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Interprofessional teamwork in stroke care

This is the third in a series of six articles that aim to encourage nurse leaders to explore how to use research findings to improve practice and services where they work. The series focuses on research that has been funded by the National Institute for Health Research (NIHR) and included in NIHR Dissemination Centre publications. The authors seek to relate the content directly to the Nursing and Midwifery Council’s code of professional standards of practice and behaviour, specifically the themes of practising safely and promoting professionalism and trust.

Stroke
Picture: iStock

 


Introduction by Elaine Maxwell, clinical adviser at the National Institute for Health Research Dissemination Centre:

Elaine_Maxwell

The NIHR Dissemination Centre aims to assist practitioners, managers and policy maker by summarising, contextualising and analysing research findings and presenting them as dependable, accessible, actionable information for those who need it.

In recent years, stroke care has been transformed, in part by changes to how care services are organised.

We brought together some of the research that has helped with this transformation in our themed review, Roads to Recovery.

One of the studies we included, Interprofessional Teamwork across Stroke Care Pathways: Outcomes and Patient and Carer Experience (Harris et al 2013), looks at how different professions work together and affect outcomes for people with stroke.

In this article, the lead researchers discuss their studies of how teamwork, or the lack of it, affects people who have had stroke and their families.

A chief nurse then reflects on the implications for providers of stroke care and the importance of whole-team visibility to achieve the best outcomes.

This is the third in a series of six articles that aim to encourage nurse leaders to explore how to use research findings to improve practice and services where they work. The series focuses on research that has been funded by the National Institute for Health Research (NIHR) and included in NIHR Dissemination Centre publications. The authors seek to relate the content directly to the Nursing and Midwifery Council’s code of professional standards of practice and behaviour, specifically the themes of practising safely and promoting professionalism and trust

Stroke
Picture: iStock

 


Introduction by Elaine Maxwell, clinical adviser at the National Institute for Health Research Dissemination Centre:

Elaine_Maxwell

The NIHR Dissemination Centre aims to assist practitioners, managers and policy makers by summarising, contextualising and analysing research findings and presenting them as dependable, accessible, actionable information for those who need it.

In recent years, stroke care has been transformed, in part by changes to how care services are organised.

We brought together some of the research that has helped with this transformation in our themed review, Roads to Recovery.

One of the studies we included, Interprofessional Teamwork across Stroke Care Pathways: Outcomes and Patient and Carer Experience (Harris et al 2013), looks at how different professions work together and affect outcomes for people with stroke.

In this article, the lead researchers discuss their studies of how teamwork, or the lack of it, affects people who have had stroke and their families.

A chief nurse then reflects on the implications for providers of stroke care and the importance of whole-team visibility to achieve the best outcomes.


Ruth Harris, professor of health care for older adults, King’s College London, and Sarah Sims, research assistant at King’s College London:

Ruth Harris
Ruth Harris

Healthcare delivery is increasingly complex, and the use of teams working across professional and organisational boundaries is promoted in healthcare policy.

Patients frequently have conditions requiring multiple treatments from a range of healthcare professionals with different skills and expertise working collaboratively.

However, despite the centrality of interprofessional teamwork in healthcare delivery and patient safety, its effect on patient experiences and outcomes is poorly understood.

Sarah Sims
Sarah Sims

Our study aimed to investigate the effect of interprofessional teamwork on a range of patient outcomes and experiences for stroke survivors and their family carers at different points in their care pathways and to develop hypotheses about which aspects of teams and teamwork are effective in improving these.

There are two main reasons for selecting stroke pathways.

First, there is strong evidence that patients who receive care from specialist interprofessional teams in stroke units are more likely to be alive, independent and living at home one year after stroke (Stroke Unit Trialists’ Collaboration 2001), yet the contribution of teams to these favourable outcomes is unclear.

