approach that incorporates systems thinking. A crucial skill, systems thinking helps nurses to meet the challenge of improving healthcare as they move beyond the application of the QSEN competencies from individual patients and families to accelerate the overall improvement of healthcare quality and safety. In this article, we review the history of QSEN and propose a framework that expands nursing focus from individual care based on personal effort and care of the individual to systems thinking and care of the system. Examples are provided to demonstrate how to integrate systems thinking in the application of QSEN competencies and how systems thinking can be taught and measured.

Although QSEN competencies have spurred quality and safety in nursing education, it is now time to accelerate their use and impact. In response to calls for improved quality and safety, leaders from schools of nursing across the country joined forces to create the Quality and Safety Education for Nurses (QSEN) initiative. The Robert Wood Johnson Foundation in 2005 funded QSEN Phase 1 and three subsequent phases followed ( Table 1). The major QSEN contribution to healthcare education was the creation of six QSEN competencies (modeled after the IOM reports) and the pre-licensure and graduate-level knowledge, skills, and attitude (KSA) statements for each competency ( Cronenwett et al., 2007). The competency statements provide a tool for faculty and staff development educators to identify gaps in curriculum so that changes to incorporate quality and safety education can be made ( Barnsteiner et al., 2013). The QSEN website serves as a national educational resource and a repository for nurses to publish contemporary teaching strategies focused on the six competencies: patient-centered care, teamwork and collaboration, evidenced-based practice, quality improvement, and informatics. Currently, there are over 100 teaching strategies posted.

Table 1. History of QSEN

Phase

Details

Websites and References

Phase 1 a

October 2005-March 2007

QSEN competencies and their requisite KSAs

QSEN.org website

qsen.org/competencies/pre-licensure-ksas/
Cronenwett et al., 2007

Phase 2 a

April 2007-October 2008

Funded 15 pilot schools to use the IHI Learning Collaborative method to develop, test, and disseminate teaching strategies

Peer reviewed teaching strategies on the website

qsen.org/about-qsen/pilot-schools-june-2007-november-2008/http://qsen.org/teaching-strategies/

Phase 3 a

November 2008-February 2012

National forums to educate nursing faculty

Incorporation of nurses into the Veterans Affairs (VA)

Quality Scholars program (VAQS- 2 year pre or post-doctoral fellowships in quality and safety)

Faculty modules to the QSEN website

8 regional Faculty Development workshops (train the trainer) were coordinated by the AACN

http://qsen.org/conferences/VAQS.org http://qsen.org/faculty-resources/learning-modules/Barnsteiner et al., 2013 http://qsen.org/faculty-resources/aacn-workshop-modules/

Phase 4 a

March 2012-March 2014

American Association of Colleges of Nursing (AACN) funded to further develop graduate competencies and coordinate 5 graduate level faculty development conferences

www.aacn.nche.edu/faculty/qsen/competencies.pdf www.aacn.nche.edu/qsen/faculty-development

San Francisco Bay Area (SFBA) QSEN Faculty

Development Institute b

2009-2013

AACN implementation and evaluation of impact of incorporating the QSEN content into 22 schools of nursing in the San Francisco Bay area. Funding for a series of workshops for faculty and clinical leaders

Disch et al., 2013 apps.aacn.nche.edu/qsenec/GBMFoverview.html

Academic/Clinical Partnership and collaboration in QSEN

Lourdes University and ProMedica c

Innovative educational model for undergraduate education that includes a clinical integration partner to assist with the QSEN-based clinical education model

Didion, Kozy, Koffel, Oneail, 2013 www.rwjf.org/en/research-publications/find-rwjf-research/2013/04/academic-clinical-partnership-and-collaboration-in-quality-and-s.html

QSEN Institute

July 2012 to present

The Frances Payne Bolton School of Nursing at Case Western Reserve University continues to host the website and the National QSEN forum

QSEN.org

aRobert Wood Johnson Foundation funding
bGordon and Betty Moore Foundation funding
c Bureau of Health Professions, Health Resource and Services Administration, Department of Health and Human Services Nurse Education Practice, Quality and Retention

QSEN competencies have been used by national nursing organizations and are the central focus of the National Council of State Boards of Nursing (n.d.) Nurse Residency program, the foundational concepts in the Massachusetts Future of Nursing Framework ( Massachusetts Department of Higher Education, 2010), and the Ohio Hospital Association ( Ohio Organization of Nurse Executives, 2013). The QSEN competencies also have been incorporated into nursing textbooks such as the medical-surgical text by Ignatavicious and Workman ( 2013), and other books, such as Quality and Safety in Nursing: A Competency Approach to Improving Outcomes ( Sherwood & Barnsteiner, 2012), Second Generation QSEN, a special issue of the Nursing Clinics of North America ( Barnsteiner & Disch, 2012) and Quality and Safety for Transformational Leadership ( Amer, 2012).

Although QSEN competencies have spurred quality and safety in nursing education, it is now time to accelerate their use and impact. The full effect of the QSEN competencies to improve the quality and safety of care can only be realized when nurses apply them at both the individual and system levels of care. Many nurse educators report that the QSEN competencies are already integrated into their curriculum, but in our practice, we have noted that often this integration is at the individual level of care, rather than at the level of the system of care. The full effect of the QSEN competencies to improve the quality and safety of care can only be realized when nurses apply them at both the individual and system levels of care. Figure 1 provides a display of how the six QSEN domains are linked to optimal patient care through both vigilant individual care and vigilant systems of care. Traditionally, nurses have focused primarily on vigilant individual care; less attention has been given to assisting nurses to provide vigilant systems of care. We propose that in addition to the emphasis on teaching critical thinking skills ( Simpson & Courtney, 2002), nurses also need to be taught the knowledge and skills associated with systems thinking. In their day-to-day work, nurses' abilities to engage in better problem-solving, priority setting, delegation, interactions and collaborations, decision making, and action-taking are greatly influenced by their ability to view how any one component of their work system is related to other components and to the whole.

Figure 1 Source: Authors

Systems thinking is the ability to recognize, understand, and synthesize the interactions and interdependencies in a set of components designed for a specific purpose. This strategy includes the ability to recognize patterns and repetitions in interactions and an understanding of how actions and components can reinforce or counteract each other. These relationships and patterns occur at different dimensions: temporal, spatial, social, technical or cultural ( Oshry, 2007). Systems thinking links a person's environment to his/her behavior. In the delivery of nursing care, this involves the nurse's understanding and valuing how components of a complex healthcare system influence care of an individual patient. Systems thinking can be viewed as a continuum, ranging from the individual to the larger internal and external environmental components. Figure 2 shows examples of care approaches that represent increasing levels of systems thinking.

Figure 2 Source: Authors

Systems thinking links a person's environment to his/her behavior. How nurses view both themselves as nurses, and their work, is shaped by the structures and processes of the systems in which they work. Most nurses provide care in healthcare organizations that are characterized as complex, multilevel, and multifunctional. Greater knowledge and application of systems thinking skills by nurses have the potential to mitigate errors in practice, improve nurse priority setting and delegation, enhance problem solving and decision-making, improve timing and quality of interactions with other professionals and patients, and enhance workplace quality improvement initiatives. The ability to engage in systems thinking has been viewed as a key component in the successful delivery of safe and high quality care ( Bataldan & Mohr, 1997; Bataldan & Leach, 2009; Batalden & Stoltz, 1993; Senge, 2006). Systems thinking is required to redesign healthcare to improve the quality and safety of care.

