Rehab Nurses Lead Multidisciplinary Efforts in Fall Prevention

At hospitals around the country rehab nurses are playing an essential role in reducing fall risk by educating their colleagues, in addition to their patients, according to an Advanced Healthcare Network for Nurses article.

At the Chicago-based Schwab Rehabilitation Hospital, nurses provide fall risk education to patients who also undergo a fall risk assessment at the time of admission. Schwab also uses stoplight model signs to identify the level of fall risk (green for low; yellow for moderate; and red for high) attached to patients’ beds and wheelchairs.

Additionally, rehab nurses at Schwab meet with hospital staff in other departments, including therapy, dietary, and environmental services, to educate them on the importance of notifying a nurse when a patient is at risk of falling. As a result of these efforts, Schwab has reduced their fall rate from 7.86 to 3.9 per 1,000 patient days over the course of a year.

INQRI grantees Patti Dykes and Blackford Middleton created a tool designed to prevent patient falls by translating an individual patient's fall risk assessment into a decision support intervention that communicates fall risk status, and creates a tailored plan that is accessible to care team members (including patients and family members).

The team constructed the Fall Prevention Toolkit (FPTK), and conducted a randomized controlled trial to examine whether the FPTK led to a decrease in the incidence of patient falls and a decrease in the incidence of patient falls with injury. The use of their toolkit did significantly lower the incidence of falls in the intervention units and several units wished to continue using the tool after the conclusion of the study. By establishing links between nursing fall risk assessment, risk communication and tailored interventions to prevent falls, Dykes and Middleton hope to raise awareness of fall risks for patients, nurses and other providers and to lower mortality and morbidity for potential fall victims.

More Nursing Schools Focus on Interdisciplinary Care

A number of the nation’s top nursing schools now require students to participate in at least one interprofessional education course or activity, according to a “dashboard” report recently released by the Future of Nursing: Campaign for Action, an initiative of RWJF and AARP.

Experts have been calling for interprofessional education for decades, but more schools are now responding because requirements are being written into health professions accreditation standards, Barbara Brandt tells RWJF’s Sharing Nursing’s Knowledge (SNK) newsletter. Brant is head of the National Center for Interprofessional Practice and Education, a public-private partnership supported by RWJF, the U.S. Health Resources and Services Administration, and other organizations. While there is not yet any comprehensive data quantifying the number of interprofessional activities and courses offered nationwide, Brandt said that there is “no question” the number of schools requiring these types of activities is growing rapidly.

INQRI is credited in the SNK article for helping to foster interdisciplinary research and collaborative practice. The ongoing impact can also be seen in health journals, where the number of articles in 10 of the top health services research journals co-authored by a registered nurse (RN) is increasing dramatically, according to a supplemental dashboard indicator, which shows that articles co-authored by RNs jumped from 80 to 145 from 2010 to 2012.

“For much of history, physicians made the major care decisions,” INQRI Grantee Joanne Spetz said. “We need to start teaching nursing students that they bring a set of skills to the table that are unique and distinct, and add value to the skills provided by other professionals. That will help them develop good, collaborative relationships over time.”

INQRI’s Mark Pauly Co-Authors New Study on Dual MBA/MD Degrees

Physicians who have both doctor of medicine (MD) and master of business administration (MBA) degrees reported that their dual training had a positive professional impact, according to a new study co-authored by INQRI co-director Mark V. Pauly. The study was published online by Academic Medicine and is one of the first to assess MD/MBA graduates’ perceptions of how their training has affected their careers. It focuses on physician graduates from the MBA program in health care management at the University of Pennsylvania.

The MD was more often cited as conveying professional credibility, while 40 to 50 percent of respondents said the MBA conveyed leadership, management, and business skills. Respondents also cited multidisciplinary experience and improved communication between the medical and business worlds as benefits of the two degrees.

The study’s authors also include David A. Asch, co-director of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars Program at the University of Pennsylvania and Clinical Scholar Mitesh S. Patel, who was quoted in a statement:

“A study published in 2009 found that among 6,500 hospitals in the United States, only 235 were run by physicians. Moving forward, changing dynamics triggered by national health care reform will likely require leaders to have a better balance between clinical care and business savvy. Graduates with MD and MBA training could potentially fill this growing need within the sector.”

Read the study, “The Role of MD and MBA Training in the Professional Development of a Physician: A Survey of 30 Years of Graduates From the Wharton Health Care Management Program,” which will also be published in the September issue of Academic Medicine.

The study was also covered on the RWJF Human Capital Blog.

‘Teamwork Works’: Lessons Learned From the Front Line of Team-Based Care

This blog post first appeared on the Robert Wood Johnson Foundation Human Capital Blog.

