Publications by authors named "Peter Nugus"

45 Publications

Embedding Identity and How Clinical Teachers Reconcile Their Multiple Professional Identities to Meet Overlapping Demands at Work.

Teach Learn Med 2021 Jul 3:1-13. Epub 2021 Jul 3.

Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway.

Phenomenon: Clinical teachers perform overlapping tasks in education and patient care. They are therefore expected to juggle many professional identities such as educator and clinician. Yet little is known about how clinical teachers negotiate their professional identities. The present research examined the lived experiences of clinical teachers as they manage and make sense of their professional identities in the context of a faculty development program.

Approach: This study adopted interpretative phenomenological analysis, which is an idiographic and inductive methodological approach that enables an in-depth examination of how people conceptualize their personal and social worlds. In-depth semi-structured individual interviews were conducted with six purposively sampled Brazilian clinical teachers who were attending a faculty development program. Each participant's lived experience was analyzed independently. Then, these individual analyses were compared against each other to identify convergence and divergence.

Findings: Participants recognized one identity, which was labeled as , containing other identities and roles. Participants integrated their professional identities in agreement with their personal identities, values, and beliefs, striving thus for identity consonance. Participants understood their craft as a relational process by which they wove themselves into their context and entangled their experience with that of others. They, however, diverged when recognizing who their peers were; whereas some named a single professional group (i.e., family physicians), others had a more comprehensive view and considered as peers healthcare professionals, students, and even patients. Finally, participants identified time constraints and lower prestige of family medicine as a medical discipline vis-à-vis other specialties as challenges posed by their contexts.

Insights: Clinical teachers have multifaceted identities, to which they give a sense, manage, and integrate into their daily practice. Participants recognized an embedding identity and looked for common points between the identities it contained, which allowed them to meaningfully reconcile the different demands from their overlapping professional identities. Thus, this research introduces the notion of embedding identity as a strategy to make sense of many professional identities. Variability in the embedding identities depicted in this investigation suggests the fluid and contextualized character of professional identity development. How participants saw themselves also influenced how they behaved and interacted with others accordingly. Understanding clinical teacher identity development enriches current perspectives of what it is like to be one of these medical professionals. Faculty development programs ought to consider these perspectives to better support clinical teachers in meeting the overlapping demands in education and patient care.
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http://dx.doi.org/10.1080/10401334.2021.1930545DOI Listing
July 2021

Decontamination effectiveness and the necessity of innovation in a large-scale disaster simulation.

Am J Disaster Med 2021 Winter;16(1):67-73

Associate Professor, Institute of Health Sciences Education and Department of Medicine, McGill University, Montreal, Canada.

Background: Chemical, biological, radiologic, nuclear, and explosive (CBRNE) events threaten the health and integrity of human populations across the globe. Effective decontamination is a central component of CBRNE disaster response.

Objective: This paper provides an objective determination of wet decontamination effectiveness through the use of a liquid-based contaminant proxy and describes the mobilization and adaptation of easily available materials for the needs of decontamination in pediatric victims.

Methods: In this in-situ disaster simulation conducted at a pediatric hospital, decontamination effectiveness was determined through a liquid-based contaminant proxy, and standard burn charts to systematically estimate affected total body surface area (TBSA) in 39 adult simulated patients. Two independent raters evaluated TBSA covered by the contaminant before and after decontamination.

Results: On average, simulated patients had 59 percent (95 percent CI [53, 65]) of their TBSA covered by the simulated contaminant prior to decontamination. Following a wet decontamination protocol, the average reduction in TBSA contamination was 81 percent (95 percent CI [74, 88]). There was high inter-rater reliability for TBSA assessment (intraclass correlation coefficient = 0.83, 95 percent CI [0.68, 0.92]. A modified infant bath was tested during the simulated decontamination of infant mannequins and thereafter integrated to the local protocol.

Conclusion: Wet decontamination can remove more than 80 percent of the initial contaminant found on adult simulated patients. The use of a liquid-based visual tool as a contaminant proxy enables the inexpensive evaluation of decontamination performance in a simulated setting. This paper also describes an innovative, low-cost adaptation of a local decontamination protocol to better meet pediatric needs.
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http://dx.doi.org/10.5055/ajdm.2021.0388DOI Listing
May 2021

Seeking coherence between 'mobile learning' applications and the everyday lives of medical residents.

Perspect Med Educ 2019 06;8(3):152-159

Department of Family Medicine, McGill University, Montreal, Canada.

Introduction: The role of technology in health professions education has received increased research attention. Research has examined the interaction between humans and technology, focusing on the mutual influence between people and technology. Little attention has been given to the role of motivation and incentives in how learning technologies are used in relation to daily activities. This research aims to understand the relationship between medical-learning technology and its users.

Methods: A mixed-method case study of a new medical-learning mobile application (app) for family medicine residents was undertaken at a Canadian university hospital. The Information Assessment Method is a custom-made app to help residents prepare for the College of Family Physicians of Canada licensing examination. Residents' use of the app was tracked over a 7-month period and individual, semi-structured interviews were conducted with users. Data were thematically analyzed and correlated with app use data.

Results: Factors identified as shaping residents' mobile app use for learning, included: efficiency, mobility and resonance with life context; credibility of information retrieved; and relevance of content. Most influential was stage of residency. Second-year residents were more selective and strategic than first-year residents in their app use.

Discussion: An emphasis on coherence between self-directed learning and externally dictated learning provides a framework for understanding the relationship between users and mobile-learning technology. This framework can guide the design, implementation and evaluation of learning interventions for healthcare professionals and learners.
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http://dx.doi.org/10.1007/s40037-019-0519-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6565641PMC
June 2019

Re-structuring the negotiated order of the hospital.

Authors:
Peter Nugus

Sociol Health Illn 2019 02;41(2):378-394

Center for Medicine Education and Department of Family Medicine, McGill University, Quebec, Canada.