The importance of systems thinking in quality improvement (QI) initiatives was identified in early literature on application of QI techniques to healthcare ( Batalden & Stoltz, 1993; Deeming & Appleby, 2000) and, more recently, was highlighted in reports from the Institute of Medicine ( IOM, 2003), the Accreditation Council for Graduate Medical Education ( Varkey, Karlapudi, Rose, Nelson, & Warner, 2009), and the article, "Quality and Safety Education for Nurses" ( Cronenwett, Sherwood & Barnsteiner, 2007). Given the hypothesized importance of systems thinking in the success of quality and safety in healthcare, it is probable that if nurses engage in better systems thinking, greater improvements in outcomes will be achieved. Knowledge and skills associated with systems thinking, however, are seldom addressed in basic or continuing nursing education. The next sections describe strategies for teaching and learning systems thinking, especially as related to QSEN competencies, and a newly developed tool for measurement of systems thinking.
Teaching and Learning Systems Thinking
Systems thinking is an essential skill for nurses. Yet, there has been little knowledge disseminated about how to assist nurses to better engage in this type of thought process, despite their key roles in planning, delivering, and improving patient care in complex organizations. To teach systems thinking it is important to enhance the learner's awareness of the interdependencies in people, processes, and services and to view problems as occurring as part of a chain of events of a larger system, rather than as independent events.

The clinical environment is an ideal place to teach systems thinking in undergraduate, graduate, and staff development education. During the clinical experience, the faculty preceptor can broaden the learner's problem identification from a focus on personal effort in a single situation to a focus on sequences of events with possible multiple causes for both individuals and populations. Table 2 provides examples of this continuum of systems thinking using the QSEN competencies. An example of a teaching technique for systems thinking is to have learners create grids such as those presented in Table 2 to expand their scope of thinking from the individual to the system level of care. Students might obtain outcome data from their unit and identify reasons for variation across time. Enhancing systems thinking skills also can be done by having learners complete an assessment of their unit or microsystem.

Assessment tools are available from the Clinical Microsystem ( 2013) Green Books for inpatient, emergency room, long-term care, and outpatient groups. These free workbooks from the Dartmouth Institute have been developed to help individuals assess the complexity of the system in which they work. Another approach to expand learners' scope of thinking to a systems level is to have them connect nursing skills and clinical issues to national quality and safety initiatives ( Armstrong & Barton, 2013). For example, urinary care is connected to the National Quality Forum ( 2012) Catheter Associated Urinary Tract Infection (CAUTI) prevention and the Joint Commission's ( 2013c) National Patient Safety Goal Number 7.

Nurses can also learn systems thinking by creating flowcharts or process diagrams that elicit the steps of a care process and the multitude of healthcare workers involved in that process. This mapping technique is one of the first steps of a quality improvement project. For example, to improve the care coordination of preparing hospitalized patients for discharge, teams of healthcare professionals could map steps in the course of a patient's stay leading to discharge. This exercise has been shown to increase knowledge about system factors and enhance awareness of the importance of interprofessional collaboration ( Brennen, Olds, Dolansky, Estrada, & Patrician, in press).

Another approach to teach systems thinking is to have learners conduct a root cause analysis ( Lambton & Mahlmeister, 2010; Tschannen & Aebersold, 2010). Root cause analysis (RCA) is a widely used technique to assist people to move beyond blame of an individual for errors made in the workplace to understanding the system factors that may have contributed to errors. Healthcare organizations routinely perform RCA after an event so that appropriate changes can be made in the system to prevent future errors. This technique could be used to understand system factors even when events "almost happen." Having nursing students participate in RCAs during their undergraduate education has been shown to be beneficial ( Dolansky, Druschel, Helba, & Courtney, 2013). For example, having students conduct an RCA for addressing a medication error may lend a new perspective to how system level factors interact with individual level factors in the creation of that error.

In the classroom setting, systems thinking also can be enhanced by using case studies. The book Set Phasers to Stun ( Casey, 1998) includes stories of design, technology, and human error that can be discussed in class. These stories identify the close connection between technology and humans. Another book, Systems Concepts in Action ( Williams & Hummelbrunner, 2011), is a practitioner's toolkit to teach the principles of systems thinking, such as system dynamics, outcome mapping, and social network analysis. Highly effective and very interactive, the game Friday Night in the ER ( 2009) guarantees learning and fun. The game is played by four people and simulates the challenge of managing a hospital during a 24-hour period. Each player is in charge of a unit. The demands of the game demonstrate that systems thinking is the key to success.

Lastly, teaching systems thinking requires guided reflection. Faculty need to assist learners to look for and recognize patterns in systems of care by standing back, reflecting on data, and considering the system as a whole. Too often in healthcare we make quick judgments that are based on limited information and preconceived ideas. Teaching nurses to step back and consider the dependencies and interconnectedness of system components will lead to a broader understanding of the healthcare system and the quality of care that results from that system.
Measurement of Systems Thinking
To improve systems thinking, we need to be able to measure it. A valid and reliable measure of systems thinking is now available. The Systems Thinking Scale (STS) is an instrument that measures healthcare professionals' systems thinking specifically related to system interdependencies. The 20-item STS has good reliability as demonstrated by a test-retest reliability assessment (N=36; correlation of .74) and internal consistency testing (N=342) using Cronbach's alpha (.89) ( Case Western Reserve University, 2013b).

...systems thinking can be taught and learned and an individual's level of systems thinking can be changed. Data from recent studies indicated that systems thinking can be taught and learned and an individual's level of systems thinking can be changed ( Abourmatar et al., 2012; Moore, Dolansky, Palmieri, Singh, & Alemi, 2010). Moore and colleagues tested three groups of healthcare professions students (n= 102) who received high, low, or no dose levels of systems thinking education. There were no differences in STS mean scores at pretest. At posttest, the high-dose systems thinking education group scored significantly higher on the STS than both the low and no-dose groups (p=.05 and .01, respectively). The STS is now publicly available for use and a website has been established to provide information on its use ( Case Western Reserve University, 2013a).

Almost 10 years have passed since the QSEN competencies were developed, and the field of quality and safety is rapidly advancing. The time has come to consider what new competencies should be added. We propose that the current QSEN competencies and knowledge, skills, and attitudes (KSAs) be reviewed and evaluated. Do the KSAs need to be updated, reclassified, or expanded? Should a systems perspective be made more prominent in the QSEN model? The QSEN competencies were developed to be a tool to promote better education for nurses in healthcare quality and safety. We need to update the QSEN competencies to be as useful as possible to prepare all nurses to ensure the highest level of care possible.

... a safe and high quality system of care requires that all healthcare professionals take responsibility to learn and apply skills associated with improving the wider system of care. Throughout QSEN history, reports from nurses and nurse faculty are that they already integrate the QSEN competencies into education and practice. However, we have observed that, despite the fact that contemporary approaches to quality and safety emphasize a systems view, much of the nursing education approach to teaching quality and safety (including application of the QSEN competencies) emphasizes personal effort at the individual level of care. Although we believe that personal expertise of the nurse with individual patients is necessary, a safe and high quality system of care requires that all healthcare professionals take responsibility to learn and apply skills associated with improving the wider system of care. We argue, therefore, that the QSEN competencies should be integrated into nursing curriculum and practice with a strong systems-perspective emphasis. Nurse faculty and staff development educators must critically evaluate the extent to which they apply QSEN competencies and at what levels.

