Teams Conflicting Messages: Examining the Dynamics of Leadership on Interprofessional Teams Lorelei Lingard, PhD, Meredith Vanstone, PhD, Michele Durrant, RN, MSc, Bonnie Fleming-Carroll, RN (EC), MN, NP-Paeds, Mandy Lowe, OT Reg (Ont), MSc, Judy Rashotte, RN, PhD, Lynne Sinclair, PT Reg (Ont), MA, and Susan Tallett, MB BS, FRCPC, MEd Abstract Purpose Despite the importance of leadership in interprofessional health care teams, little is understood about how it is enacted. The literature emphasizes a collaborative approach of shared leadership, but this may be challenging for clinicians working within the traditionally hierarchical health care system. Method Using case study methodology, the authors collected observation and interview data from five inter­ professional health care teams working at teaching hospitals in urban Ontario, Canada. They interviewed 46 health care providers and conducted 139 W ith the advent of interprofessional care, new questions about leadership 1,2 and teamwork have arisen. How should responsibility be shared and power differentials mitigated? How has the physician’s role changed?3 How do health care teams view these dimensions of their work? Without insight into these issues, we can’t know how best to educate physicians and other clinicians regarding their responsibilities on collaborative teams. The growing body of literature on interprofessional care emphasizes the essential nature of collaboration4 and contains a strong discourse of Please see the end of this article for information about the authors. Correspondence should be addressed to Dr. Lingard, Centre for Education Research and Innovation, University of Western Ontario, Room 112, Health Sciences Addition, London, ON N6A 5C1; telephone: (519) 661-2111 ext. 88999; fax: (519) 858-5131; e-mail: Lorelei.Lingard@schulich.uwo.ca. Acad Med. 2012;87:1762–1767. First published online October 22, 2012 doi: 10.1097/ACM.0b013e318271fc82 1762 hours of observation from January 2008 through June 2009. the presence of hierarchies on their teams. Results Although the members of the inter­ professional teams agreed about the importance of collaborative leadership and discussed ways in which their teams tried to achieve it, evidence indicated that the actual enactment of collaborative leadership was a challenge. The participating physicians indicated a belief that their teams functioned nonhierarchically, but reports from the nonphysician clinicians and the authors’ observation data revealed that hierarchical behaviors persisted, even from those who most vehemently denied Conclusions A collaborative approach to leadership may be challenging for interprofessional teams embedded in traditional health care, education, and medical-legal systems that reinforce the idea that physicians sit at the top of the hierarchy. By openly recognizing and discussing the tensions between traditional and interprofessional discourses of collaborative leadership, it may be possible to help interprofessional teams, physicians and clinicians alike, work together more effectively. partnership, shared leadership, and team interactions that are horizontal, relational, and situational.5–8 Some articles even equate the terms “member” and “leader.”5,9 Long and colleagues10 have named this orientation “clinical democracy,” a term that emphasizes the collective ownership of goals11 and decision making. Although this model of interprofessional practice may be enacted in different ways on different teams, it generally calls for sharing power on the basis of knowledge and experience rather than roles.12 Rather than following distinct leaders, team members work together interdependently, relying on each other’s expertise to accomplish goals and carry out tasks.13 This model is echoed in the Canadian Interprofessional Health Collaborative’s Interprofessional Competency Framework, which suggests that team leadership ought to change according to the requirements of each situation.14 This discourse has also been taken up within medicine. The Royal College of Physicians and Surgeons of Canada,15 for example, instructs physicians to learn to work in partnership with other providers, to reflect on the function of the interprofessional team, and to demonstrate leadership where appropriate. Some research has examined interprofessional practice and leadership more critically, analyzing the historical, economic, political, and social professionalization challenges to collaboration.16,17 This work acknowledges the factors influencing power differentials to be outside the control of the team’s professionals, making collaboration difficult18 or even undesirable.3 These external factors may contribute to the dissonance sometimes observed between articulated desires for collaboration and actions that undermine those desires.19 To better understand the role of “physician leadership” in the evolving landscape of collaborative health care, we looked at how five interprofessional health care teams perceived and demonstrated leadership in their daily practice. We report our findings in this article. Academic Medicine, Vol. 87, No. 12 / December 2012 Teams Method In this study, we used a multiple instrumental case study research design embedded within ethnography, which facilitates the exploration of complex, real-world phenomena.20 After receiving research ethics approval from the review boards at three teaching hospitals affiliated with two universities in urban Ontario, Canada, we asked clinical and educational leaders in each hospital to identify interprofessional clinical health care teams with reputations for strong collaborations and managerial/ administrative support. We purposively selected five teams, which represented the specialties of brain injury, complex care, mental health, oncology, and stroke, and which were located within rehabilitative, pediatric, and adult health care sectors. We invited all members of those teams to participate. Participants included physicians, nurses, physical and occupational therapists, speech language pathologists, dietitians, child and youth workers, social workers, and psychologists. For stylistic ease, we will refer to the participants who were not physicians as “clinicians,” a term that reflects the centrality of their roles to patient care. From January 2008 through June 2009, we iteratively collected and analyzed data, both within each team study and across the team studies,20 which were spread out over several months (only the third and fourth team studies overlapped significantly in time). Research assistants, trained in qualitative techniques and without preexisting relationships with any of the teams, observed each team’s work during daytime hours for three to six weeks, in blocks of 1 to 3 hours; across all five teams, they observed 139 hours of team interaction. Over the course of observation, the teams experienced a natural degree of instability due to rotating learners and staff schedules. These observations took place during team meetings, team rounds, consultations, and while shadowing individual team members. During these activities, the research assistants captured ethnographic data about the team members’ daily tasks, their interactions with other colleagues and patients, and team dynamics. Learners on the teams were observed when they interacted with staff team members, but they were not shadowed or interviewed. While embedded in the workplace, the research assistants approached individual team members to request interviews. Of the 54 members of the five teams, 46 were interviewed using a semistructured guide, which we refined for each interview on the basis of observational data. We broadly explored the theme of leadership, asking participants about the roles of each of their team members, congruencies and conflicts between roles, and who they perceived to be the leader(s) of the team. We probed their responses with follow-up questions that drew on the observational data. The interviews were audio-taped and transcribed verbatim. As a member-checking mechanism, a qualitative research technique used to elicit participants’ discussion of preliminary findings and seek further insider insights to refine interpretations, we held focus groups for each team, which were audio-taped and transcribed verbatim, with all interested and available team members. We analyzed data using a constant comparative thematic approach, comparing categories across teams, within teams, and by type of health care professional.21 Our analysis was iterative, beginning with line-by-line coding, proceeding to focused coding, and evolving to produce categories that responded to these codes. Individuals on the research team conducted the analyses, meeting in small groups to compare approaches before refining the categories to share with the research team as a whole. Results Amongst a number of recurrent themes that arose in our analysis, team leadership emerged as a dominant issue, consistently across all teams. Its importance was signaled both by its recurrence in field notes and by the enthusiasm exhibited by interviewees as they discussed topics such as professional status, hierarchy, collaboration, and decision making. Leadership in the five teams took different forms; however, each team demonstrated a tension between the ways in which they discussed leadership with us (in interviews and group sessions) and the ways in which they actually enacted leadership in daily practice or talked about it amongst themselves. Academic Medicine, Vol. 87, No. 12 / December 2012 Although the physicians and clinicians we interviewed all acknowledged the hierarchical nature of the broader health care system, they differed in their perceptions of leadership within their own teams. The physicians tended to compare themselves favorably to the wider institution, characterizing the leadership structures of their teams as democratic and nonhierarchical. The clinicians, in contrast, tended to describe the assumption of physician leadership and the presence of a medical hierarchy, although they often discussed ways in which all team members, including physicians, worked against this hierarchy. Clinical expertise and decision making were two points of tension between the explicit and implicit constructions of leadership and hierarchy. Both physicians and clinicians recognized that hierarchies are reified by institutional factors in the health care system, such as the requirement, currently under review,22 for physician referrals to enable other professionals to work with patients. Psychologist 3 (Team 2) remarked: “The physicians are on top, undeniably. Although they are trying to not have that hierarchy, my referrals come from them.” Although clinicians felt that these hierarchies influenced the way their own teams worked together, some physicians, such as Physician 4 (Team 1) and Physician 3 (Team 5), thought that their own teams avoided those hierarchical influences. This is an unorthodox team. Leadership is not preordained, but shared by the team members…. We are all in it together. You really need humility to do this work and, because of this, it destroys hierarchical levels. Sometimes people’s previous experiences can be one of the biggest obstacles. If they come from an environment which is much more hierarchical, … it is harder to make the adjustment. Despite the physicians’ denial of hierarchies on their own teams, our observational notes revealed many instances of physicians behaving in hierarchical ways. For example, a representative note from Team 1’s clinical rounds reported that “the conversation was dominated by the physicians, mostly Physician 1 and Specialist Physician 1.” A detailed confirmation of this kind of behavior came from the patient care coordinator, a nurse on Team 2, who 1763 Teams recounted during an interview that nurses sometimes feel disrespected by physicians. Every two weeks [the physicians] have their rotation, so every time a physician is on again, they rely heavily on the nurses for patient updates. This is really hard on the nurses because they have to take a lot of time to provide this information to the doctors. I don’t understand why they don’t read the charts. It’s like they don’t want to because then they’re