Researchers continue to lament the lack of organisational focus in the sociology of health and illness. Although studies have increasingly focused on boundaries between organizations, little such research has focused on the formal boundaries within the hospital itself. Given its dramatic compartmentalisation, and continuing prevalence in health systems, the lack of organisational perspective in hospital research limits insights into the effects (as well as the construction) of the order of health work and care. With a greater emphasis on 'ordering' in the concept of negotiated order, the aim of this study is to examine the manifestation and consequences of the formal boundaries of hospital departments. Fieldwork featured 12 months of ethnography, including formal and informal observations, 80 audio-recorded, semi-structured interviews, and 56 field interviews, in the Emergency Departments (EDs) of two tertiary referral hospitals. Compared with in-patient hospital departments, the ED has limited legitimacy claims of organ-specific knowledge to transfer patients out of the ED. The manifestation of specialised knowledge hierarchies in organisational structures disadvantages patients who are older and who have chronic conditions, underpinning the argument that effects as well as the negotiation of stable organisational orders deserve increased attention in the sociology of health and illness.
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http://dx.doi.org/10.1111/1467-9566.12838DOI Listing
February 2019

Interdisciplinary Crisis Resource Management Training: How Do Otolaryngology Residents Compare? A Survey Study.

OTO Open 2018 Apr-Jun;2(2):2473974X18770409. Epub 2018 May 14.

Department of Otolaryngology-Head and Neck Surgery, McGill University, Montréal, Québec, Canada.

Objective: Emergent medical crises, such as acute airway obstruction, are often managed by interdisciplinary teams. However, resident training in crisis resource management traditionally occurs in silos. Our objective was to compare the current state of interdisciplinary crisis resource management (IDCRM) training of otolaryngology residents with other disciplines.

Methods: A survey study examining (1) the frequency with which residents are involved in interdisciplinary crises, (2) the current state of interdisciplinary training, and (3) the desired training was conducted targeting Canadian residents in the following disciplines: otolaryngology, anesthesiology, emergency medicine, general surgery, obstetrics and gynecology, internal medicine, pediatric emergency medicine, and pediatric/neonatal intensive care.

Results: A total of 474 surveys were completed (response rate, 12%). On average, residents were involved in 13 interdisciplinary crises per year. Only 8% of otolaryngology residents had access to IDCRM training, as opposed to 66% of anesthesiology residents. Otolaryngology residents reported receiving an average of 0.3 hours per year of interdisciplinary training, as compared with 5.4 hours per year for pediatric emergency medicine residents. Ninety-six percent of residents desired more IDCRM training, with 95% reporting a preference for simulation-based training.

Discussion: Residents reported participating in crises managed by interdisciplinary teams. There is strong interest in IDCRM and crisis resource management training; however, it is not uniformly available across Canadian residency programs. Despite their pivotal role in managing critical emergencies such as acute airway obstruction, otolaryngology residents received the least training.

Implication: IDCRM should be explicitly taught since it reflects reality and may positively affect patient outcomes.
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http://dx.doi.org/10.1177/2473974X18770409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6239147PMC
May 2018

Community Preceptors' Motivations and Views about Their Relationships with Medical Students During a Longitudinal Family Medicine Experience: A Qualitative Case Study.

Teach Learn Med 2019 Apr-May;31(2):119-128. Epub 2018 Nov 10.

a Department of Family Medicine , Faculty of Medicine, McGill University , Montreal , Quebec , Canada.

Phenomenon: Although current evidence emphasizes various benefits of community-oriented programs, little is still known about the nature of the relationships that students and family physicians develop in this educational setting. Our aim in this study was twofold: to identify family physicians' motivations to enroll as preceptors in a longitudinal undergraduate family medicine program and to explore the nature of the student-preceptor relationships built during the course. Approach: This was a qualitative exploratory case study. The case was the first edition of a longitudinal family medicine experience (LFME), a course that makes up part of the novel Medicinae Doctor et Chirurgiae Magister curriculum in place in a Canadian medical school since August 2013. All 173 family physician community preceptors of the academic year 2013-2014 were considered key informants in the investigation. Forty-three preceptors finally participated in one of six focus groups conducted in the spring of 2014. Several organizational documents relative to the LFME course were also gathered. Inductive semantic thematic analysis was performed on verbatim interview transcripts. Documents helped contextualize the major themes emerging from the focus groups discussions. Findings: Enjoying teaching, promoting family medicine, and improving medical education where salient motivations for family physicians to become LFME preceptors. The findings also pointed out the complexity of the student-preceptor exchanges that unfolded over the academic year, and the ambiguous and changing nature of the role that LFME preceptors adopted in their relationships with students: from simply being facilitators of students' clinical observership to behaving as their mentors. Insights: Family physicians were highly motivated to become LFME preceptors of 1st-year medical students. Whereas they consistently valued the relationships built during the academic year with the students assigned to them, they also considered that exchanges did not always happen without difficulties, and gauged the roles they played as complex, ambiguous, and necessarily evolving over time.
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http://dx.doi.org/10.1080/10401334.2018.1489817DOI Listing
August 2019

New ways to get policy into practice.

J Health Organ Manag 2018 Sep 3;32(6):809-824. Epub 2018 Oct 3.

Macquarie University , Sydney, Australia.

Purpose: Health service effectiveness continues to be limited by misaligned objectives between policy makers and frontline clinicians. While capturing the discretion workers inevitably exercise, the concept of "street-level bureaucracy" has tended to artificially separate policy makers and workers. The purpose of this paper is to understand the role of social-organizational context in aligning policy with practice.

Design/methodology/approach: This mixed-method participatory study focuses on a locally developed tool to implement an Australia-wide strategy to engage and respond to mental health services for parents with mental illness. Researchers: completed 69 client file audits; administered 64 staff surveys; conducted 24 interviews and focus groups (64 participants) with staff and a consumer representative; and observed eight staff meetings, in an acute and sub-acute mental health unit. Data were analyzed using content analysis, thematic analysis and descriptive statistics.

Findings: Based on successes and shortcomings of the implementation (assessment completed for only 30 percent of clients), a model of integration is presented, distinguishing "assimilist" from "externalist" positions. These depend on the degree to which, and how, the work environment affords clinicians the setting to coordinate efforts to take account of clients' personal and social needs. This was particularly so for allied health clinicians and nurses undertaking sub-acute rehabilitative-transitional work.