Mary A. Dolansky, PhD, RN
Email: mad15@case.edu

Mary A. Dolansky is an Associate Professor at the Frances Payne Bolton School of Nursing, Case Western Reserve University in Cleveland, OH. Dr. Dolansky is Director of the QSEN Institute (Quality and Safety Education for Nurses) and Senior Fellow in the VA Quality Scholars program, mentoring pre- and post-doctoral students in quality and safety science. She has co-published two books on quality improvement, co-authored several book chapters and articles, and was guest editor on a special quality improvement education issue in the Journal of Quality Management in Health Care. She has taught the interdisciplinary course, "Continual Improvement in Health Care," at CWRU for the past 8 years and was chair of the quality and safety task force at the School of Nursing that integrated quality and safety into the undergraduate and graduate curriculum.

Shirley M. Moore, PhD, RN, FAAN
Email: smm8@case.edu

Shirley M. Moore is the Edward J. and Louise Mellon Professor of Nursing and Associate Dean for Research, Case Western Reserve University in Cleveland, OH. She is a past President of the Academy for Healthcare Improvement and is on the leadership team of the national Quality and Safety Education for Nurses (QSEN) project. She is currently leading the integration of nurse scholars in the VA Quality Scholars Program. She also is conducting NIH-funded studies testing a process improvement approach to health behavior change with patients.

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September 30, 2013

DOI: 10.3912/OJIN.Vol18No03Man01

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key words: qsen

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Quality and Safety Education for Nurses (QSEN): The Key is Systems Thinking

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Over a decade has passed since the Institute of Medicine’s reports on the need to improve the American healthcare system, and yet only slight improvement in quality and safety has been reported. The Quality and Safety Education for Nurses (QSEN) initiative was developed to integrate quality and safety competencies into nursing education.

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https://healthipe.utexas.edu/core-competencies-interprofessional-collaborative-practice

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Negative Experiences that Could Have Been Improved with Interprofessional Collaborative Practice

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The nurse practitioner role, with its expertise in both medicine and nursing, is known to enhance collaboration and promote interprofessional care delivery.

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Abstract

Objective

Interprofessional care, an aim of institutional healthcare settings globally, promotes safe, cost-effective, quality care. How professionals act to enable interprofessional care has not been described. The nurse practitioner role, with its expertise in both medicine and nursing, is known to enhance collaboration and promote interprofessional care delivery. The objective of this study was to identify, from the healthcare professionals' perspective, nurse practitioner strategies used to enhance interprofessional care.

Method

A hermeneutic phenomenology design was employed. Healthcare professionals from acute care hospitals and associated long-term care residences (n = 6) in one Canadian province were invited to participate. Individual interviews were held with healthcare professionals (n = 52) who regularly work with a nurse practitioner. The participants were asked to share experiences that held significance or value in promoting interprofessional care.

Results

Four valued role attributes were identified; consistent role presence, time to focus on the patient, effective communication, and respectful centrality. Identified strategies extending from the attributes included knowledge sharing, respectful negotiation, identifying patient issues, being open and transparent, listening to opinions, bridging professions, and working as the hub of the group. Multiple types of interprofessional relationships were perceived, with the hierarchical type as the most common.

Conclusions

Nurse practitioners in acute care hospital and long-term care settings have valued attributes that can promote interprofessional care. Effective strategies to promote interprofessional care emerge from these role attributes. However, the interprofessional relationship type perceived could enhance or impede the contribution of the strategies to interprofessional care promotion.

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A qualitative study of nurse practitioner promotion of interprofessional care across institutional settings: Perspectives from different healthcare professionals

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Interprofessional care, an aim of institutional healthcare settings globally, promotes safe, cost-effective, quality care. How professionals act to en...

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The emergence of interprofessional collaboration and practice as a means to provide patient-centered care and to decrease the current fragmentation of health care services in the 21st century provides a clear and unique opportunity for the advanced practice registered nurse (APRN) to assume a key role.

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Affiliations

¹ Professor of Nursing, Murray State University, Murray, KY 42017.. Electronic address: kfarrell@murraystate.edu.

² Professor of Nursing, WellStar School of Nursing, Kennesaw State University, Kennesaw, GA 30144.. Electronic address: lpayne3@kennesaw.edu.

³ Professor of Nursing, University Texas Health Science Center at San Antonio, TX.. Electronic address: heye@uthscsa.edu.

Affiliations

¹ Professor of Nursing, Murray State University, Murray, KY 42017.. Electronic address: kfarrell@murraystate.edu.

² Professor of Nursing, WellStar School of Nursing, Kennesaw State University, Kennesaw, GA 30144.. Electronic address: lpayne3@kennesaw.edu.

³ Professor of Nursing, University Texas Health Science Center at San Antonio, TX.. Electronic address: heye@uthscsa.edu.

Abstract

The emergence of interprofessional collaboration and practice as a means to provide patient-centered care and to decrease the current fragmentation of health care services in the 21st century provides a clear and unique opportunity for the advanced practice registered nurse (APRN) to assume a key role. For APRNs and other health care providers, to participate effectively as team members requires an interprofessional mindset. Development of interprofessional skills and knowledge for the APRN has been hindered by a silo approach to APRN role socialization. The Institute of Medicine Report (IOM; 2010) states that current health care systems should focus on team collaboration to deliver accessible, high-quality, patient-centered health care that addresses wellness and prevention of illness and adverse events, management of chronic illness, and increased capacity of all providers on the team. The purpose of this article is to demonstrate the need to incorporate interprofessional education (IPE) into the socialization models used in advanced practice nursing programs. IPE requires moving beyond profession-specific educational efforts to engage students of different health care professions in interactive learning. Being able to work effectively as member of a clinical team while a student is a fundamental part of that learning (Interprofessional Education Collaborative Expert Panel, 2011). The objective of IPE curriculum models in graduate nursing programs is to educate APRNs in the development of an interprofessional mindset. Interprofessional collaboration and coordination are needed to achieve seamless transitions for patients between providers, specialties, and health care settings (IOM, 2010). Achieving the vision requires the continuous development of interprofessional competencies by APRNs as part of the learning process, so that upon entering the workforce, APRNs are ready to practice effective teamwork and team-based care. Socialization of the professional APRN role must integrate interprofessional competencies and interactions to prepare APRNs accordingly.

Keywords: Advanced practice nursing; Interprofessional collaboration; Socialization.

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national center for biotechnology information

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Integrating interprofessional collaboration skills into the advanced practice registered nurse socialization process - PubMed

# data[].attributes.attachment_link.description
The emergence of interprofessional collaboration and practice as a means to provide patient-centered care and to decrease the current fragmentation of health care services in the 21st century provides a clear and unique opportunity for the advanced practice registered nurse (APRN) to assume a key ro ...

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According to the World Health Organization, by implementing interprofessional collaboration and learning to work together and respecting one another's perspectives in healthcare, multiple disciplines can work more effectively as a team to help improve patient outcomes.

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As the delivery of healthcare evolves to become more interconnected, coordinating care between nurses, pharmacists, physicians, social workers and other disciplines has become increasingly important. In its simplest form, interprofessional collaboration is the practice of approaching patient care from a team-based perspective.

According to the World Health Organization, by implementing interprofessional collaboration and learning to work together and respecting one another's perspectives in healthcare, multiple disciplines can work more effectively as a team to help improve patient outcomes. "Healthcare is dependent on many different disciplines working together to address patient needs," said Heidi Sanborn, RN, MSN, CCRN, a clinical assistant professor at the Arizona State University College of Nursing and Healthcare Innovation in Phoenix, Ariz.

"There is a significant amount of research to show that patient outcomes, quality of care and cost of care delivery are all optimized when disciplines work together toward a shared goal that focuses on the patient."

