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Addressing power dynamics in interprofessional health care teams

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Abstract

The balance of power among interprofessional healthcare teams influences their effectiveness. In this study, the researcher assessed the factors that influence power dynamics in interprofessional healthcare teams and the approaches they can use to address these dynamics. The study was based on a quantitative analysis of a total of 11 studies. The study’s outcome regarding the factors influencing power dynamics in interprofessional healthcare teams indicates that there are five groups of factors associated with these dynamics: team-related factors (unbalanced allocation of space and time and respect for medical hierarchy), role allocation-related factors (lack of recognition, lack of delineation of duties, lack of confidence in the skills and competencies of others), communication-related factors (nature and tone of communication, receptivity, and responsiveness), trust and respect, and individual-related factors (teamwork skills and positive team attitude). The researcher also noted that the strategies that can be adopted to address the factors associated with power imbalance include a collaborative approach, an open-door policy, direct communication, education and mentoring, and a merit-based approach when assigning leadership roles to team members.

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... A strong facilitator of IPC that was mentioned in the majority of included reviews and across all types of collaboration is co-location. This is not a surprise, as it has often been cited as a key enabler of collaborative work in the literature [65][66][67], by not only facilitating communication but also reducing power imbalances between professionals [68]. ...
... Actually, compliance with the medical hierarchy could result in power imbalances in collaborative teams [72], and lead to non-inclusive decision-making processes, poor communication and coordination issues [73]. Unfortunately, issues related to professional identity are difficult to address because they are often rooted in power struggles [68]. In fact, some authors have attempted to develop and conceptualize an interprofessional identity that could replace the existing identities of each professional group involved in IPC [74,75]. ...
... Thus, efforts could target flexibility and shared leadership between professionals [78]. In the long term, however, the most promising option seems to rely on education, and more particularly on mentoring [68]. ...
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Introduction: Interprofessional collaboration (IPC) is becoming more widespread in primary care due to the increasing complex needs of patients. However, its implementation can be challenging. We aimed to identify barriers and facilitators of IPC in primary care settings. Methods: An overview of reviews was carried out. Nine databases were searched, and two independent reviewers took part in review selection, data extraction and quality assessment. A thematic synthesis was carried out to highlight the main barriers and facilitators, according to the type of IPC and their level of intervention (system, organizational, inter-individual and individual). Results: Twenty-nine reviews were included, classified according to six types of IPC: IPC in primary care (large scope) (n = 11), primary care physician (PCP)-nurse in primary care (n = 2), PCP-specialty care provider (n = 3), PCP-pharmacist (n = 2), PCP-mental health care provider (n = 6), and intersectoral collaboration (n = 5). Most barriers and facilitators were reported at the organizational and inter-individual levels. Main barriers referred to lack of time and training, lack of clear roles, fears relating to professional identity and poor communication. Principal facilitators included tools to improve communication, co-location and recognition of other professionals' skills and contribution. Conclusions: The range of barriers and facilitators highlighted in this overview goes beyond specific local contexts and can prove useful for the development of tools or guidelines for successful implementation of IPC in primary care.
... However, concerns about the lack of teamwork within multidisciplinary teams were raised. Okpala (2020) reiterates that the unequal power balance among professionals in healthcare influences their effectiveness. ...
... A recent review by Okpala (2020) identified five domains that influence team power dynamics in healthcare: team-related factors, role allocation, communication, trust and respect, and individual traits. The implication is that effectively managed multidisciplinary teams are essential in ensuring the achievement of functional patient care and outcomes. ...
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This article uses role theory as a lens to explain the experiences of social workers working within healthcare multidisciplinary teams, which are characterised by interprofessional dominance and subordination. A qualitative case study design was used to explore and describe the experiences of social workers in working with other healthcare practitioners in multidisciplinary teams. A purposeful sampling technique was used to select sixteen participants from a particular health district. Data were collected through interviews and analysed using thematic analysis. Professional power dynamics, a sense of agency with a need for collaborative contribution, and a lack of understanding of the social work profession are three themes that summarise the findings. The article concludes that the ineffective management of multidisciplinary themes creates a barrier to different professionals’ ability to communicate, work and learn together. The article recommends preparatory training for multidisciplinary team members and the need for a structured framework for interprofessional engagement. Keywords: collaboration, healthcare, healthcare practitioner, multidisciplinary team, social worker, teamwork
... This may also indicate physician accountability in patient care. Power involves the ownership and control of various healthcare resources (Okpala, 2021). As CPs represent multidisciplinary care, it is vital for team effectiveness that members collaborate and share relevant information. ...
... As CPs represent multidisciplinary care, it is vital for team effectiveness that members collaborate and share relevant information. Therefore, team members should participate in CP-related decision making (Okpala, 2021;Saxena et al., 2019). Additionally, CP use was linked to incentives for individual physicians or clinical departments as part of their performance evaluations. ...
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Aim: This study aimed to explore the experiences of quality improvement personnel in implementing clinical pathways (CPs) in Korean hospitals. Design: A qualitative study using focus-group interviews was conducted with healthcare professionals in charge of CP development and management in hospitals. Methods: Sixteen quality improvement personnel from eight tertiary and seven general hospitals were recruited using purposive sampling. The verbatim transcribed data were analysed using qualitative content analysis. Results: Three key themes emerged: (1) the primary focus of CP development on surgeries through concerted efforts between management and frontline healthcare professionals; (2) CP fidelity management using indicators and feedback to relevant staff or departments; and (3) positive outcomes, despite concerns about system safety. The factors affecting CP use included availability of clinical evidence, flexibility of CPs, top management and clinical leadership, physicians' perceptions of CPs, computerized support systems, and external policies and regulations.
... Enacting implementation strategies without a focus on equity could allow disparities to emerge in both implementation and clinical outcomes (80). Although it is important for clinical champions to be well-networked and hold influence within their organizations, power within organizations can replicate hierarchies or systems of power and privilege reflected in society more broadly (63,81). Perceptions of core clinical champion characteristics, such as trust/respect, communication, and leadership are influenced by socio-cultural positionality, including, but not limited to, race/racism, gender/sexism, and ability/ableism (82). ...
... Power imbalance and hierarchies present in both healthcare teams and organizations can have negative impacts on implementation. Power imbalances that plague healthcare organizations include those related to communication (i.e., receptivity and responsiveness from leadership), trust and respect, as well as role allocation (i.e., lack of recognition or delineation of duties) (81). For clinical champions, imbalances related to communication may impede collaboration and educating peers about the EBP, which may reduce their overall effectiveness. ...
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Background The clinical champion approach is a highly utilized implementation strategy used to mitigate barriers and improve outcomes of implementation efforts. Clinical champions are particularly effective at addressing provider-level barriers and promoting provider-behavior change. Yet, the specific causal pathways that explain how clinical champions impact provider behavior change have not been well-explicated. The current paper applies behavior change models to develop potential causal pathway mechanisms. Methods The proposed mechanisms are informed by previous literature involving clinical champions and empirically supported behavior change models. These models are applied to link specific attributes to different stages of behavior change and barriers for providers. Results Two unique pathway mechanisms were developed, one that explicates how providers develop intention to use EBPs, while the other explicates how providers transition to EBP use and sustainment. Clinical champions may promote intention development through behavioral modeling and peer buy-in. In contrast, champions promote behavioral enactment through skill building and peer mentorship. Conclusion Clinical champions likely play a critical role in reducing provider implementation barriers for providers across various phases of behavior change. The proposed pathways provide potential explanations for how clinical champions promote provider behavior change. Future research should prioritize empirically testing causal pathway mechanisms.
... HCPs are traditionally seen as powerful when interacting with patients (Timmermans, 2020;Huynh and Dicke-Bohmann, 2020;Okpala, 2020;Potts, 2020). According to Huynh and Dicke-Bohmann (2020) and others (Okpala, 2020;Potts, 2020), HCPs, who have superior knowledge of disorders and treatments, establish their dominance as powerful 'experts'. ...
... HCPs are traditionally seen as powerful when interacting with patients (Timmermans, 2020;Huynh and Dicke-Bohmann, 2020;Okpala, 2020;Potts, 2020). According to Huynh and Dicke-Bohmann (2020) and others (Okpala, 2020;Potts, 2020), HCPs, who have superior knowledge of disorders and treatments, establish their dominance as powerful 'experts'. Potts (2020), suggests that this rhetoric is then reinforced through institutional policies, which frames patients as passive with minimal autonomy in their own healthcare decisions. ...