Originality/value: A new conceptualization of street-level bureaucracy is offered. Rather than as disconnected, it is a process of mutual influence among interdependent actors. This positioning can serve as a framework to evaluate how and under what circumstances discretion is appropriate, and to be supported by managers and policy makers to optimize client-defined needs.
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http://dx.doi.org/10.1108/JHOM-09-2017-0239DOI Listing
September 2018

Localizing Global Medicine: Challenges and Opportunities in Cervical Screening in an Indigenous Community in Ecuador.

Qual Health Res 2018 04;28(5):800-812

6 McGill University, Montreal, Québec, Canada.

This participatory research study examines the tensions and opportunities in accessing allopathic medicine, or biomedicine, in the context of a cervical cancer screening program in a rural indigenous community of Northern Ecuador. Focusing on the influence of social networks, the article extends research on "re-appropriation" of biomedicine. It does so by recognizing two competing tensions expressed through social interactions: suspicion of allopathic medicine and the desire to maximize one's health. Semistructured individual interviews and focus groups were conducted with 28 women who had previously participated in a government-sponsored cervical screening program. From inductive thematic analysis, the article traces these women's active agency in navigating coherent paths of health. Despite drawing on social networks to overcome formidable challenges, the participants faced enduring system obstacles-the organizational effects of the networks of allopathic medicine. Such obstacles need to be understood to reconcile competing knowledge systems and improve health care access in underresourced communities.
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http://dx.doi.org/10.1177/1049732317742129DOI Listing
April 2018

Comparing Medical Students' and Preceptors' Views of a Longitudinal Preclerkship Family Medicine Course.

PRiMER 2018 26;2. Epub 2018 Feb 26.

Department of Family Medicine, Faculty of Medicine, McGill University, Canada.

Introduction: Despite the increasing popularity of longitudinal primary care experiences in North America and beyond, there is a paucity of work assessing these medical undergraduate experiences using reliable and valid questionnaires. Our objective in this study was to evaluate a new preclerkship longitudinal family medicine experience (LFME) course at McGill University by assessing family physician preceptors' self-reported ratings of the perceived effects of this course, and to compare their responses with ratings provided by medical students who completed the course.

Methods: This study is part of a larger evaluative research project assessing the first edition of the LFME. Students (N=187) and preceptors (N=173) of the 2013-2014 cohort were invited to complete separate online questionnaires in the spring through summer of 2014. The preceptor survey contained 53 items, 14 of which were nearly identical to items in the student survey (published elsewhere) and served as the basis for comparing preceptor and student ratings of the LFME.

Results: Ninety-nine preceptors (57% response rate; 55% female) and 120 students (64% response rate; 58% female) completed the surveys. Preceptors and students did not significantly differ in their overall ratings of the course, as both groups were satisfied with the quality of the LFME and felt it was an appropriate and valuable educational experience. However, preceptors had more positive ratings regarding their role and the benefits of the course than did medical students.

Conclusion: This study corroborates prior work showing extensive perceived benefits of longitudinal preclerkship exposure to primary care; however, preceptors were found to report more positive reviews of the course than students. This study also provides new innovative tools to assess students' and preceptors' perceptions of longitudinal, preclerkship family medicine courses available for use over time and in different educational contexts.
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http://dx.doi.org/10.22454/PRiMER.2018.554037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7426126PMC
February 2018

Leadership in crisis situations: merging the interdisciplinary silos.

Leadersh Health Serv (Bradf Engl) 2018 02 24;31(1):110-128. Epub 2017 Nov 24.

Department of Family Medicine, Centre for Medical Education, McGill University , Montreal, Canada.

Purpose Complex clinical situations, involving multiple medical specialists, create potential for tension or lack of clarity over leadership roles and may result in miscommunication, errors and poor patient outcomes. Even though copresence has been shown to overcome some differences among team members, the coordination literature provides little guidance on the relationship between coordination and leadership in highly specialized health settings. The purpose of this paper is to determine how different specialties involved in critical medical situations perceive the role of a leader and its contribution to effective crisis management, to better define leadership and improve interdisciplinary leadership and education. Design/methodology/approach A qualitative study was conducted featuring purposively sampled, semi-structured interviews with 27 physicians, from three different specialties involved in crisis resource management in pediatric centers across Canada: Pediatric Emergency Medicine, Otolaryngology and Anesthesia. A total of three researchers independently organized participant responses into categories. The categories were further refined into conceptual themes through iterative negotiation among the researchers. Findings Relatively "structured" (predictable) cases were amenable to concrete distributed leadership - the performance by micro-teams of specialized tasks with relative independence from each other. In contrast, relatively "unstructured" (unpredictable) cases required higher-level coordinative leadership - the overall management of the context and allocations of priorities by a designated individual. Originality/value Crisis medicine relies on designated leadership over highly differentiated personnel and unpredictable events. This challenges the notion of organic coordination and upholds the validity of a concept of leadership for crisis medicine that is not reducible to simple coordination. The intersection of predictability of cases with types of leadership can be incorporated into medical simulation training to develop non-technical skills crisis management and adaptive leaderships skills.
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http://dx.doi.org/10.1108/LHS-02-2017-0010DOI Listing
February 2018

How physicians teach in the clinical setting: The embedded roles of teaching and clinical care.

Med Teach 2017 Dec 22;39(12):1238-1244. Epub 2017 Aug 22.

a Centre for Medical Education , McGill University , Montreal , Quebec , Canada.

Background: Clinical teaching lies at the heart of medical education. However, few studies have explored the embedded nature of teaching and clinical care. The goal of this study was to examine the process of clinical teaching as it naturally, and spontaneously, unfolds in a broad range of authentic contexts with medical students and residents.

Methods: This focused ethnographic study consisted of 160 hours of participant observation and field interviews with three internal medicine teams. Thematic analysis guided data organization and interpretation.

Findings: Three overlapping themes emerged: the interconnectedness between clinical work and pedagogy; a multiplicity of teachers; and the influence of space and artifacts on teaching and learning. Clinical teaching, which was deeply embedded in clinical care, was influenced by the acuity of patient problems, learner needs, and the context in which teaching unfolded; it also occurred on a spectrum that included planned, opportunistic, formal, and informal teaching (and learning).