According to Sanborn, historically, interprofessionalism was not a part of the traditional health science education system. Each discipline went to school for their specific specialty - i.e., nursing school, medical school, pharmacy school - and was immersed in a solitary perspective. However, Sanborn notes that when healthcare providers can identify themselves as an integral part of a larger healthcare team, rather than just learning their discipline-specific role, patients can receive the best care - the ultimate goal of each specialty, explained Sanborn.

"When we refocus our work through a lens of interprofessionalism, we can help reduce inefficiencies in patient care," said Sanborn. "This means that assessments and treatments are done together, and the focus is on the patient as a whole rather than a specific diagnosis or treatment."

Additionally, Sanborn noted how important it is for nurses to play a role in the healthcare team in order to offer their unique and vital perspective.

"Nursing has long been the champion profession of viewing the patient as a whole," said Sanborn. "We as nurses excel at seeing our patients within the context of their environment, whether that means family, community or other social identity. And we incorporate that view into our care plans through nursing diagnoses and the nursing process."

The national conversation about the need for interprofessional collaboration began when the Institute of Medicine first discussed the merits of team-based care and interprofessional education in 1972. Additionally, on a national level, the passage of the Recovery and Reinvestment Act in 2009 and the Patient Protection and Affordable Care Act of 2010 emphasized the importance of interprofessional practice within the primary care environment. Fast forward to 2015, and most nurses and nursing students now experience interprofessional teamwork in their clinical settings. Sanborn noted that one of the most recognizable examples of modern-day interprofessionalism is "multidisciplinary rounds," when an interprofessional team meets to discuss and develop patient care together.

"The most patient-centered, successful efforts in healthcare that we have seen so far occur in organizations that model interprofessional teamwork from the bedside right into the boardroom," said Sanborn. For nurses who would like to implement or increase interprofessionalism in their practice, Sanborn advises to simply start by embracing the nurse identity as part of a patient's team. When caring for a patient, make an effort to talk to the other disciplines involved in their care. "Share your assessments, and ask about theirs," said Sanborn.

"This process will help identify common goals and pave the way for collaborative efforts to reach these goals. Many hospital committees now involve multiple disciplines, and nurses can join these committees. The best way to learn more, and champion a change, is to become involved." For more information about the importance of fostering interprofessional collaboration, read the Campaign for Action's statement at campaignforaction.org .

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The Importance of Interprofessional Collaboration in Healthcare

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As the delivery of healthcare evolves to become more interconnected, coordinating care between nurses, pharmacists, physicians, social workers and other disciplines has become increasingly important. In its simplest form, interprofessional collaboration is the practice of approaching patient care from a team-based perspective.

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A critical assessment of current health care practices, as well as the training needs of various health care providers, is crucial for improving patient care. Several approaches have been proposed for defining these needs with attention on communication as a key competency for effective collaboration.

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Recommendation #2: Update the Scope of Practice in Nursing Informatics for ethical considerations with the use of Electronic Health Records related to interprofessional collaboration. 

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Recommendation #2: Update the Scope of Practice in Nursing Informatics for ethical considerations with the use of Electronic Health Records related to interprofessional collaboration. 

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With the passage of the Health Information Technology for Economic and Clinical Health Act in 2009, the United States, as of 2017, has achieved 95% saturation with electronic health records as a means to document healthcare delivery in acute care hospitals and guide clinical decision making. Evidence is mounting that EHRs are resulting in unintended consequences with patient safety implications. Clinical teams confront usability challenges that can present ethical issues requiring ethical decision-making models to support clinicians in appropriate action on behalf of safe, effective clinical care. The purpose of this article is to identify and address ethical issues raised by nurses in use of electronic health records. We provide a case scenario with application of the Four Component Model and describe a study of nurse experiences with the EHR. The nursing Code of Ethics, Nursing Scope and Standards, and Legal Implications are reviewed, and we conclude with recommendations and a call to action.

Key Words: electronic health records, ethics, ethical decision making, moral distress, usability, unintended consequences, patient safety, quality, Health Information Technology, Rest Four Component Model

Healthcare delivery in the United States (U.S.) is changing at a rapid pace to keep up with the ever-growing population health needs and for management of chronic diseases ( Healthy Aging Team, 2017). With the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009 ( U.S. Department of Health and Human Services, 2012), the United States, as of 2017, has achieved a 95% saturation with electronic health records (EHRs) as a means to document healthcare delivery in acute care hospitals and guide healthcare delivery clinical decision making ( Office of National Coordinator for Health Information Technology, 2017). Approximately 60% of U.S. office-based physicians have an EHR implemented and in use.

...in many respects, care has improved with use of technologies... Collectively, these trends impact nurses nationwide across all care settings. Studies have indicated that, in many respects, care has improved with use of technologies and, when meaningful use of EHRs is fully achieved and experienced by nurses, they are much more likely to be satisfied with the EHR ( McBride, Tietze, Hanley, & Thomas, 2017). Evidence is mounting that these same systems are also resulting in unintended consequences with patient safety implications, potentially contributing to provider moral distress ( Henry, Pylypchuk, Searcy, & Patel, 2016). Clinical teams often confront usability challenges that present ethical issues and require ethical decision-making models to support clinicians with appropriate action on behalf of safe and effective clinical care.

Clinical teams often confront usability challenges that present ethical issues... The purpose of this article is to identify and address ethical issues raised by nurses in use of EHRs. We provide a case scenario with application of the Four Component Model (FCM) ( Rest, 1986). To do this, a clinical case study will be presented, along with discussion of nurse experiences using the EHRs in a recent study ( McBride, Tietze, Hanley, & Thomas, 2015). Then, recommendations and a call to action are made based on the FCM in light of nursing practice standards, ethical issues, and where applicable legal issues.

...formulaic alerts can present challenges to clinical decision making... One strength associated with certified EHRs under the HITECH Act of 2009 for supporting patient safety and quality is that evidenced-based protocols can be reinforced by using clinical decision support (CDS). CDS is designed to trigger, or alert, the clinical team with the right information, through the right channels, to the right person, at the right time, for the right patient, via the correct route of the EHR or supporting technologies ( Osheroff et al., 2012). These same formulaic alerts can present challenges to clinical decision making for clinical teams working with an actual patient, raising practical and ethical considerations.

When examining ethical issues and applying frameworks to analyze a situation, clinical scenarios often help to ground discussions of problems in the day-to-day clinical care that commonly occur in healthcare delivery. The following case presents a scenario for applying a framework to address ethical concerns that nurses have raised regarding the function of some EHRs.

She suspects that the afebrile patient does not have sepsis, but instead has an exacerbation of HF with possible pulmonary edema... Nancy has worked in a busy community hospital emergency department (ED) for over ten years. She is caring for a patient that presents to the ED with the following:

sepsis suspected due to possible pneumonia

oxygen saturation 88% on 4 liters of O2 via nasal cannula

respiratory rate of 30

heart rate of 110

These symptoms trigger the EHR CDS alert for sepsis because the patient scored high on the hospital sepsis screening tool built within the EHR. The CDS fires alerts that prompt the ordering physician to fluid resuscitate the patient according to the Center for Disease Control guidelines for suspected sepsis. Nancy recognizes that not only does this patient have symptoms that could be evolving sepsis, but the EHR indicates the patient has previously been admitted for fluid overload from heart failure (HF). She suspects that the afebrile patient does not have sepsis, but instead has an exacerbation of HF with possible pulmonary edema because the patient also exhibits 2+ pitting edema and crackles in both lung bases.