Second, stroke is a common health problem that causes considerable disability and development of interprofessional teamwork is an important feature of the national strategy for stroke (Department of Health 2007).

Method

It was a challenge to decide a method for exploring the effect of interprofessional teamwork because teams operate in different modes of service delivery, with varying membership across different professional groups and agencies.

We therefore drew upon a 'realistic evaluation' approach (Pawson and Tilley 1997, Hewitt et al 2012) which provided a framework to explore the complex interaction between the contexts, mechanisms and outcomes of teamwork focusing on ‘what works, for whom and in what circumstances’ (Hewitt et al 2014, 2015, Sims et al 2015a, 2015b).

We used a longitudinal study design (over 30 months) and mixed research methods to enable us to explore trends and associations over time between service structure and interprofessional teamwork, patient outcomes and patient experiences.

The study was undertaken in five phases:

  • Mapping the organisational and service delivery context.
  • Stroke team completion of the Aston Team Performance Inventory.
  • Retrieval of anonymised patient outcome data from hospital stroke registers.
  • Interviews with 50 patients, 33 family carers and 56 members of staff about their experience of receiving or delivering care.
  • Observations of interprofessional team meetings.

Findings

Interprofessional teamwork was largely invisible to patients and their family carers. While this does not mean that the effects of teamwork were not important to them or that they did not benefit from them, it does suggest that they looked beyond how their care was delivered and focused instead on the aspects of care that were important to them.

Patients’ and carers’ perspectives of who ‘the interprofessional team’ were also varied, with suggestions that, for patients, the team is ‘the people around my bed’.

We concluded that, to improve patient and carer experience of care delivered by interprofessional teams, the focus should be on the direct interaction between the patient and whichever members of the team are involved in each interaction.

Some of the interprofessional teams were large and this had a number of detrimental effects, including staff feeling too intimidated to contribute, team leaders being less available, team members not knowing each other well and ambiguity or conflict over leadership.

However, clarity of leadership was found to be highly predictive of overall team performance. Therefore we concluded that there is a need to consider carefully the size and structure of interprofessional teams to strengthen and clarify team leadership.

Uniprofessional activity and patient contact targets for stroke care were found to inhibit opportunities to work with interprofessional team colleagues, share knowledge and skills and support each other. We concluded that targets should be interprofessional to support coordination and collaboration.

Conclusion

This was an ambitious study using a longitudinal approach and multiple methods to investigate different perspectives of interprofessional teamwork.

The use of the realist evaluation approach gave structure to reviewing a diffuse area of literature. It also enabled us to explore the specific elements of interprofessional teamwork that may influence patient and carer experience and outcomes in a systematic way.

The study makes a significant contribution to knowledge of the effectiveness of interprofessional teamwork, particularly what works, for whom and in what circumstances.


Flo Panel Coates, chief nurse at University College London Hospitals NHS Foundation Trust:

Flo_Panel-Coates
Flo Panel Coates

The complexity of healthcare and the constraints on resources, particularly the workforce resource, creates a compelling argument to examine not only clinical interventions, but also how we organise healthcare professionals’ skills to optimise patient outcomes. The value of this research study is that it attempts to do just that.

The study elected to look at the provision of two stroke services in south London due to the different interprofessional membership and cross-organisational structure of teams that these services employ.

Unfortunately, and probably as a consequence of the system’s complexities, the study was unable to explore its primary aim, namely a correlation between interprofessional teamwork and patient outcome.

The researchers found that stroke registry data was missing – between age and severity of stroke was the only statistically significant difference in outcome in the available data – and, despite differences in structure between the two pathways and thus an assumption that ways of teamwork differed, no difference in patient outcome between the two pathways was detectable.

Teamwork

The study has some interesting findings worthy of consideration, however. The first is that patients and carers are unaware of the interprofessional mix of the teams that care for them. The exception was when communication between team members broke down. This suggests that, for our patients, teamwork is visible only when it is absent.