responsible if there’s a mistake. It’s very (pause) passive– aggressive. If something isn’t done, or it’s done improperly, they’ll blame the nurses, but they won’t actually come out and say it directly. They’ll say things like “oh, you told me this,” and of course, the nurses can’t really say anything, so they end up feeling very frustrated…. The physicians are good at getting clinical information they need regarding patient care, but the nurses don’t feel like they’re respected. In contrast to the physicians, the clinicians unequivocally reported the existence of hierarchical structures on their teams. According to Speech Language Pathologist 1 (Team 2), “the physicians are on top. People like to pretend it isn’t that way, but it’s the way that it is.” However, many clinicians simultaneously credited physicians they worked with making efforts to disable this hierarchy. One such effort involved the use of inclusive language, appreciatively noted by Clinical Manager 1, a nurse working on Team 5. Everybody calls everybody by their first name here. That’s not so common in other areas. If you go to [other site], it’s “Dr. So-and-So.” I think you’ll find that in most hospitals it’s “Dr.,” whereas here it’s first names. The physicians also reported using strategies to disable hierarchies, as illustrated by Physician 4, Team 1. I have been on other wards where there are multidisciplinary rounds, but the only ones talking are the physicians. The others are just sitting there and not contributing. It’s quite troubling. I’ve been in other situations where the physician will say “my patient” or “my team.” Here we don’t use that language…. We try to lead by example and we start off with introductions on a first-name basis. The language of how you talk to each other is very important and we need to rolemodel this. These quotations reveal the different meanings given to these efforts by the physicians on one hand and the clinicians 1764 on the other. The physicians offered the examples as evidence of the progress their teams had made in comparison with other wards, whereas the clinicians brought them up to show how, despite best efforts, the hierarchical social reality remained pervasive and intractable. had a higher level of medical-legal accountability for patient care. As Nurse Practitioner 1, Team 1, explained, “I think we all have leadership roles, with respect to our expertise, but it all comes down to the physicians who are ultimately responsible.” The physicians often cited respect for clinical expertise as a reason for their teams being nonhierarchical: “There are no hierarchies on this team. It is all about expertise and what everyone brings” (Physician 1, Team 2). Physicians and clinicians alike all acknowledged that each team member has an area of clinical expertise to contribute and an area of clinical jurisdiction to be respected. While shadowing Nurse Practitioner 1 on Team 1, a research assistant observed Physician 2 deferring to the expertise and authority of Social Worker 1 in securing community resources. This dynamic of physicians’ superior authority to make clinical decisions manifested in different ways. Physician 3 (Team 5) implicitly acknowledged the tension between his espousal of clinical democracy and his retention of decisionmaking authority by discussing the ways in which his team differentiated between “team decisions” and “leadership decisions.” Physician 2 enters a patient’s room and is informed by the patient’s caregiver and Nurse Practitioner 1 that the family is upset with the lack of progress that Social Worker 1 (who is not present) is making on securing community resources necessary for discharge. Physician 2 reads the papers Nurse Practitioner 1 is making notes on and states that he has spoken to Social Worker 1 already, and he is not able to do any more than Social Worker 1. He adds that he cannot do it as well as she can. He says Social Worker 1 “can work magic sometimes.” However, in other instances, physicians were reluctant to defer to another professional’s clinical expertise, as illustrated in this exchange regarding the readiness of a particular patient for discharge, which took place during Team 3’s rounds. Physiotherapist 4: Recommend discharge for [date]. Referred to outpatient physio. Physician 2: Is her wound healed? Nurse 6 and Physiotherapist 4 both: Yes. Physician 2: I’ll have to check the wound. As this excerpt suggests, having germane expertise did not always translate into the authority to make independent clinical decisions. The data we collected from observations and interviews made it clear that physicians on all teams had more decision-making authority than clinicians. This authority was often linked to the perception, held by both physicians and clinicians, that physicians We all know when we can argue with each other and when the decision making needs to be separated out. In a crisis or critical situation, where we can’t do things by committee, there need to be decisions made quickly. So [we need] the ability to shift from “we’re all working together in a collaborative way” to points in time when there needs to be leadership and critical decisions made. We understand when those situations occur. The decision-making authority of physicians was a common point of discussion in interviews with clinicians and was observed to be strongly engrained and well understood across all teams. The process of decision making revealed professional hierarchies by distinguishing between those who can offer input (all team members) and those who actually make the decisions (usually the physicians). Clinicians felt assured that their opinions and expertise were taken into consideration. As Social Worker 2 (Team 2) remarked, “I feel [the physicians] listen to everyone’s opinion. All of us can speak freely at our weekly team meetings.” But at the same time, they knew quite clearly that they were not the final decision makers. “At the end of the day, I’m not a doctor. They make the decisions” (Social Worker 1, Team 2). And they acted accordingly, as observed in this informal exchange about discharge readiness between Occupational Therapist 1 and Nurse 5 from Team 3. OT1: From the physio and OT perspective, he can go, so it’s for the physician to decide. RN5: His wife already got the Vancomycin [prescription drug requiring intravenous injection]. Academic Medicine, Vol. 87, No. 12 / December 2012 Teams OT1: OK. So he can go after the PICC [peripherally inserted central catheter] if the physicians say. RN5: I have to talk to Dr. 2. Some clinicians spoke about the ways in which decision-making privileges entrenched a hierarchy between team members. According to Psychologist 2 on Team 5, We probably have the most extensive training in mental health, psychology. But psychiatry are the ones that have admitting and discharging privileges. So if I feel very strongly that a client should be discharged, or not be discharged, I nonetheless have to make my case to psychiatry. So admitting and discharge privileges inherently build in a hierarchy. For some clinicians, the difference in authority did not conflict with the idea of every team member’s equal value in the decision-making process. OT1 on Team 3, for example, described his contribution as one part of the clinical puzzle. Others were less sanguine, particularly those clinicians, like Psychologist 2 on Team 5, who had encountered situations in which they felt well qualified to make a decision without a physician’s input. Discussion The physicians and clinicians in the five interprofessional teams we studied perceived team leadership, particularly in the sense of a professional hierarchy and its influence on decision making, differently.23 Furthermore, although the physicians claimed to eschew leadership roles in their teams’ functioning, their observed behavior and reports from their clinician colleagues belied such claims. Clearly, physicians on interprofessional teams experience a tension between two values: They embrace the philosophy of clinical democracy but, more often than not, act on a philosophy of hierarchical leadership. In this discussion, we explore the circumstances that combine to produce this situation. The rise of interprofessional care has been accompanied by widespread acceptance of a philosophy of shared leadership6 on health care teams. “Clinical democracy,” as Long and colleagues10 have named this philosophy, is predicated on power that is distributed not on the basis of traditional social hierarchies but, instead, on whose expertise is relevant in a specific clinical situation.12 This notion has become a legitimate part of competency frameworks, both interprofessional14 and profession-specific,15 suggesting that all caregivers, if they are to be considered competent, must understand how to collaborate and share power. Why, then, do the five highly collaborative, interprofessional teams in our study still experience such tension regarding these issues? One answer, according to Whitehead, is that physicians, by necessity, operationalize this philosophy of democracy and cooperation within broader systems that not only support, but may in fact demand, their privileged status.3 Faced with this double bind— asked to share power, but forced to embody a privileged role—physicians may say one thing, but do another. To explore this provocative explanation for our findings, we briefly consider three of the broader systems that support physicians’ privileged status: the education system, the health care delivery system, and the medical-legal system. The education system Under normal circumstances in Canada and the United States, physicians, particularly specialist physicians, complete at least six years of education and training after obtaining an undergraduate degree. This educational commitment, large when compared with that of other health professionals, is seen by some as justification for physicians’ superior decision-making privileges.24 This justification loses some sway as education requirements for other health professionals increase. Clinical doctorates will be implemented by 2015 for American nurses in advanced nursing practice roles25 and are being considered for physiotherapists as well.26 Canadian physiotherapists and occupational therapists already require a master’s degree.27 During education and training, socialization shapes the practitioner’s professional identity. Professional socialization and prevalent discourses condition physicians to envision themselves as leaders of health care teams.3,28–30 The enduring dominance of medical knowledge31 in clinical decision making32 further contributes to the perception that interprofessional collaboration occurs at an uneven negotiating table.33 Academic Medicine, Vol. 87, No. 12 / December 2012 Many physicians have begun to reject their status as omniscient, all-powerful professionals,29,34 but relics of that role remain, interfering with interprofessional teamwork. For example, Nugus et al35 found evidence that physicians have been socialized to believe that they are expected, when working with other health professionals, to evaluate their colleagues’ input and determine the extent to which it should be taken into consideration. Clinicians’ education, too, may reinforce perceptions of medical dominance, socializing them to defer to physicians. As has been described in the 1960s and again more recently,32,36,37 physicians and nurses wage daily power struggles; as clinical apprentices observe this complex dance, they “acquire implicit and powerful cultural knowledge of professional roles and relationships.”38 Health care system Regulatory, institutional, and funding structures of the health care system perpetuate a hierarchical structure of health professions, placing physicians at the top.39 No matter how democratic or egalitarian a particular health care team is, it still operates within larger organizational structures that challenge nonhierarchical interprofessional relations.40 In Canada, for example, a physician’s referral is required to get funding for many services and equipment and to admit or discharge patients. Fee-for-service compensation formulas may discourage collaborative practice. The Ontario Health Insurance