The ED physician follows the CDS sepsis alerts that call for fluid resuscitation. The ED physician follows the CDS sepsis alerts that call for fluid resuscitation. Nancy questions the doctor order for aggressive fluid bolus and relates her concern that the patient is not septic. She points out the history of HF, which creates a risk for fluid overload with the bolus. The physician agrees with the nurse but states, "just drip it in slow, otherwise if we don't follow protocol we may fall out of the sepsis quality metric for the hospital. I don't want to send this patient to the ICU and have it later determined to be a sepsis case that we didn't follow protocol on!"

[Nancy] feels very distressed but hopes for the best outcome for this patient. No order for a slow drip was noted in the EHR, with only a verbal instruction on a busy ED shift for a patient ready for transfer to the ICU. Nancy questions the appropriateness of the physician orders, but follows physician instructions. She feels very distressed but hopes for the best outcome for this patient. She subsequently reports the request by the physician to drip slowly in a verbal handoff to the ICU nurse who receives the patient. The ICU nurse, recognizing that the drip does not follow the EHR recorded order, opens up the drip according to the computer provider order entry (CPOE). The patient has respiratory arrest. The patient requires intubation due to flash pulmonary edema with a subsequent diagnosis of acute onset of exacerbated fluid overload, secondary to rapid administration of intravenous (IV) fluid bolus and complication of HF. The attending intensivist on duty determines that the patient does not have sepsis.

This case presents a scenario happening across the nation in terms of EHR triggered protocols that capture electronic quality measures, often tied to value-based purchasing payer models upon which the organization will be penalized in the event measures are not met. This case study illustrates evolving guidelines that require clinical teams to use critical thinking skills when presented with CDS or information within the EHR that is not aligned with the clinical judgment of the entire clinical team. Further, this case offers several ethical considerations for examination. The scenario also reinforces nurses' statements as reported in 2015 via the Texas Nurses Association-Texas Organization of Nurse Executives (TNA-TONE) statewide study on EHRs ( McBride et al., 2015). For example, the following was one of 352 statements by nurses about EHR experiences:

Yes, the documentation of "quality standards" has greatly improved, but patient care and patient safety has not. In fact nurses have to enter false information sometimes and work around the system (I use vendor X, Y and Z) and all have similar issues. I know first-hand of 2 sentinel events caused by the systems (X and Y). Also systems audits are being used to evaluate and discipline nurses; this is a big ethical issue as nurses are charting stuff for the wrong reasons/........creating a conflict of interest.

This case scenario can be examined in terms of the overall context of ethical implications in use of the EHR. We can also consider the distress that can occur when protocols/guidelines; clinical decision support systems; nurse-patient relationship; and clinical communications between and among teams conflict with a nurse's code of ethics.

As a result of the HITECH Act in 2009, the TNA Board of Directors formed a Health Information Technology advisory committee. This committee was to evaluate the changing health technology environment and make recommendations to the TNA Board regarding steps needed to prepare Texas nurses for the rapid uptake of technology in healthcare settings required by this legislation. The TNA Board joined with the Texas Organization of Nurse Executives (TONE) to create a statewide partnership with nursing leaders to address the impact of health information technology (HIT) on nursing in the state of Texas.

The TNA-TONE HIT committee was charged with examining how Texas nurses were impacted by newly implemented EHRs across the state and to establish baseline measures of nurse satisfaction to inform evidence-based improvement strategies. A statewide study was initiated to evaluate nurse perceptions about clinical information systems such as EHRs.

... analysis of text comments found patterns and trends that reflected distress related to moral issues and ethical dilemmas... Quantitative results from the statewide study indicated that nurses were 84% more likely to be satisfied when they reported high scores related to a meaningful use maturity sensitivity index (MUMSI). The MUMSI allowed for analysis that addressed differing levels of functional status, or maturity of the given EHR using the meaningful use (MU) measures as a proxy for maturity ( McBride et al., 2017). However, analysis of text comments found patterns and trends that reflected distress related to moral issues and ethical dilemmas (please note that we are using the terms "moral" and "ethical" interchangeably in accordance with the current literature). We believe the ethical issues, in particular, warrant further exploration and require models of decision making to support clinical interprofessional teams in appropriate decision-making and subsequent action.

In the Texas-based statewide study ( McBride et al., 2015), researchers elicited additional information to learn about experiences of nurses using EHRs with this open-ended statement: "We are interested in your feedback and anything we might not have covered, please provide any additional information you care to provide." Just over 30% (352 of 1,157 participants) provided written comments about their experiences.

A thematic content analysis of the narrative responses to the open text question was used to analyze the data. Texts were organized in a spreadsheet and reviewed systematically by two qualitative researchers from the TNA/TONE committee research subgroup to identify key concepts. The text narrative responses were then reorganized according to concepts and summarized into categorical statements. Further immersion and analysis of the categories by two researchers with informatics expertise resulted in a synthesis of comments within the categories that revealed several primary themes. These are noted in Figure 1.

A conceptual model that reflects the overall common concepts detected in the thematic analysis was developed by the research group and is also noted in Figure 1. Note that "Patient Safety and Quality" is a major theme, with a minor theme "documentation/legality." This suggested that practice challenges associated with patient safety and quality were experienced. We learned that these were reflected, among other ways, in the EHR-based documentation that varied from established interprofessional practice standards. Although the case study and the Texas nurses' comments reflected ethical issues raised by nurses, there are significant implications for the entire care team given the EHR is the primary means of interprofessional communication.
Figure 1. Major and minor themes related to qualitative study comments.
[ View full size]

A sampling of these comments is provided by categories in Table 1. They are grouped by category of content.
Table 1. Comments by Nurses about their EHR Experience

Category

Comment

Training

I have almost no training on the "System." I have to fumble around to do anything on this "System" and it is purely an accident when I do find what I need.

Documentation

System was not designed by the people who would use it. It does not capture the data required by the state to successfully use it. We are unable to see any notes/assessments that we did not personally input. Very frustrating because we constantly have to do double work. Sometimes the canned responses to questions do not have the appropriate answer listed as an option, and the only way to complete the documentation is to go to another menu and enter a nurse's note. Our preop department uses entries in both the nursing module and the OR module, which necessitates constantly switching from one menu to another - time consuming and inefficient. The "copy/paste" function has made it easier for providers to not write new original assessments. Because most of the notes are copy and pasted, there are many discrepancies (on one line, the patient is intubated; on the next line of the same patient, the patient is on nasal cannula). It's made the notes semi-worthless. This system has quadrupled our workload. It is not accurate and orders tend to disappear. The pharmacy part allows expired orders to carry on and continue to be active even after stop dates which lead to medication errors. This system is difficult to view orders and communicate with others. Things do not work well. It takes several hours to get thru discharges due to links that do not work. With the ER after two weeks on the program, it developed an application error that would not let nurses go back to add information while the patient is still active and document is active.

Equipment

Our computers at times freeze inside the room. During am med pass, it is so stressful finding a good computer that does not freeze. Sometimes I have to go through 3-5 computers before finding one that works.

Critical Thinking

Sometimes I feel that the barcode scanning system for medication administration hinders critical thinking and prevents truly looking at what you are giving the patient.

The FCM describes the deliberative thought processes that occur from initial recognition of a situation with ethical content to implementation of a justifiable action... The case scenario above provides an opportunity to explore a holistic framework, the Four Component Model ( Rest, 1986), to identify and address ethical issues in nursing practice. The FCM describes the deliberative thought processes that occur from initial recognition of a situation with ethical content to implementation of a justifiable action: sensitivity, judgment, motivation, and action ( Rest, 1986; Robichaux, 2012; Robichaux, 2017; Rushton & Penticuff, 2007).

