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Identification of interprofessional practice and application to achieve patient outcomes of health care providers in the acute care setting
Journal of Interprofessional Education & Practice 9 (2017) 108e114
Contents lists available at ScienceDirect
Journal of Interprofessional Education & Practice journal homepage: http://www.jieponline.com
Identification of interprofessional practice and application to achieve patient outcomes of health care providers in the acute care setting Beth Bright, OTR/L, OTD, BCPR *, Brittany Austin, OTDS, Chelsey Garn, OTDS, Jillian Glass, OTDS, Shelby Sample, OTDS Huntington University, Fort Wayne, IN, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 26 March 2017 Received in revised form 29 August 2017 Accepted 10 September 2017
Background: Recent health care changes urge for the implementation of interprofessional practice to improve quality of patient care. Purpose: The study sought to determine the current level of workforce readiness for the implementation of interprofessional practice (IPP) in the acute care setting at a health care institution. Method: The researchers obtained descriptive data through the use of a survey instrument. Discussion: Results demonstrated that the majority (86.67%) of surveyed health care providers had a “medium” or “high” understanding of IPP. However, results exhibited that current application of IPP was inadequate with only 54.17% (n ¼ 65) of the health care professionals reporting “daily” implementation of IPP when providing direct or indirect patient care. Participants identified timing (67.50%) and scheduling conflicts (63.33%) as barriers to IPP, which may explain the exposed discrepancies. Conclusion: Further research is needed to establish protocols for the implementation of IPP based on the current study's needs assessment results. © 2017 Elsevier Inc. All rights reserved.
1. Introduction The purpose of the current study is to determine the current level of workforce readiness for the implementation of interprofessional practice in the acute care setting at a local health care institution. Interprofessional practice (IPP) occurs “when multiple health workers from different professional backgrounds work together with patients, families, caregivers, and communities to deliver the highest quality of care”.1 The World Health Organization (WHO) recognizes that in order to be prepared for IPP, health professionals must be effectively trained in interprofessional education (IPE), which occurs “when students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes”.1 The publication of the core competencies was sponsored by the Interprofessional Education Collaborative and the document outlines the standards by which IPP and IPE should be implemented and was the source
for primary definitions.2 Major quality issues in U.S. hospitals drive the movement for interprofessional practice; these issues include widespread patient error and preventable mortality and morbidity giving rise to a costly system of health care delivery.2 Growing evidence indicates IPP can improve many aspects of health care including patient satisfaction, patient safety, health care quality and health outcomes, increased job satisfaction among health professionals, and better staff recruitment and retention in health care systems.3 The current study is investigating the state of interprofessional practice in the acute care setting at a local health care institution. Priority is placed on gaining an understanding of current IPE and IPP knowledge and practices in individual health systems in order to construct well-fit protocols for the implementation of IPP within each system. 2. Literature review 2.1. Interprofessional practice
* Corresponding author. Huntington University, 1819 Carew St., Fort Wayne, IN, 46805, USA. Tel.: 260 702 9622; fax: 260 702 9626. E-mail addresses: [email protected] (B. Bright), austinb@huntington. edu (B. Austin), [email protected] (C. Garn), [email protected] (J. Glass), [email protected] (S. Sample). https://doi.org/10.1016/j.xjep.2017.09.003 2405-4526/© 2017 Elsevier Inc. All rights reserved.
2.1.1. Outcomes According to D'amour and Oandasan,4 interprofessional practice is crucial to patient care because professionals come from diverse disciplines and from different healthcare organizations, each
B. Bright et al. / Journal of Interprofessional Education & Practice 9 (2017) 108e114
carrying different conceptualizations of the client. Each discipline transmits a unique response to patient needs and complex healthcare situations, therefore owning a professional jurisdiction or scope of practice impacting the delivery of services.4 Health care has shifted in recent years, focusing on training employees to provide the best health care at the lowest cost. Supported by data relating outcomes of system changes to reduced costs, a new movement called “value-based health care” or “volume to value” has begun. Health care insurers are now rewarding outcomes and teamwork with monetary incentives to affiliated providers. In 2000, a resurgence of interest in interprofessional practice and education emerged, which focused on patient safety and strategic quality improvement of the acute care system in the U.S. The specific aim was to reduce the frequency and cost of adverse events as a result of medical error.5 2.1.2. Communication Over time, interest in interprofessional practice and interprofessional education has risen and fallen after inception in the 1970's. According to Brandt,5 collaborative practice models did not gain traction immediately and as a result, uniprofessional work or “parallel play” practices persisted. Stumpf and Clark6 stated that students were being prepared academically in a uniprofessional setting, when in practice, a multiprofessional setting is more realistic. Therefore, education was failing to prepare new health care providers for future care provision by inadequately implementing curriculum that incorporated a multiprofessional approach. According to McNair,7 health care professionals can be threatened by other disciplines who “encroach upon their territory,” resulting in a feeling of territorialism. Lack of advocacy for newer health care professions leads to lower placement on the hierarchical system. Another problem area