As the patient-centered medical home (PCMH) has emerged as a model for providing effective team-based care that can help offset the impending primary care provider shortage, so, too, is there a growing need for educational strategies that promote interprofessional collaboration. A short report published online by the Journal of Interprofessional Care describes the strategies in place at the VA Connecticut Healthcare System Center of Excellence in Primary Care Education (CoEPCE) and indicates promising results in just one year: doubled productivity in patient care delivered by faculty providers, and a marked increase in same-day clinic access for patients receiving care from an interprofessional team.

The Connecticut CoEPCE, like four other program sites funded through the U.S. Department of Veterans Affairs Office of Academic Affiliations, builds on the VA’s system-wide PCMH model, known as Patient Aligned Care Teams (PACT). It seeks to develop exportable models of interprofessional education and patient care, according to the report, “Moving From Silos to Teamwork: Integration of Interprofessional Trainees Into a Medical Home Model.” The CoEPCE sites share four core curricular domains—shared decision-making, sustained relationships, interprofessional collaboration, and performance improvement—and the Connecticut center groups together physician, nurse practitioner (NP), pharmacy, and health psychology trainees.

The trainees divide their time evenly between interactive educational sessions and caring for patients, guided by faculty who provide supervision, mentorship, and collaborative shared care. Additionally, the Connecticut center incorporates a one-year post-master’s adult NP interprofessional clinical fellowship, to further enhance clinical proficiency and teamwork experience for NPs.

“The data behind teamwork are very powerful,” said the report’s lead author, Theodore Long, MD, an Robert Wood Johnson Foundation Clinical Scholar and one of the first physician residents at the CoEPCE in Connecticut, “but having strong data doesn’t necessarily mean that teamwork is universally appreciated. There can be uncertainty about the meaning and purpose of teamwork. Seeing it in action has made a big impression on me, and on other trainees, giving us all a personal understanding of what teamwork is about and why it’s crucial to promote it on a wide scale in health care.”

In addition to increases in productivity and clinic access, the report describes clinical innovations developed by trainees, including a tool for communicating about patients as trainees change rotations, and a tool focused on safe transitions of care for high-risk patients.

Long pointed out that the PCMH in the CoEPCE setting is geared toward specific needs of veterans, of course, and “there are different challenges in different populations.” There are also “financial challenges to implementing patient-centered medical homes in general,” he said. “In the VA environment, we were fortunate to have a strong degree of buy-in from leadership up front”—something the report emphasizes as important to the success of PCMHs.

“Our experience lends support to expansion of the PCMH model across care environments,” Long added. “Teamwork works, and let’s focus on that.”

Read the report “Moving From Silos to Teamwork.”

Addressing Gender Divide and Improving Shared Educational Opportunities Could Spur More Interdisciplinary Collaboration

Lack of interdisciplinary collaboration remains a significant challenge for practicing nurses and other health care professionals and key barriers may include historical gender gaps and the lack of interprofessional educational experiences, according to the authors of a new article in The Online Journal of Issues in Nursing published by the American Nurses Association.

Many studies have shown that collaboration among nurses, physicians, and other members of the care team can improve the outcomes of care for patients. However, authors Karen Bankston and Greer Glazer argue that something often “gets in the way” of this happening.
 
“Medicine continues to be a male-dominated profession … while nursing continues as a female-dominated profession. These gender differences may continue to support gender bias and role expectations that are not conducive to collaborative behaviors,” the authors said.
 
In order for more collaboration to occur, deeply entrenched superior/subordinate relationships between medicine and nursing will need to be set aside. Additionally, more constructive dialogue is needed regarding each discipline’s scope of practice and the inter-dependencies between the disciplines, according to the authors.

Segregated educational programs for medicine and nursing could also be hindering professional collaboration in the field.  “We believe that our best opportunities for a successful transition to collaborative practice are to begin the socialization of our students to a collaborative environment when they enroll in our colleges. ... We recommend that nursing programs develop collaborative initiatives and joint experiences with other professions, while recognizing that the underlying issues of hierarchy, trust, valuing each other’s contributions, and sharing of power need to be addressed,” Bankston and Glazer said.

Several INQRI-funded projects have studied the impact of interprofessional collaboration on patient outcomes, including: “Implementation and Dissemination of an Interdisciplinary Nurse-Led Plan to Manage Delirium in Critically Ill Adults” and  “Multidisciplinary Organization and Outcomes for Chronic Heart Failure Patients in the VA.”

Promoting Rigorous Interdisciplinary Research and Building an Evidence Base to Inform Health Care Learning, Practice, and Policy

By Mary D. Naylor, PhD, RN, FAAN, Marian S. Ware Professor in Gerontology, director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, and co-director of INQRI. This commentary originally appeared on the Institute of Medicine website.

The Institute of Medicine (IOM) established the Roundtable on Value & Science-Driven Health Care to accelerate the advancement and application of science to achieve the best possible health and health care outcomes and value for Americans. The work of the roundtable is predicated on the notion that our health care system must continuously learn from rigorous evidence in order to innovate and improve. To that end, it acknowledges and promotes the importance of identifying best practices in health and health care, developing and testing innovations, and—most importantly— promoting collaborative efforts.