Ethical Sensitivity
Ethical sensitivity is described as our ability to recognize an ethical problem, the moral implications of our decisions, and how our actions affect other people ( Milliken, 2016). Its development depends on an understanding of the ethical nature of the role as an obligation of the nursing profession ( Milliken & Grace, 2017). In the case scenario, Nancy recognized that adhering to the EHR-triggered CDS guideline might result in a poor outcome. She may have also been aware of her accountability in the situation as stated in the ANA Code of Ethics for Nurses with Interpretive Statements, "Systems and technologies that assist in clinical practice are adjunct to, not replacements for, the nurse's knowledge and skill" ( American Nurses Association [ANA], 2015, p.16; hereafter referred to as Code of Ethics). Having practiced in the ED for ten years, Nancy may be respected by her nursing peers and physician colleagues and may question how her actions could potentially affect those professional relationships.

Ethical Judgment
Not all issues will require an in-depth consideration of all elements in a specific model, and the goal is to reach a prudent choice, not certainty. The second component of the FCM is ethical judgment or decision-making, a deliberative process reflecting knowledge of ethical principles, theories, and codes. There are several models (see Table 2); most have elements that outline an approach to reaching a decision through identifying facts and considering specific questions related to ethical principles and/or virtue ethics and care ethics. Not all issues will require an in-depth consideration of all elements in a specific model, and the goal is to reach a prudent choice, not certainty ( Grace, 2014; Milliken & Grace, 2017; Robichaux, 2017). Recognizing the potential harm of following the sepsis guidelines in a patient with suspected pulmonary edema, Nancy decides to share her concerns with the physician.
Table 2. Ethical Judgment/Decision-making Models
Ethical Motivation
All nurses want to be ethical and live in a manner consistent with their personal and professional values. Although they may recognize an ethical issue and be aware of their role-associated obligations, personal and/or institutional barriers may impede their motivation to act. The third component in the FCM, ethical motivation is the bridge between decision-making and action ( Robichaux, 2017).

Competing personal values... can impede motivation and action. Competing personal values such as protecting one's position or reputation can impede motivation and action. "Persevering to do the right thing" ( Grace, Robinson, Jurchak, Zollfrank, & Lee, 2014, p. 14) can also be hampered by institutional barriers. Lack of supervisory support, fear of reprisal, and hierarchal decision-making may silence nurses' moral voices ( Pavlish, Hellyer, Brown-Saltzman, Miers, & Squire, 2013). These obstacles may characterize a unit ethical climate that does not promote patient/family advocacy and nurse moral agency. Wolf et al. ( 2016) described the moral distress of ED nurses who are unable to meet their role obligations to provide safe and effective patient care in such environments.

The stress felt by Nancy in the presented ED case scenario is an example of this type of moral distress. Specific themes reflected in the case scenario and noted by Wolf and colleagues' ( 2016) qualitative investigation relate to moral distress due to overemphasis on documentation, tasks, and metrics at the expense of patient care, as well as role conflicts resulting from hierarchical decision making. These same issues are reflected in a number of comments in Table 1 (e.g., overemphasis on documentation and measurement creating inefficiencies and a distraction to patient care).

Ethical Action
Nancy questions the physician's decision to follow the sepsis quality metric and not write an order in the EHR for slow intravenous fluid administration. She verbally reports this information to the receiving ICU nurse and hopes "for the best outcome" for the patient. Could additional actions have been taken? Developing moral courage may assist in overcoming personal and institutional barriers to further nurse advocacy. Individuals with moral courage have developed skills of effective engagement and "willingness to speak out and do what is right in the face of forces that would lead a person to act in some other way" ( Lachman, 2007, p. 131). Moral courage can also be "learned, practiced, and mentored" ( Hawkins & Morse, 2014, p. 268). When moral courage and ethical action are thwarted by constraints outside the nurse's control, moral distress can result.

Nurses experience moral distress, a concept first highlighted by Andrew Jameton in 1984, when they "know the right thing to do while being in a situation in which it is nearly impossible to do it." ( Jameton, 2017, p. 617). Jameton described three components that can apply to the pain expressed by the nurses that contributed to the Texas study: knowing what is right, being in a situation that constrains acting on that knowledge, and the psychological distress resulting from that inability to do the right thing ( Jameton, 2017).

It may be challenging to remember what actions to take when encountering a situation that requires moral courage. It may be challenging to remember what actions to take when encountering a situation that requires moral courage ( Lachman, 2010; Lachman, Murray, Iseminger, & Ganske, 2012) Lachman et al. ( 2012) have developed a useful mnemonic, CODE ( Courage; Obligations to honor; Danger management; Expression), that reminds nurses of their ethical obligations and actions as detailed in the nursing Code of Ethics ( ANA, 2015). The CODE mnemonic strategy helps nurses to recall these actions and includes ways to overcome fear and reluctance to speak up including reflection, reframing, and assertiveness skills.

The accelerated growth and adoption of the EHR has produced a situation that repeatedly occurs in the history of technology and parallels the rise of bioethics. The Code of Ethics states, "Patients' rights are the primary factor in any decisions regarding personal information, whether from or about the patient. These rights of privacy and confidentiality pertain to all information in any manner that is communicated or transmitted" ( ANA, 2015, p. 10). While nurses are aware of this ethical obligation in relation to the EHR, they may be less familiar with additional ethical issues inherent in its use and development. The accelerated growth and adoption of the EHR has produced a situation that repeatedly occurs in the history of technology and parallels the rise of bioethics. From cardiopulmonary resuscitation (CPR) to genetic engineering, the creation and use of an innovative tool may surpass the knowledge and resources required to ensure an ethical and appropriate use ( Goodman, 2015).

The current and potential positive impact of the EHR on quality care is not disputed. However, ethical issues surrounding dominance of institutional priorities over autonomous patient-centered practice and care driven by application of decision-support, templates, and/or clinical practice guidelines (CPGs) have been documented ( Lown & Rodriguez, 2012; McBride, Tietze, Hanley, & Thomas, 2015; Sulmasy, López, & Horwitch, 2017). Perhaps the most troubling ethical issue noted is the potential erosion of the patient-nurse relationship ( de Ruiter, Liaschenko, & Angus, 2016; Rathert, Mittler, Banerjee, & McDaniel, 2016).

The centrality of the patient-nurse relationship to the nursing discipline is reflected in the interpretive statement, "The nurse's primary commitment is to the recipients of nursing and health care services" ( ANA, 2015, p. 5). Effective communication is vital to this relationship, and the EHR may have a negative effect. Research suggests that it can become a "third party "in the process, potentially reshaping the interaction, changing the patient narrative, and diverting nurse attention away from the patient ( Rathert et al., 2016).

Perhaps the most troubling ethical issue noted is the potential erosion of the patient-nurse relationship. The use of computers and communication technologies will impact more lives in the 21st century than any other technology, including stem cells, transplants, and nanomedicine ( Goodman, 2015). As the largest group of healthcare professionals who document, more than any other discipline in acute care organizations, ( OÊ¼Brien, Weaver, Settergren, Hook, & Ivory, 2015) nurses are at the forefront to ensure that the EHR is patient-centered and contributes to safe, ethical practice.