Conclusions: Study findings suggest that clinical teaching, which is marked by an intersection between service and teaching, can be viewed as an example of work-based teaching. They also yield suggestions for the enhancement of clinical teaching in inpatient settings, faculty development, and educational policies that recognize clinical teaching and learning.
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http://dx.doi.org/10.1080/0142159X.2017.1360473DOI Listing
December 2017

Error Detection-Based Model to Assess Educational Outcomes in Crisis Resource Management Training: A Pilot Study.

Otolaryngol Head Neck Surg 2017 06 25;156(6):1080-1083. Epub 2017 Apr 25.

1 Department of Otolaryngology-Head and Neck Surgery, McGill University, Montréal, Canada.

Otolaryngology-head and neck surgery (OTL-HNS) residents face a variety of difficult, high-stress situations, which may occur early in their training. Since these events occur infrequently, simulation-based learning has become an important part of residents' training and is already well established in fields such as anesthesia and emergency medicine. In the domain of OTL-HNS, it is gradually gaining in popularity. Crisis Resource Management (CRM), a program adapted from the aviation industry, aims to improve outcomes of crisis situations by attempting to mitigate human errors. Some examples of CRM principles include cultivating situational awareness; promoting proper use of available resources; and improving rapid decision making, particularly in high-acuity, low-frequency clinical situations. Our pilot project sought to integrate CRM principles into an airway simulation course for OTL-HNS residents, but most important, it evaluated whether learning objectives were met, through use of a novel error identification model.
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http://dx.doi.org/10.1177/0194599817697946DOI Listing
June 2017

An Electronic Competency-Based Evaluation Tool for Assessing Humanitarian Competencies in a Simulated Exercise.

Prehosp Disaster Med 2017 Jun 21;32(3):253-260. Epub 2017 Feb 21.

6Department of Family Medicine,McGill University,Montreal,Canada.

Methods: The evaluation tool was first derived from the formerly Consortium of British Humanitarian Agencies' (CBHA; United Kingdom), now "Start Network's," Core Humanitarian Competency Framework and formatted in an electronic data capture tool that allowed for offline evaluation. During a 3-day humanitarian simulation event, participants in teams of eight to 10 were evaluated individually at multiple injects by trained evaluators. Participants were assessed on five competencies and a global rating scale. Participants evaluated both themselves and their team members using the same tool at the end of the simulation exercise (SimEx).

Results: All participants (63) were evaluated. A total of 1,008 individual evaluations were completed. There were 90 (9.0%) missing evaluations. All 63 participants also evaluated themselves and each of their teammates using the same tool. Self-evaluation scores were significantly lower than peer-evaluations, which were significantly lower than evaluators' assessments. Participants with a medical degree, and those with humanitarian work experience of one month or more, scored significantly higher on all competencies assessed by evaluators compared to other participants. Participants with prior humanitarian experience scored higher on competencies regarding operating safely and working effectively as a team member.

Conclusion: This study presents a novel electronic evaluation tool to assess individual performance in five of six globally recognized humanitarian competency domains in a 3-day humanitarian SimEx. The evaluation tool provides a standardized approach to the assessment of humanitarian competencies that cannot be evaluated through knowledge-based testing in a classroom setting. When combined with testing knowledge-based competencies, this presents an approach to a comprehensive competency-based assessment that provides an objective measurement of competency with respect to the competencies listed in the Framework. There is an opportunity to advance the use of this tool in future humanitarian training exercises and potentially in real time, in the field. This could impact the efficiency and effectiveness of humanitarian operations. Evans AB , Hulme JM , Nugus P , Cranmer HH , Coutu M , Johnson K . An electronic competency-based evaluation tool for assessing humanitarian competencies in a simulated exercise. Prehosp Disaster Med. 2017;32(3):253-260.
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http://dx.doi.org/10.1017/S1049023X1700005XDOI Listing
June 2017

Packaging Patients and Handing Them Over: Communication Context and Persuasion in the Emergency Department.

Ann Emerg Med 2017 Feb 10;69(2):210-217.e2. Epub 2016 Dec 10.

Netherlands Institute for Health Services Research, Utrecht, the Netherlands.

Study Objective: Communication is commonly understood by health professional researchers to consist of relatively isolated exchanges of information. The social and organizational context is given limited credit. This article examines the significance of the environmental complexity of the emergency department (ED) in influencing communication strategies and makes the case for adopting a richer understanding of organizational communication.

Methods: This study draws on approximately 12 months (1,600 hours) of ethnographic observations, yielding approximately 4,500 interactions across 260 clinicians and staff in the EDs of 2 metropolitan public teaching hospitals in Sydney, Australia.

Results: The study identifies 5 communication competencies of increasing complexity that emergency clinicians need to accomplish. Furthermore, it identifies several factors-hierarchy, formally imposed organizational boundaries and roles, power, and education-that contribute to the collective function of ensuring smooth patient transfer through and out of the ED. These factors are expressed by and shape external communication with clinicians from other hospital departments.

Conclusion: This study shows that handoff of patients from the ED to other hospital departments is a complex communication process that involves more than a series of "checklistable" information exchanges. Clinicians must learn to use both negotiation and persuasion to achieve objectives.
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http://dx.doi.org/10.1016/j.annemergmed.2016.08.456DOI Listing
February 2017

Assessing students' perceptions of the effects of a new Canadian longitudinal pre-clerkship family medicine experience.

Educ Prim Care 2016 May 28;27(3):180-7. Epub 2016 Apr 28.

b Faculty of Medicine, Department of Family Medicine , McGill University , Montreal , Canada.

Background: Despite the implementation of longitudinal community-based pre-clerkship courses in several Canadian medical schools, there is a paucity of data assessing students' views regarding their experiences. The present study sought to measure students' perceived effects of the new Longitudinal Family Medicine Experience (LFME) course at McGill University.

Methods: A 34-item questionnaire called the 'LFME Survey (Student Version)' was created, and all first-year medical students completed it online.

Results: The participation rate was 64% (N = 120). Eight factors were identified in the factor analysis performed: overall satisfaction, satisfaction with preceptor, knowledge, affective learning, clinical skills, teaching/feedback, professional identity/professionalism and attitude toward primary care. Factor composite scores were above 4.5/7,indicating that students had positive perceptions of the LFME. Students felt that the LFME was a valuable educational experience and that their preceptors were good role-models. The course improved students' confidence, reinforced their commitment to being a physician and increased their positive attitude toward primary care.

