Conflict Resolution - RCPI

Report
INTERPROFESSIONAL
EDUCATION AND
PRACTICE
Université Laval
Dr. Lesley Bainbridge
University of British Columbia
OVERVIEW
Introduction
Emerging evidence
Conceptual framework and applications
Examples of IPE approaches
A “new” lens for collaboration
Questions and discussion
Introduction
History
Drivers
Why now?
Why me?
Why you?
EMERGING EVIDENCE
EMERGING EVIDENCE
Evidence for IPC
Collaborative practice strengthens health systems and improves
health outcomes.
Health leaders who choose to contextualize, commit and
champion interprofessional education and collaborative
practice position their health system to facilitate achievement
of the health-related Millennium Development Goals (MDGs).
Evidence clearly demonstrates the need for a collaborative practice
ready health workforce, which may include health workers from
regulated and non-regulated professions.
EMERGING EVIDENCE
Improved outcomes
A team-based approach to
health-care delivery maximizes
the strengths and skills of each
contributing health worker.
(Mickan SM. Evaluating the
effectiveness of health care
teams. Australian Health Review,
2005, 29(2):211-217.)
IPC can assist in recruitment and
retention of health workers and
possibly help mitigate health
workforce migration. (Yeatts D,
Seward R. Reducing turnover
and improving health care in
nursing homes: The potential
effects of self-managed work
teams. The Gerontologist, 2000,
40:358–363.)
Improved workplace practices and
productivity
Improved patient outcomes
Raised staff morale
Improved patient safety
Better access to health-care
In both acute and primary care
settings, patients report higher
levels of satisfaction, better
acceptance of care and improved
health outcomes following
treatment by a collaborative team.
EMERGING EVIDENCE
Collaborative practice can improve:
access to and coordination of
health-services
appropriate use of specialist
clinical resources
health outcomes for people
with chronic diseases
patient care and safety
References:
Hughes SL et al. A randomized
trial of the cost-effectiveness of
VA hospital-based home care for
the terminally ill. Health Services
Research, 1992, 26:801–817.
Jansson A, Isacsson A, Lindholm
LH. Organisation of health care
teams and the population’s
contacts with primary care.
Scandinavian Journal of Health
Care, 1992, 10:257–265.
Lemieux-Charles L et al. What do
we know about health care team
effectiveness? A review of the
literature. Medical Care Research
and Review, 2006, 63:263–300.
EMERGING EVIDENCE
References:
Collaborative practice can
decrease:
total patient
complications
length of hospital stay
tension and conflict
among caregivers
staff turnover
hospital admissions
clinical error rates
mortality rates
Holland R et al. Systematic review of multidisciplinary interventions in
heart failure. Heart, 2005, 91:899–906.
Lemieux-Charles L et al. What do we know about health care team
effectiveness? A review of the literature. Medical Care Research and
Review, 2006, 63:263–300.
McAlister FA et al. Multidisciplinary strategies for the management of
heart failure patients at high risk for admission. Journal of the American
College of Cardiology, 2004, 44:810–819.
Mickan SM. Evaluating the effectiveness of health care teams. Australian
Health Review, 2005, 29(2):211-217.
Morey JC et al. Error reduction and performance improvements in the
emergency department through formal teamwork training: Evaluation
results of the MedTeams project. Health Services Research, 2002, 37:1553–
1581.
Naylor CJ, Griffiths RD, Fernandez RS. Does a multidisciplinary total
parenteral nutrition team improve outcomes? A systematic review.
Journal of Parenteral and Enteral Nutrition, 2004, 28:251–258.
Teamwork in healthcare: Promoting effective teamwork in healthcare in
Canada. Ottawa, Canadian Health Services Research Foundation, 2006
(http://www.chsrf.ca/research_themes/pdf/teamworksynthesisreport_e.pdf).
West MA et al. Reducing patient mortality in hospitals: the role of human
resource management. Journal of Organisational Behaviour, 2006, 27:983–
1002.
Yeatts D, Seward R. Reducing turnover and improving health care in
nursing homes: The potential effects of self-managed work teams. The
Gerontologist, 2000, 40:358–363.