Plan remunerates physicians only for services provided to patients; it does not cover collaborative activities such as interprofessional team meetings where many patients are discussed.41 These hospital, health care delivery, and insurance systems, by privileging physicians’ knowledge and requiring that they green-light services from other health professionals,17 consolidate medical power42 and institutionalize physicians’ leadership of health care teams. In Ontario, physicians are licensed to perform all but 1 of 13 controlled acts—significantly more than other regulated health professionals.43 This has the effect of enshrining physician autonomy to operate independently from the team, but, in exchange for this autonomy, physicians may assume higher levels of liability.10 The regulation 1765 Teams of exclusive scopes of practice may act as an obstacle to clinical democracy in an interprofessional team setting by compartmentalizing services39; overlapping scopes of practice may be a more effective way to encourage collaboration.30,44 The medical-legal system Many participants in this study and others20 perceived physicians as shouldering more legal or professional liability; this reasoning was often used to justify their superior decision-making authority.24 Exploring the dynamics of interprofessional medical-legal liability is outside of the scope of this article, and very few Canadian court decisions have addressed the liability of interprofessional health care teams, but two legal issues may help explain the participants’ perception of greater physician liability. First, Canada’s legal system does not recognize unincorporated teams as entities that can be sued.45 Liability is examined on a case-by-case basis, with fault assigned to specific individuals and entities, although multiple providers may be found jointly negligent.46 Second, physicians and other health care providers have different legal relationships with hospitals, which may assume vicarious liability for negligent acts committed by their employees. Although courts assess the existence of an employee–employer relationship in each case,47 they have traditionally found nurses to be employees of hospitals,47–49 whereas physicians are often, but not always, considered independent contractors.50,51 As independent contractors, physicians must bear any liability for what occurs within the context of their practice. Although these factors appear to support the sense that physicians have more legal accountability for (and therefore more clinical authority over) medical decisions, there is a change afoot in the legal landscape. With the rise in interprofessional work, Canadian courts are working with liability in a different way,45 recognizing that team members are entitled to rely on each other to practice to their own standard of care.52 All regulatory colleges in Ontario now require their members to maintain professional liability insurance as a condition of registration.52–54 This wider distribution of responsibility may 1766 remove some barriers to interprofessional practice.45,55 Conclusions Although physician leadership is not problematic in and of itself, we have found that it raises issues within interprofessional teams. Tensions arise, both between physician and clinician, and between the emerging discourse of clinical democracy and the well-engrained incentives for keeping structural hierarchies in place. Fortunately, these tensions open doors to discussion and reflection about the nature of leadership and collaboration. Openly acknowledging and confronting the challenges may enable interprofessional teams to address specific issues and improve their collaborative practices. On a macro level, addressing the issue of interprofessional collaboration will require a broad and multifaceted approach, which will involve dialogue within and across professions, as well as with patients and their families and with regulatory, governmental, and academic institutions. Because the context within which qualitative data are collected is essential to their interpretation, we recognize that our findings are not generalizable. Context is particularly important in this study because of our emphasis on specific institutional and medical-legal systems. Research in other educational, health care, and medical-legal contexts can only add to our understanding of leadership in team settings and may suggest initiatives that help interprofessional teams better collaborate and more deftly navigate the tensions between the old ways and the new. Acknowledgments: The authors wish to thank the institutions and individuals who participated in the research reported here. Funding/Support: This work was funded by a grant from the Health Force Ontario Interprofessional Care/Education Fund (agreement no. ICEF0708014). Other disclosures: None. Ethical approval: Ethical approval was granted at all institutions at which this research was conducted. Previous presentations: This material was presented as an oral abstract at the Canadian Conference on Medical Education, May 2009. Dr. Lingard is professor, Department of Medicine, and director, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada. Dr. Vanstone is a postdoctoral fellow at the Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada. Ms. Durrant is advanced nursing practice educator, Hospital for Sick Children, and clinical tutor, University of Toronto, Toronto, Ontario, Canada. Ms. Fleming-Carroll is associate chief of nursing and interprofessional education, Hospital for Sick Children, and adjunct lecturer, Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada. Ms. Lowe is director of education and professional development, University Health Network, associate director, Centre for Interprofessional Education, University of Toronto, and assistant professor, Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. Dr. Rashotte is director, Nursing Research and Knowledge Transfer Consultant, Children’s Hospital of Eastern Ontario, Ottawa, Canada, and adjunct professor, School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada. Ms. Sinclair is assistant professor, Department of Physical Therapy, Faculty of Medicine, and innovative programs and external development lead, Centre for Interprofessional Education, both at the University of Toronto, Toronto, Ontario, Canada. Dr. Tallett was professor of pediatrics, Faculty of Medicine, University of Toronto, and chief of education, Hospital for Sick Children, Toronto, Ontario, Canada. She retired October 1, 2011. References 1 McCallin A. Interdisciplinary practice—A matter of teamwork: An integrated literature review. J Clin Nurs. 2001;10:419–428. 2 Fagin CM. Collaboration between nurses and physicians: No longer a choice. Acad Med. 1992;67:295–303. 3 Whitehead C. The doctor dilemma in interprofessional education and care: How and why will physicians collaborate? Med Educ. 2007;41:1010–1016. 4 Wilson N, Gleason M. Team Roles and Leadership. Houston, Tex: Baylor College of Medicine’s Huffington Center on Aging; 2001. 5 Bruner C. Thinking Collaboratively: Ten Questions and Answers to Help Policy Makers Improve Children’s Services. Washington, DC: Education and Human Services Consortium; 1991. 6 Freeth D, Reeves S. Learning to work together: Using the presage, process, product (3P) model to highlight decisions and possibilities. J Interprof Care. 2004;18:43–56. 7 McCallin A. Interdisciplinary team leadership: A revisionist approach for an old problem? J Nurs Manag. 2003;11:364–370. 8 Leathard A. Models for interprofessional collaboration. In: Leathard A, ed. Interprofessional Collaboration: From Policy to Practice in Health and Social Care. New York, NY: Brunner-Routledge; 2003:90. Academic Medicine, Vol. 87, No. 12 / December 2012 Teams 9 Aronson JMS, Ferguson L, Macdonald MB, Murray BL, Fowler-Kerry S, Bally JMG. The anatomy of interprofessional leadership: An investigation of leadership behaviors in team-based health care. J Leadersh Stud. 2009;3:17–25. 10 Long D, Forsyth R, Iedema R, Carroll K. The (im)possibilities of clinical democracy. Health Sociol Rev. 2006;15:506–519. 11 Heinemann G, Zeiss A. Team Performance in Health Care: Assessment and Development. New York, NY: Kluwer Academic/Plenum Publishers; 2002. 12 Oandasan I, D’Amour D, Zwarenstein M, et al. Interdisciplinary Education for Collaborative, Patient-Centred Practice. Ottawa, Ontario, Canada: Health Canada; 2004. 13 Bronstein LR. A model for interdisciplinary collaboration. Soc Work. 2003;48:297–306. 14 Canadian Interprofessional Health Collaborative. A National Interprofessional Competency Framework. February 2010. http://www.cihc.ca/files/CIHC_ IPCompetencies_Feb1210.pdf. Accessed August 17, 2012. 15 Frank J, ed. The CanMEDS 2005 Physician Competency Framework. Ottawa, Ontario, Canada: Royal College of Physicians and Surgeons; 2005. 16 Jansen L. Collaborative and interdisciplinary health care teams: Ready or not? J Prof Nurs. 2008;24:218–227. 17 Sandall J, Benoit C, Wrede S, Murray S, van Teijlingen E, Westfall R. Social service professional or market expert? Curr Sociol. 2009;57:529–553. 18 Corser WD. A conceptual model of collaborative nurse–physician interactions: The management of traditional influences and personal tendencies. Sch Inq Nurs Pract. 1998;12:325–334, 336–341. 19 Hayward L, DeMarco R, Lynch M. Interprofessional collaborative alliances. In: Lecca PJ, Valentine P, Lyons KJ, eds. Allied Health: Practice Issues and Trends in the New Millennium. New York, NY; London, UK: Haworth Press; 2003:247. 20 Stake RE. The Art of Case Study Research. Thousand Oaks, Calif: Sage Publications; 1995. 21 Strauss AL, Corbin JM. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 2nd ed. Thousand Oaks, Calif: Sage Publications; 1998. 22 Health Professions Regulatory Advisory Council. Critical Links: Transforming and Supporting Patient Care. A Report to the Minister of Health and Long-Term Care on Mechanisms to Facilitate and Support Interprofessional Collaboration and a New Framework for the Prescribing and Use of Drugs by Non-Physician Regulated Health Professions. http:// www.hprac.org/en/reports/resources/ HPRACCriticalLinksEnglishJan_09.pdf. Accessed August 17, 2012. 23 Sinclair LB, Lingard LA, Mohabeer RN. What’s so great about rehabilitation teams? 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Academic Medicine, Vol. 87, No. 12 / December 2012 An ethnographic study of interprofessional collaboration in a rehabilitation unit. Arch Phys Med Rehabil. 2009;90:1196–1201. Baker L, Egan-Lee E, Martimianakis MA, Reeves S. Relationships of power: Implications for interprofessional education. J Interprof Care. 2011;25:98–104. American Association of Colleges of Nursing. Position Statement on the Practice Doctorate in Nursing. http://www.aacn.nche.edu/ publications/position/DNPpositionstatement. pdf. Accessed August 17, 2012. Plack M, Wong C. The evolution of the doctorate of physical therapy: Moving beyond the controversy. J Phys Ther Educ. 2002;16:48–59. Redenbach D, Bainbridge L. Canadian physiotherapy education: The University of British Columbia example. Phys Ther Rev. 2007;12:92–104. Leipzig RM, Hyer K, Ek K, et al. Attitudes toward working on interdisciplinary health care teams: A comparison by discipline. Geriatrics. 2002;50:1141–1148. Larson EL. New rules for the game: Inter­ disciplinary education for health professionals. Nurs Outlook. 1995;43:180–185. Hall P. Interprofessional teamwork: Professional cultures as barriers. J Interprof Care. 2005;19(suppl):S188–S196. Page S, Meerabeau L. Hierarchies of evidence and hierarchies of education: Reflections on a multiprofessional education initiative. Learn Health Soc Care. 2004;3:118–128. Coombs M, Ersser SJ. Medical hegemony in decision-making—A barrier to interdisciplinary working in intensive care? J Adv Nurs. 2004;46:245–252. Kritek PB. Negotiating at an Uneven Table: Developing Moral Courage in Resolving Our Conflicts. 2nd ed. San Francisco, Calif: Jossey-Bass; 2002. Haas J, Shaffir W. Becoming Doctors: The Adoption of a Cloak of Competence. Greenwich, Conn: JAI Press; 1987. Nugus P, Greenfield D, Travaglia J, Westbrook J, Braithwaite J. How and where clinicians exercise power: Interprofessional relations in health care. Soc Sci Med. 2010;71:898–909. Stein LI. The doctor–nurse game. Arch Gen Psychiatry. 