As indicated in the case scenario and the study findings, the use of the EHR can result in a unique set of ethical and legal challenges. Nurses must be prepared to face these challenges and recognize the requirements of state and federal law, workplace policies, and obligations of the profession. A study in 2006 revealed that nurses spent a majority of indirect nursing time documenting in the EHR, demonstrating the critical necessity of proper usage to satisfy quality of patient care ( Kim, 2006). The Scope and Standards of Nursing Practice ( ANA, 2015) establishes the standard of practice for registered nurses in the United States, noting "Nurses must document relevant data accurately and in a manner accessible to the interprofessional team" ( ANA, 2015, p. 54). Documentation in the nursing record must follow principles of "factuality, accuracy, completeness, timeliness, organization, and compliance" ( ANA, 2015, p. 270). Documentation must be clear and accurate to provide a basis for the contribution of nurses to patient outcomes and the viability of healthcare organizations ( ANA, 2015).

Documentation that fails to meet these principles can result in undesirable outcomes for the nurse, patients and families, or for the healthcare organization ( ANA, 2015). Nursing documentation, electronic or handwritten, are legal documents that can, under some circumstances, be used in legal proceedings. Nurses maintain competence regarding the legal significance of documentation and therefore must demonstrate legible and comprehensive reporting ( Larsen, 2012). Some EHR systems are designed as templates or 'fill-in' instruments, which allow for auto-population of lab results or other critical information ( Sittig & Singh, 2011). The auto-fill function can result in unintentional documentation of a clinical finding that may not be within a nurse's clinical purview ( Sittig & Singh, 2011). Once documentation has been electronically recorded and signed by the nurse, the liability of that acknowledgement is not clear.

A number of healthcare organizations have implemented 'copy and paste' policies for documenting in the EHR. The copy and paste functionality includes copying, pasting, cloning, auto-filling, carrying forward, replicating data and reusing content from one section to another within the EHR ( Scruth, 2014). The copy and paste phenomenon has caused significant debate from those who argue its necessity for time efficiency weighed against the significant risk of inaccuracy and patient safety errors ( Harrington, 2017). Copy and paste functionalities can result in unintentional reliance on outdated or inaccurate clinically relevant information, such as treatment plan; distracted notes; diagnostic biases; incorrect information for a specific patient visit; and expired patient symptoms and assessments ( Scruth, 2014; Weis & Levy, 2014). These practices can result in timeliness issues or time-related accuracy of documentation in any EHR.

... healthcare providers have experienced notable challenges to balance necessary time for patient care with computer entry. EHRs are designed to facilitate easier provider order entry and have been shown to reduce prescription errors ( Scruth, 2014). They have tremendous potential to improve efficiency of healthcare delivery and improvement of quality patient care. However, healthcare providers have experienced notable challenges to balance necessary time for patient care with computer entry ( McBride et al., 2017; Wolf et al., 2016). In the early 1990s 'charting by exception' was an acceptable method to decrease charting in nursing ( de Ruiter et al., 2016). Historically, it was assumed that all standards of care were met unless documented otherwise. However, with the introduction of the EHR, complete documentation requires charting of all clinical assessments, care plans, interventions, and outcomes requiring more time for documentation ( de Ruiter et al., 2016).

As a result of time constraints and usability issues, nurses have reportedly been intentionally entering false information to bypass or 'work-around' EHR systems ( McBride & Tietze, 2017). Although privacy, security, and confidentiality have been identified as three main areas of concern when using EHRs, little attention has focused on false entries, work-arounds, or system bypasses ( Ayatollahi, Mirani, & Haghani, 2014; CMPA, 2015).

...a false entry into an EHR can follow a patient for years. Additionally, alert fatigue and clinical information overrides must be addressed within the organization. Legal concerns over notification of federally regulated drug interactions, through pop-ups or alerts, can be overwhelming or desensitizing to the nurse ( Sittig & Singh, 2011). Overriding content in what is often an undesirable system design can result in misinformation in charting that can have detrimental effects on the nurse, patient, and healthcare organization. For example, a false entry into an EHR can follow a patient for years. The patient is likely unaware of the false entry, but subsequently applies for health or life insurance. The patient may be denied insurance coverage based on a one-time false entry that was replicated over time.

We conclude with a call to action for interprofessional teams, associations, industry, and others to collaboratively address these issues on behalf of the health and safety of the nation, and equally as important, the health and well-being of the healthcare workforce. To do that, the authors suggest the following recommendations to address challenges with EHRs. These recommendations may help mitigate ethical and legal issues arising as a result of the massive uptake of technology that has resulted in the digital age of healthcare delivery.

Support
Nurses must have a seamless mechanism for reporting EHR challenges... Nurses face time constraints, overstaffing, and unfamiliarity with EHR systems on a daily basis. Healthcare organizations must have structures in place at the unit, management, and administrative levels to facilitate effective use of EHRs in nursing practice. For example, some EHR contracts have "hold harmless clauses" which restrict nurses' ability to effectively and timely report EHR problems ( Sittig & Singh, 2011). Nurses must have a seamless mechanism for reporting EHR challenges (e.g., inappropriate or cumbersome alerts) without an arduous process or fear of reprisal. This type of support could potentially mitigate the moral distress noted in the case scenario.

Culture of Safety
Nurse managers and executives have a particular obligation to ensure that direct care nurses are empowered to identify and engage in ethical situations associated with EHRs. All nurses are "responsible for contributing to a moral environment" in healthcare ( ANA, 2015, p. 24). Nurse managers and executives have a particular obligation to ensure that direct care nurses are empowered to identify and engage in ethical situations associated with EHRs. The ANA Scope and Standards of Practice for Nursing Administration (2009) cites the obligation of nurse administrators to advocate for practice that reflects the Code of Ethics ( ANA, 2015). It specifies duties that nurses in leadership and managerial roles have, particularly in transformational and servant leadership frameworks, to open communication and to act "entirely on the behalf of those led" ( ANA, 2009, p. 8) to identify problems and integrate ethical provisions in all areas of practice. Nurses in administrative roles should promote a culture of safety in their settings that include reducing the risk of harm arising from inadequate EHR design, and usability ( ANA, 2009).

Education
Studies have shown that nurses with one year or less in practice demonstrate almost 70% more timely charting than nurses with more years of experience ( Ahn, Choi, & Kim, 2016). This emphasizes the need for continuing education for novice and expert nurses in EHR management and documentation. Informatics specialty nurses and advanced practice nurses can serve as leaders to assess and research documentation for timeliness and accuracy, along with providing continuing education on a frequent basis ( Scruth, 2014). Education about principles of documentation and competence in specific EHR system usage is needed to foster nurse mastery and development to successfully improve health outcomes ( Goodman, 2015).

Awareness of Support of Interprofessional Imperatives
Guidelines and best practices, such as the American College of Physicians position paper on clinical documentation ( Kuhn, Basch, Barr, & Yackel, 2015), ANA ( 2015) position statement on Privacy and Confidentiality,and American Nursing Informatics Association ( 2015) position statement on Addressing the Safety of Electronic Health Records are critical to ensuring that nurses are able to efficiently and appropriately meet principles of documentation. The American Health Information Management Association ( AHIMA, 2011) Code of Ethics has 11 principles with interpretive statements, referred to as guidelines, that seem to underscore the importance of practices that stand in stark contrast to the experiences of nurse participants in the Texas nursing research ( McBride et al., 2015). The AHIMA principles cite the primacy of accuracy, avoidance of conflicts of interest, and similar to the ANA code, "respect [for] the inherent dignity and worth of every person" ( AHIMA, 2011, 11). Under this AHIMA principle, the noteworthy guideline to "ensure all voices are listened to and respected" ( AHIMA, 2011, 11.4) demands that health information managers not only welcome input from nurses who find the technological determinism of EHRs violates ethical practice and clinical judgment, but also seek out that input.