limiting communication concerns a lack of clarity over professional roles including responsibilities and accountability, which could be resolved with greater implementation of interprofessional education on the understanding of the roles of other professionals.8 Health care providers recognize that one of the most prevalent problems in medicine today is poor communication. Poor communication has led to significant medical errors including preventable hospital deaths. Between 44,000 and 98,000 patient deaths resulted from poor communication in American hospitals annually.9 In 2013, an estimated 440,000 patients experienced preventable harm according to The Journal of Patient Safety.10 Lack of coordination between health care disciplines led to negative outcomes, medication errors, avoidable hospitalizations, increased costs, and patient dissatisfaction.9 Successful communication is a requirement for successful interprofessional practice; therefore, teaching health care providers how to implement IPP is likely to solve the costly medical errors of today's hospitals. 2.1.3. Medical errors A medical error is defined as “a failure in the process of delivering care” by the Institute of Medicine.11 Error occurs in all tasks, but in the field of health care, the results of errors can potentially be life threatening.12 Five types of medical errors were identified by the Journal of Patient Safety including (a) errors of commission, (b) errors of omission, (c) errors of communication, (d) errors of context, and (e) diagnostic errors.10 To increase quality of patient care with the least amount of medical errors, health care practitioners would benefit from the implementation of interprofessional practice. Due to the complex nature of many patient cases, the basis of IPP involves the collective action of multiple health care providers to address patient needs.13 In order to prepare health care providers for a collective approach to case management, IPP must be introduced prior to professional
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practice in the form of IPE. 2.1.4. Interprofessional education Interprofessional education prepares health professional students to intentionally collaborate; students are able to expand from one sole perspective in order to improve quality of patient care.14,15 Through the implementation of IPE, students learn about other professions, build teamwork skills, and learn about the collaborative practice that will exist in the near future.16 The purpose of interprofessional education is to prepare students to fully understand and to be able to navigate through the complexity of interprofessional practice, in order to deliver effective, team-based care. Though the idea of IPE appears simple, the effectiveness of the concept is difficult to evaluate due to the diverse academic programs and learning opportunities presented for students.16 Successful implementation of IPE requires educators to play a crucial role as enablers to the students' opportunities to gain the necessary collaborative competencies.4 Chen, Delnat, and Gardner17 suggested an issue of disconnect between IPE and IPP resulting from the lack of professional role models to support collaborative competencies. Safe and efficient patient care is dependent upon effective communication across multiple health care disciplines, yet research has revealed that many health care professionals enter practice without IPP training.18,19 Despite the lack of research in regards to IPE, the idea is not a new concept in the health care profession. 3. Methodology 3.1. Participants The participants were selected using a convenience sampling technique and a snowball sampling technique. Participation in the study was completely voluntary and responses remained anonymous and confidential. Inclusion criteria consisted of full-time, part-time, and pro re nata (PRN) employees at the local health care institution that were employed from May 1st, 2016 to August 3rd, 2016. Exclusion criteria included volunteers at the local health care institution during the time of May 1st, 2016 to August 3rd, 2016. Health care providers recruited to complete the survey included physicians, nurses, occupational therapists, physical therapists, social workers, physician assistants, nurse practitioners, direct care providers, speech therapists, and managers or department heads. The survey contained an “other” category to include any health care disciplines not listed. Incomplete surveys were excluded from the study. The researchers personally handed out and collected the surveys in each acute care department at the local health care institution. The researchers collected surveys from 135 participants. However, 15 survey responses were incomplete and therefore excluded from the study; resulting in a total of 120 participants. 3.2. Instrument The current study employed a survey instrument created by the study preceptor. The survey instrument, the Interprofessional Practice Survey (Appendix 1), contained a total of 10 questions with two optional questions, which were not included in the data analysis. The survey addressed the participants' current health care occupation and understanding of IPP within the acute care setting. See Appendix I for a copy of the survey. The participants reported collaboration with other health care disciplines and frequency of IPP. The survey was not formally tested for validity, however to increase reliability each participant received the same copy of the survey. The survey was expert reviewed by two health care
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B. Bright et al. / Journal of Interprofessional Education & Practice 9 (2017) 108e114
Table 1 The Interprofessional Practice Survey questions of interest. Interprofessional Practice Survey Questions Question 1 Question 3 Question 5 Question 7 Question 10
“In general, how would you rate your level of understanding pertaining to interprofessional practice?” “How often do you implement interprofessional practice when directly or indirectly providing patient care?” “How many times have you participated in interprofessional Rounding or team rounding in the past 12 months?” “Do you expect interprofessional practice to be a future Requirement in the inpatient setting?” “What do you feel are barriers for interprofessional practice?”