Article
Purpose Historically, clinical reasoning has largely been considered from an empirical, biomedical standpoint. This epistemology, rooted in imperial rule, is influential in how healthcare practitioners practice. An empirical approach to healthcare often oversimplifies the complex nature of clinical reasoning by obscuring the influence of imperial ideologies on decision-making. This can perpetuate inequitable approaches to healthcare delivery which deepen social, political and economic divides globally. This paper aims to explore and challenge this standpoint by exploring how power, imperialism and performativity influences healthcare provision and decision-making amongst healthcare practitioners in dysphagia rehabilitation. Methods Qualitative exploratory interviews were undertaken with seven South African trained SLPs with experience working in dysphagia. To allow for participation and collaboration from participants, three data collection tools were employed within the interviews: oral histories, cognitive mapping and arts-based tasks. An initial modified thematic analysis followed by a further ideological analysis were undertaken to analyse the data collected. Results The results suggest that the participants felt influenced by several manifestations of power within healthcare. We argue that this demonstrates that imperial practices can influence knowledge, interaction and context and therefore affect how healthcare practitioners make decisions. Conclusion By acknowledging the impact of imperialism and power dynamics on healthcare provision and clinical reasoning we can potentially begin to transform the epistemology from which we approach healthcare provision in favour of one which is better suited to the current realities of healthcare to allow for equitable service provision.
... The composition of the panel was designed to include clinical, administrative, and front-line care delivery and care recipient perspectives. Deliberately recruiting a minority of physicians, equal in number to pharmacists and family caregivers, and fewer than nurses, was intended to mitigate the inherent power differential that can arise in interprofessional activities that include physicians [13]. The intention of having more than one family caregiver was to increase the weight of the family's voice in the deliberation process relative to the clinicians' voice. ...
... Throughout our process, the research team was sensitive to the historical imbalances of academic-participant collaborations [29], hierarchical imbalances arising from combining healthcare professionals and lay persons to the same team, and interprofessional power imbalances deeply ingrained in healthcare systems [13]. Within the UK context our design process might be labelled as 'co-production' of research [30,31], with egalitarian participation and voice being the goal throughout the research design process from beginning (i.e. the research question) to end, we describe our process as collaborative [30], with the role of the stakeholders being two-fold: adding valuable knowledge and skills to the research process, and providing experiential information about the hospice environment in which the study would be implemented and research findings will be used [32]. ...
Article
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Background Clinical trials in home hospice settings are important to build the evidence base for practice, but balancing the burden and benefit of clinical trial conduct for clinicians, patients, and family caregivers is challenging. A stakeholder-engaged process can help inform and refine key aspects of home hospice clinical trials. The aim of this study was to describe a stakeholder-engaged process to refine, design, and implement aspects of an educational intervention trial in home hospice, including recommendations for refining intervention content and delivery, recruitment and enrollment strategies, and content and frequency of outcome measurement. Methods A panel of interprofessional (1 hospice administrator, 3 nurses, 2 physicians, 2 pharmacists) and 2 former family caregiver stakeholders was systematically selected and invited to participate based on expertise, representing 2 geographically distinct hospices who were participating in the clinical trial. Teleconferences followed a predetermined procedural sequence: 1. pre-meeting materials distribution and review; 2. pre-meeting email solicitation of concerns in response to materials; 3. teleconference with structured and guided discussion; and 4. documentation and distribution of minutes for accuracy review and future meeting guidance. Discussion topics were distinct for each panel meeting. Written reflections on the stakeholder engagement process were collected from panel members to further refine our process. Results Five initial biweekly teleconferences resulted in recommendations for recruitment strategy, enrollment process, measurement frequency, patient inclusion, and primary care physician notification of the patient’s trial involvement. The panel continues to participate in quarterly teleconferences to review progress and unexpected questions and concerns. Panelist reflections reveal personal and professional benefit from participation. Conclusions An interprofessional stakeholder process is feasible and invaluable for developing home hospice intervention studies, contributing to better science, successful trial implementation, and relevant, valid outcomes. Trial registration Clinicaltrials.gov, NCT03972163 , Registered June 3, 2019.
... By providing transparency, careful listening and knowledge exchange among the healthcare professionals from different specialities, it improves the delivery of healthcare and at last, it improves the outcomes of the patients. (4) An improved patient information flow, less misconceptions and collaborative decision-making are all made possible through IPE. It facilitates the collaboration of healthcare professionals, utilizing the distinct abilities and perceptions to produce an integrated approach to patient care that improves medical outcomes and satisfaction among patients. ...
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The Interdiscipline Education Perception Scale (IEPS) was used in this research to gauge health science librarians' views toward interprofessional cooperation and to learn more about their participation in such activities. The IEPS and questions regarding respondents' past and recent experience with IPE were addressed to librarians in the interprofessional education special interest group (IPE-SIG) and research section (RS) of the medical library association (MLA). To evaluate attitudes, the research compared the mean IEPS scores of each MLA group with several other demographic variables. The IEPS results for health science librarians showed favourable sentiments regarding IPE. There is no group differences were significantly varies from the others. The mean IEPS score of health science librarians was comparable to the mean score of health profession students commencing previous research. Fewer people worked on group or participated in extracurricular activities like reading clubs and grand rounds; the majority often reported interprofessional engagement was instructing or facilitating learning behaviour for students in the health profession. Health science librarians in this research had favourable sentiments regarding IPE, which is consistent with the common among other health professionals and subsequently the subject of research. The replies to the poll were not significantly influenced by the existence of an experience, prior professions as a health expert, or past work supporting IPE as a librarian. This implies that health science librarians are supportive of IPE, whether or not librarian actively promote IPE initiatives or engage in interprofessional activities
... This may be particularly relevant in the acute care setting as "site of service" changes have made reimbursement for imaging completed in hospital settings more challenging in recent years (Jeph et al., 2023). These factors may cumulatively pose challenges for SLPs advocating for AP view inclusion, particularly when facing resistance from physicians who hold higher hierarchical positioning within health care settings (Noyes, 2022;Okpala, 2021). ...
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Purpose This study explored factors influencing speech-language pathologists' (SLPs') decision making surrounding anterior–posterior (AP) view inclusion practices during videofluoroscopic swallowing studies (VFSSs) in the United States. Method SLPs completing VFSSs were recruited to complete an online anonymous survey. Questions represented six constructs of interest including: (a) clinician demographics, (b) practice patterns, (c) diagnostic perceptions, (d) professional influences, (e) training and education, and (f) logistical facilitators and barriers. Binary logistic regression was used to explore the relationship between construct items and likelihood of AP view inclusion. Results A total of 136/213 (64%) of respondents reported obtaining an AP view routinely. Facilitators of AP view inclusion were post-acute work setting (OR = 3.40, p = .001); perception that department practices “probably” (OR = 5.65, p = .006) or “definitely” align (OR = 5.30, p = .006) with evidence-based practice; perception the AP view has “a lot” (OR = 4.17, p = .025) or “a great deal” (OR = 4.77, p = .028) of diagnostic value; perception that their department is “definitely” supportive (OR = 4.69, p = .040); “moderate” (OR = 4.75, p = .001) or “no” (OR = 7.51, p < .001) equipment limitations; and radiologist support greater than “extremely unsupportive or resistant” (“somewhat unsupportive” [OR = 5.74, p = .041], “neutral” [OR = 11.23, p = .002], “somewhat supportive” [OR = 13.92, p = .001], or “extremely supportive” [OR = 13.92, p = .001]). Barriers to AP view inclusion were geographic location in the southern U.S. census region (OR = 0.31, p = .007), being “significantly” influenced by coworker opinions (OR = 0.13, p = .018), and productivity tracking (OR = 0.21, p = .008). Conclusion Environmental factors and organizational culture heavily influence AP view inclusion practices.
... Multi-disciplinary teams facilitate implementation of randomised trials. Team dynamics, including the roles of status and gender, can be important influences in productive collaborations [41,44,27,37,47]. This might be of particular importance when considering the role of the statistician in a collaboration, who historically were considered a contributor rather than a partner in research [2]. ...