EMERGING EVIDENCE
In community mental health settings
collaborative practice can:
increase patient and carer
satisfaction
promote greater acceptance of
treatment
reduce duration of treatment
reduce cost of care
reduce incidence of suicide
increase treatment for psychiatric
disorders
reduce outpatient visits
References:
Jackson G et al. A new community mental health team
based in primary care: a description of the service and
its effect on service use in the first year. British
Journal of Psychiatry, 1993, 162:375–384.
Malone D et al. Community mental health teams
(CMHTs) for people with severe mental illnesses and
disordered personality. Framework for Action on
Interprofessional Education and Collaborative
Practice Cochrane Database of Systematic Reviews,
2007, Issue 2. (Art. No.: CD000270. DOI:
10.1002/14651858.CD000270.pub2)
Simmonds S et al. Community mental health team
management in severe mental illness: a systematic
review. The British Journal of Psychiatry, 2001,
178:497–502.
EMERGING EVIDENCE
Terminally and chronically ill
patients who receive team-based
care in their homes:
are more satisfied with their
care
report fewer clinic visits
present with fewer symptoms
report improved overall
health
References:
Hughes SL et al. A
randomized trial of the costeffectiveness of VA hospitalbased home care for the
terminally ill. Health Services
Research, 1992, 26:801–817.
Sommers LS et al. Physician,
nurse, andsocial worker
collaboration in primary care
for chronically ill seniors.
Archives of Internal Medicine,
2000, 160:1825–1833.
EMERGING EVIDENCE
Health systems can benefit from the
introduction of collaborative practice
which has reduced the cost of:
setting up and implementing
primary health-care teams for
elderly patients with chronic
illnesses
redundant medical testing and the
associated costs
implementing multidisciplinary
strategies for the management of
heart failure patients
implementing total parenteral
nutrition teams within the hospital
setting
References:
McAlister FA et al. Multidisciplinary
strategies for the management of
heart failure patients at high risk
for admission. Journal of the
American College of Cardiology,
2004, 44:810–819.
Naylor CJ, Griffiths RD, Fernandez
RS. Does a multidisciplinary total
parenteral nutrition team improve
outcomes? A systematic review.
Journal of Parenteral and Enteral
Nutrition, 2004, 28:251–258.
Sommers LS et al. Physician, nurse,
and social worker collaboration in
primary care for chronically ill
seniors. Archives of Internal
Medicine, 2000, 160:1825–1833.
REFERENCES
Barr H et al. Evaluations of interprofessional education: a United
Kingdom review for health and social care. London, BERA/CAIPE, 2000.
Barr H et al. Effective interprofessional education: assumption,
argument and evidence. Oxford, Blackwell Publishing, 2005.
Cooper H et al. Developing an evidence base for interdisciplinary
learning: a systematic review. Journal of Advanced Nursing, 2001,
35:228–237.
Hammick M et al. A best evidence systematic review of
interprofessional education. Medical Teacher, 2007, 29:735–751.
Holland R et al. Systematic review of multidisciplinary interventions in
heart failure. Heart, 2005, 91:899–906.
Malone D et al. Community mental health teams (CMHTs) for people
with severe mental illnesses and disordered personality. Framework
for Action on Interprofessional Education and Collaborative Practice
Cochrane Database of Systematic Reviews, 2007, Issue 2. (Art. No.:
CD000270. DOI: 10.1002/14651858.CD000270.pub2)
between nurses and doctors. Cochrane Database of Systematic Reviews, 2000, Issue 1.
REFERENCES
McAlister FA et al. Multidisciplinary strategies for the management of
heart failure patients at high risk for admission. Journal of the
American College of Cardiology, 2004, 44:810–819.
Naylor CJ, Griffiths RD, Fernandez RS. Does a multidisciplinary total
parenteral nutrition team improve outcomes? A systematic review.
Journal of Parenteral and Enteral Nutrition, 2004, 28:251–258.
Reeves S. Community-based interprofessional education for medical,
nursing and dental students. Health and Social Care in the Community,
2001, 8:269–276.
Reeves S. A systematic review of the effects of interprofessional
education on staff involved in the care of adults with mental health
problems. Journal of Psychiatric Mental Health Nursing, 2001, 8:533–
542.