professionals prior to distribution to the participants; modifications were made based on critiques. Although the current survey was not tested for validity, the survey was drafted by pulling questions from previously developed surveys that were tested for validity. The instrument was adapted using terminology from the “Core Competencies for Interprofessional Collaborative Practice”.2 3.3. Procedure The current study used a quantitative research design to investigate the nature of interprofessional practice in the acute care setting at a local health care institution. The study was approved by both Huntington University's Institutional Review Board (IRB) and Lutheran Hospital's IRB. The study involved the use of a 10-question survey instrument for data collection. The researchers distributed and collected surveys on three different days in June 2016 and two days in July 2016. The researchers distributed surveys to multiple acute care units at the local health care institution. The survey was handed out to the included disciplines and participants were given privacy to complete the survey onsite. On average, the survey took approximately five minutes to complete. The researchers collected the completed surveys from the participants and stored the surveys in a sealed envelope, which was kept in a secure location. 3.4. Data analysis The survey instrument produced strictly descriptive data. The survey provided the researchers with ordinal data, which was then converted to interval data and entered into an Excel document. The researchers used Excel to obtain frequency counts from key
questions on the survey. The key questions included in the data analysis can be found in Table 1 below. The researchers compared the survey responses from question 1 to questions 3 and 5. The aim was to compare the understanding of IPP and the collaboration dynamic that existed among various disciplines within the acute care setting. Responses to question 7 were compared to responses to question 5, and the top three responses were determined for question 10. The participant's current implementation of IPP was compared to the participants' perception of whether or not IPP will be a future requirement for the inpatient setting. The researchers also identified the top three barriers to the implementation of IPP. The data analysis gave the researchers an overall understanding of the current nature of IPP in the local health care institution.
3.5. Results The survey results included a total of 120 completed surveys. Participating disciplines included (a) physicians [n ¼ 13] and physician assistants [n ¼ 3], (b) nurses [n ¼ 53], nurse practitioners [n ¼ 3], and patient care assistants [n ¼ 11], (c) pharmacists [n ¼ 1] and pharmacy technicians [n ¼ 2], (d) social workers [n ¼ 3], (e) management [n ¼ 6], (f) occupational therapists [n ¼ 9], physical therapists [n ¼ 7], speech therapists [n ¼ 1], and rehabilitation technicians [n ¼ 1], (g) dieticians [n ¼ 5], (h) respiratory care [n ¼ 1], and (i) registration [n ¼ 1]. According to the survey results demonstrated in Fig. 1, the researchers determined that the majority (86.67%) of health care professionals surveyed had a “medium” or “high” understanding of interprofessional practice (medium [n ¼ 53]; high [n ¼ 51]). Also of interest to the researchers was the frequency of IPP implementation when directly or indirectly providing patient care. Only 54.17% (n ¼ 65) of the health care professionals surveyed reported implementing IPP “daily” when providing direct or indirect patient care. The survey revealed that 10% (n ¼ 12) of participants implement IPP “weekly”, 32.5% (n ¼ 39) of participants implement IPP “monthly”, and 3.33% (n ¼ 4) of participants “never” implement IPP when providing direct or indirect patient care. The researchers also asked participants to report how many times the respondent participated in interprofessional rounding in the past 12 months. Only 52.5% (n ¼ 63) of surveyed health care professionals reported participating in interprofessional rounding 10 or more times in the past 12 months. The survey results also
Fig. 1. Percentage of participants' level of understanding of interprofessional practice.
B. Bright et al. / Journal of Interprofessional Education & Practice 9 (2017) 108e114 Table 2 Barriers for interprofessional practice. Barriers for Interprofessional Practice
Total Number of Participants (n ¼ 120)
Time to round on each patient Scheduling conflicts Multiple job requirements Productivity/Efficiency Buy in from other disciplines Lack of understanding of rounding Lack of support Medical complexity Unknown outcomes of rounding Limited benefits to patients
n n n n n n n n n n
¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
81 76 60 36 23 23 21 13 7 3
showed that only 7.5% (n ¼ 9) of respondents participated in interprofessional rounding 6e10 times in the past year, 24.17% (n ¼ 29) of respondents participated in interprofessional rounding 1e5 times in the past year, and 15.83% (n ¼ 19) of respondents did not participate in interprofessional rounding at all in the past 12 months. The researchers were interested to see how many health care professionals expected IPP to be a future requirement in the inpatient setting. The majority (98.33%, n ¼ 118) of surveyed health care professionals reported “yes” IPP could become a future requirement in the inpatient setting. Only 1.67% (n ¼ 2) of participants reported IPP will not be a future requirement in the inpatient setting. The last survey question the researchers investigated was the perceived barriers to interprofessional practice implementation. The majority (67.5%, n ¼ 81) of the surveyed health care professionals reported that “time to round on each patient” was the leading barrier to IPP. The next most prevalent barrier was “scheduling conflicts,” which was reported by 63.33% (n ¼ 76) of health care professionals. “Multiple job requirements” was reported by 50% (n ¼ 60) of participants, being the third most commonly recognized barrier. As seen in Table 2, other barriers to IPP were identified, but frequency counts for the remaining barriers were distinctly lower than the top three barriers, previously reported. 