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Background Dichotomisation of statistical significance, rather than interpretation of effect sizes supported by confidence intervals, is a long-standing problem. Methods We distributed an online survey to clinical trial statisticians across the UK, Australia and Canada asking about their experiences, perspectives and practices with respect to interpretation of statistical findings from randomised trials. We report a descriptive analysis of the closed-ended questions and a thematic analysis of the open-ended questions. Results We obtained 101 responses across a broad range of career stages (24% professors; 51% senior lecturers; 22% junior statisticians) and areas of work (28% early phase trials; 44% drug trials; 38% health service trials). The majority (93%) believed that statistical findings should be interpreted by considering (minimal) clinical importance of treatment effects, but many (61%) said quantifying clinically important effect sizes was difficult, and fewer (54%) followed this approach in practice. Thematic analysis identified several barriers to forming a consensus on the statistical interpretation of the study findings, including: the dynamics within teams, lack of knowledge or difficulties in communicating that knowledge, as well as external pressures. External pressures included the pressure to publish definitive findings and statistical review which can sometimes be unhelpful but can at times be a saving grace. However, the concept of the minimally important difference was identified as a particularly poorly defined, even nebulous, construct which lies at the heart of much disagreement and confusion in the field. Conclusion The majority of participating statisticians believed that it is important to interpret statistical findings based on the clinically important effect size, but report this is difficult to operationalise. Reaching a consensus on the interpretation of a study is a social process involving disparate members of the research team along with editors and reviewers, as well as patients who likely have a role in the elicitation of minimally important differences.
... The new tasks the therapists had to handle were more generic tasks that several other professional health groups might handle, which constitute an imbalance as the therapists' work becomes less specialised. A mismatch between qualifications and tasks in therapists' roles can contribute to poor team collaboration and job satisfaction (31)(32)(33). As some authors argue, a prerequisite for an excellent interdisciplinary collaboration environment is a mutual understanding of individual team member's roles (17,34). ...
... Lastly, it is important to recognize the power dynamics among various health professionals, particularly in relation to disparate educational backgrounds, licensure, certification, and policies (Okpala, 2021). Similar to other health professions, these power dynamics can create unintended tensions between SWs and CHWs in terms of disparate levels of role familiarity, different levels of respect from health care leaders and administrators or other care team members, and pay inequities (Center for Health and Social Integration at Rush, 2022). ...
Article
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Community health worker (CHW) and social worker (SW) collaboration is crucial to illness prevention and intervention, yet systems often engage the 2 workforces in silos and miss opportunities for cross-sector alignment. In 2021, a national workgroup of over 2 dozen CHWs, SWs, and public health experts convened to improve CHW/SW collaboration and integration across the United States. The workgroup developed a conceptual framework that describes structural, systemic, and organizational factors that influence CHW/SW collaboration. Best practices include standardized training, delineated roles and scopes of practice, clear workflows, regular communication, a shared system for documentation, and ongoing support or supervision.
... Furthermore, power dynamics among management teams are not solely determined by formal positions or hierarchical structures. Informal networks, alliances, and interpersonal relationships also play a significant role in shaping power dynamics within hospital management (Okpala, 2021). Individuals with strong interpersonal skills or access to critical information may wield influence disproportionate to their formal authority. ...
Article
This paper aims to explore how power dynamics shape strategic decisions and performance measurement systems in hospital management, elucidating their impact on managerial choices in healthcare settings. Key themes and factors related to power dynamics in hospitals are identified, including the distribution of power among management teams, the influence of individual and group power dynamics, and the effects of power on decision-making across organizational levels. By synthesizing insights from previous research, this paper informs the development of theoretical frameworks and methodological approaches for studying the interplay between power dynamics and strategic decision-making in hospital management. Furthermore, it offers practical implications for hospital administrators and managers, providing guidance on navigating power dynamics to enhance decision-making effectiveness and organizational performance. This paper contributes to advancing our understanding of the complex dynamics of power and decision-making in hospital management, offering valuable insights for both research and practice in healthcare administration.
... responding individuals (i.e., "people"; Table 2). Considering health sciences education is replete with high achieving individuals, who are more likely to respond to surveys than less academically inclined individuals (Hutchison et al., 1987;Dey, 1997;Sax et al., 2003;Porter & Whitcomb, 2005;Porter & Umbach, 2006), and learners/trainees who may feel pressured by medicine's power dynamics (Kumar, 2019;Kapadia, 2021;Okpala, 2021) to complete surveys, it is not too surprising the health sciences education literature boasts higher survey response rates than other fields. Education and learning topics are also known to yield higher response rates (Wu et al., 2022). ...
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Growth in the online survey market may be increasing response burden and possibly jeopardizing higher response rates. This meta‐analysis evaluated survey trends over one decade (2011–2020) to determine: (1) changes in survey publication rates over time, (2) changes in response rates over time, (3) typical response rates within health sciences education research, (4) the factors influencing survey completion levels, and (5) common gaps in survey methods and outcomes reporting. Study I estimated survey publication trends between 2011 and 2020 using articles published in the top three health sciences education research journals. Study II searched the anatomical sciences education literature across six databases and extracted study/survey features and survey response rates. Time plots and a proportional meta‐analysis were performed. Per 2926 research articles, the annual estimated proportion of studies with survey methodologies has remained constant, with no linear trend (p > 0.050) over time (Study I). Study II reported a pooled absolute response rate of 67% (95% CI = 63.9–69.0) across 360 studies (k), totaling 115,526 distributed surveys. Despite response rate oscillations over time, no significant linear trend (p = 0.995) was detected. Neither survey length, incentives, sponsorship, nor population type affected absolute response rates (p ≥ 0.070). Only 35% (120 of 339) of studies utilizing a Likert scale reported evidence of survey validity. Survey response rates and the prevalence of studies with survey methodologies have remained stable with no linear trends over time. We recommend researchers strive for a typical absolute response rate of 67% or higher and clearly document evidence of survey validity for empirical studies.
... For example, one highlighted benefit was that the AI-CDSS promoted team dialog about patient needs (Romero-Brufau et al., 2020). In another study (Beede et al., 2020), the AI-CDSS tool was found to have the potential to shift the asymmetrical power dynamics between physicians and nurses-a teamwork and organizational issue which often leads to the clinical opinions and assessments of nurses being undervalued or dismissed by physicians (Okpala, 2021)-by providing outputs that nurses can use as a reference to prove their judgement about the patient status and demonstrate their expertise to more senior clinicians. ...
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Introduction Artificial intelligence (AI) technologies are increasingly applied to empower clinical decision support systems (CDSS), providing patient-specific recommendations to improve clinical work. Equally important to technical advancement is human, social, and contextual factors that impact the successful implementation and user adoption of AI-empowered CDSS (AI-CDSS). With the growing interest in human-centered design and evaluation of such tools, it is critical to synthesize the knowledge and experiences reported in prior work and shed light on future work. Methods Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic review to gain an in-depth understanding of how AI-empowered CDSS was used, designed, and evaluated, and how clinician users perceived such systems. We performed literature search in five databases for articles published between the years 2011 and 2022. A total of 19874 articles were retrieved and screened, with 20 articles included for in-depth analysis. Results The reviewed studies assessed different aspects of AI-CDSS, including effectiveness (e.g., improved patient evaluation and work efficiency), user needs (e.g., informational and technological needs), user experience (e.g., satisfaction, trust, usability, workload, and understandability), and other dimensions (e.g., the impact of AI-CDSS on workflow and patient-provider relationship). Despite the promising nature of AI-CDSS, our findings highlighted six major challenges of implementing such systems, including technical limitation, workflow misalignment, attitudinal barriers, informational barriers, usability issues, and environmental barriers. These sociotechnical challenges prevent the effective use of AI-based CDSS interventions in clinical settings. Discussion Our study highlights the paucity of studies examining the user needs, perceptions, and experiences of AI-CDSS. Based on the findings, we discuss design implications and future research directions.
... Power dynamics affect shared planning, decision-making, role perceptions between and within professional groups, and service delivery, influencing patient experiences [57]. A quantitative analysis study conducted to assess the determinants influencing power dynamics in interprofessional healthcare groups suggested adapting strategies such as a collaborative effort, clear correspondence, learning and mentorship, and a performance-oriented model while allocating leadership position roles to groupmates to overcome power imbalance [58]. ...