Interpretation: Along with similar pre-clerkship courses, the LFME provides a valuable context for developing students' clinical skills, providing real-world cases, teaching patient-centred care and improving attitudes toward primary care. The LFME Survey appears to be a promising and innovative tool that deserves further validation.
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http://dx.doi.org/10.1080/14739879.2016.1172033DOI Listing
May 2016

How we made professionalism relevant to twenty-first century residents.

Med Teach 2015 16;37(6):538-42. Epub 2015 Jan 16.

McGill University , Canada.

The complexity of the current medical trainee work environment, including the impact of social media participation, is underappreciated. Despite rapid adoption of social media by residents and the introduction of social media guidelines targeted at medical professionals, there is a paucity of data evaluating practical methods to incorporate social media into professionalism teaching curricula. We developed a flipped classroom program, focusing on the application of professionalism principles to challenging real-life scenarios including social media-related issues. The pre-workshop evaluation showed that the participants had a good understanding of basic professionalism concepts. A post-workshop survey assessed residents' comfort level with professionalism concepts. The post-workshop survey revealed that the postgraduate trainees perceived significant improvement in their understanding of professionalism (p < 0.05). Resident responses also exposed some challenges of real-life clinical settings. There was an apparent contradiction between placing a high value on personal health and believing that physicians ought to be available to patients at any time. Participants' satisfaction with the course bodes well for continual modification of such courses. Innovative flipped classroom format in combination with simulation-based sessions allows easy incorporation of contemporary professionalism issues surrounding social media.
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http://dx.doi.org/10.3109/0142159X.2014.990878DOI Listing
April 2016

Improving delirium care for hospitalized older patients. A qualitative study identifying barriers to guideline adherence.

J Eval Clin Pract 2014 Dec 31;20(6):813-9. Epub 2014 Jul 31.

NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands.

Rationale, Aims And Objectives: Guidelines are intended as a means of getting research evidence into practice and ensuring provided care is of sufficient quality. However, the effect of guidelines is hindered by limited guideline adherence. The aim of this study is to identify and classify barriers to adherence by nurses to a guideline on delirium care.

Methods: Open-ended interviews were conducted with a purposive sample of 63 research participants. The sample included 28 nurses, 18 doctors and 17 policy advisors working in 19 hospitals in the Netherlands. The interviews were conducted between June and September 2011. The data were analysed using thematic analysis.

Results: Barriers to guideline adherence that were identified could be grouped into four themes: motivation and goals, knowledge and skills, professional role and identity, and context and resources. While the interviews with nurses, doctors and policy advisors produced similar views of the current situation, doctors and policy advisors placed a higher importance on education as a means of stimulating adherence.

Conclusions: This study illustrates that individual, social and organizational factors play a role in nurse's adherence to a delirium guideline. The potential benefits of following a guideline, both for patients and for nursing staff, need to be highlighted in order to motivate nurses. When formulating new guidelines, nurses' perceptions of their professional role and patient care need to be taken into account to ensure that policy makers and managers are realistic about guideline adherence and engage with nurses from a position of mutual respect and trust.
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http://dx.doi.org/10.1111/jep.12229DOI Listing
December 2014

Achieving patient-centred care: the potential and challenge of the patient-as-professional role.

Health Expect 2015 Dec 7;18(6):2616-28. Epub 2014 Jul 7.

Centre for Clinical Governance Research, Australian Institute of Health Innovation, The University of New South Wales, Sydney, NSW, Australia.

Background: The patient-as-professional concept acknowledges the expert participation of patients in interprofessional teams, including their contributions to managing and coordinating their care. However, little is known about experiences and perspectives of these teams.

Objective: To investigate (i) patients' and carers' experiences of actively engaging in interprofessional care by enacting the patient-as-professional role and (ii) clinicians' perspectives of this involvement.

Design, Setting And Participants: A two-phased qualitative study. In Phase 1, people with chronic disease (n = 50) and their carers (n = 5) participated in interviews and focus groups. Phase 2 involved interviews with clinicians (n = 14). Data were analysed thematically.

Findings: Patients and carers described the characteristics of the role (knowing about the condition, questioning clinicians, coordinating care, using a support network, engaging an advocate and being proactive), as well as factors that influence its performance (the patient-clinician partnership, benefits, barriers and applicability). However, both patients and carers, and clinicians cautioned that not all patients might desire this level of involvement. Clinicians were also concerned that not all patients have the required knowledge for this role, and those who do are time-consuming. When describing the inclusion of the patient-as-professional, clinicians highlighted the patient and clinician's roles, the importance of the clinician-patient relationship and ramifications of the role.

Conclusion: Support exists for the patient-as-professional role. The characteristics and influencing factors identified in this study could guide patient engagement with the interprofessional team and support clinicians to provide patient-centred care. Recognition of the role has the potential to improve health-care delivery by promoting patient-centred care.
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http://dx.doi.org/10.1111/hex.12234DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5810639PMC
December 2015

Developing an inter-organizational community-based health network: an Australian investigation.

Health Promot Int 2015 Dec 22;30(4):868-80. Epub 2014 Apr 22.

Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW, Australia.

Networks in health care typically involve services delivered by a defined set of organizations. However, networked associations between the healthcare system and consumers or consumer organizations tend to be open, fragmented and are fraught with difficulties. Understanding the role and activities of consumers and consumer groups in a formally initiated inter-organizational health network, and the impacts of the network, is a timely endeavour. This study addresses this aim in three ways. First, the Unbounded Network Inter-organizational Collaborative Impact Model, a purpose-designed framework developed from existing literature, is used to investigate the process and products of inter-organizational network development. Second, the impact of a network artefact is explored. Third, the lessons learned in inter-organizational network development are considered. Data collection methods were: 16 h of ethnographic observation; 10 h of document analysis; six interviews with key informants and a survey (n = 60). Findings suggested that in developing the network, members used common aims, inter-professional collaboration, the power and trust engendered by their participation, and their leadership and management structures in a positive manner. These elements and activities underpinned the inter-organizational network to collaboratively produce the Health Expo network artefact. This event brought together healthcare providers, community groups and consumers to share information. The Health Expo demonstrated and reinforced inter-organizational working and community outreach, providing consumers with community-based information and linkages. Support and resources need to be offered for developing community inter-organizational networks, thereby building consumer capacity for self-management in the community.
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http://dx.doi.org/10.1093/heapro/dau021DOI Listing
December 2015

Development of a model to guide decision making in amyotrophic lateral sclerosis multidisciplinary care.