1967;16:699–703. Stein LI, Watts D, Howell T. The doctor–nurse game revisited. N Engl J Med. 1990;322: 546–549. Lingard L, Reznick R, DeVito I, Espin S. Forming professional identities on the health care team: Discursive constructions of the ‘other’ in the operating room. Med Educ. 2002;36:728–734. Bourgeault IL, Mulvale G. Collaborative health care teams in Canada and the USA: Confronting the structural embeddedness of medical dominance. Health Sociol Rev. 2006;15:481–495. Currie G, Finn R, Martin G. Accounting for the ‘dark side’ of new organizational forms: 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 The case of health care professionals. Hum Relat. 2008;61:539–564. Mulvale G, Bourgeault IL. Finding the right mix: How do contextual factors affect collaborative mental health care in Ontario? Can Public Policy. 2007;33(suppl):S49–S64. Armstrong P, Armstrong H. Wasting Away: The Undermining of Canadian Health Care. 2nd ed. Don Mills, Ontario, Canada: Oxford University Press; 2003. State of Ontario. Regulated Health Professions Act. http://www.e-laws.gov.on.ca/ html/statutes/english/elaws_statutes_91r18_e. htm. Accessed August 27, 2012. Ontario Ministry of Health and Long-Term Care. Backgrounder: Improving Patient Care in Ontario. http://www.health.gov. on.ca/english/media/news_releases/archives/ nr_09/may/bg_20090511.pdf. Accessed March 19, 2012. [No longer available.] Conference Board of Canada. Liability Risks in Interdisciplinary Care: Thinking Outside the Box. http://www.conferenceboard.ca/eLibrary/abstract.aspx?did=1979. Accessed August 17, 2012. Lahey W, Currie R. Regulatory and medicolegal barriers to interprofessional practice. J Interprof Care. 2005;19(Suppl):S197–S223. Canadian Nurses Protective Society. Collaborative Practice: Are Nurses Employees or Self-Employed? http://www.cnps.ca/index. php?page=40. Accessed August 17, 2012. Morris JJ, Ferguson M, Dykeman MJ. Canadian Nurses and the Law. 2nd ed. Toronto, Ontario, Canada: Butterworths; 1999. Morris JJ. Law for Canadian Health Care Administrators. Toronto, Ontario, Canada: Butterworths; 1996. Sneiderman B, Irvine JC, Osborne PH. Canadian Medical Law: An Introduction for Physicians, Nurses and Other Health Care Professionals. 3rd ed. Scarborough, Ontario, Canada: Thomson, Carswell; 2003. Thornton R. Responsibility for the acts of others. Proc (Bay Univ Med Cent). 2010;23:313–315. Martin JJ. Liability issues and collaborative practice. Coll Diet Ontario Resume. Winter 2008:5. Canadian Medical Protective Association, Canadian Nurses Protective Society. CMPA/CNPS Joint Statement on Liability Protection for Nurse Practitioners and Physicians in Collaborative Practice. http://www.cnps.ca/index.php?page=29. Accessed August 17, 2012. College of Occupational Therapists of Ontario. Registration: General Practising Certificate Requirements. http://www.coto. org/registration/default.asp. Accessed August 17, 2012. Canadian Medical Protective Association. Collab­­­­orative care: A medical liability perspective. https://www.cmpa-acpm. ca/cmpapd04/docs/submissions_papers/ pdf/06_collaborative_care-e.pdf. Accessed August 17, 2012. 1767 Journal of Interprofessional Education & Practice 8 (2017) 95e102 Contents lists available at ScienceDirect Journal of Interprofessional Education & Practice journal homepage: http://www.jieponline.com Perceptions of interprofessional collaborative practice and patient/family satisfaction MaryDee Fisher, DNP, RN, CPN a, *, Donna Weyant, MSN, RN, CPN b, Susan Sterrett, EdD, MSN, MBA c, Heather Ambrose, DNP, RN, CPON, CPN b, Abraham Apfel d a Chatham University, Eastside Campus: Office #230, Woodland Road, Pittsburgh, PA 15232, USA Children's Hospital of Pittsburgh of UPMC, 4401 Penn Ave, Pittsburgh, PA 15224, USA Chatham University, Woodland Rd., Pittsburgh, PA 15232, USA d DBE Core of Center for Translational Science Institute, Biostatistics - University of Pittsburgh, Parran Hall, Room 127, 4200 Fifth Ave, Pittsburgh, PA 15260, USA b c a r t i c l e i n f o a b s t r a c t Article history: Received 21 December 2016 Accepted 15 July 2017 Interprofessional providers of healthcare services need to function effectively as a team to deliver patient-focused interventions that are safe, of high quality, and clinically effective to generate improved patient outcomes. An academic pediatric hospital conducted a descriptive, correlational study to (a) describe clinicians' perceptions of interprofessional (IP) collaboration and to (b) identify the relationship between Collaborative Practice Assessment Tool (CPAT) scores with selected items from the Press Ganey® (PG) patient satisfaction survey. The results of the study indicated a moderately high perception of IPCP (M ¼ 5.51, SD ¼ 0.75), with the highest perceptions noted in the domains of Patient Involvement (M ¼ 6.18, SD ¼ 0.95) and Decision Making (M ¼ 4.53, SD 0.82). There was no relationship between average CPAT scores and responses on PG (r ¼ 0.009, p ¼ 0.964). Results of this study provide baseline data for future research and can be used to develop strategies that further enhance interprofessional collaborative team practices. © 2017 Elsevier Inc. All rights reserved. Keywords: Interprofessional collaborative practice Patient satisfaction Teamwork Pediatric Clinical care Healthcare functions in a complex environment. Patients have multiple comorbidities and chronic conditions and technology is advancing at rates not previously envisioned. Interprofessional (IP) providers of healthcare services need to deliver innovative and patient-focused interventions that are safe, of high quality and clinically effective to generate improved outcomes. For nearly two decades, the need for change within the United States Health Care delivery system has been well documented. Safer health care systems1 necessitate interprofessional education,2 and a redesign of health care systems.3 Undoubtedly, key elements to the successful redesign of health care delivery systems are interprofessional education (IPE) and interprofessional collaborative practice (IPCP). Health care can no longer afford to ignore the need to link IPE and IPCP with population-directed outcomes.4,5 * Corresponding author. E-mail addresses: mfisher@chatham.edu (M. Fisher), Donna.weyant@chp.edu (D. Weyant), ssterrett@chatham.edu (S. Sterrett), Heather.Ambrose@chp.edu (H. Ambrose), aba44@pitt.edu (A. Apfel). http://dx.doi.org/10.1016/j.xjep.2017.07.004 2405-4526/© 2017 Elsevier Inc. All rights reserved. A critical foundation necessary for IPCP has been recognized as IPE.4,6,7 Interprofessional education has been defined as two or more students learning about, from, and with one another in order to enable effective collaboration and improved patient health outcomes.8 IPE positively impacts students' abilities to work collaboratively in clinical practice.9,10 In a systematic review of the literature, Thistlethwaite summarized that interprofessional collaboration is encouraged and improves patient care, as a result of positive interactions occurring within IPE exchanges.9 In addition, IPCP contributes to patient care improvements, in partnership with families, while also meeting demands of the health care system.11 Further, IPCP both as an intervention and an intermediate outcome, supports the Institute for Health Care (IHI) Improvement's Triple Aim (2016). The Triple Aim targets reduced health care costs per capita, improved overall health of populations, and an improved quality of and satisfaction with the overall patient care experiences.12,13 IPCP is envisioned to enable teams to meet goals that no one member could accomplish in isolation.14 96 M. Fisher et al. / Journal of Interprofessional Education & Practice 8 (2017) 95e102 One collaborative model of care delivery that supports achievement of the Triple Aim is that of Family-Centered Care (FCC). Integration of key concepts from the FCC model, such as dignity and respect, information sharing, participation and also collaboration, enables a partnership approach to build on the inherent strengths of children and families.15 FCC, paired with interprofessional care delivery practices that also strive for mutual respect, may well positively impact care outcomes.16 Patient Centered Care (PCC), philosophically congruent to Family Centered Care, acknowledges and empowers families as partners in care delivery.17 PCC is also highlighted as one of the Institute of Medicine's six health care aims that attempt to ensure patient values assist in guiding all clinical decisions.3 FCC, practiced at the site of the research study, is a care delivery model that supports the Triple Aims of health care. Integrated teams, with common goals and shared decisionmaking, are essential to effectively implement a FCC model in healthcare.18 Shared decision making is fundamental to enable IPCP. IPCP enables team members work collectively together and strive to deliver comprehensive primary health care, fully applying their knowledge and skills, in order to effectively meet the needs of a particular population,19. Additionally, in support of this shared decision-making concept, “interprofessional collaboration is the process of developing and maintaining effective interprofessional working relationships with learners, practitioners, patients, clients, families and communities to enable optimal health outcomes” (as cited in,9). The Family Centered Care model requires collaboration which is constructed upon this shared decision-making concept. It supports clinical practices where patients and families are integral and equal partners in care delivery practices.15 This approach enhances effective teamwork within healthcare arenas. Brandt asserts “the most successful health care systems are focusing on becoming learning organizations to implement teams of not only health professionals but also to meaningfully partner with patients, families, and communities” (as cited in,20). 1. Interprofessional collaborative practice With IPE as a foundation, IPCP improves the delivery of healthcare services and positively impacts patient outcomes.7 However, a comprehensive review of multiple studies calls for more rigorous research studies to specifically examine these IP collaborative practices. There is a clear need to link the impact of practice-based IPC interventions to subsequent healthcare outcomes (as cited in,21). In 2014, Brandt, Lutfiyya, King, and Chioreso presented a scoping review of the IPP and IPE literature, assessing the status of research studies connecting interprofessional education and interprofessional practices towards the development of the Triple Aims of effective, quality patient care delivered with positive patient outcome experiences. They concluded that the impacts of IPE, and also IPP on patient care have not yet been demonstrated through clinical research. 