3.6. Discussion Determining the current level of understanding of interprofessional practice was one of the most important areas of investigation to the researchers. Also of interest to the researchers was comparing the level of understanding to current practices of IPP implementation. An interesting finding from the research was that the majority of surveyed health care professionals (86.67%) reported having a “medium” or “high” understanding of IPP, yet only slightly more than half of professionals (54.17%) reported implementing IPP “daily” when providing direct or indirect patient care. The results demonstrate an obvious discrepancy between health care professionals' understanding and actual implementation of IPP in the acute care setting. Also supporting the aforementioned discrepancy was the finding that only 52.5% of surveyed health care professionals participated in interprofessional team rounding 10 or more times in the past 12 months. The researchers discovered another interesting discrepancy from the survey results regarding the question of whether health care professionals expected IPP to be a future requirement for the inpatient setting. The majority of surveyed health care professionals (98.33%) reported the expectation of IPP being a future requirement in the inpatient setting, yet current IPP implementation does not support such a requirement. Only 52.5% of health care professionals reported participation in interprofessional rounding
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10 or more times in the past year and the remaining health care professionals reported participation of fewer than 10 times. The data supports that health care professionals are not prepared for a requirement of interprofessional practice; although, health care professionals expect to see the requirement in the future. The researchers asked participants to identify barriers to IPP and three barriers in particular stood out from the rest with high frequencies reported. The top three barriers included a) “time to round on each patient,” b) “scheduling conflicts,” and c) “multiple job requirements.” The identified barriers may be an explanation for the discrepancies revealed to the researchers by the survey results. With the information, proper considerations and operational adjustments can be made in order to allow more effective implementation of interprofessional practice in the acute care setting. Understanding the current nature of collaborative practices in a health care institution is necessary prior to creating a protocol for implementing interprofessional practice. The results divulged in the current study reveal the present nature of IPP in the local health care institution of interest and expose the barriers and needs of health care professionals in order to implement successful IPP. Obviously the field of medicine is moving in the direction of IPP; therefore, health care providers must be prepared to deliver care collaboratively. The needs of each unique health care institution must be established for the proper application of IPP to each particular health care setting. 3.7. Limitations The current study was considered a needs assessment to investigate the current level of workforce readiness for the implementation of interprofessional practice. Though the study produced interesting findings, the researchers acknowledge that limitations exist. The sample size consisted of 120 participants, which is small in comparison to the actual number of employees at the local health care institution. Therefore, decreasing the generalizability of the findings. Another limitation existed in regards to the instrument used in the study. The Interprofessional Practice Survey was not tested for validity or reliability but was reviewed by two professionals in the health care field. The researchers only conducted data collection on five occasions in June and July on a Monday, Tuesday, or Friday. Consequently, the health care professionals not working on the three weekdays mentioned were unable to participate in the research study. Since the researchers handed out and collected the surveys in person, the presence of the researchers may have inadvertently skewed the results. Passing out the surveys during the work day may have encouraged the participants to rush through the survey or not fully take the time to understand the questions due to the participant's time constraints. 3.8. Future implications The recent driving forces behind the movement for implementation of IPP, urge that future research is necessary for further action. Future research is necessary in the area of developing instruments for assessing outcomes associated with IPP in various health care settings. With the findings from the current study, future research could explore the creation of an IPP protocol to evaluate the effectiveness of IPP on patient outcomes in acute care. Future research is needed to add concrete evidence supporting the benefits of IPP and IPE. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Appendix 1
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(continued).
References 1. Gilbert J, Yan J, Hoffman S. A WHO report: framework for action on interprofessional education and collaborative practice. J Allied Health. 2010;39(3): 196e197. 2. Interprofessional Education Collaborative (IPEC) Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington, D.C.: Interprofessional Education Collaborative; 2011. 3. Morgan Sonya, Pullon Susan, McKinlay Eileen. Observation of interprofessional collaborative practice in primary care teams: an integrative literature review. Int J Nurs Stud. 2015;52(7):1217e1230. 4. D'amour Danielle, Oandasan Ivy. Interprofessionality as the field of interprofessional practice and interprofessional education: an emerging concept. J Interprof. Care. 2005;19(sup1):8e20. 5. Brandt BF. Interprofessional education and collaborative practice: welcome to the “new” forty-year old field. Advis. 2015:9e17. 6. Stumpf SH, Clark JZ. The promise and pragmatism of interdisciplinary education. J allied health. 1999;28(1):30e32.