Health Expect 2015 Oct 23;18(5):1769-82. Epub 2013 Dec 23.

Royal Prince Alfred Hospital, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.

Background: Patients with amyotrophic lateral sclerosis (ALS) face numerous decisions for symptom management and quality of life. Models of decision making in chronic disease and cancer care are insufficient for the complex and changing needs of patients with ALS .

Objective: The aim was to examine the question: how can decision making that is both effective and patient-centred be enacted in ALS multidisciplinary care?

Setting And Participants: Fifty-four respondents (32 health professionals, 14 patients and eight carers) from two specialized ALS multidisciplinary clinics participated in semi-structured interviews. Interviews were transcribed, coded and analysed thematically.

Results: Comparison of stakeholder perspectives revealed six key themes of ALS decision making. These were the decision-making process; patient-centred focus; timing and planning; information sources; engagement with specialized ALS services; and access to non-specialized services. A model, embedded in the specialized ALS multidisciplinary clinic, was derived to guide patient decision making. The model is cyclic, with four stages: 'Participant Engagement'; 'Option Information'; 'Option Deliberation'; and 'Decision Implementation'.

Discussion: Effective and patient-centred decision making is enhanced by the structure of the specialized ALS clinic, which promotes patients' symptom management and quality of life goals. However, patient and carer engagement in ALS decision making is tested by the dynamic nature of ALS, and patient and family distress. Our model optimizes patient-centred decision making, by incorporating patients' cyclic decision-making patterns and facilitating carer inclusion in decision processes.

Conclusions: The model captures the complexities of patient-centred decision making in ALS. The framework can assist patients and carers, health professionals, researchers and policymakers in this challenging disease environment.
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http://dx.doi.org/10.1111/hex.12169DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5060893PMC
October 2015

Supporting patients to self-manage chronic disease: clinicians' perspectives and current practices.

Aust J Prim Health 2014 ;20(3):257-65

Centre for Clinical Governance Research, Australian Institute of Health Innovation, AGSM Building, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia.

This study investigated: clinicians' perspectives of the scope of self-management, which self-management support initiatives are used, and the factors clinicians consider when deciding which initiative to use with individual patients. Three phases of data collection were used. First, clinicians were interviewed about their attitudes toward self-management (n=14). Second, clinicians and managers completed a survey about the support initiatives they use (n=38). Third, in interviews clinicians described the applications of initiatives (n=6). Data were descriptively and thematically analysed. Clinicians believed that supporting self-management involved a holistic approach. However, some also thought that not all patients had the capacity to self-manage. This idea may be at odds with the underlying notion of self-management and impact on the support provided. Clinicians reported using 54 initiatives to support self-management and identified a range of situations when each initiative may or may not be suitable. This suggests that clinicians need to be familiar with a range of support initiatives as one will not suit everyone. Deciding which initiative is most appropriate may be aided by the development of guidelines.
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http://dx.doi.org/10.1071/PY13002DOI Listing
October 2014

The emergency department "carousel": an ethnographically-derived model of the dynamics of patient flow.

Int Emerg Nurs 2014 Jan 10;22(1):3-9. Epub 2013 May 10.

Australian Institute of Health Innovation, Faculty of Medicine, Level 1, AGSM Building (G27), University of New South Wales, Sydney, NSW 2054, Australia.

Emergency department (ED) overcrowding reduces efficiency and increases the risk of medical error leading to adverse events. Technical solutions and models have done little to redress this. A full year's worth of ethnographic observations of patient flow were undertaken, which involved making hand-written field-notes of the communication and activities of emergency clinicians (doctors and nurses), in two EDs in Sydney, Australia. Observations were complemented by semi-structured interviews. We applied thematic analysis to account for the verbal communication and activity of emergency clinicians in moving patients through the ED. The theoretical model that emerged from the data analysis is the ED "carousel". Emergency clinicians co-construct a moving carousel which we conceptualise visually, and which accounts for the collective agency of ED staff, identified in the findings. The carousel model uniquely integrates diagnosis, treatment and transfer of individual patients with the intellectual labour of leading and coordinating the department. The latter involves managing staff skill mix and the allocation of patients to particular ED sub-departments. The model extends traditional patient flow representations and underlines the importance of valuing ethnographic methods in health services research, in order to foster organisational learning, and generate creative practical and policy alternatives that may, for example, reduce or ameliorate access block and ED overcrowding.
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http://dx.doi.org/10.1016/j.ienj.2013.01.001DOI Listing
January 2014

What are the roles of carers in decision-making for amyotrophic lateral sclerosis multidisciplinary care?

Patient Prefer Adherence 2013 28;7:171-81. Epub 2013 Feb 28.

Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales.

Purpose: Family carers of patients with amyotrophic lateral sclerosis (ALS) are presumed to have frequent involvement in decision-making for symptom management and quality of life. To better understand and improve decision-making, we investigated the range and extent of carer participation in decision-making. By focusing on the perspectives of ALS support carers, the study aimed to explore carer participation in decision-making, to identify carer roles, and determine the facilitators and barriers to carer participation in decision-making for ALS multidisciplinary care.

Participants And Methods: An exploratory, in-depth study was conducted with eight carers of ALS patients from two specialized ALS multidisciplinary clinics. Carers participated in semi-structured interviews that were audio recorded and transcribed then coded and analyzed for emergent themes.

Results: Carers made a significant contribution to ALS decision-making. Their roles were: promoting the patient voice, promoting patient health literacy, and providing emotional support and logistical assistance. Facilitators of carer participation in decision-making were perceived to be: health professional endorsement of patients' decision-making style; access to credible information sources; evidence-based information from the ALS clinic, ALS support association, and health practitioners; supportive relationships with family and friends; spiritual faith; ease of contact with ALS services; and availability of physical and practical support for carers. Barriers to carer participation included: changes to patient communication and cognition; conflict between respect for patients' independence and patients' best interest; communication breakdown between patient, carer, and service providers; the confronting nature of disease information; credibility of Internet sites; carer coping strategies; lack of support for the carer; and the burden of care.