2. Interprofessional collaborative practice and family satisfaction outcomes Outcome measurements related to IPCP have been scarcely reported scarcely in the scholarly literature. The recently published report, Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes, included an examination of studies attempting to specifically correlate the impact of IPE with patient and population outcomes. This comprehensive report noted less than a handful of studies reported results striving to clearly relate IPCP to patient and/or family communications (n ¼ 2) and/or outcomes (n ¼ 1), while the majority of reviewed works focused on processes related to practices within the organization overall.4 The challenges in concluding the associations within these relationships, in part appear to be due to the complex nature of the overall healthcare environment, with many factors simultaneously influencing actual practices, perceptions and final outcomes. Few studies have been published that examine this complex issue. Specifically, one study by Shaw, Davidson, Smilde, Sondooza and Agan,22 examined family satisfaction in the intensive care unit (ICU). Ninety-eight interprofessionals were educated in patient communication techniques. Family satisfaction scores improved post clinician education. This study did not focus on team collaboration specifically, but education on individual clinician's communication with patients and families. Fifteen years earlier, a randomized control trial focused similarly on education related to patient communication techniques. However, while clinicians reported a moderate improvement in their communication skills, in this study patient satisfaction scores did not improve as a result of the training of the clinicians.23 In addition, well over two decades ago, it was noted that IP collaboration, specifically between RNs and MDs, decreased the amount of negative patient outcomes related to patient transfer status.24 A common indicator used to measure quality of healthcare is patient/family satisfaction.25 Patient satisfaction has been referred to as a critical outcome indicator.26 As noted, above, there are minimal studies that explored the impact of IPCP with the outcome of family satisfaction. These limited studies clearly conclude conflicting results. No study specifically explored the relationship between perceptions of collaborative practices, using a valid and reliable tool, and the outcome of patient and family satisfaction. This research study attempts to bridge the gap in the literature and to establish baseline data for future investigation. The study was undertaken to discover relationships between IPCP and patient/family satisfaction outcomes. The specific purposes of this study were to gain an understanding of clinicians' perceptions of the level of collaboration between disciplines on individual units and to identify the relationship between scores on an IPCP assessment and scores on patient/family satisfaction quality survey. Study results will also lead to development of future strategies targeted to improving collaboration among clinicians, removing barriers to collaborative practice, and improving the quality of care delivery and ultimately patient outcomes. The specific research questions addressed were: What are the perceptions and the degree to which interprofessional team members collaborate with one another to provide comprehensive, timely, and appropriate care? Is there a correlation between the average scores on Collaborative Practice Assessment (CPAT) and the average patient/ family satisfaction scores? 3. Methods 3.1. Design Researchers from a pediatric hospital collaborated with researchers from a local university to conduct a prospective, descriptive, mixed-methods research study. The purpose of the study was to gain an understanding of clinicians' perceptions of the level of teamwork and collaboration between interprofessionals on patient care units and to identify any relationships between interprofessional collaborative practices and patient/family satisfaction quality outcomes. The study was deemed exempt after reviews by the affiliated practice and academic Institutional Review Boards. Ethical Considerations for the protection of human subjects and the M. Fisher et al. / Journal of Interprofessional Education & Practice 8 (2017) 95e102 consent to participate were addressed through the privacy of recruitment emails; an introductory script explaining the study including the option to withdraw; and the collection of confidential information on the survey. Consent to participate was acknowledged by a subject's willingness to complete the survey, after reading the introductory script and then accessing the secure link to begin the survey. Although no identifiers were collected on the CPAT survey, there was minimal risk of researchers knowing the identity of a subject from survey responses matched with specific demographic data. Subjects were notified of this minimal risk in the introductory script. 3.2. Setting A free-standing, urban, pediatric, tertiary care, academic medical center in the Mideast served as the setting for the study. The research facility is a Level 1 Trauma Center with 315 total licensed beds, including 103 critical care beds (55 beds neonatal intensive care, 36 beds pediatric intensive care, and 12 beds cardiac intensive care). The medical center routinely serves neonates, infants and children up to 18 years of age. The average yearly volume of patients includes: over 20, 000 combined inpatient and observation stays; roughly 80,000 Emergency Department visits; approximately 23,500 surgical procedures; and more than 1,000,000 outpatient visits. Specialty services are offered to children undergoing organ transplantation, cardiovascular surgery, oncology treatment regimes, and gastroenterology procedures to name a few. As noted, the model for patient care delivery is one of Family Centered Care.15 Several patient and family-centered initiatives have previously been implemented using an interprofessional collaborative practice approach, such as routine bedside rounding and patient care conferences that enhance shared decision-making practices as well. 97 web-based application designed to support and manage data capture for research studies.27 Potential subjects were provided a direct link to the survey within the email introductory script. The survey remained open for 30 days to obtain maximum number of subject responses. 3.5. Survey tools The Collaborative Practice Assessment Tool (CPAT) was developed to collect background information about collaborative practices that assess the degree of provision of comprehensive, timely, and appropriate patient care.11 The CPAT is a 56 item, seven-point Likert scale type survey tool, measuring clinicians' perceptions of teamwork and collaborative practice. It was used with permission from Queen's University Ontario and reproduced electronically for ease of survey distribution, data collection, and subsequent analysis. Possible responses on the Likert scale range from strongly disagree to strongly agree. The 56 Likert items are further categorized across eight domains of collaborative practice including: mission, meaningful purpose, goals; general relationships; team leadership; general role responsibilities, autonomy; communications and information exchange; community linkages and coordination of care; decision-making and conflict management; and patient involvement.11 Reliability and validity testing of the CPAT were reported by the researchers through two separate pilot tests.11 Follow-up confirmatory analysis revealed a Normed Fix Index (NFI) with a range of 0.901e0.970, a Comparative Fix Index (CFI) with a range of 0.943e0.986, and a Tucker Lewis Index with ranges from 0.851 to 973. For each of the above mentioned statistics, a score of 1.0 would indicate a perfect fit, and anything above 0.90 is considered acceptable. These comprehensive analyses indicate the CPAT provides a “good measure of collaborative practice”.11 Only one research study using this CPAT tool has been published thus far.6 3.3. Participants and recruitment 3.6. CPAT background and open-ended questions A convenience sample of clinical staff was recruited to participate in a one-time voluntary survey. Clinical staff defined as interprofessional care providers, were those having a direct impact on the clinical care of the pediatric patients. These interprofessional individuals included staff in the roles of nurses, nurse practitioners, patient care technicians, pediatric medical/surgical residents, fellows and attending physicians, pharmacists, occupational therapist, physical therapists, social workers, child life specialists, respiratory therapists, and also care coordinators. Potential subjects were identified by leadership across 16 different patient care areas throughout the hospital. These areas were clustered into four unit categories; medical, medical-surgical, intensive care, and surgical/perioperative. Units were clustered according to common standards and processes for patient care flow need within hospitals across the nation. The four units were clustered according to types of patients serviced, level of care needed and types of providers required to deliver the necessary care. This clustering offers a common language and will assist with future comparison studies. Subjects were invited, and reminded twice, to participate in the survey through an introductory script delivered via email. These emails, offering study participation, were sent at three different time points within the 30 days of data collection. 3.4. Data collection Study data collected included the survey Likert items and three open-ended questions, as well as selected items from a patient/ family satisfaction tool. Study data were collected and managed using REDCap (Research Electronic Data Capture), which is a secure, Subjects provided additional background information that included gender, profession, years working in the profession, and which unit of the hospital they work most of the time. Some clinicians work on multiple units across the hospital and were directed to select the unit worked on most of the time in order to complete the tool. Individual units of the hospital were clustered to align with the unit type, using national benchmark classifications for the purposes of future analysis and data comparisons. The third set of data collected with the CPAT were the openended questions related to collaboration and collaborative practices that were included at the end of the survey. The three questions were: (a) What does your team do well with regards to collaborative practice? (b) In your practice what are the most difficult challenges to collaboration? (c) What does your team need help with to improve collaborative practice? 3.7. Patient satisfaction survey The Press Ganey© Inpatient Pediatric Survey was used to determine parental satisfaction with overall hospitalization experience.28 The outcome of satisfaction was measured by selected items from the Press Ganey© (PG) survey tool. The PG survey is typically sent electronically to parents/families of all patients discharged from the hospital, with the allotment of one survey every 90 days. The tool is used to measure standards of care related to patient experiences at the research facility. Satisfaction scores are reported anonymously and clustered for reporting into aggregate means measured on a five-point Likert scale, with responses 98 M. Fisher et al. / Journal of Interprofessional Education & Practice 8 (2017) 95e102 ranging from very poor to very good. The research team selected two questions from the PG survey that would potentially be directly impacted through interprofessional collaborative practices. The PG tool is known to be a reasonable and valid measure of patient/family satisfaction outcomes. The two PG questions selected were “staff efforts to include you in decisions about your child's treatment” and “how well staff worked together to care for your child” and.28 The satisfaction scores were collected from the quarter corresponding with CPAT administration and included responses from all of the hospital unit clusters represented in the research study. 3.8. Data analysis design Quantitative and qualitative data analyses were performed on the research data. Analysis of the descriptive and open-ended CPAT survey tool data, as well as correlation with Press Ganey© satisfaction responses from two questions were completed. Survey tool results were entered into the REDCap system then downloaded into an Excel database. Measures of central tendency (mean) and dispersion (standard deviation, range) were used to describe continuous characteristics. ANOVA was used to compare the means of the clusters of units for each domain of items on the CPAT and the Bonferroni adjustment for multiple comparisons was made. The primary goal of the correlations was to assess the association between each of the Press Ganey© questions and the CPAT data. A Spearman correlation coefficient was used to assess the association between the average overall CPAT (across all items) score for each individual unit and the corresponding unit's average score for each of the Press Ganey© questions. Qualitative analysis of the open-ended questions was done using thematic text analysis. This is a descriptive qualitative approach involving the generation of codes and then developing overarching themes from the participant responses. 