7. McNair RP. The case for educating health care students in professionalism as the core content of interprofessional education. Med Educ. 2005;39(5): 456e464. 8. Caldwell K, Atwal A. The problems of interprofessional healthcare practice in hospitals. Br J Nurs (Mark Allen Publ. 2003 Nov 13-26;12(20):1212e1218. 9. Moyers PA, Metzler CA. Interprofessional collaborative practice in care coordination. Am J Occup Ther. 2014;68:500e505. 10. Boerner H. Eliminating harm: how hospital systems are working to reverse medical errors. Physician Leadersh J. 2016;3(2):30e32. 11. McLean TR. Why the distribution of medical errors matters. Am J Surg. 2015;210(1):188e192. http://dx.doi.org/10.1016/j.amjsurg.2014.10.032. 12. Taifoori L, Valiee S. Understanding or nurses' reactions to errors and using this understanding to improve patient safety. ORNAC J. 2015;33(3):13e22. 13. Thannhauser J, Russell-Mayhew S, Scott C. Measures of interprofessional education and collaboration. J Interprof. Care. 2010;24(4):336e349. 14. Funnell P. Exploring the value of interprofessional shared learning. Interprof. Relat Health Care. 1995:163e171. 15. Barr H. Ends and means in interprofessional education: towards a typography.
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Educ Health. 1996;9:341e352. 16. Thistlethwaite J. Interprofessional education: a review of context, learning and the research agenda, research agenda. Med Educ. 2012;46(1):58e70. 17. Chen F, Delnat CC, Gardner D. The current state of academic centers for interprofessional education. J Interprof. Care. 2015;29(5):497e498.
18. Abu-Rish E, Kim S, Choe L, et al. Current trends in interprofessional education of health sciences students: a literature review. J Interprof. Care. 2012;26(6): 444e451. 19. Greiner AC, Knebel E. Health Professions Education: A Bridge to Quality. National Academies Press; 2003.
Contents lists available at ScienceDirect
Journal of Interprofessional Education & Practice journal homepage: http://www.jieponline.com
Identification of interprofessional practice and application to achieve patient outcomes of health care providers in the acute care setting Beth Bright, OTR/L, OTD, BCPR *, Brittany Austin, OTDS, Chelsey Garn, OTDS, Jillian Glass, OTDS, Shelby Sample, OTDS Huntington University, Fort Wayne, IN, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 26 March 2017 Received in revised form 29 August 2017 Accepted 10 September 2017
Background: Recent health care changes urge for the implementation of interprofessional practice to improve quality of patient care. Purpose: The study sought to determine the current level of workforce readiness for the implementation of interprofessional practice (IPP) in the acute care setting at a health care institution. Method: The researchers obtained descriptive data through the use of a survey instrument. Discussion: Results demonstrated that the majority (86.67%) of surveyed health care providers had a “medium” or “high” understanding of IPP. However, results exhibited that current application of IPP was inadequate with only 54.17% (n ¼ 65) of the health care professionals reporting “daily” implementation of IPP when providing direct or indirect patient care. Participants identified timing (67.50%) and scheduling conflicts (63.33%) as barriers to IPP, which may explain the exposed discrepancies. Conclusion: Further research is needed to establish protocols for the implementation of IPP based on the current study's needs assessment results. © 2017 Elsevier Inc. All rights reserved.
1. Introduction The purpose of the current study is to determine the current level of workforce readiness for the implementation of interprofessional practice in the acute care setting at a local health care institution. Interprofessional practice (IPP) occurs “when multiple health workers from different professional backgrounds work together with patients, families, caregivers, and communities to deliver the highest quality of care”.1 The World Health Organization (WHO) recognizes that in order to be prepared for IPP, health professionals must be effectively trained in interprofessional education (IPE), which occurs “when students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes”.1 The publication of the core competencies was sponsored by the Interprofessional Education Collaborative and the document outlines the standards by which IPP and IPE should be implemented and was the source
for primary definitions.2 Major quality issues in U.S. hospitals drive the movement for interprofessional practice; these issues include widespread patient error and preventable mortality and morbidity giving rise to a costly system of health care delivery.2 Growing evidence indicates IPP can improve many aspects of health care including patient satisfaction, patient safety, health care quality and health outcomes, increased job satisfaction among health professionals, and better staff recruitment and retention in health care systems.3 The current study is investigating the state of interprofessional practice in the acute care setting at a local health care institution. Priority is placed on gaining an understanding of current IPE and IPP knowledge and practices in individual health systems in order to construct well-fit protocols for the implementation of IPP within each system. 2. Literature review 2.1. Interprofessional practice
* Corresponding author. Huntington University, 1819 Carew St., Fort Wayne, IN, 46805, USA. Tel.: 260 702 9622; fax: 260 702 9626. E-mail addresses: [email protected] (B. Bright), austinb@huntington. edu (B. Austin), [email protected] (C. Garn), [email protected] (J. Glass), [email protected] (S. Sample). https://doi.org/10.1016/j.xjep.2017.09.003 2405-4526/© 2017 Elsevier Inc. All rights reserved.