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Background One of the ’best buys’ for preventing Non-Communicable Diseases (NCDs) is to reduce tobacco use. The synergy scenario of NCDs with tobacco use necessitates converging interventions under two vertical programs to address co-morbidities and other collateral benefits. The current study was undertaken with an objective to ascertain the feasibility of integrating a tobacco cessation package into NCD clinics, especially from the perspective of healthcare providers, along with potential drivers and barriers impacting its implementation. Methods A disease-specific, patient-centric, and culturally-sensitive tobacco cessation intervention package was developed (published elsewhere) for the Health Care Providers (HCPs) and patients attending the NCD clinics of Punjab, India. The HCPs received training on how to deliver the package. Between January to April 2020, we conducted a total of 45 in-depth interviews [medical officers (n = 12), counselors (n = 13), program officers (n = 10), and nurses (n = 10)] within the trained cohort across various districts of Punjab until no new information emerged. The interview data wereanalyzed deductively based on six focus areas concerning feasibility studies (acceptability, demand, adaptation, practicality, implementation, and integration) using the 7- step Framework method of qualitative analysis and put under preset themes. Results The respondent’s Mean ± SD age was 39.2± 9.2 years, and years of service in the current position were 5.5 ± 3.7 years. The study participants emphasized the role of HCPs in cessation support (theme: appropriateness and suitability), use of motivational interviewing, 5A’s & 5R’s protocol learned during the training & tailoring the cessation advice (theme: actual use of intervention activities); preferred face-to-face counseling using regional images, metaphors, language, case vignettes in package (theme: the extent of delivery to intended participants). Besides, they also highlighted various roadblocks and facilitators during implementation at four levels, viz. HCP, facility, patient, and community (theme: barriers and favorable factors); suggested various adaptations to keep the HCPs motivated along with the development of integrated standard operating procedures (SOPs), digitalization of the intervention package, involvement of grassroots level workers (theme: modifications required); the establishment of an inter-programmatic referral system, and a strong politico-administrative commitment (theme: integrational perspectives). Conclusion The findings suggest that implementing a tobacco cessation intervention package through the existing NCD clinics is feasible, and it forges synergies to obtain mutual benefits. Therefore, an integrated approach at the primary & secondary levels needs to be adopted to strengthen the existing healthcare systems.
... Future research should explore if this was due to people occupying different positions within existing intersectional power dynamics. Other research has documented that power dynamics related to professional roles and scope of work can impact team performance (Okpala, 2021); explicit attention to team power dynamics thus may offer learners unique tools for addressing these tensions in their teams. The curriculum overlapped in places with training that many behavioral health professionals experience; additional course development could better complement the existing skills of behavioral health colleagues and bring the communication practices of different health professions into greater alignment. ...
Article
Purpose: The purpose of the study's mixed-methods evaluation was to examine the ways in which a relational leadership development intervention enhanced participants' abilities to apply relationship-oriented skills on their teams. Design/methodology/approach: The authors evaluated five program cohorts from 2018-2021, involving 127 interprofessional participants. The study's convergent mixed-method approach analyzed post-course surveys for descriptive statistics and interpreted six-month post-course interviews using qualitative conventional content analysis. Findings: All intervention features were rated as at least moderately impactful by at least 83% of participants. The sense of community, as well as psychological safety and trust created, were rated as impactful features of the course by at least 94% of participants. At six months post-intervention, participants identified benefits of greater self-awareness, deeper understanding of others and increased confidence in supporting others, building relationships and making positive changes on their teams. Originality/value: Relational leadership interventions may support participant skills for building connections, supporting others and optimizing teamwork. The high rate of skill application at six months post-course suggests that relational leadership development can be effective and sustainable in healthcare. As the COVID-19 pandemic and systemic crises continue to impact the psychological well-being of healthcare colleagues, relational leadership holds promise to address employee burnout, turnover and isolation on interprofessional care teams.
... 7 While the lower pay of health support workers coincides with their lower level of education and training-and inequitable access to said education and training-this pay differential has real implications individually, in the workplace, and within teams that affects personal finances and family security, job stability, communication, trust, respect, teamwork skills, and a positive team attitude. 9 Physicians as Advocates Given the importance of team-based care and the existence of disparities within the health care team, we argue that physicians have a duty not only to coordinate among team members but also to advocate for them as part of helping patients meet their care goals. Advocating for improvements in working conditions and benefits and including the voice of health care workers with lower wages and less power will not only benefit those workers directly but also benefit patients and communities as a whole. ...
Article
Team-based care is a strong focus and narrative in medical and health education and within health care systems. Yet it is essential to consider that there are vast differences in power, education, compensation, and job security among team members in most health professional teams. How should clinicians of status play a role in advocating for lower status members of their health care teams, and why is that role important in improving equity within clinic walls and equity and better patient care for the communities they serve?
... Power dynamics or power disparity are considered to be significant contributing factors. [16] This interpretation holds that bullying arises directly out of the positional dominance/power that traditional hierarchal systems confer. Nurses are sometimes dominated and exploited by senior nurses, physicians, and individuals from other multidisciplinary teams. ...
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Nurses are the backbone of healthcare organizations. However, as frontline workers, nurses are regularly exposed to perilous conditions and workplace harassment, with a few or no avenues to report or seek adequate support. This causes frustration and stress among nurses and can eventually lead to compromised patient care. This also contributes to workplace bullying, which results in a toxic and stressful work environment. This problem is a global health and safety issue due to its highly negative impact on both individuals and organizations. Recent studies indicate that the COVID 19 pandemic has significantly increased incidents of workplace bullying against nurses. Several contributing factors have been highlighted, when considering the underlying causes of workplace bullying against nurses, including power disparity, organizational attributes, and the image of nurses, as portrayed in the media. Because the pandemic has brought the challenge of creating a safe work environment for nurses to the fore, now more than ever, healthcare organizations need to take bold actions to protect nurses. Nursing management needs to implement bullying prevention interventions that provide nurses with a safe work environment. Using empirical and theoretical literature as its basis, this paper aims to discuss workplace bullying against nurses and consider how this problem has been impacted by the COVID 19 pandemic. This paper recommends the application of a Socio Ecological Model (SEM), which provides evidence-based interventions intended to reduce workplace bullying against nurses.
... Nurses are described throughout the literature as historically subordinate to and dominated by doctors (Dyson, 2017;Keddy et al., 1986). This "steep hierarchical gradient" (Green et al., 2017, p. 450) perceives doctors as superior to nurses (Okpala, 2021). In practice, nurses may feel intimidated by doctors and 3 SDG5 seeks to "[a]chieve gender equality and empower all women and girls." ...
Article
Significant global events in recent years have had a substantial impact on the nursing profession. The COVID‐19 pandemic, climate change, and systemic racism are a few of the many complex issues that create a landscape of disruption and uncertainty in healthcare. With the aims of protecting both people and the planet, the United Nations’ Sustainable Development Goals offer a road map to combat these global concerns, yet require more widespread consideration as a way forward. Education on the Sustainable Development Goals is recognised as a key aspect for healthcare professionals to take action towards achieving the targets of the goals. For student nurses, the undergraduate curriculum offers an opportunity to enculturate future nurses on the important role they play in the global agenda to transform our world. Brazilian pedagogue Paulo Freire's theoretical approach to education, critical pedagogy, espouses transformation with conscientization, dialogue and liberation, which may create a paradigm shift toward global action. This discussion paper seeks to provide an argument for embedding the Sustainable Development Goals into nursing curricula using the philosophies of Freire's critical pedagogy. It will argue that a critical approach to education is required to create the transformation needed for student nurses to be educated on the Sustainable Development Goals.
... It may be more productive to recognize power as something diffuse that shifts as collaborators assert their power by adopting a variety of adversarial and collaborative stances to create alliances around issues of importance to their organizational priorities. Occupational therapy training, research, and practice remain embedded in the hierarchical power structures of the health care system (Green et al., 2017;Okpala, 2020); thus, disability studies-informed CBPR researchers must critically examine their implicit biases and understand how these inform the execution of CBPR. ...