4. Results 4.1. Quantitative findings 4.1.1. Demographic data A total of 1358 clinicians were identified by leadership for potential recruitment into the study. There were 173 subjects that participated in the study, yielding an overall response rate of 13%, which is below what researchers anticipated. The responses of each profession roughly approximated the target sample, however there was slight underrepresentation for the MD and a slight overrepresentation of the RN group. Again, units were clustered based on national benchmark groupings. This unit type of clustering was reflective of units similar in specialty patient population types, teamwork, and processes. It also provides the best data sets for this specific study results and analysis, as well as the potential for external comparisons. Interprofessionals viewed themselves as “team” members from one chosen unit to answer the survey. Sample characteristics are outlined in Table 1. 4.1.2. Results of CPAT Analysis of individual CPAT scores revealed a mean score of 5.51 (SD ¼ 0.75), on the seven-point Likert scale. This finding supports a high degree of interprofessional collaborative team practices among direct patient care providers across the hospital. Subject demographics such as age, education, etc. were not found to significantly impact the overall CPAT scores. However, the group with over 10 years' experience up to 20 years' experience had the highest mean CPAT score at 5.78 (SD ¼ 0.59). Mean scores from all subjects were described according to the eight domains (see Table 2). The domain of Patient Involvement had the highest mean at 6.18 (SD ¼ 0.95), and the domain of Decision Making and Conflict Management had the lowest mean of 4.53 (SD ¼ 0.82). Overall CPAT scores were further clustered by unit categories as previously described. Mean unit type scores of the clustered units were reported as: Surgical/Perioperative (M ¼ 5.56, SD ¼ 0.69); ICU (M ¼ 5.53, SD ¼ 0.70); Medical/Surgical (M ¼ 5.52, SD ¼ 0.88); and Medical (M ¼ 5.53, SD ¼ 0.61). There was no statistically significant difference between the clustered units in overall CPAT scores (p ¼ 0.7605). Additionally, clustered unit type domain scores were analyzed to highlight overall perceptions, areas of strength in collaborative practices, as well as opportunities to impact barriers perceived by interprofessional team members. Statistical significance was not detected across the unit type groupings, in any of the eight domains. Mean domain scores revealed Decision Making had the lowest mean across three of the four unit types; and Patient Involvement had the highest mean in three of four unit types (see Table 2). Lastly, an analysis was completed to determine if members of various professions perceive interprofessional collaborative teamwork differently. Table 3 outlines these results. There was an overall borderline significant difference between professions with a pvalue of 0.057. However, there were no pairwise significant differences due to the Bonferroni multiple comparison correction. Clinical care coordinators scored the highest of any interprofessional group. Unfortunately, no OT, PT or pharmacy interprofessionals are represented in the research sample. 4.1.3. Association of CPAT with Press Ganey© scores Patient/parent satisfaction scores from Press Ganey ©28 were computed from a total of 312 survey respondents. Scores for the questions “staff efforts to include you in decisions about your child's treatment” and “how well staff worked together to care for your child” were calculated. The PG raw scores were on a Likert scale from one to five and were converted to a scale of zero to 100 as directed by PG staff.29 Responses ranged from very poor to very good on the tool: 1 ¼ 0% very poor, 2 ¼ 25% poor, 3 ¼ 50% fair, 4 ¼ 75% good, and 5 ¼ 100% very good). See Table 4. A spearman correlation coefficient of average CPAT scores across a unit to the Table 1 Participant characteristics. Total participants Gender Male Female Not identified Years of Experience Up to 3 years Over 3 - up to 4 years Over 10 - up to 20 years Over 20 years Profession Registered Nurse Physician Resident Physician Attending/Fellow Patient Care Technician Social Worker Child Life Specialist Respiratory Therapist Clinical Care Coordinator Other Medical Medical - Surgical Surgical - Perioperative Intensive Care Unit Did not indicate 173 20 (11.56%) 151 (87.28%) 2 (1.12%) 49 60 35 25 (28.3%) (34.7%) (20.2%) (14.5%) 113 (65.3%) 7 (4.0%) 15 (8.7%) 12 (6.9%) 3 (1.7%) 2 (1.2%) 3 (1.7%) 3 (1.7%) 15 (8.7%) 17 (9.83%) 54 (31.21%) 31 (17.92%) 70 (40.46%) 1 (0.5%) M. Fisher et al. / Journal of Interprofessional Education & Practice 8 (2017) 95e102 average Press Ganey© scores across the corresponding unit showed no significant correlation for the areas of inclusion about decisions (r ¼ 0.009, p ¼ 0.964) and working together as a team (r ¼ 0.230, p ¼ 0.516). 4.2. Qualitative findings Using thematic text analysis, data from the open-ended questions were entered into Atlas.ti (vers. 6.2.28). Initially, codes were generated from the respondents' words. Major categories of communication, process and values were predominant in initial coding. In continued analysis meaningful themes were generated using participant wording. Frequency and co-occurrence of themes were evaluated. Question 57. The first question asked the participants to identify what they do well in regards to collaborative practice. Responses were broken into categories of communication, process or values. Communication. Several respondents indicated “some work well together.” A theme of inconsistency was identified supported by the following comments: “some better than others;” “some doctors better than others;” “depends on the shift;” or “depends on the attending.” However, during emergency or critical situations, collaboration occurred consistently as supported by the following comments, “Everyone always pulls together” and “everyone understands their role and executes their tasks.” Process. Twenty-five responses could be coded as process related. Most were positive, expressing that their team had developed successful processes. The theme identified under the process category was collaboration as demonstrated by rounding, huddles or team meetings. Rounding was mentioned most often (n ¼ 12) in this question relating to successful practices. Values. The third category was that of values. The primary theme was respect. Specifically mentioned was “respect for the bedside nurse” and “respectfully abiding by care plan even if disagreements.” Another theme was team cooperation toward a shared goal. Question 58. Question 58 asked the respondent to detail the most difficult challenges to collaboration. There were 71 responses to this question recorded. Categories of communication, process and values were evident here also, but from the perspective of what is not working. Communication. When asked to identify the challenges to collaboration, themes identified included not listening and rudeness. “Some of the doctors not listening to our concerns and being rude.” The relationship between novice nurses and some nurse practitioners was preserved as being intimidating and hindering communication at times. Processes. Respondents described processes that didn't function effectively due to the many services involved and the constant change in care. One respondent stated, “Having everyone on the same page pretty much sums it up.” Decisions are made in one service and not communicated to others. 99 Values. Lack of respect was a theme. Many clinicians perceive a distrust of novice nurses. Novices perceive being excluded from decisions and increased anxiety to call physicians. The need for mentoring of novice nurses was also identified. Question 59. What does your team need help with to improve collaborative practice? Thirty-one respondents answered this question. The categories included education and process. Education. Requests were made for education related to professionalism, listening, communicating with patient's families as well as using the courses already available at their institution on quality. Process. Many suggestions were made for improving team processes. Suggestions included utilizing Ipads for access to data by bedside nurses, more formal rounds including family, and use of an existing QI program. One staff expressed thanks that their input was solicited to improve the collaborative atmosphere on their unit. The qualitative responses reflected similar themes throughout the three questions with an overwhelming desire for a respectful, positive work environment. The suggestions to create the environment are not costly, but require a culture change. 5. Discussion To improve collaborative practice among healthcare providers in the acute care setting, the insights of clinicians regarding themselves as a team, must first be explored. This research study provides baseline of perceptions of IPCP, which has not been previously described in the literature. Despite the inability to demonstrate statistical significance, this research project was able to: identify perceptions of the concepts of team and collaborative practices of interprofessionals working on various units; and to identify specific dimensions of collaborative practices within the eight domains of the CPAT tool. Researchers identified across all levels of acute care, interprofessionals perceived a moderately high level of IPCP with a mean score across all participants of 5.51 on the 7-point Likert scale. This finding indicates overall interprofessional team collaborative practices are present within the research hospital. The qualitative analysis of data indicates strong relationships on units leading to the sharing of a common vision, a critical skill for quality care delivery. Processes such as rounding, huddles and team meetings, when successfully carried out positively impacted team members' sense of collaborative practice. This finding aligns with Earnest & Brandt,14 who suggest that IPCP teams can meet goals more effectively than when attempting to accomplish goals individually. Although it is encouraging to discover the positive identification of IPCPs, further exploration of the composition and characteristics of individuals within interprofessional teams may be warranted, including fluidity of membership on the team. Typical levels of teamwork at this institution are also valuable for future comparisons at this and other institutions. Table 2 Mean scores of CPAT by overall hospital and unit types. Domain Overall Mission, Meaningful Purpose, Goals General Relationships Team Leadership General Role Responsibilities, Autonomy Communication & Information Exchange Community Linkages & Coordination of Carea Decision Making & Conflict Management Patient Involvement 5.84 5.93 5.48 5.41 5.59 4.85 4.53 6.18 a (SD (SD (SD (SD (SD (SD (SD (SD ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ 0.81) 0.89) 0.89) 0.76) 0.89) 1.25) 0.82) 0.95) One domain item inadvertently omitted on electronic survey tool. ICUs Medical/-Surgical 5.81 (SD ¼ 0.81) 5.87 (SD ¼ 0.89) 5.41 (SD ¼ 0.84) 5.42 (SD ¼ 0.80) 5.64 (SD ¼ 0.83) 4.92 (SD ¼ 1.14) 4.6 (SD ¼ 0.82) 6.20 (SD ¼ 0.97) 5.84 5.88 5.60 5.52 5.69 5.01 4.42 6.35 (SD (SD (SD (SD (SD (SD (SD (SD ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ 0.99) 1.04) 0.87) 0.64) 0.85) 1.24) 0.85) 0.69) Medical 5.76 5.97 5.15 5.17 5.10 4.10 4.54 6.14 (SD (SD (SD (SD (SD (SD (SD (SD Surgical/Perioperative ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ 0.66) 0.57) 1.05) 0.69) 1.00) 1.26) 0.83) 0.79) 5.96 6.09 5.65 5.34 5.56 4.80 4.52 5.87 (SD (SD (SD (SD (SD (SD (SD (SD ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ 0.56) 0.78) 0.95) 0.87) 1.01) 1.42) 0.78) 1.30) 100 M. Fisher et al. / Journal of Interprofessional Education & Practice 8 (2017) 95e102 Table 3 Mean scores of CPAT by interprofessional team members.a Profession Number of participants Mean Standard Deviation Clinical Care Coordinator Other Patient Care Technician (PCT) Physician Attending Social Worker Respiratory Therapist Registered Nurse Child Life Specialist Physician Resident 3 15 12 15 3 3 113 2 7 6.09 5.96 5.75 5.70 5.65 5.63 5.42 5.26 5.00 0.18 0.59 0.76 0.76 0.40 0.42 0.70 0.47 1.43 a Borderline significance with a p-value ¼ 0.057. Examining mean CPAT scores