Reeves S et al. Knowledge transfer and exchange in interprofessional
education: synthesizing the evidence to foster evidence-based decisionmaking. Vancouver, Canadian Interprofessional Health Collaborative,
2008.
REFERENCES
Reeves S et al. Interprofessional education: effects on professional
practice and health care outcomes. Cochrane Database of Systematic
Reviews, 2008, Issue 1.
Simmonds S et al. Community mental health team management in
severe mental illness: a systematic review. The British Journal of
Psychiatry, 2001, 178:497–502.
The primary health care package for South Africa– a set of norms and
standards. Pretoria, South Africa, Department of Health, 2000
(http://www.doh.gov.za/docs/policy/norms/fullnorms.html).
Working together, learning together: aframework for lifelong learning
for the NHS. London, Department of Health, 2001
(http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Public
ationsPolicyAndGuidance/DH_4009558).
CONCEPTUAL
FRAMEWORK AND
APPLICATIONS
1.
National Competency Framework for Interprofessional
Collaboration (CIHC, 2010):
CIHC Framework
Domains:
Communication
Patient-focused
Care
Role Clarification
Team Function
Interprofessional
Conflict Resolution
Collaborative
Leadership
Background:
Quality
Improvement
Spiral complexity
Simple
Complicated
Complex
Context of Practice
UBC Model
2. UBC Model: Exposure, Immersion, Mastery
Exposure: knows about
e.g. shadowing,lectures and workshops
Immersion: knows how
e.g. interprofessional placement
Mastery: can teach
e.g. looked to an an excellent collaborator
A Framework for Interprofessional Education in Health Programs
A Framework for Interprofessional Education in Health Programs
A Framework for Interprofessional Education in Health Programs
A Framework for Interprofessional Education in Health Programs
Role Clarification
A Framework for Interprofessional Education in Health Programs
Role Clarification
Collaborative Leadership
A Framework for Interprofessional Education in Health Programs
Role Clarification
Collaborative Leadership
A Framework for Interprofessional Education in Health Programs
Role Clarification
A Framework for Interprofessional Education in Health Programs
Collaborative Leadership
Interprofessional
Collaboration
Role Clarification
A Framework for Interprofessional Education in Health Programs
Collaborative Leadership
Simple
Clinical Clusters/
Academic
Component
Role Clarification
Complicated
Clerkship/Fieldwork/
Practicum
Interprofessional
Collaboration
Residency/New Health
Professionals
Complex
A Framework for Interprofessional Education in Health Programs
Exposure
Simple
Clinical Clusters/
Academic
Component
Role Clarification
Complicated
Clerkship/Fieldwork/
Practicum
Immersion
Interprofessional
Collaboration
Collaborative Leadership
Mastery
Residency/New Health
Professionals
Complex
A Framework for Interprofessional Education in Health Programs
Exposure
Role Clarification
Complicated
Simple
Clinical Clusters/
Academic
Component
Collaborative Leadership
Immersion
Interprofessional
Collaboration
Clerkship/Fieldwork/
Practicum
Attitudinal Change
Mastery
Residency/New Health
Professionals
Complex
EXAMPLES OF IPE
APPROACHES
EXAMPLES
Orientation
The educator pathway
The passport
IP-PBL
IP Placements
Standardized Patients
Other
A “NEW” LENS FOR
COLLABORATION
Current model
Co-location of students
Learning “with, from and about” each other
Much of the IPE is extracurricular
Learning together starts early (exposure) and becomes
more focused later (immersion).
Schedules and logistics are the main barriers.
IPE is explicit in some programs and implicit in other
programs.
Current model
Competency model is most common.
Learning objectives follow the competency model.
Roles and responsibilities of each profession are central
to current IPE.
The clinical setting is seen as an effective place for IPE
but so is the academic setting.
“IPE” curricula are common.
The focus is more on the education than the outcomes.
IPE is often seen as an ends rather than a means.
The focus is on the team and less on the individual.
Assumptions
Students must learn together in order to work together
collaboratively.
More than one profession is necessary to teach
interprofessionally.
Early exposure is good.
Students must be together to learn how to collaborate.
Role clarification is a key part of IPE.
A competency based model translates well into learning
objectives.
Assumptions
IPE is currently a train that is moving fast.
IPE leads to improved collaboration.
Improved collaboration improves health outcomes.