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Importance: Disability studies–informed occupational therapy is predicated on full and equal partnerships among occupational therapy practitioners, researchers, and disability communities. Community-based participatory research (CBPR) is an approach to research that aligns with this vision yet is not without challenges. Understanding the tensions that arise from stakeholders’ perspectives and priorities is critical for promoting collaboration between occupational therapy professionals and disability community partners. Objective: To understand the group dynamics and relational processes of a CPBR team in the context of an intervention development study focused on health management for people with disabilities (PWD). Design: This 9-mo ethnographic study included semistructured interviews and participant observation. Data were analyzed thematically. Setting: Community-based multiagency collaborative. Participants: Nine participants (6 academic team members, 4 of whom were trained as occupational therapists; 2 disability partners; and 1 managed-care organization representative) took part. Three participants self-identified as PWD. Findings: CBPR processes, although productive, were fraught with challenges. Team members navigated competing priorities, varying power dynamics, and multifaceted roles and identities. Flexibility was needed to address diverse priorities, respond to unexpected challenges, and facilitate the project’s success. Conclusions and Relevance: Deep commitment to a shared goal of health care justice for PWD and team members’ willingness to address tensions promoted successful collaboration. Intentional relationship building is needed for occupational therapy researchers to collaborate with members of disability communities as equal partners. What This Article Adds: Disability studies–informed occupational therapy research demands that team members intentionally nurture equitable relationships through shared governance, clear communication, and recognition of the fluid nature of power dynamics.
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Background: Dichotomisation of statistical significance, rather than interpretation of effect sizes supported by confidence intervals, is a long-standing problem. Methods: We distributed an online survey to clinical trial statisticians across the UK, Australia and Canada asking about their experiences, perspectives and practices with respect to interpretation of statistical findings from randomised trials. We report a descriptive analysis of the closed-ended questions and a thematic analysis of the open-ended questions. Results: We obtained 101 responses across a broad range of career stages (24% professors; 51% senior lecturers; 22% junior statisticians) and areas of work (28% early phase trials; 44% drug trials; 38% health service trials). The majority (93%) believed that statistical findings should be interpreted by considering (minimal) clinical importance of treatment effects, but many (61%) said quantifying clinically important effect sizes was difficult, and fewer (54%) followed this approach in practice. Thematic analysis identified several barriers to forming a consensus on the statistical interpretation of the study findings, including: the dynamics within teams, lack of knowledge or difficulties in communicating that knowledge, as well as external pressures. External pressures included the pressure to publish definitive findings and statistical review which can sometimes be unhelpful but can at times be a saving grace. However, the concept of the minimally important difference was identified as a particularly poorly defined, even nebulous, construct which lies at the heart of much disagreement and confusion in the field. Conclusion: The majority of participating statisticians believed that it is important to interpret statistical findings based on the clinically important effect size, but report this is difficult to operationalise. Reaching a consensus on the interpretation of a study is a social process involving disparate members of the research team along with editors and reviewers, as well as patients who likely have a role in the elicitation of minimally important differences.
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Effective communication plays a vital role in healthcare especially between the nurses and patients who are the primary stakeholders in the healthcare sector. However, language barriers can create communication difficulties leading to miscommunicat - ion and misunderstandings. To address this issue, we have developed a mobile application to facilitate communication through images as a part of a first-year course named “Design thinking for Social Innovation ''. It features a wide range of images and diagrams that can be used to illustrate various medical conditions. The app heavily relies on visual diagrams like body diagrams (to identify the area of discomfort), when (referring to the number of days the patient is suffering from the particular medical condition or disease), problem duration (selecting a period in a day when the patient feels the pain is more), pain scaling illustrations (depicting the level of pain on a scale of 1 to 10) and to choose if they have any allergies. The app has a simple User Interface for patients to use. The Design Thinking Methodology was used to build the project starting from gathering requirements to developing a solution. The results of the study highlight that the solution can become a product to help nurses or any healthcare professionals diagnose and treat their patients more accurately, resulting in better patient outcomes. Keywords—Enter Cross-cultural communication, Language Barrier, Design Thinking, Application, Awareness.
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This study aimed to explore the power dynamics in interprofessional teamwork by conducting an ethnographic study of three interprofessional teams working in mental health and substance use services in Norway. Data were collected through 14 observation sessions and 18 in-depth interviews with health and social work professionals. Given the potential difference between “what people say and what people do,” we explored how ideas of power were articulated by health and social care professionals and how such structures were observed to be played out in practice. The findings suggest a presence of contrasting egalitarian and hierarchical structures, and that professionals were aware of the resulting tension and operated within it. This study contributes to the literature on interprofessional health and social care through providing an analysis of the power dynamics of teamwork interaction and how professionals relate to such structures. The results are relevant to a broad context of interprofessionalism as they provide valuable insight into how power should be understood as a continuum of changeable positions and motivations.
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Social workers on interprofessional teams help highlight the mental health aspects of wellness and alert teams to potential social barriers to care. Social work students have been valued in new interprofessional education (IPE) initiatives across the United States; however, researchers have shown that social work practitioners often feel outside of and not valued by interprofessional teams. Social work student reflections were analyzed as research data to explore experiences on student IPE teams. This was an inductive, qualitative study informed by literary analysis methods, reading for power dynamics and implicit bias. This analysis uncovered social work students holding on to stereotypes of other professions as well as detrimental stereotypes of their own profession. Displays of respect for social work and early opportunities for successful advocacy allowed social work students to feel confident in their role and encouraged participation. This study considers how social work participation can be encouraged on interprofessional student teams.
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Background: With the onset of the COVID-19 pandemic, a large urban academic hospital responded by creating the temporary role of a "Safety Officer (SO)." The key task of the SO role was to supervise staff donning and doffing personal protective equipment (PPE) and provide real-time feedback on their performance. The support for safe donning and doffing would contribute to staff well-being by reducing their fear of infection transmission. Methods: A Collaborative Change Leadership (CCL) approach was used to facilitate the development, implementation, and evaluation of the role. This included an iterative feedback process with clinicians and safety officers to continually refine the role. Findings: Feedback indicated value in the initiative as increasing staff confidence about preventing virus transmission, as well as their sense of safety at work. Areas for future improvement included additional communication strategies for interprofessional teams and external partners, as well as planning around logistics to better support the safety officers in performing this new, temporary role. Conclusions/application to practice: The Safety Officer role was able to help alleviate concerns regarding potential infection transmission and contribute positively to staff well-being.
Chapter
Meaningful mentoring founded on trust and transparency can challenge and energize nurses. Mentoring moments occur in our personal and professional worlds and can be intentionally structured or a serendipitous opportunity. When open to the possibilities of mentoring—both as mentor and mentee—nurses are exposed to new ideas and through humility develop a growth mindset to discover their inner potential.Our shared stories highlight how our global mentoring experience provided a safe space to be vulnerable, build confidence, and practice new ways of thinking. In meaningful, trusting mentoring partnerships, the roles may flip, which fosters a culture of shared creativity to identify innovative approaches and overcome challenges in our personal and professional journeys.The authentic human connections we developed through our meaningful mentoring experiences allowed us as professional nurses to develop long-lasting relationships, develop our nursing leadership skills, and with joy, always remain aware of the importance of “paying it forward.”KeywordsGlobal mentoringGrowth mindsetPay it forwardAuthenticTransparent relationshipsPersonal and professional vulnerability
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By valuing the knowledge of each discipline holistic patient-centered care can be achieved as decisions arise from expertise rather than established hierarchies. While healthcare has historically operated as a hierarchical power structure (i.e., some voices have more influence), these dynamics are rarely discussed. This review addresses this issue by appraising extant quantitative measures that assess multidisciplinary team (MDT) power dynamics. By identifying psychometrically sound measures, change agents can uncover the collective thought processes informing power structures in practice and develop strategies to mitigate power disparities. Several databases were searched. English language articles were included if they reported on quantitative measures assessing power dynamics among MDTs in acute/hospital settings. Results were synthesized using a narrative approach. In total, 6,202 search records were obtained of which 62 met the eligibility criteria. The review reveals some promising measures to assess power dynamics (e.g., Interprofessional Collaboration Scale). However, the findings also confirm several gaps in the current evidence base: 1) need for further psychometric and pragmatic testing of measures; 2) inclusion of more representative MDT samples; 3) further evaluation of unmatured power dimensions. Addressing these gaps will support the development of future interventions aimed at mitigating power imbalances and ultimately improve collaborative working within MDTs.