2.1.1. Outcomes According to D'amour and Oandasan,4 interprofessional practice is crucial to patient care because professionals come from diverse disciplines and from different healthcare organizations, each
B. Bright et al. / Journal of Interprofessional Education & Practice 9 (2017) 108e114
carrying different conceptualizations of the client. Each discipline transmits a unique response to patient needs and complex healthcare situations, therefore owning a professional jurisdiction or scope of practice impacting the delivery of services.4 Health care has shifted in recent years, focusing on training employees to provide the best health care at the lowest cost. Supported by data relating outcomes of system changes to reduced costs, a new movement called “value-based health care” or “volume to value” has begun. Health care insurers are now rewarding outcomes and teamwork with monetary incentives to affiliated providers. In 2000, a resurgence of interest in interprofessional practice and education emerged, which focused on patient safety and strategic quality improvement of the acute care system in the U.S. The specific aim was to reduce the frequency and cost of adverse events as a result of medical error.5 2.1.2. Communication Over time, interest in interprofessional practice and interprofessional education has risen and fallen after inception in the 1970's. According to Brandt,5 collaborative practice models did not gain traction immediately and as a result, uniprofessional work or “parallel play” practices persisted. Stumpf and Clark6 stated that students were being prepared academically in a uniprofessional setting, when in practice, a multiprofessional setting is more realistic. Therefore, education was failing to prepare new health care providers for future care provision by inadequately implementing curriculum that incorporated a multiprofessional approach. According to McNair,7 health care professionals can be threatened by other disciplines who “encroach upon their territory,” resulting in a feeling of territorialism. Lack of advocacy for newer health care professions leads to lower placement on the hierarchical system. Another problem area limiting communication concerns a lack of clarity over professional roles including responsibilities and accountability, which could be resolved with greater implementation of interprofessional education on the understanding of the roles of other professionals.8 Health care providers recognize that one of the most prevalent problems in medicine today is poor communication. Poor communication has led to significant medical errors including preventable hospital deaths. Between 44,000 and 98,000 patient deaths resulted from poor communication in American hospitals annually.9 In 2013, an estimated 440,000 patients experienced preventable harm according to The Journal of Patient Safety.10 Lack of coordination between health care disciplines led to negative outcomes, medication errors, avoidable hospitalizations, increased costs, and patient dissatisfaction.9 Successful communication is a requirement for successful interprofessional practice; therefore, teaching health care providers how to implement IPP is likely to solve the costly medical errors of today's hospitals. 2.1.3. Medical errors A medical error is defined as “a failure in the process of delivering care” by the Institute of Medicine.11 Error occurs in all tasks, but in the field of health care, the results of errors can potentially be life threatening.12 Five types of medical errors were identified by the Journal of Patient Safety including (a) errors of commission, (b) errors of omission, (c) errors of communication, (d) errors of context, and (e) diagnostic errors.10 To increase quality of patient care with the least amount of medical errors, health care practitioners would benefit from the implementation of interprofessional practice. Due to the complex nature of many patient cases, the basis of IPP involves the collective action of multiple health care providers to address patient needs.13 In order to prepare health care providers for a collective approach to case management, IPP must be introduced prior to professional
109
practice in the form of IPE. 2.1.4. Interprofessional education Interprofessional education prepares health professional students to intentionally collaborate; students are able to expand from one sole perspective in order to improve quality of patient care.14,15 Through the implementation of IPE, students learn about other professions, build teamwork skills, and learn about the collaborative practice that will exist in the near future.16 The purpose of interprofessional education is to prepare students to fully understand and to be able to navigate through the complexity of interprofessional practice, in order to deliver effective, team-based care. Though the idea of IPE appears simple, the effectiveness of the concept is difficult to evaluate due to the diverse academic programs and learning opportunities presented for students.16 Successful implementation of IPE requires educators to play a crucial role as enablers to the students' opportunities to gain the necessary collaborative competencies.4 Chen, Delnat, and Gardner17 suggested an issue of disconnect between IPE and IPP resulting from the lack of professional role models to support collaborative competencies. Safe and efficient patient care is dependent upon effective communication across multiple health care disciplines, yet research has revealed that many health care professionals enter practice without IPP training.18,19 Despite the lack of research in regards to IPE, the idea is not a new concept in the health care profession. 3. Methodology 3.1. Participants The participants were selected using a convenience sampling technique and a snowball sampling technique. Participation in the study was completely voluntary and responses remained anonymous and confidential. Inclusion criteria consisted of full-time, part-time, and pro re nata (PRN) employees at the local health care institution that were employed from May 1st, 2016 to August 3rd, 2016. Exclusion criteria included volunteers at the local health care institution during the time of May 1st, 2016 to August 3rd, 2016. Health care providers recruited to complete the survey included physicians, nurses, occupational therapists, physical therapists, social workers, physician assistants, nurse practitioners, direct care providers, speech therapists, and managers or department heads. The survey contained an “other” category to include any health care disciplines not listed. Incomplete surveys were excluded from the study. The researchers personally handed out and collected the surveys in each acute care department at the local health care institution. The researchers collected surveys from 135 participants. However, 15 survey responses were incomplete and therefore excluded from the study; resulting in a total of 120 participants. 3.2. Instrument The current study employed a survey instrument created by the study preceptor. The survey instrument, the Interprofessional Practice Survey (Appendix 1), contained a total of 10 questions with two optional questions, which were not included in the data analysis. The survey addressed the participants' current health care occupation and understanding of IPP within the acute care setting. See Appendix I for a copy of the survey. The participants reported collaboration with other health care disciplines and frequency of IPP. The survey was not formally tested for validity, however to increase reliability each participant received the same copy of the survey. The survey was expert reviewed by two health care
110
B. Bright et al. / Journal of Interprofessional Education & Practice 9 (2017) 108e114
Table 1 The Interprofessional Practice Survey questions of interest. Interprofessional Practice Survey Questions Question 1 Question 3 Question 5 Question 7 Question 10
“In general, how would you rate your level of understanding pertaining to interprofessional practice?” “How often do you implement interprofessional practice when directly or indirectly providing patient care?” “How many times have you participated in interprofessional Rounding or team rounding in the past 12 months?” “Do you expect interprofessional practice to be a future Requirement in the inpatient setting?” “What do you feel are barriers for interprofessional practice?”