Conclusion: Carers enhance ALS patient-centered care through their participation in decision-making. They collaborate with patients and health professionals to form a decision-making triad within specialized multidisciplinary ALS clinical care. Nevertheless, health professional engagement with carers as collaborative partners is acknowledged to be a significant challenge.
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http://dx.doi.org/10.2147/PPA.S40783DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3589077PMC
March 2013

What influences patient decision-making in amyotrophic lateral sclerosis multidisciplinary care? A study of patient perspectives.

Patient Prefer Adherence 2012 27;6:829-38. Epub 2012 Nov 27.

Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, New South Wales, Australia.

Background: Patients with amyotrophic lateral sclerosis (ALS) are required to make decisions concerning quality of life and symptom management over the course of their disease. Clinicians perceive that patients' ability to engage in timely decision-making is extremely challenging. However, we lack patient perspectives on this issue. This study aimed to explore patient experiences of ALS, and to identify factors influencing their decision-making in the specialized multidisciplinary care of ALS.

Methods: An exploratory study was conducted. Fourteen patients from two specialized ALS multidisciplinary clinics participated in semistructured interviews that were audio recorded and transcribed. Data were analyzed for emergent themes.

Results: Decision-making was influenced by three levels of factors, ie, structural, interactional, and personal. The structural factor was the decision-making environment of specialized multidisciplinary ALS clinics, which supported decision-making by providing patients with disease-specific information and specialized care planning. Interactional factors were the patient experiences of ALS, including patients' reaction to the diagnosis, response to deterioration, and engagement with the multidisciplinary ALS team. Personal factors were patients' personal philosophies, including their outlook on life, perceptions of control, and planning for the future. Patient approaches to decision-making reflected a focus on the present, rather than anticipating future progression of the disease and potential care needs.

Conclusion: Decision-making for symptom management and quality of life in ALS care is enhanced when the patient's personal philosophy is supported by collaborative relationships between the patient and the multidisciplinary ALS team. Patients valued the support provided by the multidisciplinary team; however, their focus on living in the present diverged from the efforts of health professionals to prepare patients and their carers for the future. The challenge facing health professionals is how best to engage each patient in decision-making for their future needs, to bridge this gap.
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http://dx.doi.org/10.2147/PPA.S37851DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3514070PMC
December 2012

Continuing differences between health professions' attitudes: the saga of accomplishing systems-wide interprofessionalism.

Int J Qual Health Care 2013 Feb 29;25(1):8-15. Epub 2012 Nov 29.

Australian Institute of Health Innovation, Centre for Clinical Governance Research, University of New South Wales, NSW 2052, Australia.

Objective: To compare four health professions' attitudes towards interprofessional collaboration (IPC) and their evaluations of a programme aimed at enhancing IPC across a health system.

Design: Questionnaire survey.

Setting: Australian Capital Territory health services.

Participants: Sample of medical (38), nursing (198), allied health (152) and administrative (30) staff.

Intervention: s) A 4-year action research project to improve IPC.

Main Outcome Measure: Questionnaire evaluating the project and responses to the 'Attitudes toward Health Care Teams' and 'Readiness for Interprofessional Learning' scales.

Results: Significant professional differences occurred in 90% of the evaluation items. Doctors were the least and administrative staff most likely to agree project aims had been met. Nurses made more favourable assessments than did allied health staff. Doctors made the most negative assessments and allied health staff the most neutral ratings. Improved interprofessional sharing of knowledge, teamwork and patient care were among the goals held to have been most achieved. Reduction in interprofessional rivalry and improved trust and communication were least achieved. Average assessment of individual goals being met was agree (31.9%), neutral (56.9%) and disagree (11.2%). On the two attitude scales, allied health professionals were most supportive of IPC, followed by nurses, administrators and doctors.

Conclusions: Although overall attitudes towards IPC were favourable, only a third of participants reported that project goals had been achieved indicating the difficulties of implementing systems change. The response profiles of the professions differed. As in the previous research, doctors were least likely to hold favourable attitudes towards or endorse benefits from social or structural interventions in health care.
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http://dx.doi.org/10.1093/intqhc/mzs071DOI Listing
February 2013

Engaging in patient decision-making in multidisciplinary care for amyotrophic lateral sclerosis: the views of health professionals.

Patient Prefer Adherence 2012 27;6:691-701. Epub 2012 Sep 27.

Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, New South Wales, Australia.

Background: The aim of this study was to explore clinician perspectives on patient decision-making in multidisciplinary care for amyotrophic lateral sclerosis (ALS), in an attempt to identify factors influencing decision-making.

Methods: Thirty-two health professionals from two specialized multidisciplinary ALS clinics participated in individual and group interviews. Participants came from allied health, medical, and nursing backgrounds. Interviews were audio recorded, and the transcripts were analyzed thematically.

Results: Respondents identified barriers and facilitators to optimal timing and quality of decision-making. Barriers related to the patient and the health system. Patient barriers included difficulties accepting the diagnosis, information sources, and the patient-carer relationship. System barriers were timing of diagnosis and symptom management services, access to ALS-specific resources, and interprofessional communication. Facilitators were teamwork approaches, supported by effective communication and evidence-based information.

Conclusion: Patient-centered and collaborative decision-making is influenced by a range of factors that inhibit the delivery of optimal care. Decision-making relies on a fine balance between timing of information and service provision, and the readiness of patients to receive them. Health system restrictions impacted on optimal timing, and patients coming to terms with their condition. Clinicians valued proactive decision-making to prepare patients and families for inevitable change. The findings indicate disparity between patient choices and clinician perceptions of evidence, knowledge, and experience. To improve multidisciplinary ALS practice, and ultimately patient care, further work is required to bridge this gap in perspectives.
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http://dx.doi.org/10.2147/PPA.S36759DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3468167PMC
November 2012

Visualising differences in professionals' perspectives on quality and safety.

BMJ Qual Saf 2012 Sep;21(9):778-83

School of Public Health and Community Medicine, University of New South Wales, Randwick, Australia.