If we are really to put patients at the centre of our care, ensuring that we function effectively as a team should be a front-and-centre consideration. When did you last sit down with your team, as a team, and reflect on what you are, and are not doing well?

The second finding that I found particularly interesting was about the size of teams. The authors report reviewing five teams comprising 263 members. That suggests that each team had about 50 members.

Simon MacRory, author of Wake Up and Smell the Coffee: The Imperative of Teams (MacRory 2018) would probably choke on his coffee at this point. He suggests that the optimal team size is fewer than ten. Why? Because of the number of relationships that require maintaining within a team structure.

With a team of three, three relationships need maintaining; with a team of four, this increases to six relationships; with a team of five, ten relationships; and so on. In a team of ten, there are a staggering 45 relationships. No wonder the authors observed communication and coordination challenges in these teams, and the development of sub-teams often clustered around their professional roles.

Funding

This article presents independent research commissioned by the National Institute for Health Research (NIHR) under Health Service (HS) and Delivery Research (DR) (Grant Reference Number 08/1819/219).

The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

The sponsor of the study had no role in study design, data analysis, data interpretation or writing of the report.

Discussion

This raises some important questions about configuration of teamwork in patient care. Are interprofessional pathways, such as stroke pathways, simply a series of overlapping teams? Does it matter?

I suggest that it certainly does matter, especially when one considers how best to deliver effective leadership within these pathways. The authors suggest that where there was unambiguous leadership there was better team performance. However, ambiguity in leadership was a problem identified in this study, which reflects a wider leadership crisis in healthcare delivery.

The final and perhaps most important point for the nursing profession to reflect on is how crucial and valued is the contribution of nursing staff in these teams.

The authors report that nursing staff appear to be the least involved in the interprofessional team despite having the most contact with patients and carers. Given that patients and carers value face-to-face communication to feel safe and have confidence in the entire team, how can teams best support the nursing staff in their contact with patients?

And how, in turn, can the nursing community empower colleagues to have confidence within large multidisciplinary teams?

References

  • Department of Health (2007) A New Ambition for Stroke: A Consultation on a National Strategy. DH, London.
  • Harris R, Sims S, Hewitt G et al (2013) Interprofessional Teamwork across Stroke Care Pathways: Outcomes and Patient and Carer Experience. Final Report. NIHR Service Delivery and Organization Programme. (Project Report) Southampton, UK. The Stationery Office, London.
  • Hewitt G, Sims S, Harris R (2012) The realist approach to evaluation research: an introduction. International Journal of Therapy and Rehabilitation. 19, 5, 250-260.
  • Hewitt G, Sims S, Harris R (2014) Using realist synthesis to understand the mechanisms of interprofessional teamwork in health and social care. Journal of Interprofessional Care. 28, 6, 501-506.
  • Hewitt G, Sims S, Harris R (2015) Evidence of communication, influence and behavioural norms in interprofessional teams: a realist synthesis. Journal of Interprofessional Care. 29, 2, 100-105.
  • MacRory S (2018) Wake Up and Smell the Coffee: The Imperative of Teams. LID Publishing, London.
  • Pawson R, Tilley N (1997) Realistic Evaluation. Sage Publications, London.
  • Sims S, Hewitt G, Harris R (2015a) Evidence of a shared purpose, critical reflection, innovation and leadership in interprofessional healthcare teams: a realist synthesis. Journal of Interprofessional Care. 29, 3, 209-215.
  • Sims S, Hewitt G, Harris R (2015b) Evidence of collaboration, pooling of resources, learning and role blurring in interprofessional healthcare teams: a realist synthesis. Journal of Interprofessional Care. 29, 1, 20-25.
  • Stroke Unit Trialists’ Collaboration (2001) Organised Inpatient (Stroke Unit) Care for Stroke. Cochrane Database of Systematic Reviews. 3, CD000197.

Further information

Using research findings to improve practice and services

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