professionals prior to distribution to the participants; modifications were made based on critiques. Although the current survey was not tested for validity, the survey was drafted by pulling questions from previously developed surveys that were tested for validity. The instrument was adapted using terminology from the “Core Competencies for Interprofessional Collaborative Practice”.2 3.3. Procedure The current study used a quantitative research design to investigate the nature of interprofessional practice in the acute care setting at a local health care institution. The study was approved by both Huntington University's Institutional Review Board (IRB) and Lutheran Hospital's IRB. The study involved the use of a 10-question survey instrument for data collection. The researchers distributed and collected surveys on three different days in June 2016 and two days in July 2016. The researchers distributed surveys to multiple acute care units at the local health care institution. The survey was handed out to the included disciplines and participants were given privacy to complete the survey onsite. On average, the survey took approximately five minutes to complete. The researchers collected the completed surveys from the participants and stored the surveys in a sealed envelope, which was kept in a secure location. 3.4. Data analysis The survey instrument produced strictly descriptive data. The survey provided the researchers with ordinal data, which was then converted to interval data and entered into an Excel document. The researchers used Excel to obtain frequency counts from key
questions on the survey. The key questions included in the data analysis can be found in Table 1 below. The researchers compared the survey responses from question 1 to questions 3 and 5. The aim was to compare the understanding of IPP and the collaboration dynamic that existed among various disciplines within the acute care setting. Responses to question 7 were compared to responses to question 5, and the top three responses were determined for question 10. The participant's current implementation of IPP was compared to the participants' perception of whether or not IPP will be a future requirement for the inpatient setting. The researchers also identified the top three barriers to the implementation of IPP. The data analysis gave the researchers an overall understanding of the current nature of IPP in the local health care institution.
3.5. Results The survey results included a total of 120 completed surveys. Participating disciplines included (a) physicians [n ¼ 13] and physician assistants [n ¼ 3], (b) nurses [n ¼ 53], nurse practitioners [n ¼ 3], and patient care assistants [n ¼ 11], (c) pharmacists [n ¼ 1] and pharmacy technicians [n ¼ 2], (d) social workers [n ¼ 3], (e) management [n ¼ 6], (f) occupational therapists [n ¼ 9], physical therapists [n ¼ 7], speech therapists [n ¼ 1], and rehabilitation technicians [n ¼ 1], (g) dieticians [n ¼ 5], (h) respiratory care [n ¼ 1], and (i) registration [n ¼ 1]. According to the survey results demonstrated in Fig. 1, the researchers determined that the majority (86.67%) of health care professionals surveyed had a “medium” or “high” understanding of interprofessional practice (medium [n ¼ 53]; high [n ¼ 51]). Also of interest to the researchers was the frequency of IPP implementation when directly or indirectly providing patient care. Only 54.17% (n ¼ 65) of the health care professionals surveyed reported implementing IPP “daily” when providing direct or indirect patient care. The survey revealed that 10% (n ¼ 12) of participants implement IPP “weekly”, 32.5% (n ¼ 39) of participants implement IPP “monthly”, and 3.33% (n ¼ 4) of participants “never” implement IPP when providing direct or indirect patient care. The researchers also asked participants to report how many times the respondent participated in interprofessional rounding in the past 12 months. Only 52.5% (n ¼ 63) of surveyed health care professionals reported participating in interprofessional rounding 10 or more times in the past 12 months. The survey results also
Fig. 1. Percentage of participants' level of understanding of interprofessional practice.