Background: The safety-and-quality movement is now two decades old. Errors persist despite best efforts, indicating that there are entrenched overt and perhaps less explicit barriers limiting the success of improvement efforts. OBJECTIVES AND HYPOTHESES: To examine the perspectives of five groups of healthcare workers (administrative staff, nurses, medical practitioners, allied health and managers) and to compare and contrast their descriptions of quality-and-safety activities within their organisation. Differences in perspectives can be an indicator of divergence in the conceptualisation of, and impetus for, quality-improvement strategies which are intended to engage healthcare professions and staff.

Design, Setting And Participants: Study data were collected in a defined geographical healthcare jurisdiction in Australia, via individual and group interviews held across four service streams (aged care and rehabilitation; mental health; community health; and cancer services). Data were collected in 2008 and analysed, using data-mining software, in 2009.

Results: Clear differences in the perspectives of professional groups were evident, suggesting variations in the perceptions of, and priorities for, quality and safety.

Conclusions: The visual representation of quality and safety perspectives provides insights into the conceptual maps currently utilised by healthcare workers. Understanding the similarity and differences in these maps may enable more effective targeting of interprofessional improvement strategies.
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http://dx.doi.org/10.1136/bmjqs-2011-051755DOI Listing
September 2012

The politics of action research: "if you don't like the way things are going, get off the bus".

Soc Sci Med 2012 Dec 1;75(11):1946-53. Epub 2012 Aug 1.

Centre for Clinical Governance Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Australia.

Participatory action research is lauded for its emancipatory potential and practice relevance. Little research has focused on the ethical and political dimensions of power relations between management gatekeepers and staff in large organizations in the negotiation of action research. To illuminate the dynamics of this engagement, this paper is informed by Aristotle's practical ethics of phronesis, arguing that ethics emerge through human interaction. The paper reports on a multi-method study and intervention in inter-professional learning and collaboration, conducted between 2008 and 2010, across an Australian health system. It draws on results from researchers' progress notes, 139 semi-structured interviews and focus groups (492 participants), more than 200 h of organizational document analysis, and more than 200 h of ethnographic observation. From conventional thematic analysis, we note that the project had considerable support from senior managers who were gatekeepers for the research. Such support stemmed from managerialist tendencies, with senior managers explicitly aligning inter-professionalism with prospective health reforms and improvements to quality of care and patient safety. Senior managers were also enthusiastic about standardized processes. Many frontline staff were less supportive, and some were suspicious of or hostile towards management-led processes to improve and evaluate care. Some senior managers' self perceived alignment with and support for the research process changed to resistance once this finding was presented. This paradox in the interplay of research findings and research process evinces the inherent tension between organizational politics and conducting action research that reflexive researchers need to negotiate in knowledge translation, exchange or mobilization exercises.
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http://dx.doi.org/10.1016/j.socscimed.2012.06.024DOI Listing
December 2012

A four-year, systems-wide intervention promoting interprofessional collaboration.

BMC Health Serv Res 2012 Apr 20;12:99. Epub 2012 Apr 20.

Faculty of Medicine, University of New South Wales, Kensington, NSW 2052, Australia.

Background: A four-year action research study was conducted across the Australian Capital Territory health system to strengthen interprofessional collaboration (IPC) though multiple intervention activities.

Methods: We developed 272 substantial IPC intervention activities involving 2,407 face-to-face encounters with health system personnel. Staff attitudes toward IPC were surveyed yearly using Heinemann et al's Attitudes toward Health Care Teams and Parsell and Bligh's Readiness for Interprofessional Learning scales (RIPLS). At study's end staff assessed whether project goals were achieved.

Results: Of the improvement projects, 76 exhibited progress, and 57 made considerable gains in IPC. Educational workshops and feedback sessions were well received and stimulated interprofessional activities. Over time staff scores on Heinemann's Quality of Interprofessional Care subscale did not change significantly and scores on the Doctor Centrality subscale increased, contrary to predictions. Scores on the RIPLS subscales of Teamwork & Collaboration and Professional Identity did not alter. On average for the assessment items 33% of staff agreed that goals had been achieved, 10% disagreed, and 57% checked neutral. There was most agreement that the study had resulted in increased sharing of knowledge between professions and improved quality of patient care, and least agreement that between-professional rivalries had lessened and communication and trust between professions improved.

Conclusions: Our longitudinal interventional study of IPC involving multiple activities supporting increased IPC achieved many project-specific goals. However, improvements in attitudes over time were not demonstrated and neutral assessments predominated, highlighting the difficulties faced by studies targeting change at the systems level and over extended periods.
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http://dx.doi.org/10.1186/1472-6963-12-99DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3359212PMC
April 2012

Contested innovation: the diffusion of interprofessionalism across a health system.

Int J Qual Health Care 2011 Dec 14;23(6):629-36. Epub 2011 Oct 14.

School of Public Health and Community Medicine and Centre for Clinical Governance Research, Australian Institute for Health Innovation, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia.

Objective: Interprofessionalism (IP) has emerged as a new movement in healthcare in response to workforce shortages, quality and safety issues and professional power dynamics. Stakeholders can push for IP (e.g. education providers to the health system) or pull (e.g. the health system to the education provider). Based on innovation theory, we hypothesized that there would be unequal forces within and across stakeholder domains which would work to facilitate or resist IP. The strongest pull pressures would be from the health system and services; push pressures for IP would come from government and higher education; with weaker push forces and levels of resistance, from protectionist professional bodies.

Design:

Setting And Participants: /st> Our model was tested in a geographically bounded health jurisdiction. Information was gathered and analysed via individual (n= 99 participants) and group (n= 372 participants) interviews with stakeholders, and through document analysis.

Results: /st> The health system and services exerted the strongest pull in demanding IP. The strongest push factor was individual champions in positions of power. Professional bodies balanced their support of IP competencies with their role as advocates for their individual professions. A weak push factor came from government support for health workforce reform.

Conclusions: /st> Our hypothesis was supported, as were our predictions that the strongest pull would be from the providers and the strongest push from government and higher education. Our original model should be extended to account for contextual factors such as large-scale workplace and professional reform, which worked both for and against, IP.
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http://dx.doi.org/10.1093/intqhc/mzr064DOI Listing
December 2011
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