across professions revealed an overall borderline significance with a p-value of 0.057, however no pairwise significant differences were noted. Researchers were not surprised to learn that among the different professions the clinical care coordinators mean composite score was highest overall at 6.09 (SD ¼ 0.18). It is reasonable to conclude that given their job description, this was not unanticipated as their work routinely involves multiple interprofessional team members in coordinating the discharge plan. Patient care technicians (PCT) scored third highest with an overall CPAT score of 5.75 (SD ¼ 0.76). The dyad mode of operation is intrinsic within daily functioning in the life of a PCT is the Registered Nurse (RN) and PCT. In the dyad, the RN routinely and consistently delegates tasks to the PCT throughout the day. The constant exchange of information requires a team approach to effectively care for the patient and could explain the high score of the PCTs' perception of team work on the CPAT tool. Further examination of each domain within the CPAT tool can help providers to narrow clinicians' perceptions of IPCP and to identify specific areas of high and low perceived IPCP. These perceptions offer a foundation for the development of strategies aimed at improving overall IPCP or support for continued effective collaboration processes. Regarding the overall CPAT scores, there was no statistically significant difference between domains. With a hospital-wide mean (M ¼ 6.18), staff agreed to the concept of teamwork within the domain of patient involvement. Additionally, this domain was the highest scoring domain in three of four unit clusters. The CPAT scores ranked highest related to patient involvement. This domain had the highest overall mean score and reinforces the foundational model of Family Centered Care and shared decision making practices enacted at the research institution. The two domains of General Relationships and Mission, Meaningful Purpose and Goals were also ranked very highly as noted previously (5.93 and 5.84 respectively). In the qualitative data analysis, some professionals mentioned their team was welcoming and sought input from all team members. These types of teams may serve as models for team education and repurposing. These study findings are consistent with Nancarrow et al.’s assertions that characteristic principles of good interdisciplinary teamwork include, “positive leadership and management attributes; communication strategies and structures; personal rewards, training and development; appropriate resources and procedures; appropriate skill mix; supportive team climate; individual characteristics that support interdisciplinary team work; clarity of vision; quality and outcomes of care; and respecting and understanding roles” (2013, p 1).30 In contrast, the Decision Making and Conflict Management domain scored the lowest, across the hospital and again in three of four unit types with a mean score of 4.53. Consistent with the recommended usage of the CPAT tool, this appears to be an identified professional development need and the team may potentially be impacted by educational interventions. Paired with qualitative results, that indicated although there was an overall call for an atmosphere of respect, newer staff particularly is often intimidated, especially by nurse practitioners and physicians. Thus, this particular finding has implications as an identified barrier to collaborative team practices. Improvement in managing conflict is an essential step to developing shared decision making in a team, a critical aspect of successful collaboration18 The Brinkert31 review of healthcare literature on conflict communication, finds this issue to be pervasive in acute care and costly due to burnout, turnover and absenteeism. Potential interventions identified as successful in the literature include enhanced communication mechanisms,32 preceptorship programs33 and problem-based learning strategies.34 The clustered units scores ranged from a high of 5.56 (Surgery/ Perioperative) to a low score of 5.33 (Medical). Although no direct statistical correlations were able to be made between CPAT and PG scores, it is noteworthy that the surgery/perioperative cluster also had the highest PG scores. This relationship is worth exploring in future investigations in order to further build on the strengths of these teams and to develop strategies for application in other areas. This study also looked for a relationship between clustered units' CPAT scores and two questions selected from the respected Press Ganey© survey, that in the opinion of the research team, are associated with teamwork and collaboration. As was noted, although a positive correlation was anticipated, no relationship was uncovered. It is possible that the PG question identified to measure outcomes are more global in nature and are not specific enough to measure the impact IPCP. This broader relationship between patient/family outcomes and team collaborative functioning is notably outlined in the Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes (2015). The document puts forth discussions of the difficulty of this challenge to correlate linkage in a well-defined manner, due to the complexities and intricacies within care environments impacting outcome measures. Table 4 Mean scores of press Ganey© by overall hospital and unit type. Staff efforts to include you in decisions about your child's treatment How well staff worked together to care for your child Overall Hospital N ¼ 312 Medical N ¼ 71 Medical-Surgical N ¼ 138 ICUs N¼6 Surgical-Perioperative N ¼ 96 89.13 91.69 85.56 89.08 89.96 91.85 60 83.3 91.46 93.49 M. Fisher et al. / Journal of Interprofessional Education & Practice 8 (2017) 95e102 Identified benchmark levels of interprofessional collaborative practices, as well as key domain IPCP scores, were established. However, the lack of correlation between IPCP and patient outcomes in this study is consistent with the significant gap identified across all health care professions that highlights the need to develop a framework to measure the impact of IPE on collaborative practice and patient outcomes.35 6. Limitations The lack of paired data complicated the association calculations were identified as a limitation. The need to treat the unit clusters as individual data points for the correlation analysis, lead to the small number of pairings. Thus, the small number of data points available for analysis, created by the clustering of units by specialty patient population types, teamwork, and processes may have been a factor in the lack of correlation between CPAT scores and outcomes. The ICU cluster reported an extremely low number of responses, as children are not routinely discharged from the ICU units. This very small N (6) may contribute to skewed results on the overall Press Ganey© for this unit cluster and no generalizations are able to be made about this specific data. Reporting on the Press Ganey© survey also depends on parental memory of events and is not completed in real time of care delivery, potentially altering reported results. Some elements of the research study design could be strengthened. The smaller sample sizes for both tools is recognized and generalizability of the findings should be done with caution. The sample distribution was roughly representative of the institution as a whole. However, all participants in the sample were interprofessionals working in a pediatric facility and this collective voice may actually be strength of the study. 7. Implications and recommendations The goal of the study was to identify the current status of collaborative practice at the site through identifying the insights of clinicians. Clinician responses to the survey and open-ended questions lay the groundwork for creating an effective model of IPCP and education that fits the culture of the institution. Areas of strength, and those calling for development to increase the collaboration were identified in eight different domains. Strengths can be built upon, and areas of weakness used as a foundation for team learning. The study also has implications for the institution's leadership awareness and development. Professional and institutional accrediting standards recently began including interprofessional collaborative practice requirements.36 Very different from quality improvement of clinical issues, these standards require changing individual communication styles as well as the overall culture of the institution. The study tool allowed the state of the communication culture to be identified in an in-depth way. The study presents a piece of the puzzle of identifying outcomes of IPCP on patient and family satisfaction and quality clinical care. The question of correlation between the average scores on the CPAT and the average patient/family satisfaction scores revealed no direct correlation. This can however be the groundwork for future studies further exploring relationships between collaborative practices and patient and family satisfaction. Combining knowledge gained from the CPAT results with the latest effective pedagogical strategies will lead to development of a model of practice and education that will move the institution towards improved team collaboration. Models using the Communities of Practice model37,38 provide an interesting framework. At a recent leadership summit, Graham McMahon, President of the 101 Accreditation Council for Continuing Medical Education, noted the many benefits of a community of practice where open reflection and sharing on issues can occur.39 Johns Hopkins Hospitals has developed clinical communities as a bottom-up approach to quality improvement that supports peer learning and develops shared norms.40 Communities of Practice create the collaborative approach within the learning process, modeling collaboration as it is learned. These models stimulate collaboration within their structure. Clearly, expansion of the current team structure to other interprofessionals included in the discussions, to begin to develop interventions, is warranted and key to consensus building and crafting a strategic plan to successfully move forward. An option may be to select members with particular years' experience (10e20 years), as they have the most optimal communication interactions with interprofessional team members. Engaging family members and patients to assist in redesign of structures and processes of care delivery is ideal. The use of daily interdisciplinary rounds and care conferences increases the involvement of multiple practitioners. Transition from historically medical-led to nurse-led bedside rounds is also an option to consider, that may enable visible plans of care to all interprofessionals and patients/families alike, strengthening the common vision for collaborative practices and shared decision-making. Effective teams have a clear purpose, mechanism for conflict resolution and places patients at the center of practice that enables improved patient care and enhanced patient safety.41 Thus, consideration of a process change to a hospital wide shared governance model e not merely nursing shared governance e may well impact the decision making and conflict management domain rated lowest overall. Systematic structure and process initiatives, including education for effective decision-making and conflict management, are essential for strengthened effective interprofessional practice. Coalitions sharing experiences with other pediatric centers may identify best practices and curricula for this specific type of practice. Recommendations for future research include specific dyad pairing of IP team members with the patient and family dyad within research institutions. This process would omit some convolutions and contributing variables for a stronger data analysis that could include a paired t-test and a more classical correlation analysis. A Power Analysis, to determine the sample size necessary to potentially uncover even a small effect size, may be warranted. However, a few confounding variables would remain, due to the complex nature of the overall environment and the complexity of teamwork. In the future it may be appropriate to ask IP clinicians if they have had formal IPE when surveying with CPAT, as this correlation would further strengthen the link between IPE and IPCP, the very foundation necessary for improved patient outcomes. 