... the patient's story of his/her illness may be lost to the goal of generating standard data points that, in turn, trigger algorithms and practice recommendations. For care characterized by "screen-driven information gathering" ( Lown & Rodriguez, 2012, p. 393) the patient's story of his/her illness may be lost to the goal of generating standard data points that, in turn, trigger algorithms and practice recommendations ( Brown, 2015). This computational capacity may establish EHR information as authoritative, potentially displacing work processes critical to nurse-patient interaction.

As evidenced in the study themes and the case scenario presented, critical thinking may be hindered and experiential knowledge devalued ( Campbell & Rankin, 2017). Most importantly, the EHR must not substitute for a current and accurate clinical assessment, and appropriate intervention ( Campbell & Rankin, 2017; Lown & Rodriguez, 2012; Sulmasy et al., 2017). Systems and technologies such as EHRs that assist in clinical practice are adjunct to, not replacements for, nurse knowledge and skill ( ANA, 2015).

Most importantly, the EHR must not substitute for a current and accurate clinical assessment, and appropriate intervention. Finally, as reflected in the Texas study and clinical scenario, current technology in the healthcare industry often presents challenges with usability, design, implementation, and failure to adequately support clinical teams. This results in ethical situations often associated with feelings of moral distress. Application of the FCM can assist clinical teams to explore and potentially resolve these issues. Additionally, the authors recommend further research into the moral distress noted in emerging evidence, including the TNA-TONE statewide study and the case scenario presented. As such, the healthcare industry has an imperative to identify and address ethical issues with use of EHRs.

The authors wish to acknowledge the support for the study by Texas Nurses Association (TNA) and the Texas Organization of Nurse Executive (TONE). From the beginning in 2010 when the TNA Board of Directors resolution was passed, the two organizations created the partnership that provided cumulative guidance, funding, and dissemination efforts throughout the years. Specifically, we would like to acknowledge the staff of these organizations, the dozens of volunteer committee members who have served, and the report writing sub-committee of Susan McBride, Mary Anne Hanley, Cindy Zolnierek, Laura Thomas, Mari Tietze, and Huaxin Song. Finally, we acknowledge the many subject-matter experts who, through numerous focus groups, helped yield the final surveys. Please see the TNA/TONE HIT Web site for the long list of names.

Susan McBride, PhD, RN-C, CPHIMS, FAAN
Email: susan.mcbride@ttuhsc.edu

Dr. McBride is a Professor at the Texas Tech University Health Sciences Center School of Nursing whose research focus is on methods development for implementing, evaluating and utilizing health information technology to address patient safety, quality and population health. Dr. McBride was the Principal Investigator for a Texas Statewide Study of Nurses Satisfaction with their electronic health records. She is a professor with teaching responsibilities supporting graduate courses in statistics, informatics, and epidemiology. She is a Fellow in the Academy of Nursing and sits on the Information Technology and Informatics Expert Panel.

Mari Tietze, PhD, RN-BC, FHIMSS
Email: mtietze@twu.edu

Dr. Tietze is a Professor at the Texas Woman's University (TWU) College of Nursing, teaching informatics courses focused on interprofessional collaborative practice and Director of the Graduate Certificate in Interprofessional Informatics program. Dr. Tietze is the Doswell Endowed Chair for Nursing Informatics aimed at advancing nursing informatics at TWU. Since 2010, she has been the co-chair of the Texas Nurses Association/Texas Organization of Nurse Executives Health Information Technology committee to represent nurses' experiences related to information technology use in their practice of patient care delivery. Research focus is telehealth with a telemedicine, remote management and mobile health component. Dr. Tietze has been certified since 2000 by ANA in Informatics Nursing.

Catherine Robichaux, PhD, RN, APRN, Alumna CCRN
Email: robichaux@uthscsa.edu

Dr. Robichaux is an Adjunct Assistant Professor at University of Texas Health; San Antonio, Texas and The University of Mary in Bismarck, North Dakota. She has taught ethics at the undergraduate and graduate levels and conducted research on moral distress and ethical climate among other issues. Catherine was a member of the Steering Committee to revise the Code of Ethics and is currently a member of the ANA Ethics Advisory Board.

Liz Stokes, JD, MA, RN
Email: liz.stokes@ana.org

Ms. Stokes is the Director of the American Nurses Association Center for Ethics and Human Rights. She worked for several years as a critical care nurse and later received her law degree. She worked as a consultant for the D.C. Board of Nursing interpreting professional ethics provisions and recently completed her masters in bioethics. Her leadership is demonstrated through various charitable roles. Liz serves as an Associate Editor for the Journal of Bioethical Inquiry and is a volunteer with the D.C. Bar Association. She is currently an American Academy of Nursing Jonas Health Policy Scholar.

Eileen Weber, DNP, JD, BSN, PHN, RN
Email: weber058@umn.edu

Dr. Weber is a nurse attorney and Clinical Assistant Professor at the University of Minnesota School of Nursing, where she teaches ethics, leadership, and public policy in the context of a continuum of interprofessional healthcare. She founded and leads the Upper Midwest Healthcare Legal Partnership Learning Collaborative. She serves on the American Nurses Association Center for Ethics and Human Rights Advisory Board and the University of Minnesota Medical Center (Fairview) ethics committee.

Office of National Coordinator for Health Information Technology. (2017). Health IT dashboard:
Quick stats. Retrieved from https://dashboard.healthit.gov/quickstats/quickstats.php

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Figure 1. Major and minor themes related to qualitative study comments.
[ View full size]
Table 1. Comments by Nurses about their EHR Experience

Category

Comment

Training

I have almost no training on the "System." I have to fumble around to do anything on this "System" and it is purely an accident when I do find what I need.

Documentation

System was not designed by the people who would use it. It does not capture the data required by the state to successfully use it. We are unable to see any notes/assessments that we did not personally input. Very frustrating because we constantly have to do double work. Sometimes the canned responses to questions do not have the appropriate answer listed as an option, and the only way to complete the documentation is to go to another menu and enter a nurse's note. Our preop department uses entries in both the nursing module and the OR module, which necessitates constantly switching from one menu to another - time consuming and inefficient. The "copy/paste" function has made it easier for providers to not write new original assessments. Because most of the notes are copy and pasted, there are many discrepancies (on one line, the patient is intubated; on the next line of the same patient, the patient is on nasal cannula). It's made the notes semi-worthless. This system has quadrupled our workload. It is not accurate and orders tend to disappear. The pharmacy part allows expired orders to carry on and continue to be active even after stop dates which lead to medication errors. This system is difficult to view orders and communicate with others. Things do not work well. It takes several hours to get thru discharges due to links that do not work. With the ER after two weeks on the program, it developed an application error that would not let nurses go back to add information while the patient is still active and document is active.

Equipment

Our computers at times freeze inside the room. During am med pass, it is so stressful finding a good computer that does not freeze. Sometimes I have to go through 3-5 computers before finding one that works.

Critical Thinking

Sometimes I feel that the barcode scanning system for medication administration hinders critical thinking and prevents truly looking at what you are giving the patient.

Table 2. Ethical Judgment/Decision-making Models

January 31, 2018

DOI: 10.3912/OJIN.Vol23No01Man05

# data[].attributes.attachment_link.keywords[]
key words: electronic health records

# data[].attributes.attachment_link.title
Identifying and Addressing Ethical Issues with Use of Electronic Health Records

# data[].attributes.attachment_link.description
With the passage of the Health Information Technology for Economic and Clinical Health Act in 2009, the United States, as of 2017, has achieved 95% saturation with electronic health records as a means to document healthcare delivery in acute care hospitals and guide clinical decision making.