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Context Hospice aides provide essential direct care to hospice patients, yet there is minimal research examining hospice aide visits. Objectives describe the prevalence and frequency of hospice aide visits, and 2) evaluate patient, community, and hospice characteristics associated with these visits. Methods Longitudinal cohort study of Medicare Current Beneficiary Survey (MCBS) participants who died between 2010-2018 and received routine hospice care in the 6 months prior to death (n=674). We characterized prevalence and frequency of hospice aide visits over time and used generalized linear modelling to identify factors associated with visits. Results 64% of hospice enrollees received hospice aide visits and average visit frequency (1.3 per week) remained stable throughout enrollment. The only patient characteristic associated with receipt of hospice aide visits was primary hospice diagnosis (respiratory diagnosis vs. dementia: OR 0.372, p=0.040). Those living in community-based residential housing and those cared for by hospices with aides employed as staff were more likely to receive any hospice aide visits (OR 2.331, p=0.047 and OR 4.612, p=0.002, respectively.) Conclusion : Hospice aide visits are a common component of hospice care, but visit frequency does not increase as death approaches. Receipt of hospice aide visits was primarily associated with community and hospice agency (rather than patient) characteristics. Future work is needed to ensure that hospice aides are integrated in the hospice interdisciplinary team and that access to hospice aide visits is meaningfully driven by patient and family needs, rather than the practice norms and business models of individual hospice agencies.
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We investigated the factors that shape the working environment and workload, as these are reflected by the presence of conflicts among employees of a General Hospital in Greece. A cross-sectional study was conducted using a 20-part questionnaire, which was administered to 200 health care professionals. 24,5% of the participants referred that they want to quit their profession soon and nurses showed the majority and the doctors the lowest percentage (60%vs 7%). The willingness to change the working environment did not appear to depend on gender, marital status, work position and work schedule. The majority of the respondents reported that conflicts occur at their workplace, with the medical staff showing the greatest average number of conflicts in relation to both the other two professional groups. In particular, it was found that those who did not have a managerial position were 3.9 times more likely to choose to compromise in a conflict.
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Background Modern healthcare is burgeoning with patient centered rhetoric where physicians “share power” equally in their interactions with patients. However, how physicians actually conceptualize and manage their power when interacting with patients remains unexamined in the literature. This study explored how power is perceived and exerted in the physician-patient encounter from the perspective of experienced physicians. It is necessary to examine physicians’ awareness of power in the context of modern healthcare that espouses values of dialogic, egalitarian, patient centered care. Methods Thirty physicians with a minimum five years’ experience practicing medicine in the disciplines of Internal Medicine, Surgery, Pediatrics, Psychiatry and Family Medicine were recruited. The authors analyzed semi-structured interview data using LeCompte and Schensul’s three stage process: Item analysis, Pattern analysis, and Structural analysis. Theoretical notions from Bourdieu’s social theory served as analytic tools for achieving an understanding of physicians’ perceptions of power in their interactions with patients. Results The analysis of data highlighted a range of descriptions and interpretations of relational power. Physicians’ responses fell under three broad categories: (1) Perceptions of holding and managing power, (2) Perceptions of power as waning, and (3) Perceptions of power as non-existent or irrelevant. Conclusions Although the “sharing of power” is an overarching goal of modern patient-centered healthcare, this study highlights how this concept does not fully capture the complex ways experienced physicians perceive, invoke, and redress power in the clinical encounter. Based on the insights, the authors suggest that physicians learn to enact ethical patient-centered therapeutic communication through reflective, effective, and professional use of power in clinical encounters.
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How to Obtain Contact Hours by Reading this Issue Instructions: 1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded after you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf . In order to obtain contact hours you must: 1. Read the article, “The Elephant in the Room: Nursing and Nursing Power on an Interprofessional Team,” found on pages 349–355, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz. 2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study. 3. Go to the Villanova website to register for contact hour credit. You will be asked to provide your name, contact information, and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated. This activity is valid for continuing education credit until July 31, 2018 . Contact Hours This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated. Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Objectives Describe how perceptions of power, voice, and status affect interprofessional team participation. Define social and structural factors that can assist nurses on an interprofessional team. Disclosure Statement Neither the planners nor the author have any conflicts of interest to disclose. Notions of competency development frequently underlie discussions of interprofessional education and practice. Yet, by focusing primarily on the development of competencies, the discourse remains at a surface level, thus obscuring the root of many of the tensions that commonly occur in interprofessional collaborative teamwork. This qualitative study explored how perceptions of status influenced participation on an interprofessional team. Findings indicate that underlying tensions exist, despite an overarching commitment in both interprofessional practice and client-centered care. In particular, notions of perceived power, voice, and status intersected to create a narrative about the role and status of nursing in an interprofessional team. Both nurses and non-nurses recognized the influence of this narrative on team dynamics and function. This narrative was enacted through verbal and nonverbal behaviors, with passive and active resistance often appearing as a strategy used by nurses to address perceived power imbalances. This study has implications for interprofessional education and practice as it relates to nursing. J Contin Educ Nurs. 2015;46(8):349–355.
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Modern healthcare is delivered by multidisciplinary, distributed healthcare teams who rely on effective teamwork and communication to ensure effective and safe patient care. However, we know that there is an unacceptable rate of unintended patient harm, and much of this is attributed to failures in communication between health professionals. The extensive literature on teams has identified shared mental models, mutual respect and trust and closed-loop communication as the underpinning conditions required for effective teams. However, a number of challenges exist in the healthcare environment. We explore these in a framework of educational, psychological and organisational challenges to the development of effective healthcare teams. Educational interventions can promote a better understanding of the principles of teamwork, help staff understand each other's roles and perspectives, and help develop specific communication strategies, but may not be sufficient on their own. Psychological barriers, such as professional silos and hierarchies, and organisational barriers such as geographically distributed teams, can increase the chance of communication failures with the potential for patient harm. We propose a seven-step plan to overcome the barriers to effective team communication that incorporates education, psychological and organisational strategies. Recent evidence suggests that improvement in teamwork in healthcare can lead to significant gains in patient safety, measured against efficiency of care, complication rate and mortality. Interventions to improve teamwork in healthcare may be the next major advance in patient outcomes.
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The movement toward accountable care organizations and patient-centered medical homes will increase with implementation of the Affordable Care Act (ACA). The ACA will therefore give further impetus to the growing importance of teams in health care. Teams typically involve 2 or more people embedded in a larger social system who differentiate their roles, share common goals, interact with each other, and perform tasks affecting others. Multiple team types fit within this definition, and they all need support from leadership to succeed. Teams have been invoked as a necessary tool to address the needs of patients with multiple chronic conditions and to address medical workforce shortages. Invoking teams, however, is much easier than making them function effectively, so we need to consider the implications of the growing emphasis on teams. Although the ACA will spur team development, organizational leadership must use what we know now to train, support, and incentivize team function. Meanwhile, we must also advance research regarding teams in health care to give those leaders more evidence to guide their work.
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Ongoing care for chronic conditions such as diabetes is best provided by a range of health professionals working together. There are challenges in achieving this where collaboration crosses organisational and sector boundaries. The aim of this article is to explore the influence of power dynamics and trust on collaboration between health professionals involved in the management of diabetes and their impact on patient experiences. A qualitative case study conducted in a rural city in Australia. Forty five health service providers from nineteen organisations (including fee-for-service practices and block funded public sector services) and eight patients from two services were purposively recruited. Data was collected through semi-structured interviews that were audio-taped and transcribed. A thematic analysis approach was used using a two-level coding scheme and cross-case comparisons. Three themes emerged in relation to power dynamics between health professionals: their use of power to protect their autonomy, power dynamics between private and public sector providers, and reducing their dependency on other health professionals to maintain their power. Despite the intention of government policies to support more shared decision-making, there is little evidence that this is happening. The major trust themes related to role perceptions, demonstrated competence, and the importance of good communication for the development of trust over time. The interaction between trust and role perceptions went beyond understanding each other's roles and professional identity. The level of trust related to the acceptance of each other's roles. The delivery of primary and community-based health services that crosses organisational boundaries adds a layer of complexity to interprofessional relationships. The roles of and role boundaries between and within professional groups and services are changing. The uncertainty and vulnerability associated with these changes has affected the level of trust and mistrust. Collaboration across organisational boundaries remains challenging. Power dynamics and trust affect the strategic choices made by each health professional about whether to collaborate, with whom, and to what level. These decisions directly influenced patient experiences. Unlike the difficulties in shifting the balance of power in interprofessional relationships, trust and respect can be fostered through a mix of interventions aimed at building personal relationships and establishing agreed rules that govern collaborative care and that are perceived as fair.