IPC is cost effective.
The system is changing to embrace IPE and IPC.
If students don’t see it in practice they will not
embrace it – it being IPC.
The learning must be clinically relevant.
Potential flaws
Scheduling barriers create curriculum changes that
are more for logistical reasons than good pedagogy or
the changes do not occur because of the barrier and
therefore IPE is restricted..
Competency based models are useful but do not get
beyond the behaviourally obvious characteristics of
collaboration.
Role clarification may reinforce stereotyping.
Potential flaws
Individual focus on collaborative practice skills is
overshadowed by team based collaboration skills.
The clinical setting is not fully exploited as an IPE
opportunity for the individual or the team.
Assessment of performance in collaboration is weak
and not well-developed except perhaps in the area of
attitudes. But would those scales change if we were to
focus on the individual rather than the team?
The long term change in practice because of IPE is
unknown to a large extent.
Potential new model
Focus is on training for collaboration.
Uniprofessional learning in the academic
setting is used to prepare students for
collaboration in clinical settings.
The focus for the training is on:
Social capital
Rhetoric
Perception checking
Conflict resolution
Building relationships
Negotiating priorities
Potential new model
Early educational interventions include single
professions and use scenarios, cases, videos,
small group work, simulation, virtual patients
etc. to establish personal insights into how
they as individuals can build a collaborative
network/resource network for themselves.
Clinical placements are used as the stage for
observations of collaboration, practice in
checking perceptions, building social capital,
using language to establish a positive
encounter etc.
Assessment of student skills in collaboration is
defined and quantifiable.
Assumptions
Students can learn collaboration within their
own professions while they build a professional
identity.
Putting the “I” in TEAM is important to ensure
personal responsibility and accountability for
collaborative behaviour.
Long term change will occur if the individual
ability to develop and sustain relationships is
well trained.
Assumptions
The clinical setting provides the best stage for
practicing collaboration.
A new way of looking at IPC can lead the way to
major change without RCT evidence that it works.
The work done to date in IPE lays the groundwork
for a new way of looking at it.
While in some circumstances the learning must be
clinically relevant, the processes of collaboration
are the focus in such a way that they can be
transferred from context to context.
Potential flaws
No one will buy into this new model.
The “evidence” argument gets in the way.
It is seen as going backwards into professional silos.
The responsibility for the integration of the new way of
addressing teaching collaboration falls to the community
partners.
The new model is seen as negating the old model.
It is too difficult to understand and link to the competencybased models.
The train is too far down the track for people to want to look
at IPE a new way.
…putting the “I” back in team…
Social capital
Rhetoric or framing
Perspective taking
Negotiating priorities
Resolving conflict
Building relationships
What are they and how do we teach them?
Social Capital

“Existing studies have almost exclusively relied upon Putnam’s (1993, 1995,
1996, 1998, 2000, 2001) conceptualization of social capital, which consists of
features such as interpersonal trust, norms of reciprocity, and social
engagement that foster community and social participation and can be used to
impact a number of beneficial outcomes, including health” p 165

“I propose that it would be more useful to conceive of social capital in a more
traditionally sociological fashion: as consisting of actual or potential resources
that inhere within social networks or groups for personal benefit.” P.166

“This conceptualization is consistent with the social capital theory of Pierre
Bourdieu (1986), which emphasizes the collective resources of groups that can
be drawn upon by individual group members for procuring benefits and services
in the absence of, or in conjunction with, their own economic capital.” P 166
Social Capital
Individual confounders:
•
•
•
•
•
•
•
Negotiation skill set
Communication skills
Perceptiveness
Ability to create social trust
Educational level
Hierarchical position
Overall competence
Thoughts
What do we all contribute to the central “pot” in
any given clinical case, what can only “we” do,
and what do we call upon others to do or take
on ourselves as part of the exchange of capital?
Have we viewed the health workplace as a
social system and if we do what does that imply
for collaborative working relationships?
Do we need to look at social space and
symbolic power?
Rhetoric or Framing
Rhetoric:
The art of effective or persuasive speaking or writing.
Language designed to have a persuasive or impressive effect on
its audience...
Framing:
Setting an approach or query within an appropriate context to
achieve a desired result or elicit a precise answer.