8. Conclusion Practicing health care collaboratively is vital to improving patient care outcomes. This study adds to the limited research literature on collaborative practice in the acute care setting by examining the perceptions of healthcare providers' sense of teamwork. It may serve as a baseline for future studies to build a body of evidence for effective team collaboration. Research documenting the effectiveness of team-based care impacting the Triple Aims identified by the IOM, guides evidence-based approaches to collaboration. Use of the results of this study can add to the collective foundation being laid that will truly influence outcomes, so that “a century hence, this moment will clearly stand out as one ripe with both need and opportunity”,14 p. 500). 102 M. Fisher et al. / Journal of Interprofessional Education & Practice 8 (2017) 95e102 Acknowledgements Data analysis for this project was supported (in part) by National Institutes of Health: Grant numbers UL1RR024153 & UL1TR 000005. Support for the use of REDCap (Research Electronic Data Capture) application was supported by National Institutes of Health: Grant number UL1TR000005. References 1. Paterson M, Medves J, Dalgarno N, O'Riordan A, Grigg R. The timely open communication for patient safety project. J Res Interprof Pract Educ. 2013;3(1): 22e42. Retrieved from: http://www.jripe.org/index.php/journal/article/view/ 65/70. 2. Schroeder C, Medves J, Paterson M, et al. Development and pilot testing of the collaborative practice assessment tool. J Interprof Care. 2011;25(3):189e195. http://dx.doi.org/10.3109/13561820.2010.532620. 3. Institute for Family Centered Care. (n.d). Patient and family ecentered care. Retrieved from: http://www.ipfcc.org/pdf/CoreConcepts.pdf. 4. Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P, Roots A. Ten principles of good interdisciplinary team work. Hum Resour Health. 2013;11(1):19. http:// dx.doi.org/10.1186/1478-4491-11-19. 5. Seren S, Ustun B. Conflict resolution skills of nursing students in problem-based compared to conventional curricula. Nurse Educ Today. 2008;28(4):393. 6. Gardner Deborah B. Health policy and politics - implementing a vision for interprofessional team practice & education: an interview with Barbara Brandt. Nurs Econ. July-August 2014;32(4):221e223. 7. Institute for Patient and Family Centered Care. (2016). Retrieved from: http:// www.ipfcc.org/advance/topics/better-together.html. 8. Thistlethwaite J. Interprofessional education: a review of context, learning and the research agenda. Med Educ. 2012;46(1):58e70. http://dx.doi.org/10.1111/ j.1365-2923.2011.04143.x. 9. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 10. Press Ganey Associates, Inc. Path to better patient experiences. Retrieved from: http://www.pressganey.com/about/path-to-better-patient-experiences; 2015. 11. Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2009;(3), Art. No.: CD000072. http:// dx.doi.org/10.1002/14651858.CD000072.pub2. 12. Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: National Academy of Sciences; 2003. 13. Institute for Healthcare Improvement. IHI triple aim initiative. Retrieved from: http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx; 2016. 14. Brandt B, Lutfiyya MN, King JA, Chioreso C. A scoping review of interprofessional collaborative practice and education using the lens of the Triple Aim. J Interprof Care. 2014;28(5):393e399. http://dx.doi.org/10.3109/13561820. 2014.906391. 15. Brinkert R. A literature review of conflict communication causes, costs, benefits and interventions in nursing. J Nurs Manag. 2010;18:145e156. http:// dx.doi.org/10.1111/j.1365-2834.2010.01061.x. 16. Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington, DC.: Interprofessional Education Collaborative; 2011. 17. Way D, Jones L, Baskerville B, Busing N. Primary health care services provided by nurse practitioners and family physicians in shared practice. Can Med Assoc J. 2001;165(9):1210e1214. 18. World Health Organization (WHO). Framework for Action on Interprofessional Education and Collaborative Practice. Geneva, Switzerland: World Health Organization; 2010. Retrieved from: http://www.who.int/iris/handle/10665/ 70185. 19. Baggs JG, Ryan SA, Phelps CE, Richeson JF, Johnson JE. The association between interdisciplinary collaboration and patient outcomes in a medical ICU. Heart & Lung. 1992;21(1):18e24. 20. Brown JB, Boles M, Mullooly J, Levinson W. Effect of clinician communication skills training on patient satisfaction. Ann Intern Med. 1999;131(11):822e829. http://dx.doi.org/10.7326/0003-4819-131-11-199912070-00004. 21. Sterrett S. Becoming an Interprofessional community of practice: a Qualitative study of an Interprofessional fellowship. J Res Interprof Pract Educ. 2010;1(3): 247e262. Retrieved from: http://www.jripe.org/index.php/journal/article/vie w/33. 22. Joint Accreditation Interprofessional Continuing Education. By the team for the team: evolving interprofessional continuing education for optimal patient care. Retrieved from: http://education.accme.org/news-publications/publications/o ther-accme-reports/team-team-evolving-interprofessional-continuing; 2016. 23. Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M. Interprofessional education: effects on professional practice and healthcare outcomes (update). Cochrane Database Syst Rev. 2013. http://dx.doi.org/10.1002/14651858. cd002213.pub3. 24. Canadian Health Service Research Foundation. Making patients part of the health care team slide set. Retrieved from: http://www.cfhi-fcass.ca/migrated/ pdf/2010_06_23_RoC_Presentation1.pdf; 2010. 25. Prakash B. Patient satisfaction. J Cutan Aesthetic Surg. 2010;3(3):151e155. 26. Palese A, Tomietto M, Suhonen R, et al. Surgical patient satisfaction as an outcomes of nurses' caring behaviors: a descriptive and Correlational Study in Six European Countries. J Nurs Scholarsh. 2011;43(4):341e350. Doi: 10.1111fj.1547-5069.2011.01413. 27. Press Ganey. Star rating calculation methodology. Retrieved from: http://www. pressganey.com/docs/default-source/default-document-library/star_calculatio n_methodology.pdf?sfvrsn¼0; 2015. 28. Reeves S, Goldman J, Gilbert J, et al. A scoping review to improve conceptual clarity of interprofessional interventions. J Interprof Care. 2011;25(3):167e174. http://dx.doi.org/10.3109/13561820.2010.529960. 29. Canadian Health Service Research Foundation in Ontario. Teamwork in healthcare [Video file]. Retrieved from: https://youtu.be/luLpITUkgO8; 2010. 30. Buiser M. Surviving managed care: the effect on job satisfaction in hospitalbased nursing. Medsurg Nurs. 2000;9(3):129e134. 31. Gould L, Wachter P, Aboumater H, et al. Clinical communities at Johns Hopkins Medicine: an emerging approach to quality improvement. Jt Comm J Qual Patient Saf. 2015;41(9):387e396. 32. Shaw DJ, Davidson JE, Smilde RI, Sondoozi T, Agan D. Multidisciplinary team training to enhance family communication in the ICU. Crit Care Med. 2014;42(2):265e271. http://dx.doi.org/10.1097/ccm.0b013e3182a26ea5. 33. National Learning Consortium. Fact sheet. Retrieved from: https://www.healthi t.gov/sites/default/files/nlc_shared_decision_making_fact_sheet_0.pdf; 2013. 34. Wenger E. Communities of Practice: Learning, Meaning, and Identity. first ed. Cambridge, England: Cambridge University Press; 1998. 35. Earnest M, Brandt B. Aligning practice redesign and interprofessional education to advance triple aim outcomes. J Interprof Care. 2014;28(6):497e500. http:// dx.doi.org/10.3109/13561820.2014.933650. 36. Kohn L, Corrigan J, Donaldson M. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. 37. World Health Organization. Learning Together to Work Together for Health Report of a WHO Study Group on Multiprofessional Education of Health Personnel: The Team Approach. Geneva: Switzerland; 1988. 38. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)da metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inf. 2009;42(2):377e381. http://dx.doi.org/10.1016/j.jbi.2008.08.010. 39. Constanza ME. Measuring the impact of interprofessional education on collaborative practice and patient outcomes. J Interprof Educ Pract. 2015;1(2): 34e35. 40. Murphy S, O'Connor C. Modern pneumatic tourniquets in orthopaedic nursing practice. J Orthop Nurs. 2007;11:3e4, 224e228. 41. Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes. (2015). doi: 10.17226/21726. Week 3 - 704 Questions . 1. Discuss your organization's readiness for change relative to your evidencebased practice change project. How do you know the organization is ready? The proposed evidenced based intervention that will be implemented is the Brief Psychiatric Rating Scale -18 (BPRS). The initial version was developed by Overall and Gorham (1962) to create a tool that analyzed symptoms in a quick, efficient manner yet thoroughly gauged a significant cluster of symptoms, addressing psychosis, mood disorders and anxiety. The providers within the organization are eager to apply a tool to assess patients for psychosis, as we do not formally have a consistent tool to gauge psychosis among our patient population. I started a casual dialogue when I was accepted into the DNP program over a few lunches and as we were writing our problem identification, I started polling the providers of their concerns when assessing and diagnosing patients who has a past diagnosis of psychosis or schizophrenia. One of the lunches and learn sessions, we collectively realized that we never used a formal assessment tool and began researching the various assessments available and is efficient for an outpatient mental health initial assessment. Currently, outside of the four psychiatric nurse practitioners, there are two master prepared licensed therapist, a clinical psychologist and three licensed eligible master prepared therapist. They will be participating and implementing the proposed interventions among their clients as well. As a team we have collaborated on a plethora of patients that are seen at the practice for both therapy and medication management. Yet, we have not collaborated on a project where it requires all clinicians to implement the same assessment tool. Interprofessional collaboration is important an entail the following competencies to be successful 1) Values/ethics for interprofessional practice 2) Roles and responsibilities 3) Interprofessional communication and 4) Team and teamwork (Hickey & Brosnan, 2017). The challenges that may arise are the clinical interviews. A biopsychosocial is used often in psychotherapy versus a psychiatric evaluation by nurse practitioners. Secondly, the implementation of the BPRS that often leads to medication management for optimal mental health outcomes, yet it could be difficult for the therapist to treat psychosis with non-pharmacological methods according to the severity. Lastly, there is a concern of time management when applying the BPRS. All initial evaluations are usually 60 minutes and currently most of the providers need every moment. The challenge will be how to implement this scale within the one-hour time frame. References: Hickey, J. V., & Brosnan, C. A. (2017). Evaluation of health care quality for DNPs (2nd ed.). Springer Publishing. Overall, J. E., & Gorham, D. R. (1962). The brief psychiatric rating scale. Psychological Reports, 10(3), 799-812. https://doi.org/10.2466/pr0.1962.10.3.799 Week 6 Question 1: How should we prepare health professional students so that they are able to be an effective Interprofessional team member in the clinical environment? Question 2: How can/does emotional intelligence influence interprofessional collaborative practices? Please share your quiz results only as you are comfortable. My results were a 61 – which indicated: Great! You're an emotionally intelligent person. You have great relationships, and you probably find that people approach you for advice. However, when so many people admire your people skills, it's easy to lose sight of your own needs. Read our tips below to find out how you can continue to build your EI. Researchers h...
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