12 WK

Wk. 12.
Chronic Illness and the Interprofessional

Team
Synthesized definition-Interprofessional
collaboration(IPC)
 An evolving Interpersonal process involving a
diverse team of health care and other
community providers who interdependently
engage in frequent communication and shared
decision-making to provide optimal health and
social care services to clients living with chronic
illness and their families.
 Team composition and team processes are
flexible and consistently evaluated to effectively
and efficiently meet client needs.
 Occurs across the continuum of care- Acute
hospital- LTC, Client's home.
 Other terms used to explain the same IPC –
- multidisciplinary team; interdisciplinary
collaboration.
- Partnership.
Interprofessional collaboration
• Collaboration and its meaning-
• Provided some definitions on IPC from existing
literature
Concept analysis IPC-
Interprofessional collaboration and chronic

disease management: A concept analysis
• Concept analysis
• Antecedents
• Attributes
• Consequences
Interprofessional collaboration in CDM -
Antecedents
1.Antecedents of interprofessional collaboration
include:
1.Awareness of roles, skills and contributions-
role of the RN,
2.Interprofessional education, trust between
team
3.Members belief in interprofessional
collaboration
4.improves care and organizational support.
Interprofessional collaboration -Attributes
Key Attributes include
1.An evolving interpersonal process
2.Shared goals, decision-making and care
planning
3.Interdependence
4.effective and frequent interpersonal
communication
5.Evaluation of team processes
6.Involving older adults and family members in
the team
7.Diverse and flexible team membership.
Interprofessional collaboration-Consequences
Consequences include
1.Comprehensive care planning and
coordination of services
2.Improved provider knowledge
3.Redefining team composition
4.Confidence and job satisfaction
Creating a Collaborative Culture
• Common goals-client focused
• Open, safe communication
• Mutual respect
• Shared decision making:
• Role clarity
• Message clarity
Ho et al-Interprofessional Collaboration(IPC) End

Of Life decision making.
Although many patient that had completed their
advance directives, in Only 30% of cases the clients
stated wishes was accurately described in the health
record.
A great need exists with an emphasis on client EOL
care preferences , coordination of care amongst the
various health personnel and congruence in care.
Interprofessional Collaboration(IPC) Ho et al
Themes that emerged from the study
1. Discomfort with death and dying-next slide
2. Confusion about role responsibility
3. Lack of coordinated care
• Discomfort with death and dying
Factors that support EOL discussion
1. Interprofessional team work
2. Cohesive teams
Outcomes of IPC as it relates to EOL
1. Promoting quality experience for the client and
family.
2. Acknowledging the unequal power structures
between and amongst HCP, and between the
HCP the client and family members.
Heng etal -Enablers and Barriers to IPC
Study relates to HCP views on the enablers and
barriers to providing Education to clients about falls
prevention.
Client falls remain an important issue.
Falls Range from 6-17/1000pt days.
Consequences of pt. falls are varied-simple to death.
Preventing pt. falls is multifactorial and includes
pt. education; training of providers; Rehab;
environmental modifications; and optimal falls
prevention polices and systems
Enablers to Education on decreasing client falls
includes
1.Facilitating IPC teamwork and collaboration
1.Effective, timely communication, use of
common language
2.Implementing strategies to increase pt.
empowerment
1.Individualising pt. education and ensuring
that the material was relevant to the clients
situation. Ex clients with language barrier.
2.Selecting effective modes of education
delivery.
3.HCP access to effective pt. educational
materials.
Barriers to Education on decreasing pt. falls
includes
1.Limited IPC Communication.
2. Sub-optimal systems-polices and procedures-
Occurs at the organizational level-Ex assessing
documenting procedures for falls, fall risk and falls
prevention;
Poor communication amongst HCP
3. Perceived pt. related barriers to falls education.
Role
Traditional pattern of behavior and self-expression
performed by or expected of an individual within a
given society.
Some roles are acquired at birth, while others are
earned through formal education and experience.
The role of the professional nurse is one that is
being acquired by students during their formal
educational process and continues in the workplace
upon graduation.
Advanced practice roles in nursing have become
common. Due to variations among state nurse
practice acts, clarity of advanced practice roles may
be limited. Many students entering nursing with the
intent of becoming an advanced practice nurse.
Patient Advocate Roles
• Main goal: to empower clients and to help them
attain the services they need for self-
management of health issues
• Nurses behaviors:
• protect, defend, and support a patient’s
rights and/or intervene on behalf of patients
who cannot do so for themselves.
• facilitate access to essential health care
services for patients
• act as a liaison between patients and the
health care system

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Wk. 12.

Chronic Illness and the Interprofessional

Concept analysis IPC-

Interprofessional collaboration and chronic

Ho et al-Interprofessional Collaboration(IPC) End

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