B. Bright et al. / Journal of Interprofessional Education & Practice 9 (2017) 108e114 Table 2 Barriers for interprofessional practice. Barriers for Interprofessional Practice
Total Number of Participants (n ¼ 120)
Time to round on each patient Scheduling conflicts Multiple job requirements Productivity/Efficiency Buy in from other disciplines Lack of understanding of rounding Lack of support Medical complexity Unknown outcomes of rounding Limited benefits to patients
n n n n n n n n n n
¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
81 76 60 36 23 23 21 13 7 3
showed that only 7.5% (n ¼ 9) of respondents participated in interprofessional rounding 6e10 times in the past year, 24.17% (n ¼ 29) of respondents participated in interprofessional rounding 1e5 times in the past year, and 15.83% (n ¼ 19) of respondents did not participate in interprofessional rounding at all in the past 12 months. The researchers were interested to see how many health care professionals expected IPP to be a future requirement in the inpatient setting. The majority (98.33%, n ¼ 118) of surveyed health care professionals reported “yes” IPP could become a future requirement in the inpatient setting. Only 1.67% (n ¼ 2) of participants reported IPP will not be a future requirement in the inpatient setting. The last survey question the researchers investigated was the perceived barriers to interprofessional practice implementation. The majority (67.5%, n ¼ 81) of the surveyed health care professionals reported that “time to round on each patient” was the leading barrier to IPP. The next most prevalent barrier was “scheduling conflicts,” which was reported by 63.33% (n ¼ 76) of health care professionals. “Multiple job requirements” was reported by 50% (n ¼ 60) of participants, being the third most commonly recognized barrier. As seen in Table 2, other barriers to IPP were identified, but frequency counts for the remaining barriers were distinctly lower than the top three barriers, previously reported. 3.6. Discussion Determining the current level of understanding of interprofessional practice was one of the most important areas of investigation to the researchers. Also of interest to the researchers was comparing the level of understanding to current practices of IPP implementation. An interesting finding from the research was that the majority of surveyed health care professionals (86.67%) reported having a “medium” or “high” understanding of IPP, yet only slightly more than half of professionals (54.17%) reported implementing IPP “daily” when providing direct or indirect patient care. The results demonstrate an obvious discrepancy between health care professionals' understanding and actual implementation of IPP in the acute care setting. Also supporting the aforementioned discrepancy was the finding that only 52.5% of surveyed health care professionals participated in interprofessional team rounding 10 or more times in the past 12 months. The researchers discovered another interesting discrepancy from the survey results regarding the question of whether health care professionals expected IPP to be a future requirement for the inpatient setting. The majority of surveyed health care professionals (98.33%) reported the expectation of IPP being a future requirement in the inpatient setting, yet current IPP implementation does not support such a requirement. Only 52.5% of health care professionals reported participation in interprofessional rounding
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10 or more times in the past year and the remaining health care professionals reported participation of fewer than 10 times. The data supports that health care professionals are not prepared for a requirement of interprofessional practice; although, health care professionals expect to see the requirement in the future. The researchers asked participants to identify barriers to IPP and three barriers in particular stood out from the rest with high frequencies reported. The top three barriers included a) “time to round on each patient,” b) “scheduling conflicts,” and c) “multiple job requirements.” The identified barriers may be an explanation for the discrepancies revealed to the researchers by the survey results. With the information, proper considerations and operational adjustments can be made in order to allow more effective implementation of interprofessional practice in the acute care setting. Understanding the current nature of collaborative practices in a health care institution is necessary prior to creating a protocol for implementing interprofessional practice. The results divulged in the current study reveal the present nature of IPP in the local health care institution of interest and expose the barriers and needs of health care professionals in order to implement successful IPP. Obviously the field of medicine is moving in the direction of IPP; therefore, health care providers must be prepared to deliver care collaboratively. The needs of each unique health care institution must be established for the proper application of IPP to each particular health care setting. 3.7. Limitations The current study was considered a needs assessment to investigate the current level of workforce readiness for the implementation of interprofessional practice. Though the study produced interesting findings, the researchers acknowledge that limitations exist. The sample size consisted of 120 participants, which is small in comparison to the actual number of employees at the local health care institution. Therefore, decreasing the generalizability of the findings. Another limitation existed in regards to the instrument used in the study. The Interprofessional Practice Survey was not tested for validity or reliability but was reviewed by two professionals in the health care field. The researchers only conducted data collection on five occasions in June and July on a Monday, Tuesday, or Friday. Consequently, the health care professionals not working on the three weekdays mentioned were unable to participate in the research study. Since the researchers handed out and collected the surveys in person, the presence of the researchers may have inadvertently skewed the results. Passing out the surveys during the work day may have encouraged the participants to rush through the survey or not fully take the time to understand the questions due to the participant's time constraints. 3.8. Future implications The recent driving forces behind the movement for implementation of IPP, urge that future research is necessary for further action. Future research is necessary in the area of developing instruments for assessing outcomes associated with IPP in various health care settings. With the findings from the current study, future research could explore the creation of an IPP protocol to evaluate the effectiveness of IPP on patient outcomes in acute care. Future research is needed to add concrete evidence supporting the benefits of IPP and IPE. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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(continued).
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