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Rising dementia incidence is likely to increase pressures on healthcare services, making effective well coordinated care imperative. Yet, barriers to this care approach exist which, we argue, might be understood by focussing on identity dynamics at the frontlines of care. In this article, we draw upon findings from an ethnographic study of healthcare assistants (HCAs) from three dementia wards across one National Health Service mental health trust. Data revealed that the HCAs are a close-knit 'in-group' who share low group status and norms and, often highlight their own expertise in order to promote self worth. HCAs' social identity is considered as a barrier to effective teamwork with strong ingroup behaviour suggested as a consequence of their marginalisation. We explore these findings with reference to social identity theory (Tajfel, 1974; Turner, 1978 ) and discuss implications for delivering multiprofessional and interprofessional care.
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Multidisciplinary teamwork is recommended for various disorders and it has been suggested that it is a way to meet the new challenges and demands facing general practitioners (GPs) in modern society. Attempts to introduce the method in primary care have failed partly due to GPs' unwillingness to participate. The aim of this study was to measure attitudes towards collaboration among GPs and district nurses (DN) and to investigate whether there is a correlation between a positive attitude toward collaboration and high self-esteem in the professional role. The Jefferson Scale of Attitudes toward Physician Nurse Collaboration and the Professional Self-Description Form (PSDF) was used to study a cohort of 600 GPs and DNs in Västra Götaland region. The purpose was to map differences and correlations of attitude between DNs and GPs, between male and female GPs, and between older and younger DNs and GPs. Four hundred and one answers were received. DNs (mean 51.7) were significantly more positive about collaboration than GPs (mean 49.4). There was no difference between younger and older, male and female GPs. DNs scored higher on the PSDF-scale than GPs. DNs were slightly more positive about collaboration than GPs. A positive attitude towards collaboration did not seem to be a part of the GPs' professional role to the same extent as it is for DNs. Professional norms seem to have more influence on attitudes than do gender roles. DNs seem more confident in their profession than GPs.
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Health workforce is an integral part of the health system. Adopting a people-centred approach to health system reforms will depend on the ability to mobilize competent health workers. Governance of the health workforce will be an important consideration. The paper reviews the existing literature to identify current challenges in health workforce governance and provides suggestions on building a people-centred health workforce. Given the intersectoral and interdisciplinary context of the health workforce, governance processes have to challenge the traditional ‘silo’ approach. Efforts have to be directed towards strengthening and forging new partnerships, aligning priorities and galvanizing intersectoral commitment to advance the health workforce agenda. These actions have to be supported by an enabling regulatory environment that breaks down the healthcare silos and augments professional accountability to provide people-centred care.
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This research study explores hospice caregivers’ perceptions of service quality during end-of-life care. More strictly, this study measures how service dimensions of the SERVQUAL Analysis, (1) reliability, (2) assurance, (3) empathy, and (4) responsiveness, impacts caregiver satisfaction. Face-to-face and telephone interviews were conducted with 26 informal caregivers to determine their perceptions of quality produced while an interdisciplinary team cared for their family members. The research indicated that while reliability was the dominant dimension, peripheral dimensions (i.e. assurance, empathy, and responsiveness) integrated humanistic constituencies throughout the hospice continuum. This led to an improved quality of life (emotionally, socially, and spiritually), a positive disconfirmation of expectations (service expectations were met or exceeded), and positive caregiver satisfaction. A discussion of the results and conclusions will provide robust insight into the depth of the qualitative findings.
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The study explored the key factors associated with the increase in the prevalence of chronic health conditions and the appropriate collaborative leadership approaches pursued by the healthcare managers and other stakeholders involved in the management of chronic diseases. The study utilized grounded theory methodology and the data were selected through a rigorous approach that ensured that the selected databases were comprehensive, relevant and inclusive. The study showed that the integrated efforts towards enhanced disease awareness lead to a significant increase in positive lifestyle change (t = 2.009, P = 0.0001), similar results were observed with increased disease screening (t = 2.192, P = 0.001). A significant reduction in the prevalence of chronic diseases was also achieved through integrated efforts aimed at disease screening (t = 3.223, P = 0.002) and disease awareness (t = 2.009, P = 0.0001). The adoption of team-based self-management of chronic health conditions was also reported to result in a significant reduction in the disease severity (r = −0.43, P = 0.03), cost of care (r = −0.56, P = 0.002), and increased quality of life (r = 0.711, P = 0.005). This study suggests that the healthcare managers should liaise with other stakeholders in the adoption of enhanced disease awareness, increased disease screening, and team-based self-management in the management of chronic health conditions.
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Breakthrough Collaborative (BC) aims at learning through networking, mainly at micro level, and is used as a tool to improve care and welfare organizations. The aim of this study was to explore and illuminate the challenges when applying BC model at meso and macro level. In 2010, the Swedish Health and Medical Services Act stated the responsibility of healthcare professionals to consider children’s needs as relatives. This study uses an interactive collaborative research model. To support healthcare organizations in the implementation of the regulation, county councils/regions in Sweden were invited to take part in a BC during 2015. Six teams from different county councils/regions participated. Team members were interviewed several times during the project time. Data were analyzed with an explorative and descriptive qualitative content analysis. The result illuminates the challenges faced when applying BC at meso and macro level. Most challenges concern preparation, support structures and system connections. There are similarities with the challenges met at micro level when BC is used at meso and macro level. But it seems even more important to consider how the team is constituted at meso and macro level to make use of the learnings and achieve long-term impact in the home organization.
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In healthcare, mistakes that are potentially harmful or fatal to patients are often the result of poor communication between members of a team. This is particularly important in high-risk areas such as operating theatres or during any intervention, and the ability to challenge colleagues who are in authority when something does not seem right or is clearly wrong, is crucial. Colleagues in oral and maxillofacial surgery recognised the importance of this as early as 2004, and it is now well known that failure or reluctance to challenge others who might be wrong can severely compromise a patient’s safety. The Royal College of Surgeons of Edinburgh runs popular regular courses (Non-technical Skills for Surgeons, NOTSS) that teach how to ensure safety through good communication and teamwork. In this paper we introduce the concept of hierarchical challenge, and discuss models and approaches to address situations when problems arise within a team.
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It is widely believed that interprofessional care teams can improve patient care and increase safety. This belief among key stakeholders has often led to the imposition of team-based approaches without an adequate understanding of internal team dynamics, with attendant problems in implementation, that have made their performance often fall short of their promise. In this essay, we will first explore the promise of teamwork while providing a definition. In actual practice, the internal dynamics of teams often impede their successful operation. Communication difficulties, status differences, and the complexity of the task all present substantial obstacles to the successful implementation of teams. However, in spite of these problems, teams are the latest fad with their symbolic adoption decoupling them from their actual performance.
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In order to succeed in today's health care environment, interprofessional teams are essential. The terms "multidisciplinary care" and "interdisciplinary care" have been replaced by the more contemporary term "interprofessional practice and education" (IPE), which occurs when individuals "from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes." This commentary discusses new models of care, team members who contribute to IPE, and incentives and challenges. ©2016 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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Aim: To explore the unsettling effects of increased mobility of nurses, surgeons and other healthcare professionals on communication and learning in the operating theatre. Background: Increasingly, healthcare professionals step in and out of newly formed transient teams and work with colleagues they have not met before, unsettling previously relatively stable team work based on shared, local knowledge accumulated over significant periods of close collaboration. Design: An ethnographic case study was conducted of the operating theatre department of a major teaching hospital in London. Method: Video recordings were made of 20 operations, involving different teams. The recordings were systematically reviewed and coded. Instances where difficulties arose in the communication between scrub nurse and surgeons were identified and subjected to detailed, interactional analysis. Findings: Instrument requests frequently prompted clarification from the scrub nurse (e.g. 'Sorry, what did you want?'). Such requests were either followed by a relatively elaborate clarification, designed to maximize learning opportunities, or a by a relatively minimal clarification, designed to achieve the immediate task at hand. Conclusions: Significant variation exists in the degree of support given to scrub nurses requesting clarification. Some surgeons experience such requests as disruptions, while others treat them as opportunities to build shared knowledge.