Rhetoric or Framing
“the ability to shape the meaning of a subject, to judge
its character and significance. To hold the frame of a
subject is to choose one particular meaning (or set of
meanings) over another. When we share our frames
with others (the process of framing), we manage
meaning because we assert that our interpretations
should be taken as real over other possible
interpretations.” (p. 3)
The Art of Framing (Fairhurst & Sarr, 1996)
Rhetoric or Framing
Becoming conscious of a goal purposely but
unconsciously predisposes us to manage meaning in
one direction or another to communicate our frames . . .
We may be conscious of a goal . . . but unconscious of
how we will select, structure, and exchange words with
another person to achieve that goal. Our unconscious
mind makes certain communication options available to
us for the framing that we ultimately do. These options
are not always ones we would have consciously
chosen, as we are painfully aware when we blunder and
succumb to ‘foot-in-mouth’ disease. But . . . we can
‘program’ our unconscious toward the selection of
certain options over others via priming. (pp. 144–5)
Rhetoric or Framing
Four ways not to persuade:
Effective persuasion:
1. attempt to make your case with
an up-front, hard sell
1. effective persuaders establish
credibility
2. resist compromise
2. they frame their goals in a way
that identifies common ground
with those they intend to persuade
3. think the secret of persuasion
lies in presenting great arguments
4. assume persuasion is a oneshot effort
3.they reinforce their positions
using vivid language and
compelling evidence
4. they connect emotionally with
their audience
(Conger, 1998)
Perspective Taking
The ability to entertain the perspective of another has long
been recognized as a critical ingredient in proper social
functioning. Davis (1983) found that perspective-taking, as
measured by an individual-difference measure, was
positively correlated with both social competence and
self-esteem. Piaget (1932) marked the ability to shift
perspectives as a major developmental breakthrough in
cognitive functioning, and Kohlberg (1976) recognized its
importance in his classification of moral reasoning.
Galinsky, Moskovitz, 2000
Perspective Taking
Perspective-taking also affects attributional thinking and
evaluations of others. Galinsky, Moskovitz, 2000
Perspective-taking, however, appears to diminish not
just the expression of stereotypes but their accessibility.
The constructive process of taking and realizing another
person's perspective furthers the egalitarian principles
themselves; perspective-taking is an effective
reinforcement of contemporary admonitions to consider
previously ignored or submerged perspectives as a
routine part of social interchange and inquiry. Galinsky,
Moskovitz, 2000
Negotiating priorities
Combined with the limited information we have about the
others’ true goals and interests, it is not always obvious
what to offer, how to offer it or how to find out what
would be worth offering. The way we communicate with
each other can have a significant and often unintended
impact on the outcome. And the relationships we form or
develop during the negotiation process can have a
significant impact not only on the present negotiation,
but also on potential future negotiations with these
parties and with others.
Fairman, 2012
Negotiating priorities
Factors influencing negotiation:
The power of skill and knowledge
The power of a good relationship
The power of a good alternative to negotiation
The power of an elegant solution
The power of legitimacy
The power of commitment
Fisher, 1983
Conflict Resolution
Thomas & Kilman
Conflict Resolution
Importance of the relationship
Relationship Building
Relationship Centred Care (RCC) is founded upon 4
principles:
(1) that relationships in health care ought to include the
personhood of the participants
(2) that affect and emotion are important components of
these relationships,
(3) that all health care relationships occur in the context
of reciprocal influence, and
(4) that the formation and maintenance of genuine
relationships in health care is morally valuable.
Beach et al, 2006
Relationship Building
The central task of health professions education—in
nursing, medicine, dentistry, public health, pharmacy,
psychology, social work, and the allied health
professions—must be to help students, faculty, and
practitioners learn how to form caring, healing
relationships with patients and their communities,
with each other, and with themselves.
Report of the Pew-Fetzer Task Force on Advancing
Psychosocial Health Education (2006)
So what?
This alternative lens seems to me to get at the very
heart of collaboration.
It puts responsibility for collaboration within each of
us.
It acknowledges the complexity of human
interaction across different professional cultures.
It provides each of us with a way to create our own
collaborative networks – even in the face of
resistance.
It paves the way for truly patient-focused care.
QUESTIONS AND
DISCUSSION

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