This vision for improving health and health care is shared by the Robert Wood Johnson Foundation, which funds an innovative and unique initiative to improve patient care by examining the role nurses play in improving care quality: the Interdisciplinary Nursing Quality Research Initiative (INQRI). Mark Pauly of the University of Pennsylvania and I have had the great privilege of serving as co-directors of this program since its inception in 2005.

More than 3.1 million strong, nurses represent the largest segment of the health care professional workforce in the United States and are the professionals who provide the most direct patient care. But, until the launch of the INQRI program, there was little rigorous research linking nursing’s contributions to patient outcomes. INQRI has served to advance the science of health care by investigating those linkages and providing evidence to inform policies and practices that improve patient care and outcomes, thereby improving our health care system overall.

Since INQRI’s launch, the program has encouraged researchers to develop new strategies to improve health care value and demonstrate nursing’s role in accomplishing that aim. To date, INQRI has supported 48 multidisciplinary teams of scholars whose studies have dramatically increased the evidence linking nursing to quality of care. These teams not only examine the nursing practices and processes that affect the patients’ experience with care and outcome, but also design and implement nurse-led interventions to improve patient outcomes. Equally important, findings from INQRI teams have helped to distinguish effective ideas from solutions that are often popular, yet ineffective.

A series of articles recently published in a special supplement of Medical Care revealed that, collectively, these studies have helped to improve the rigor of research methodology, built a solid base of evidence demonstrating linkages between nursing care and patient outcomes, and helped advance interdisciplinary research and practice. To a large extent, INQRI’s contributions to our knowledge are a function of the singular requirement that every INQRI research team include investigators from more than one discipline. As IOM’s Roundtable on Value & Science-Driven Health Care has drawn on the insights of a multidisciplinary community, so have INQRI teams. By requiring that researchers collaborate across disciplines, the program raises the bar for the level of rigor, ensuring that diverse perspectives contribute to the design of each study and are also brought to bear in the analysis of the findings.

The roundtable has sought to accelerate progress through six stakeholder Innovation Collaboratives: 1) Best Practices; 2) Clinical-Effectiveness Research; 3) Evidence Communication; 4) Digital Learning; 5) Systems Approaches for Health; and 6) Value Incentives. To make significant change, we must look at all aspects of the health care system. To that end, INQRI attempts to understand the nurses’ role in delivering high-quality care across a variety of patient populations and settings.

INQRI has funded several studies that examined nursing practices and tested interventions that can improve patient care and safety, including

• changes in nursing processes and the practice environment to facilitate nurses’ ability to intercept costly and dangerous medication errors;
• nurse-led innovations to reduce the incidence of facility-acquired
• pressure ulcers among residents in long-term care settings; and
• strategies to improve intensive care unit patients’ ability to communicate with nurses and other health team members regarding their care needs and preferences.

INQRI grantees have also applied rigorous research methods to examine a broad range of approaches to improving the value of health care—increasing quality while reducing health care costs associated with issues such as patient falls, hospital-acquired infections, and rehospitalizations. Studies aimed at reducing events that drive up health care costs have included

• an analysis of the factors that influence the quality of preparation of patients and family caregivers for the transition from hospitals to home and the impact of enhanced preparation on patients’ perceived readiness and rates of re-hospitalization;
• relationships between the level of professional nursing practice, adoption of evidence-based care strategies, and the number and kind of injuries from falls;
• effects on patients’ health of diabetes prevention information delivered by visiting nurses to residents in subsidized housing units; and
• linkages between nurse staffing levels in neonatal intensive care units and outcomes for very-low-birth-weight infants in those units.

In addition to contributing to continuous learning in our nation’s health care system, improving the rigor of research, and identifying the linkages between nursing and the quality of patient care, INQRI has helped to define what we mean by “quality” in the context of health care and to identify new metrics and measures that should be used in future health care research. As any research endeavor should, INQRI has proven to be greater than the sum of its parts.

Suggested citation: Naylor, M. Promoting rigorous interdisciplinary research and building an evidence base to inform health care learning, practice, and policy. Commentary, Institute of Medicine, Washington, DC. http://iom.edu/interdisciplinaryresearch

HRSA Grant Funds Interprofessional Educational Experiences

The University of Texas at Austin School of Nursing (SON) received a three-year, $1 million grant from the Health Resources and Services Administration to help integrate interprofessional education experiences with medicine, pharmacy, and social work into the curriculum, Nurse.com reports.

The expanded curriculum will be for students in the graduate level adult-gerontology clinical nurse specialist program.

“In many cases, physicians, nurses, pharmacists and other allied health practitioners have struggled to find ways to work together for the good of the patient,” said Alexa Stuifbergen, dean of SON. “Because learning how to work in teams with other health care providers shouldn’t begin on the job, several years ago we began to incorporate collaborative educational experiences into all levels of the nursing curricula.”