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To identify facilitators and barriers influencing collaboration and teamwork between general practitioners and nurses working in general (family) practice. Internationally, a shortage of doctors entering and remaining in general practice and an increasing burden of chronic disease has diversified the nurse's role in this setting. Despite a well-established general practice nursing workforce, little attention has been paid to the ways doctors and nurses collaborate in this setting. Integrative literature review. CINAHL, Scopus, Web of Life, Cochrane Library, Joanna Briggs Institute Library of Systematic Reviews and Trove (dissertation and theses) were searched for papers published between 2000 and May 2014. This review was informed by the approach of Whittemore and Knafl (2005). All included papers were assessed for methodological quality. Findings were extracted, critically examined and grouped into themes. Eleven papers met the inclusion criteria. Thematic analysis revealed three themes common to the facilitators of and barriers to collaboration and teamwork between GPs in general practice: (1) roles and responsibilities; (2) respect, trust and communication; and (3) hierarchy, education and liability. This integrative review has provided insight into issues around role definition, communication and organizational constraints which influence the way nurses and general practitioners collaborate in a team environment. Future research should investigate in more detail the ways doctors and nurses work together in general practice and the impact of collaboration on nursing leadership and staff retention. © 2015 John Wiley & Sons Ltd.
Article
Background: There is emerging consensus that enhanced inter-professional teamwork is necessary for the effective and efficient delivery of primary care, but there is less practical information specific to primary care available to guide practices on how to better work as teams. Objective: The purpose of this study was to describe how primary care practices have overcome challenges to providing team-based primary care and the implications for care delivery and policy. Approach: Practices for this qualitative study were selected from those recognized as patient-centered medical homes (PCMHs) via the most recent National Committee for Quality Assurance PCMH tool, which included a domain on practice teamwork. Participants: Sixty-three respondents, ranging from physicians to front-desk staff, were interviewed from May through December of 2013. Practice respondents came from 27 primary care practices ranging in size, type, geography, and population served. Key results: Practices emphasizing teamwork overcame common challenges through the incremental delegation of non-clinical tasks away from physicians. The roles of medical assistants and nurses are expanding to include template-guided information collection from patients prior to the physician office visit as well as many other tasks. The inclusion of staff input in care workflow redesign and the use of data to demonstrate how team care process changes improved patient care were helpful in gaining staff buy-in. Team "huddles" guided by pre-visit planning were reported to assist in role delegation, consistency of information collected from patients, and structured communication among team members. Nurse care managers were found to be important team members in working with patients and their physicians on care plan design and execution. Most practices had not participated in formal teamwork training, but respondents expressed a desire for training for key team members, particularly if they could access it on-site (e.g., via practice coaches or the Internet). Conclusions: Participants who adopted new forms of delegation and care processes using teamwork approaches, and who were supported with resources, system support, and data feedback, reported improved provider satisfaction and productivity. There appears to be a need for more on-site teamwork training.
Article
AimThis study explores the current state of collaboration and communication between nurses and general practitioners in nursing homes, as well as needs and expectations of nursing home residents and their families. Finally, we aim to develop a new model of collaboration and communication.Background Rising numbers of residents in nursing homes present a challenge for general practice and nursing in most Western countries. In Germany, general practitioners visit their patients in nursing homes, where nurses work in shifts. This leads to a big variety of contacts with regard to persons involved and ways of communication.DesignQualitative multicentre study.Methods Study part 1 explores needs and problems in interprofessional collaboration in interviews with nursing home residents and their relatives, general practitioners and nurses. Simultaneously, general practitioners' visits in nursing homes are observed directly. In study part 2, general practitioners and nurses will discuss findings from study part 1 in focus groups, aiming to develop strategies for the improvement of shortcomings in a participatory way. Based on the results, experts will contribute to the emerging model of collaboration and communication in a multi-professional workshop. Finally, this model will be tested in a small feasibility study. The German Federal Ministry of Education and Research approved funding in March 2011.DiscussionThe study is expected to uncover deficits and opportunities in interprofessional collaboration in nursing homes. It provides deeper understanding of the concepts of all involved person groups and adds important clues for the interaction between professionals and older people in this setting.
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Abstract Increased emphasis on team care has accelerated interprofessional education (IPE) of health professionals. The health mentors program (HMP) is a required, longitudinal, interprofessional curriculum for all matriculating students from medicine, nursing, occupational therapy, physical therapy, pharmacy, and couple and family therapy. Volunteer lay health mentors serve as educators. Student teams complete four modules over 2 years. A mixed-methods approach has been employed since program inception, evaluating 2911 students enrolled in HMP from 2007 to 2013. Program impact on 577 students enrolled from 2009-2011 is reported. Two interprofessional scales were employed to measure attitudes toward IPE and attitudes toward interprofessional practice. Focus groups and reflection papers provide qualitative data. Students enter professional training with very positive attitudes toward IPE, which are maintained over 2 years. Students demonstrated significantly improved attitudes toward team care, which were not different across programs. Qualitative data suggested limited tolerance for logistic challenges posed by IPE, but strongly support that students achieved the major program goals of understanding the roles of colleagues and understanding the perspective of patients. Ongoing longitudinal evaluation will further elucidate the impact on future practice and patient outcomes.
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Abstract Interprofessional teamwork has become an integral feature of healthcare delivery in a wide range of conditions and services in many countries. Many assumptions are made in healthcare literature and policy about how interprofessional teams function and about the outcomes of interprofessional teamwork. Realist synthesis is an approach to reviewing research evidence on complex interventions which seeks to explore these assumptions. It does this by unpacking the mechanisms of an intervention, exploring the contexts which trigger or deactivate them and connecting these contexts and mechanisms to their subsequent outcomes. This is the second in a series of four papers reporting a realist synthesis of interprofessional teamworking. The paper discusses four of the 13 mechanisms identified in the synthesis: collaboration and coordination; pooling of resources; individual learning; and role blurring. These mechanisms together capture the day-to-day functioning of teams and the dependence of that on members' understanding each others' skills and knowledge and learning from them. This synthesis found empirical evidence to support all four mechanisms, which tentatively suggests that collaboration, pooling, learning, and role blurring are all underlying processes of interprofessional teamwork. However, the supporting evidence for individual learning was relatively weak, therefore there may be assumptions made about learning within healthcare literature and policy that are not founded upon strong empirical evidence. There is a need for more robust research on individual learning to further understand its relationship with interprofessional teamworking in healthcare.
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The healthcare system is plagued with increasing cost and poor quality outcomes. A major contributing factor for these issues is that outdated leadership practices, such as leader-centricity, linear thinking, and poor readiness for innovation, are being used in healthcare organizations. Complexity leadership theory provides a new framework with which healthcare leaders may practice leadership. Complexity leadership theory conceptualizes leadership as a continual process that stems from collaboration, complex systems thinking, and innovation mindsets. Compared to transactional and transformational leadership concepts, complexity leadership practices hold promise to improve cost and quality in health care.
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Since the publication of its reports, Health professions education: A bridge to quality (2003) and To err is human: Building a safer health system (2000), the Institute of Medicine has continued to emphasize interprofessional education (IPE), founded on quality improvement and informatics, as a better way to prepare healthcare professionals for practice. As this trend continues, healthcare education will need to implement administrative and educational processes that encourage different professions to collaborate and share resources. With greater numbers of students enrolled in health professional programs, combined with ethical imperatives for learning and reduced access to quality clinical experiences, medical and nursing education increasingly rely on simulation education to implement interdisciplinary patient safety initiatives. In this article, the authors describe one approach, based on the Core Competencies for Interprofessional Collaborative Practice released by the Interprofessional Education Collaborative (2011) • Interprofessional Education Collaborative Expert Panel Core competencies for interprofessional collaborative practice. Interprofessional Education Collaborative, Washington, DC 2011 • Google Scholar , toward providing IPE to an audience of diverse healthcare professionals in academia and clinical practice. This approach combines professional standards with the authors’ practical experience serving on a key operations committee, comprising members from a school of medicine, a school of nursing, and a large healthcare system, to design and implement a new state-of-the-art simulation center and its IPE-centered curriculum.
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